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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p rollover motor crash major surgical or invasive procedure: repair of left hand extensor tendon/stsg history of present illness: 18 yo female unrestrained driver, s/p rollover mvc; ejected from vehicle. was found ~50 ft from vehicle with obvious left hand deformity. she was intubated at scene secondary to combativeness. she was transferred to for continued care. past medical history: none family history: noncontributory pertinent results: 03:25pm glucose-132* lactate-2.0 na+-138 k+-4.6 cl--107 tco2-21 03:15pm glucose-146* urea n-10 creat-0.8 sodium-141 potassium-3.6 chloride-111* total co2-20* anion gap-14 03:15pm amylase-87 03:15pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 03:15pm wbc-19.8* rbc-4.11* hgb-12.9 hct-35.1* mcv-86 mch-31.4 mchc-36.8* rdw-13.0 03:15pm plt count-154 ct head w/o contrast reason: ?ich medical condition: 18 year old woman with ams on scene s/p rollover reason for this examination: ?ich contraindications for iv contrast: none. indications: 18-year-old woman status post motor vehicle collision. comparisons: none. technique: non-contrast head ct. findings: there is a small left-sided acute subdural hematoma along the anterior left frontal convexity, up to 3 mm in thickness. there is also a suspected thin subdural along the posterior aspect of the falx cerebri up to 4 mm in diameter. a punctate 2 mm density in the subcortical white matter, within the right frontal lobe, is suggestive of a hemorrhagic contusion. additional punctate densities along the medial periventricular white matter adjacent to the right lateral ventricle, and within the right side of the corpus callosum, are suspicious for diffuse axonal injury with hemorrhage, based on their locations. there is no mass effect, hydrocephalus or shift of the normally midline structures. the ventricles, cisterns, and sulci are unremarkable without effacement. the -white matter differentiation appears preserved. there is a small air-fluid level in the left maxillary sinus which can be seen in intubation. there is slight mucosal thickening in the sphenoid sinus. the mastoid air cells are clear. the osseous structures are unremarkable. there is bilateral soft tissue swelling above the orbits anteriorly. impression: 1. small left frontal subdural hematoma, with suspected small subdural along the posterior falx cerebri as well. 2. small right frontal hemorrhagic contusion. 3. dense foci along the right lateral ventricle, and within the corpus callosum, suspicious for diffuse axonal injury with hemorrhage. the findings were discussed shortly after the study with dr. and posted to the er dashboard. when clinically appropriate, an mr is suggested in order to better evaluate the extent of injury, as mri is more sensitive, in particular, for detection diffuse axonal injury, particularly for foci not associated with hemorrhage. ct c-spine w/o contrast reason: ?fx medical condition: 18 year old woman with ams on scene s/p rollover reason for this examination: ?fx contraindications for iv contrast: none. indications: 18-year-old woman with altered mental status after motor vehicle accident. comparisons: none. technique: axial non-contrast ct images of the cervical spine were obtained, and sagittal and coronal reconstructions were also performed. findings: the alignment of the cervical spine is normal, without listhesis. there is no evidence of fracture, dislocation, bony destruction, or prevertebral soft tissue swelling. the osseous structures appear normal. the patient is intubated, and there is a nasogastric tube passing through the esophagus. in the left upper lobe, there is a peripheral 4-mm nodular density which may represent a lung nodule, or perhaps a small contusion, although there is no evidence of surrounding injury to suggest chest injury. there is mild dependent change in the visualized right apex. impression: 1. no evidence of fracture or dislocation. 2. small density in the left upper lobe, which could represent a small contusion or nodule. follow-up after three months is suggested to ensure resolution. chest (portable ap) reason: cp processes medical condition: 18 year old woman with fever reason for this examination: cp processes impression: 18-year-old with fever, status post motor vehicle accident. comparison: . findings: lungs are clear except some residual opacity in the right apex, not significantly changed from the previous examination. there are no pleural effusions. cardiomediastinal silhouette is unremarkable. no evidence of central lymphadenopathy. right picc terminates in the distal svc. a feeding tube terminates in the expected location of distal stomach. impression: unchanged appearance of residual right apical opacity, otherwise clear lungs blood urine csf other fluid microbiology recent last day last week last 30 days all results hide comments from date to date hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 07:00am 9.5 3.81* 11.6* 32.4* 85 30.4 35.8* 13.9 543* differential neuts bands lymphs monos eos baso atyps metas myelos 02:02am 80.4* 12.7* 5.8 0.5 0.7 red cell morphology hypochr anisocy poiklo macrocy microcy polychr 02:20am normal1 normal normal normal normal normal 1 normal manual basic coagulation (pt, ptt, plt, inr) pt ptt plt smr plt ct inr(pt) 07:00am 543* chemistry renal & glucose glucose urean creat na k cl hco3 angap 07:00am 101 34* 0.8 134 3.7 98 24 16 11:20am 120* 37* 0.9 137 3.7 100 25 16 07:15am 106* 37* 1.2* 144 4.5 106 26 17 06:51am 125* 37* 1.2* 149* 4.2 112* 26 15 02:02am 143* 36* 1.4* 146* 3.7 110* 25 15 12:37pm 129* 37* 1.3* 142 3.8 106 27 13 03:03am 159* 31* 1.4* 141 3.6 104 26 15 12:45am 104 9 0.6 138 3.9 99 26 17 01:17pm 110* 138 3.8 101 27 14 source: line-art 03:46am 83 12 0.5 136 3.9 101 28 11 03:05am 140* 9 0.5 139 4.2 106 25 12 02:38am 101 9 0.4 140 3.5 104 29 11 02:01am 89 10 0.5 142 4.1 108 27 11 02:20am 115* 8 0.4 141 4.1 109* 25 11 11:36am 3.7 source: line-a-line 04:01am 115* 5* 0.5 142 3.6 110* 25 11 02:23pm 3.7 source: line-aline 03:13am 128* 3* 0.5 140 3.8 108 24 12 02:31am 109* 3* 0.6 139 3.8 111* 20* 12 added alb 8:35am 11:34am 94 2*1 0.5 137 3.7 112* 20* 9 1 verified - consistent with other data 02:55am 92 3* 0.6 138 3.7 114* 17* 11 04:55pm 81 0.6 140 3.5 112* 20* 12 source: line-art 02:20am 91 10 0.6 139 3.4 110* 21* 11 03:15pm 146* 10 0.8 141 3.6 111* 20* 14 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 03:15pm 87 chemistry totprot albumin globuln calcium phos mg uricacd iron 07:00am 9.8 4.4 2.0 antibiotics vanco 06:52am 6.2*1 vancomycin @ trough 1 updated reference range as of == represents therapeutic trough neuropsychiatric phenyto 03:05am 3.2* toxicology, serum and other drugs asa ethanol acetmnp bnzodzp barbitr tricycl 03:15pm neg neg1 neg neg neg neg 1 neg 80 (these units) = 0.08 (% by weight) lab use only holdblu redhold 04:12am hold1 1 hold discard greater than 24 hrs old blood gas blood gases type temp rates tidal v peep fio2 o2 flow po2 pco2 ph caltco2 base xs intubat vent comment 01:30pm art 82* 41 7.44 29 3 09:52am art 37.9 50 187* 38 7.47* 28 4 03:57am art 400 5 50 200* 48* 7.40 31* 4 intubated whole blood, miscellaneous chemistry glucose lactate na k cl calhco3 01:30pm 112* 3.8 09:52am 121* 0.8 hemogloblin fractions ( cooximetry) o2 sat 06:30pm 85 calcium freeca 01:30pm 1.23 brief hospital course: she was admitted to the trauma service. neurosurgery and plastic surgery were consulted because of her injuries. her neurosurgical issues were nonoperative; she was loaded with dilantin and continued on a scheduled dose for 10 days; serial head ct scans were followed and were stable. she will follow up in clinic in 5 weeks for repeat head ct scan. plastic surgery was consulted for her left hand degloving injury. she was taken to the operating room for repair of her extensor tendon and stsg. she will follow up with plastic surgery in weeks after discharge. because of her behavioral neurology was consulted as patient was having behavior issues; periods of extreme restlessness and agitation. during her icu stay she was receiving haldol and ativan and required 1:1 sitters. it was recommended that these agents be placed on hold as could have been contributing to her delirium. her behavior dramatically improved, mental status such that she knew the date and place. during her icu stay she was initially difficult to wean; discussions took place with family as to possibility of tracheostomy. she eventually was able to wean and then was extubated. she was transferred to the step-down unit days following her extubation. speech and swallow were evaluated early on during her hospital stay; initially she did not pass her bedside swallow; a dobhoff tube was placed and tube feedings were initiated. she was re-evaluated by speech several days later once her mental status improved; her diet was upgraded to nectar thick liquids and soft solids. her tube feedings were cycled; she was also placed on calorie counts. because of the dramatic improvement in her mental status it is expected that the dobhoff will be very short term and she will eventually have her diet upgraded with continued evaluation by slp once at rehab. on the morning of her discharge she was in the bathroom and while sitting on the toilet slipped hitting her right foot, on examination there was no point tenderness or swelling. no other injuries were identified. physical and occupational therapy were also consulted and have recommended rehab stay. case management initiated this process and she was accepted by . social work was closely involved with patient and family for coping and support. medications on admission: ocp discharge medications: 1. insulin regular human 100 unit/ml solution sig: one (1) injection four times a day as needed for per sliding scale. 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) dose injection (2 times a day). 3. docusate sodium 150 mg/15 ml liquid sig: fifteen (15) ml's po bid (2 times a day). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 5. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml's po bid (2 times a day). 6. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime). 7. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). 8. fluoxetine 10 mg capsule sig: one (1) capsule po daily (daily). discharge disposition: extended care facility: rehab hosp of cape and islands discharge diagnosis: s/p rollover motor vehicle crash degloving injury left hand small subdural hematoma diffuse axonal injury discharge condition: good discharge instructions: no procedures left arm because of the injury that was sustained. followup instructions: follow up with plastic surgery clinic in 1 week, call for an appointment. follow up with neurosurgery, dr. in 5 weeks. call and inform the office that you will need a repeat head ct scan for this appointment. md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Arterial catheterization Bronchoscopy through artificial stoma Transfusion of packed cells Other suture of other tendon of hand Other skin graft to hand Excision of other lesion of soft tissue of hand Diagnoses: Anemia, unspecified Open wound of forehead, without mention of complication Pneumonitis due to inhalation of food or vomitus Open wound of hand except finger(s) alone, with tendon involvement Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Other specified complications of procedures not elsewhere classified Injury to nerves, unspecified site Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle

allergies: altace attending: chief complaint: shortness of breath, increased angina major surgical or invasive procedure: central line placement history of present illness: ms. is a 74 year-old woman with a history of cad s/p cabg in 10/84 with redo in 11/84, stent to left subclavian in and repeat dx cath without intervention in , ef of 35% on echo in , atrial fibrillation diagnosed in managed with rate control and anti-coagulation, hypertension, lipids and asthma/possible copd (no pft's noted in record/no smoking history) admitted now with sob/unstable angina. the patient's current symptomatology began last friday when she developed uri symptoms including nasal congestion and cough. since then she has noted increased dyspnea, increased episodes of her anginal pain including at rest and cough productive of yellow/celery colored sputum. dyspnea has increased to point where she has trouble with stairs now where recently she has not. has dry cough at baseline attributed to mavik, but her current cough is different. has also had significantly increased fatigue over this time. takes combivent or albuterol with some relief of shortness of breath. her sob brought her to see her pcp . cxr was obtained and revealed no acute process. other history from that visit is unobtainable. last night she had palpitations and her shortness of breath subsequently worsened which ultimately brought her to today. reports taking all her medications. has had some dietary indiscretion recently including salted fish last friday and dining out recnetly. also reports increased stress and exposure to dogs at family members house. denies fever or chills. denies feeling dizzy, syncope. no weight loss. appetite has been good. past medical history: cad as above atrial fibrillation htn increased lipids asthma ?copd(non-smoker) gerd anemia social history: no history of smoking. occasional alcohol and no ivdu. lives in area with excellent support from family. family history: non-contributory physical exam: vs: t: 97.5 bp 124/63 hr: 90's rr 18 95% 3l (on nitro) general: no distress but mildly increased work breathing resting pleasant, heent: perlla, eomi, mmm, no pharyngeal exudate, no conj injection, sclarae anicteric, no lymphadneopathy. jvp to about 12cm. no carotid bruits. neck is supple lung: wheezing throughout the lung fields heart: tachy, irregular, s1 and s2 wnl, no murmurs/rubs or gallops abd; +b/s, soft, non-tender, non-distended, no masses extr: +2 pitting edema bilaterally,swelling is symmetric in lower extremities. non-tender. dp and femoral pulses are 1+. no femoral bruits. neuro; alert and oriented x 3. no focal deficits appreciated--strength appropriate for age, normal cerebellar and reflexes. cnii-xii intact pertinent results: chest x-ray: pa and lateral views of the chest: the patient is s/p cabg. there is a vascular stent projecting above the aorta again demonstrated and unchanged. the cardiac and mediastinal contours are stable. no evidence of failure. the lungs are clear. there is no pleural effusion. impression: no evidence of pneumonia. no evidence of chf. (pulmonary vascular congestion, cardiomegaly) admit labs: 12:10pm wbc-8.8 rbc-3.84* hgb-11.7* hct-34.6* mcv-90 mch-30.3 mchc-33.6 rdw-14.4 12:10pm neuts-83.9* lymphs-9.4* monos-5.6 eos-1.1 basos-0.1 12:10pm plt count-237 12:10pm glucose-180* urea n-15 creat-1.1 sodium-138 potassium-3.9 chloride-99 total co2-27 anion gap-16 01:45pm pt-21.3* ptt-31.7 inr(pt)-2.9 ischemia labs: 12:10pm ck(cpk)-95 12:10pm ctropnt-<0.01 06:00pm ck(cpk)-147* 06:00pm ck-mb-6 ctropnt-0.06* last cath: procedure date: indications for catheterization: chest pain. prior cabg. s/p subclavian stent. final diagnosis: 1. native three vessel coronary artery disease with extensive bridging collaterals of the rca. 2. known occluded saphenous vein grafts. 3. patent lima to lad. 4. patent left subclavian stent. 5. mild mitral regurgitation. 6. mild systolic ventricular dysfunction. 7. mild right common-femoral vascular disease. comments: 1. coronary arteriography in this right dominant system showed native three-vessel coronary artery disease. the lmca had mild luminal irregularities. the lad artery was occluded in the mid-vessel. the left circumflex artery was proximally occluded with two distal oms with a "jump" segment filling via left to left collaterals. the rca was proximally occluded with many bridging collaterals supplying the distal rca and posterior lv branches. 2. saphenous vein grafts were known to be occluded from a prior catheterization dated and were therefore not visualized. 3. graft angiography showed a widely patent lima to lad, supplying the distal of the lad and large collaterals to the rca and r-pda. 4. left subclavian angiography showed a widely patent left subclavian stent. 5. resting hemodynamics showed normal left-sided filling pressure. 6. left ventriculography showed mild global hypokinesis with more pronounced hypokinesis of the inferior wall. there was trace mitral regurgitation. the calculated lvef was 45%. 7. limited left ilio-femoral peripheral angiography showed a mild 30% stenosis of the common femoral artery. ekg: afib, left axis deviation, st depression and twi in v2-v6. echo: study continues from tape w487 to tape w 509, starting at 0:15 for an additional seven minutes of recording. left atrium: mild la enlargement. right atrium/interatrial septum: mildly dilated ra. left ventricle: normal lv cavity size. suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. depressed lvef. cannot assess lvef. right ventricle: rv not well seen. aorta: normal aortic root diameter. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. tricuspid valve: mild tr. mild pa systolic hypertension. pericardium: no pericardial effusion. general comments: suboptimal image quality - poor echo windows. conclusions 1. the left atrium is mildly dilated. 2. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. lv systolic function appears depressed. overall left ventricular systolic function cannot be reliably assessed. 3. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 4. there is mild pulmonary artery systolic hypertension. cath: procedure date: indications for catheterization: ekg changes. final diagnosis: 1. three vessel coronary artery disease. 2. patent lima-lad comments: 1. selective coronary angiography of this right dominant system revealed three vessel disease. the lmca was diffusely disease. the lad was occluded mid-vessel and filled distally via the lima. the lcx was occluded proximally, and filled distally from collaterals from the lcx. the rca was occluded proximally and filled distally via bridging collaterals. 2. graft angiography revealed a patent lima-lad. the svgs were not imaged as they were known to be occluded. 3. left ventriculography was not performed. 4. the left subclavian stent was widely patent. liver or gallbladder ultrasound. indication: 74 year old female with abdominal pain, increased lfts. evaluate for gallstones, or liver disease. there are no prior studies for comparison. the patient is status post cholecystectomy. the common bile duct measures 5 mm, and is within normal limits status post cholecystectomy. the liver shows no focal abnormalities. the liver parenchyma is mildly hyperechoic in echotexture, consistent with fatty infiltration. the right kidney measures 8.3 cm. there is a mild hyperechoic focus within the interpolar right kidney, with no evidence of posterior shadowing, possibly representing a small parenchymal calcification within the lateral aspect of the right kidney, in the interpolar region, there is a 1.2-cm anechoic focus, most likely representing a simple cyst. the left kidney measures 8.1 cm, with no focal abnormalities. impression: 1) patient is status post cholecystectomy. 2) the liver is echogenic, consistent with fatty liver. however, other forms of liver disease, and more advanced liver disease, including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. chest x-ray: indication: shortness of breath, s/p extubation. check status. findings: a single ap semi-upright image. comparison study dated . the heart shows slight left ventricular enlargement. there is evidence of a prior cabg procedure. a vascular stent is noted in the left brachiocephalic vessel. the pulmonary vessels are normal. no pulmonary infiltrates are seen. there is slight blunting of the right costophrenic angle and slight widening of the minor fissure consistent with a small effusion. the hila and mediastinum are otherwise unremarkable. the ett and the ng line remain well positioned. impression: possible small right pleural effusion. no other acute cardiopulmonary abnormality. prior cabg surgery noted and prior left brachiocephalic stent in place. brief hospital course: 72 year-old woman with cad s/p cabg in , stent to left subclavian in , re-cath in 02 as above, history of chf, depressed ef, hypertension, afib astham/copd who presents now with increasing sob and anginal episodes after uri last friday. cardiovascular: a)ischemia: concerning past history, very high risk and now with good story for unstable angina admit. patient was ruled out for mi on admission. after stabilization of her pulmonary issues, given her history and an echo which could not fully assess lvef and could not rule out rwma, she went for cardiac catherterization and found to have no new lesions, patent lima to lad. patient maintained on ace, beta-blocker, statin, aspirin, imdur. imdur and beta-blocker titrated up. d/ced calcium channel blocker with likely systolic dysfunction and definite diastolic chf. sublingual nitro as needed. had been on mavik for unclear reason, tolerating ace here--would titrate up for heart failure as below. continues to have seom angina with stress. b)pump: patient noted to have depressed ef in past-35%? but no recent echo on admission. echo here showed: 1. the left atrium is mildly dilated. 2. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. lv systolic function appears depressed. overall left ventricular systolic function cannot be reliably assessed. 3. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 4. there is mild pulmonary artery systolic hypertension. on admission, the patient was felt to be euvolemic to slightly volume overloaded and gently diuresed but her sob was primarily due to astham/copd exacerbation. after transfer to icu(see below) patient received lots of fluids and needed to be diuresed. diuresed adequately for discharge--felt to be dry for discharge by exam and labs. given that she was acutely decompensated from pulmonary perspective and volume overloaded when echo was done, it was not felt to be fully accurate of baseline status. maintained on beta-blocker, ace for ischemia and hf. should titrate ace/beta to hf goals based on repeat echo (lisinopril 20/toprol 150). c)rhythm; afib: has always been rate controlled, never cardioverted. poor control now and had sensation of palpitations on night pta. unclear if ratelead to chf or chf lead to increased rate and component of ischemia?--increaed demand leading to ischemia vs. ischemia leading to tachy-- patient maintained on metoprolol for rate control with good affect. had been on dilt but with ? heart failure, systolic-held and went up on beta-blocker for control. concerning anti-coagulation, we are holding coumadin until patient has outpatient colonoscopy-had guiac positive stools and crit drop (also with neck hematoma after central line placement.) scheduled for outpatient colonoscopy and then to re-start coumadin then. shortness of breath/hypoxemia: chf vs. post uri reactive airways disease vs. copd vs. pe vs. pneumonia--on admission, sob felt secondary to astham exacerbation-patient acutely decompensated, wheezy on exam, sent to unit on day 2 of admission for intubation. treated with predniesone, flovent, azithromycin then levaquin as well as nebs/inhalers. had 5 day icu stay and then was transferred out. by discharge, not wheezy satting well on room air. felt to be rad post bronchitis. was not fluid overloaded on admit--was diuresed after icu stay with lots of fluids. on discharge satting well on room air. anemia at baseline/crit drop/guiaic positive: patient had crit drop while in icu. she had a hematoma after central line placement as well as guiac positive stools. was on heparin during this time for her afib, stopped at this time. she stabilized after transfusion in icu, and needed no further transfusions. neck hematoma is resolving. guiac positive stools-she is scheduled for outpatient colonoscopy. re-address anti-coagulation for afib after this. do not want her on iron until after colonoscopy. elevated lft's, tbili and ptt: after being off heparin (on it for afib), stopped for crit drop in ptt remained elevated. was on subcu heparin, lft's obtained which showed mild transaminase elevation and t bili elevation. subcu heparin stopped, ruq u/s obtained showed fatty liver/h/o cholecystectomy. lft's, t. bili and ptt trended down on discharge. patient will need follow -up of these studies as an outpatient. ? med affect. lipitor was increased from 10 to 40 given significant coronary disease--although unlikely to cause acute elevations. hsitory of dm: not on meds prior to admission. needs primary care follow-up. hypothyroidism: levoxyl continued, tsh normal gerd: protonix continued, no acute issues. general care: vit d, calcium, multi-vitamins full code medications on admission: cardizem 120 levoxyl 75 warfarin 1/2/2 3 day rotation protonix 40 lipitor 10 hctz 25 imdur 45 metoprolol 12.5 mavick o.5 multi-vitmain citrate ferrous gluconate aspirin 81 discharge disposition: extended care facility: bay - discharge diagnosis: newly depressed ef- systolic heart failure acute renal failure hypercoagulability neck hematoma cad diabetes reactive airway disease s/p bronchitis transaminitis discharge condition: stable, ambulating with assistance discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 2l call your doctor if you experience any further chest pain, shortness of breath. all medications as prescribed. you will need to follow up with dr. and dr. this week. please call to make appointments. they will decide about re-starting coumadin after you colonscopy. will also need to have , pt/ptt checked at that time. please check ast, alt, alk phos and total bilirubin every few days and trend results. if increasing dramatically then md for further work up. outpatient doctor to re-institute coumadin over next few weeks. followup instructions: dr. within one week. provider: , follow-up appointment should be in 1 week call dr. this week to set up appointment. need to repeat echo in 3 monthsprovider: radiology where: radiology phone: date/time: 4:00 date/time: 10:30 provider: ,md where: building ( complex) phone: date/time: 10:30 you are scheduled for colonscopy on . provider: west,room five gi rooms where: gi rooms date/time: 10:30 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Coronary arteriography using two catheters Left heart cardiac catheterization Other and unspecified coronary arteriography Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Transfusion of packed cells Transfusion of other serum Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Other pulmonary insufficiency, not elsewhere classified Unspecified acquired hypothyroidism Coronary atherosclerosis of autologous vein bypass graft Atrial fibrillation Hematoma complicating a procedure Hypotension, unspecified Chronic obstructive asthma with (acute) exacerbation Acute combined systolic and diastolic heart failure Acute bronchitis Nonspecific abnormal findings in stool contents

allergies: altace / bactrim attending: chief complaint: chest pain, hematochezia major surgical or invasive procedure: ia tpa, merci clot retrieval history of present illness: 79 yo female with cad s/p cabg in , recent cath with only lima-lad patent, htn, hlp, copd, and afib who presents with 5 day history of red/maroon stools. patient was at her pcp's office earlier last week and was found to be anemic (hct not in system) and was planned for a colonscopy this week. she was at home, and earlier today developed substernal chest pressure that was persistent. she describes this pressure as a squeezing sensation, different and worse than her usual anginal symptoms for which she takes nitro. usually her pain occurs with exertion or at night when she's not wearing her oxygen and is limited to her arm, but today it was also in her chest as well. she described the pain as initially, and nitro at home did not help, nor did increasing her o2 from 2-> 3l. . in the ed, initial vs: 97.8, 99, 116/, 24, 100%ra. initially, the patient was noted to have bright red blood on rectal exam. she was tachycardic to the low 100s, but bp remained stable. she received nitro sl and morphine which improved her cp to . cardiology was consulted for the std seen in the lateral leads, but they felt this was likely c/w demand ischemia given her significant anemia and severe coronary disease. she was given 2 units of prbcs and 2 units of ffp prior to transfer. gi was called, and felt the patient should have reversal of her inr (4.5). she was given 5 mg iv vitamin k as well. her bp remained stable, and her hr improved to the 80s. she had a 20 and 16g piv placed. her vitals prior to transfer to the micu were 110/65, 89, 20, 98% 3l. she did complain of some dyspnea/tachypnea prior to transfer, but her o2 sats remained 98% with 3l of o2. past medical history: - coronary artery disease, s/p 3v cabg ef 50% - left subclavian stent /. - atrial fibrillation. - hypertension. - hyperlipidemia. - copd (fev1/fvc 53, fev1 0.63) - gerd - anemia. - hypothyroidism social history: denies tobacco, etoh, or drugs. family history: mother with myocardial infarction in her 60s. no diabetes mellitus. grandfather with chronic obstructive pulmonary disease. physical exam: vs - temp 99.0f, bp 102/56, hr 72, r 28, o2-sat 96 2l% ra general - nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, jvd up to ears, no carotid bruits lungs - bibasilar crackles, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, pertinent results: 06:20pm blood wbc-9.9# rbc-2.45*# hgb-7.0*# hct-22.5*# mcv-92 mch-28.8 mchc-31.2 rdw-15.1 plt ct-251 11:26pm blood hct-26.6* 11:35am blood hct-31.6* 04:54am blood wbc-13.0* rbc-3.47* hgb-10.1* hct-31.0* mcv-90 mch-29.2 mchc-32.6 rdw-16.4* plt ct-201 06:55am blood wbc-11.4* rbc-3.58* hgb-10.6* hct-32.1* mcv-90 mch-29.8 mchc-33.2 rdw-15.4 plt ct-187 06:58am blood wbc-10.4 rbc-3.28* hgb-10.0* hct-28.7* mcv-88 mch-30.4 mchc-34.8 rdw-15.2 plt ct-173 12:25pm blood hct-31.7* . echo:the left atrium is dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is severe global left ventricular hypokinesis (lvef = 20-30 %) with regional variation. there is no ventricular septal defect. right ventricular chamber size is normal. with severe global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior report (images unavailable for review) of , the left ventricular ejection fraction is markedly reduced. . cxr :findings suggesting mild congestive heart failure. ct head, cta head/neck, ctp non-contrast ct: there is no evidence of acute intracranial or parenchymal hemorrhage. there is mild bihemispheric hypoattenuation of the periventricular and subcortical white matter consistent with sequelae of small vessel ischemic disease. the bilateral basal ganglia show small hypoattenuations consistent with old lacunar infarcts. there is calcification of the intracranial carotid artery. also noted is a left maxillary sinus mucosal thickening. the other paranasal sinuses and mastoid air cells are well aerated. cta of the neck and head: there is abrupt cutoff of the right mca at the junction of the m1 and m2 segments. this represents a thrombus within the right mca . also noted is calcification of the bilateral carotid bulbs. the remaining intracranial and cervical vessels are unremarkable. the vertebral and carotid ostia are unremarkable. a stent is noted in the left subclavian artery which is patent. also noted are sternotomy wires, bibasilar atelectatic changes in the visualized lung apices and a hypoplastic or absent thyroid gland. clinical correlation is recommended. there are several enlarged mediastinal lymph nodes, the largest of which is precarinal and measures 14.3 mm. ct perfusion: there is increased mean transit time in a large right mca territory distribution in the right frontoparietal region. this is associated with decreased cerebral blood flow but normal cerebral blood volume. this likely represents an acute large infarct with some mismatch possibly representing an area of penumbra. rotation of the c1 over c2 vertebra is likely positional in nature. impression: acute right mca vascular territory infarct as described above. ct head impression: no intracranial hemorrhage or edema. hba1c 5.5 ldl 33 brief hospital course: 79 yo female with cad s/p cabg with only patent lima-lad, copd, htn, afib who presents with hematochezia, anemia, and angina, sent to micu initally where she was transfused with hct back up to 31, c/b nstemi with chf. . # stroke: has h/o afib but her anticoagulation was held in the setting of acute gib complicated by nstemi. it was felt she would restart asa 325mg upon discharge. the pt was intact neurologically throughout admission until when she was found to have acute onset dysarthria, l facial droop, l hemiparesis. code stroke was called and pt was found to have r mca embolic infarct on ct head. she was sent emergently to neuro ir for ia tpa and merci clot retrieval. she was initially transferred to the neuro icu and has been continuing to improve clinically. her coumadin has been re-started and her hematocrit has remained stable. her ldl was 33 and hba1c was 5.5. her inr on day of transfer () was 3.1 and today's dose will be held. please monitor daily for goal . . # hematochezia: likely due to angiodysplasia vs diverticulosis as pt had colonoscopy in with only polyps. on transfer out of the micu her hct was up to 31 (was initially 22.5 on admission) after 3u prbc. while on the floor she was transfused 1 more unit of blood and her hct was maintained around 30 without any evidence of gi bleeding (stools were without blood). she was continued on po pantoprazole. her hematocrit has remained stable in the low 30s. gastroenterology plans to perform a colonoscopy as an outpatient in weeks. given her other comorbidities and stable hematocrit it was decided to defer this procedure at this immediate time. . # nstemi: patient has known bad coronary disease with diseased grafts as well taking up to 3 ntg daily for anginal pain. patient's initial ecg with afib with rvr and lateral std and twi; most likely due to demand ischemia. pt had cp and 1st set ce was neg, but then subsequent had trp peak up to 1.8 (ck 556, ckmb 10.4) c/w nstemi in setting of acute lower gi bleed. cardiology was consulted and recommended holding anticoagulation until she was stable from her gib. her chest pain improved with transfusions, nitro, and morphine, and now pt has been cp free while on the floor. she was started on metoprolol 25 tid, atorvastatin 80mg. her lisinopril and imdur were held to avoid hypotension in the setting of gib. her lisinopril has been resumed and her blood pressure has been well-controlled. . # dyspnea/tachypnea: patient has copd at baseline, and uses o2 (2l) at night for comfort and angina with exertion. during the day, she should be using her o2 but she has not been using it due to difficulty with portability. now with ef 20-30% severely dropped form 50% in , likely due to nstemi. also likely worsened initially in micu in the setting of volume (blood, ffp, and ivfs). diuresed well with iv lasix in the micu and on the floor. she was started on po 20mg lasix daily and maintained on her fluticasone and ipratropium nebs. she is currently doing well on her home requirements of 2l o2 via nasal cannula. . # afib: patient on metoprolol and coumadin as an outpatient. given her above h/o gib complicated by nstemi, cardiology/gi consults recommended that due to her chads2 score of 3 she should be restarted on asa 325mg once her gib was stabilized. it was felt that the pt would have this started upon d/c. despite these efforts the pt suffered from an embolic stroke entailed above and therefore will be continued on coumadin with goal inr . . # hypothyroidism: cont levothyroxine . # dm2: riss. glipizide may be resumed at the time of transfer. . # ckd: creat 1.3-1.5 at the time of presentation, now trending down to 0.9-1. . medications on admission: albuterol coumadin 1 mg daily fluticasone 220 mcg 1 puff glipizide 5 mg daily imiquimond 5% packet apply twice a week imdur 90 mg daily lisinopril 2.5 mg daily levothyroxine 75 mcg daily (150 mcg on sunday) atorvastatin 40 mg daily macrobid 50 mg qhs pantoprazole 40 mg daily hctz 50 mg daily spiriva 1 puff daily metoprolol succinate 100 mg daily aspirin 81 mg daily ferrous gluconate 325 mg daily coenzyme q10 100 mg daily calcium/vitamin d daily mvi daily discharge medications: 1. nitroglycerin 0.3 mg tablet, sublingual : one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. 2. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours) as needed for wheezing. 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation q6h (every 6 hours) as needed for wheezing. 4. metoprolol tartrate 50 mg tablet : one (1) tablet po tid (3 times a day). 5. simvastatin 10 mg tablet : two (2) tablet po daily (daily). 6. warfarin 1 mg tablet : one (1) tablet po once daily at 4 pm: adjust as needed for goal inr . 7. levothyroxine 75 mcg tablet : one (1) tablet po daily (daily): q mon, tues, wed, thurs, fri, sat. 8. levothyroxine 75 mcg tablet : two (2) tablet po daily (daily): on sunday only. 9. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 10. lisinopril 5 mg tablet : 0.5 tablet po daily (daily). 11. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 12. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 13. glipizide 5 mg tablet : one (1) tablet po once a day. discharge disposition: extended care facility: hospital - discharge diagnosis: nstemi right mca stroke lower gi bleed discharge condition: a&ox3, dysarthric. r gaze preference, surgical pupil (left eye). l facial droop. extinction to l on dss. antigravity strength in all extremities. discharge instructions: you were initially admitted with a gastrointestinal bleed and chest pain. during your hospital course you had a stroke which was treated with intraarterial tpa and merci clot retrieval. your hematocrit has remained stable and you will be transferred to a rehabilitation facility for further care. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: provider: , md phone: date/time: 8:40 provider: in phone: date/time: 1:15 provider: , md phone: date/time: 1:00 please call dr. (neurology) to schedule a follow up appointment in two months. his office can be reached at (. md Procedure: Injection or infusion of thrombolytic agent Arteriography of cerebral arteries Procedure on single vessel Endovascular removal of obstruction from head and neck vessel(s) Diagnoses: Subendocardial infarction, initial episode of care Esophageal reflux Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified acquired hypothyroidism Coronary atherosclerosis of autologous vein bypass graft Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Angiodysplasia of intestine with hemorrhage Cerebral embolism with cerebral infarction Other specified hemiplegia and hemiparesis affecting unspecified side Dysarthria Chronic obstructive asthma, unspecified

allergies: altace / bactrim / sulfa (sulfonamide antibiotics) attending: chief complaint: occult positive stools, h/o stroke while off of anticoagulation for gib. major surgical or invasive procedure: laparoscopy and open right ileocolectomy, history of present illness: 81 yo f with pmh of cva, stage iii ckd, cad s/p lima to lad, afib on dabigatran who presents for a colonoscopy planned for guiaic positive stools and a recent admission for gib. the patient denies any current complaints and has not noted any recent bloody stools. she does complain of some right upper quadrant "heaviness" that does not radiate. it is in intensity. denies any relieving or exacerbating factors. she notices it most at night time when she is trying to fall asleep. she denies any change with diet. she denies any n/v, diarrhea, constipation. she otherwise feels at her baseline with respect to her health. . review of systems: pain assessment on arrival to the floor: 0/10 (no pain). no recent illnesses. no fevers, chills, or night sweats. appetite is good and weight is stable. no sob, new cough. she has chronic angina that typically occurs when she wakes up or sometimes at night time after a busy day, relieved with 1 slng, this is stable but frequent (sometimes takes slng daily). no pnd or orthopnea. no urinary symptoms. no le edema. no skin changes. no arthralgias or joint swelling. other systems reviewed in detail and all otherwise negative. past medical history: - coronary artery disease, s/p 3v cabg ef 50% - left subclavian stent /. - atrial fibrillation. - hypertension. - hyperlipidemia. - copd (fev1/fvc 53, fev1 0.63) - gerd - anemia. - hypothyroidism - stage iii ckd - cva - fractured pelvis in fall several months ago social history: she lives alone. she has extensive support from her daughters. she denies tobacco, etoh, or drugs family history: mother with myocardial infarction in her 60s. no diabetes mellitus. grandfather with chronic obstructive pulmonary disease. physical exam: vital signs: t 97.9 bp 101/66 p 77 rr 18 spo2 100% on 2l physical examination: - gen: well-appearing in nad. - heent: conj/sclera/lids normal, left surgical pupil, right pupil reactive. eom full, and no nystagmus. oropharynx clear w/out lesions. - neck: supple with no thyromegaly or lymphadenopathy. - chest: normal respirations and breathing comfortably on room air. lungs clear to auscultation bilaterally. - cv: irregularly irregular. normal s1, s2. ii/vi systolic murmur at left sternal border. jvp <5 cm. - abdomen: normal bowel sounds. soft, nontender, nondistended. liver not enlarged. neg sign. - extremities: no ankle edema. - skin: no lesions, bruises, rashes with exception of stasis dermatitis bilateral shins - neuro: alert, oriented x3. good fund of knowledge. able to discuss current events and memory is intact. cn 2-12 intact. speech and language are normal. no involuntary movements or muscle atrophy. normal tone in all extremities. motor in upper and lower extremities bilaterally. sensation to light touch intact in upper and lower extremities bilaterally. - psych: appearance, behavior, and affect all normal. no suicidal or homicidal ideations. pertinent results: 04:40pm wbc-8.3 rbc-3.44* hgb-9.5* hct-29.5* mcv-86 mch-27.5 mchc-32.1 rdw-16.5* 04:40pm neuts-74.6* lymphs-13.7* monos-8.9 eos-2.4 basos-0.4 04:40pm pt-20.0* ptt-47.3* inr(pt)-1.8* 04:40pm glucose-72 urea n-27* creat-1.4* sodium-134 potassium-4.1 chloride-99 total co2-27 anion gap-12 04:40pm calcium-9.5 phosphate-3.8 magnesium-1.7 . ekg - afib, lad, unchanged c/w prior with exception that tw is upright in i instead of inverted. no acute st/tw changes. brief hospital course: ms. was admitted to the medical service and started on a colonoscopy preparation, her pradexa was held and she was started on a heparin drip. she was taken to the gi suite on for endoscopy which showed an "ulcerated mass with necrotic base highly suggestive of carcinoma" in the cecum. she had a ct scan of the chest/abdomen/pelvis to assess for metastasis and further define the tumor. it confirmed colonoscopy findings and did not show evidence of metastasis. she was taken to the operating room for a right colectomy with dr. of colorectal surgery on . there was 500 cc of estimated blood loss.please refer to dr. operative note for further details. she was started on cipro/flagyl prophylactically after the procedure. after a brief stay in the pacu she was transferred to the floor but over the course of the night had low urine output, her blood pressure dropped to the systolic 80s/40s and her atrial fibrillation frequently took her heart rate to the 120s-130s. she was transferred to the icu given her extensive cardiac history and unclear etiology of her hypotension -- cardiogenic vs. septic. she was continued on antibiotic coverage and the plan was for volume resuscitation with close monitoring of other aspects of her clinical picture. she was asymptomatic and felt well throughout the process, though somewhat tired. she was transfused one unit of prbcs, volume resuscitated with crystalloid and albumin and eventually her systolic pressures returned to the 90s-100s systolic. she was deemed stable for transfer to the floor. on pod 5 she reported passing flatus, she was advanced in diet progressive to a low-residue regular diet on pod 8. remaining aspects of her hospitalization, by systems: neuro: no issues. pain controlled on a regimen of iv and po medications when tolerating. mental status appropriate throughout hospitalization. cardiac: multiple cardiac issues assessed by cardiology service preoperatively and which recommended continuing current care. multiple episodes of anginal chest pain relieved with sublingual nitroglycerin. no ekg changes until pod 7 when chest pain was accompanied by questionable ischemic changes on ekg. cardiology recommended nitroglycerin prn as well as cycling enzymes which returned at 0.05->0.05->0.04. her afib was monitored on telemetry and she was treated with 5 mg iv lopressor q6 hours when npo and transitioned to 25 mg po bid. respiratory: baseline used oxygen at home was kept on 2l oxygen in the hospital and maintained good saturations in the high 90 percents. she did have some respiratory difficulty and increased oxygen requirement while in the icu but this resolved after effective diuresis. at time of discharge satting 90s on room air. heme: once the patient's hematocrit was stable, a heparin drip was started to bridge her to coumadin therapy. however, patient developed melenic stools and hematuria when heparin drip restarted. all anticoagulation except aspirin was held and no further episodes of bleeding occured. patient's coumadin will need to be restarted when her nutritional status is more improved. id: cipro/flagyl initially post-operatively and dc'd on pod 7. afebrile throughout course. complained of vaginal itching, given single dose of oral diflucan. course pt was transferred to the on for management of hypotension and low urine output in setting of recent colectomy. . # hypotension: noted to be progressively hypotensive through today (pod1) with concern for hypovolemia however could also be related to evolving sepsis picture she is currently on cipro/flagyl since last night. given extensive cards history could also be cardiogenic shock related to missed event given her 500cc blood loss intraoperatively and prior hx of ischemic event in setting of blood loss in 01/. lower concern for this given current clinical and exam status. given hx of recurrent utis (on home macrobid suppressive tx) could also be related to urosepsis. currently mentating at baseline. plan to volume resuscitate until increase in o2 requirement. she received 1u prbc on arrival to floor with 500cc lr ivf boluses x 2. her bp improved to 90-110 wo pressors. she did not require a cvl and declined this on her icu consent form as well. nicom was placed which showed 33% change in ci, indicating likely fluid responsiveness. her uo improved to 20cc/hr but remained there with crystalloid boluses. per surgery recs, she was changed to albumin 5% ivf hydration. she was given lasix for volume overload xxxx. she was broadened to vancomycin, zosyn and ciprofloxacin for double gnr coverage overnight given higher likelihood of gi etiology related to recent surgery and instrumentation. given her remarkable hemodynamic improvement overnight she was changed back to cipro/flagyl. she was recultured for urine and blood. her ekg was checked and at baseline. cardiac enzymes were cycled and mildly elevated trop attributed to underlying ckd and possible demand ischemia tachycardia on presentation. . # cad: extensive cardiac hx including recent nstemi in setting of gib and cva at same time. has been on home dabigatran. follows as outpt w dr. . increasing nsl use for her anginal equivalent altho per cards notes, outpt cards is not concerned for ischemic etiology. last tte 8/. she was continued on heparin sq, 81mg asa and pneumoboots. her transfusion goals were for hct<30 per cardiology recs pre-operatively. ekg in the icu was rechecked and at baseline. cardiac enzymes were cycled (see above). . # afib: on dabigatran at home for other comorbidities, chads2 score is 6. currently in afib. her home betablocker was held for hemodynamic monitoring. she was noted to be in 100-130s afib with mild sob but otherwise comfortable. her betablocker was restarted on and xxxx. . # chf: systolic ef 35% on tte and global lv hypokinesis. cards consulted pre-op w recommendation to gently diurese for vol overload on presentation - last given 20mg iv lasix . pleural effusion on am chest xray and crackles on exam on transfer to the icu. home diuretic was held on admission to the icu for bp stabilization and restarted xxx. . # cecal mass: necrotic appearance on colonoscopy concerning for malignancy. s/p colectomy . pathology is pending. . # ckd: unclear baseline but likely 0.9-1.1. on outpt procrit. creatinine elevated on admission. fena this am 1%, concern for possible atn related to hypovolemia. repeat urine lytes notable for fena = 0.1% indicating prerenal hypovolemic picture. urine output was monitored and responded to ivf boluses w increase to 20cc/hour. . # copd/asthma: on home o2 via nasal cannula at baseline. unclear pulmonary disease hx. she was continued on home dose fluticasone, and spiriva. albuterol held for tachycardia and restarted on xxx. . # htn: on home ace, and bblocker. holding now for hemodynamic monitoring. . # hl: cont home lipitor . # hypothyroidism: continued on home dose levothyroxine . # dm: on home glipizide. holding oral meds, cont iss. . fen: ivf to map>60, replete electrolytes, npo for now prophylaxis: subcutaneous heparin, pantoprazole iv q24 access: peripherals code: dnr, ok to intubate, no cvl communication: patient, hcp medications on admission: albuterol sulfate - 90 mcg hfa four times daily prn aspirin - 81mg tablet - one every day pradexa 75 mg fluticasone - 220 mcg aerosol twice daily glipizide - 1.25 mg tablet daily levoxyl - 75mcg tablet - one every day; 150 mcg on sunday lipitor - 40mg tablet - one every day lisinopril - 2.5 mg tablet - 1 tablet(s) by mouth daily nitrofurantoin - 50 mg nightly protonix - 40mg tablet, delayed release (e.c.) - one every day tiotropium bromide - 18 mcg daily toprol xl - 25 mg daily otc: calcium carbonate-vitamin d3 600 mg-400 unit tablet - twice a day coenzyme q10 - 100 mg capsule by mouth daily multivitamin-minerals-lutein - 1 tablet(s) by mouth daily discharge medications: 1. levothyroxine 75 mcg tablet : one (1) tablet po daily (daily). 2. fluticasone 110 mcg/actuation aerosol : four (4) puff inhalation (2 times a day). 3. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 4. guaifenesin 100 mg/5 ml syrup : ten (10) ml po bid (2 times a day). 5. atorvastatin 20 mg tablet : two (2) tablet po daily (daily). 6. hydromorphone 2 mg tablet : one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*45 tablet(s)* refills:*0* 7. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day): hold for loose stool. 8. pantoprazole 40 mg tablet, delayed release (e.c.) : one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for pain. 10. polyvinyl alcohol-povidone 1.4-0.6 % dropperette : drops ophthalmic prn (as needed) as needed for dryness. 11. ipratropium bromide 0.02 % solution : one (1) neb inhalation q6h (every 6 hours). 12. levalbuterol hcl 0.63 mg/3 ml solution for nebulization : one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 13. nitroglycerin 0.3 mg tablet, sublingual : one (1) tablet, sublingual sublingual prn as needed for chest pain. 14. metoclopramide 10 mg tablet : one (1) tablet po every eight (8) hours for 3 doses: for three doses only once patient is at rehab. afterwards, this medication should be discontinued. disp:*3 tablet(s)* refills:*0* 15. blood draw : one (1) blood draw once, : please check inr value for coumadin dosing. disp:*1 blood draw* refills:*0* 16. metoprolol tartrate 25 mg tablet : one (1) tablet po twice a day. 17. fluticasone 110 mcg/actuation aerosol : four (4) puff inhalation (2 times a day). 18. pramoxine-mineral oil-zinc 1-12.5 % ointment : one (1) appl rectal (2 times a day) as needed for anal itching. 19. camphor-menthol 0.5-0.5 % lotion : one (1) appl topical tid (3 times a day) as needed for puritis r/t dry skin on back. 20. insulin lispro 100 unit/ml solution : one (1) subcutaneous asdir (as directed). 21. lisinopril 5 mg tablet : 0.5 tablet po daily (daily). discharge disposition: extended care facility: renaisance gardens discharge diagnosis: cecal adenocarcinoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital because of a bleed from your gastrointestinal tract. it was discovered that you had a colonic mass upon further investigation and you then had a surgical procedure called a right colectomy. regarding your anticoagulation, you have been very mal nourished and when our surgical team attempted to anticoagulate you you developed further gi bleeding and some blood in your urine. your anticoagulation has been on hold for the time being. the rehabilitation facility should restart this anticoagulation at a time they see as appropriate when you nutrtional status has improved some. in the coming days as you continue to recover, please keep in mind the following: please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. while taking narcotic pain medication, please emember to take colace (to avoid constipation) and please do not drive or operate heavy machinery. please follow-up with your primary care physician (in addition to your surgeon) in the coming weeks to reconcile all of your medications and to touch base regarding other medical issues or concerns after the surgery. incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until your follow-up appointment. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. please call your doctor if you experience the following: *you experience new chest pain, pressure, squeezing or tightness. *new or worsening cough, shortness of breath, or wheeze. *if you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience a discharge. *your pain is not improving within 8-12 hours or is not gone within 24 hours. call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *any change in your symptoms, or any new symptoms that concern you. followup instructions: patient needs to have her inr checked on monday, , and have her coumadin dosing readjusted per results. primary care physician, . at , , , and phone to arrange for appointment on monday. please follow-up with dr. in weeks. call ( to schedule the appointment. please call on monday, . Procedure: Percutaneous abdominal drainage Endoscopic polypectomy of large intestine Open and other right hemicolectomy Other small-to-large intestinal anastomosis Closed [endoscopic] biopsy of large intestine Diagnoses: Other iatrogenic hypotension Esophageal reflux Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Aortocoronary bypass status Chronic kidney disease, Stage III (moderate) Hemorrhage complicating a procedure Other and unspecified angina pectoris Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Old myocardial infarction Paralytic ileus Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Chronic obstructive asthma, unspecified Malignant neoplasm of cecum Acute systolic heart failure Secondary malignant neoplasm of skin Seroma complicating a procedure Do not resuscitate status Gross hematuria Anticoagulants causing adverse effects in therapeutic use

allergies-asa neuro--pt remains paralysed on doxacurium gtt, pt moving ad breathing over vent this am. gtt inc x3 and pt with 7cc doxacurium with good effect. remains on fent gtt at 75mc/hr, versed gtt 5mg/hr. cv--please see careview for swan numbers, and cardiac arrest record. heparin off for pericardiocentesis at bedside under fluoro. this am, rv perforated and then tamponade, and pea arrest. cpr initiated. cath placed by ct and treatment started with perfusionist present. pt trans to or for draininge of effusion. id--wbc remain elevated 27,000. cooling blanket on this am as pt spiking temp through tylenol. conts on iv vanco, levoquin, vanco ceftriaxone. resp--pt remains orally intub on ac 25 350 peep 18 fio2 decreased to 90% with no2 40ppm via vent. sx'd via ett for thick tan plugs. o2 sat probe conts to not pick up due to cool extremites. gi--abd firm, distended with absent bs. ogt removed for tee/pericardiocentesis. no bm this shift. gu--u/o via foley, creat 0.5 this am, pt making small amounts of urine. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Pericardiocentesis Thoracentesis Other bronchoscopy Arterial catheterization Incision of mediastinum Closed [endoscopic] biopsy of bronchus Other local excision or destruction of lesion or tissue of lung Injection or infusion of nesiritide Infusion of drotrecogin alfa (activated) Diagnoses: Anemia, unspecified Acute kidney failure, unspecified Severe sepsis Secondary malignant neoplasm of other specified sites Accidental puncture or laceration during a procedure, not elsewhere classified Unspecified disease of pericardium Acute respiratory failure Cardiogenic shock Septic shock Pneumococcal septicemia [Streptococcus pneumoniae septicemia] Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Secondary malignant neoplasm of lung

allergies: aspirin causes eye swelling in eyes. medications: codeine exact prescription unknown. family history: the patient has a sister with cell disease and is thought to have cell trait. social history: the patient was endorsed that she had been sexually active in the past but denies unprotected intercourse. denies intravenous drug use, alcohol or tobacco. as previously mentioned, the patient is a recently emigrated haitian. she joined her brother and sister here in the united states and leaves a mother in . physical examination: upon presentation to the emergency department, the patient is described as a somewhat frail- appearing haitian woman in some distress. she had a temperature maximum and temperature currently of 97.8 degrees. she was extremely tachycardiac at 170 beats per minute. blood pressure was 142/100. respirations 30s, sating 100 percent on a nonrebreather mask but 91 percent on room air. in general, she was pale and cachectic using accessory muscles for breathing. head, eyes, ears, nose and throat examination showed dry mucous membranes and unable to visualize posterior discs. neck is supple, there is, however, a small 1 cm scar seen on the left side, no evidence of any thyromegaly or anterior or posterior lymph node chain adenopathy. chest shows decreased breath sounds bilaterally but in particular on the left side. there are coarse crackles throughout bilaterally. cardiac examination is tachycardiac, no evidence of any murmurs, rubs or gallops. abdomen is soft, nontender, nondistended with positive bowel sounds. extremities, show 2 plus lower extremity edema. laboratory results on presentation: sodium 135, potassium 8.8, chloride 100, carbon dioxide 23, bun 10, creatinine 0.5, glucose 92, white blood cell count 14.4, hematocrit 26.9, platelets 720, lactate 1.2, liver function tests pending at the time of admission. radiology: the patient had a patchy interstitial infiltrates, left side greater than right with left pleural effusions as well as some poorly differentiated pleural thickening throughout. brief hospital course: based on the patient's initial presentation, it was thought that her presentation was a most likely acute and chronic etiology. scenarios considered were pneumonia, pulmonary embolism secondary to recent air travel, severe asthma. given the tachypnea and poor oxygenation, the patient was admitted directly to the cardiac intensive care unit. there she was made a full code. shortly after arrival, therapeutic thoracentesis was performed. this removed greater than 250 mm of serosanguinous fluid from the left side. there was some improvement in her pulmonary function thereafter. within two hours of presentation to the medical intensive care unit the patient became tachypneic and arterial blood gases showed increasing difficulty with oxygenation. she was shortly intubated thereafter with confirmation of placement of an endotracheal tube via chest x- ray. bronchoscopy performed soon thereafter likewise showed good placement of her endotracheal tube. aspiration showed a large amount of purulent, sometimes bloody material within the lung parenchyma. thereafter the patient's presentation became increasingly consistent with aseptic etiology. she was started on zigress per the sepsis protocol. by morning, her respiratory status had worsened and again there became increasing problems with oxygenation. initial consultation by cardiac surgery for possible extracorporeal membrane oxygenation was obtained and cardiac surgery deemed the patient an appropriate candidate and emphasized their readiness to perform procedure as necessary. this initial extracorporeal membrane oxygenation evaluation took place on . however, the decision was made to delay extracorporeal membrane oxygenation over night and to reassess in the morning. by hospital day number 2, the patient's presentation had evolved to florid sepsis. human immunodeficiency virus tests as well as critical stem tests had all come back negative. by mid morning, the patient had been maxing out all of her ventilation possibilities and oxygenation was still extremely challenged. bedside echocardiogram showed evidence of a large pericardial effusion. it was not clear if this was secondary to the pneumonia, pulmonary embolism or other etiology. cardiology was consulted and the decision was made to do a pericardiocentesis. the procedure was performed at the bedside under ultrasound guidance. during this maneuver, there was some damage noted to the right ventricle, most likely secondary to a large dilated ventricle in the setting of high right-sided pressures. the patient was taken emergently to the operating room. in the operating room a midline sternotomy was performed and a pericardial tamponade was repaired. during the course of this repair, several lesions in the surface of the heart and lungs were noted. these were biopsied intraoperatively. initial intraoperative pathology showed pathology consistent with neuroendocrine carcinoma, again highly unusual for a woman of this age and this presentation. given the unclear etiology of these lesions and the patient's overall presentation, decision was made to continue aggressive treatment and while in the operating room the patient was catheterized per the right femoral vein and artery and extracorporeal membrane oxygenation was started. the patient at that time was transferred to the cardiothoracic surgery unit and her care team was transferred from the medical service to the cardiac surgery service under the care of dr. . over the next 48 hours, the patient remained reasonably stable on extracorporeal membrane oxygenation. her oxygenation was maintained. a chest x-ray showed a gradually improving lung field, although the starting point from this was complete whiteout of both fields. a single sputum culture did show streptococcus pneumonia. the patient was started empirically on vancomycin, ceftriaxone and levofloxacin. while on extracorporeal membrane oxygenation, the patient's sedation was lightened intermittently and she was confirmed to be able to move all four extremities. she likewise underwent daily bronchoscopy and several mucous plugs and purulent material was removed from her lungs. on hospital day 5 through 7, intense review of the surgical samples was undergone by the pathology department in concert with the oncology group. initial staining of the tissue likewise was thought to be neuroendocrine tumor, however, subsequent specialized staining with amino peroxidase showed this tumor to, in fact, to be consistent with a poorly differentiated large cell carcinoma. in further reviewing the patient's history, both by record and in discussion with her siblings and her mother in , it appears that the patient had a small lesion removed from her neck somewhere in the republic. the exact nature of this mass, its size, pathology and follow up was never obtained although it was thought to be quite suspicious. by hospital day 9 or postoperative day 6, final evaluation by oncology had been completed and in discussion with the primary team, oncology and the patient's family decision was made that attempt would be made to wean her from the extracorporeal membrane oxygenation machine, given that there was no clear interventions to be directed towards the cancer itself. on , , after intensive optimization of her ventilator settings, fluid status and introduction of nitric oxide, attempt was made to wean the patient from extracorporeal membrane oxygenation. this was tried unsuccessfully during the course of the day and by late in the afternoon, the patient ultimately had to be returned to full extracorporeal membrane oxygenation support. by the following day after an additional review by the cardiac surgery service, opinion rendered by the ethics support service, dr. , and position taken by the legal department, decision was made for a final wean of the extracorporeal membrane oxygenation machine. prior to this maneuver, the patient's brother and sister were intensively consulted, and indeed spent much of day in the patient's room. several conference calls were initiated both directly and through a creole translator to the patient's mother in . pastoral services as well as ethics committee were consulted throughout this and the patient's family was fully aware and in agreement of what was happening with the patient. at approximately 2 pm in the afternoon of , the patient's ventilator settings were once again optimized. a surgical team was brought into her intensive care room and after complete wean of the extracorporeal membrane oxygenation machine, vascular surgery service decannulated intake and output catheters and closed the enterotomies in both vessels. over the next two to three hours, the patient required increasing pressure support, maxing out levophed, epinephrine, natrecor, neo-synephrine and ventilator settings, none of which were to maintain a blood pressure compatible with life. lactaid increasingly increased. likewise ph dropped consistently to 7.1 despite several cycles of bicarbonate. at approximately 7 pm the patient became asystolic and unresponsive to further chemical interventions. there were several long discussions at that time with the patient's brother and sister as well as various members of the creole community. several hours later, a conference call was set up and in the company of the intensive care unit staff, the patient's brother and sister informed the mother of the sister's passing. the patient's mother did appear willing and anxious to have an autopsy performed and this was arranged. the patient's case was presented to the medical examiners office and likewise was declined. , Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Pericardiocentesis Thoracentesis Other bronchoscopy Arterial catheterization Incision of mediastinum Closed [endoscopic] biopsy of bronchus Other local excision or destruction of lesion or tissue of lung Injection or infusion of nesiritide Infusion of drotrecogin alfa (activated) Diagnoses: Anemia, unspecified Acute kidney failure, unspecified Severe sepsis Secondary malignant neoplasm of other specified sites Accidental puncture or laceration during a procedure, not elsewhere classified Unspecified disease of pericardium Acute respiratory failure Cardiogenic shock Septic shock Pneumococcal septicemia [Streptococcus pneumoniae septicemia] Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Secondary malignant neoplasm of lung

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: esophageal variceal hemorrhage major surgical or invasive procedure: intubation, mechanical ventilation, egd without intervention, ivc filter placement. history of present illness: 55 yo man with hx of alcoholism, admitted with gi bleed to osh, with gelatinous bright red blood emesis, and weakness, found to be unresponsive, bp 68/38, hr 130s, hct 19 at . he was then was intubated for airway protection, given 2uprbc and 2-3l ns, sbp came up to 100. pt transferred here to for further evaluation. in the micu, he received 9 units prbc, 4 units ffp (for coagulopathy that has since resolved). he was seen by gi who did multiple egds; these showed no active bleeding, grade 2 esophageal varices, and portal gastropathy. no intevention was performed. he was also seen by neuro for some ?myoclonic jerks that were thought to be etoh withdrawal vs. anoxic brain injury vs. hepatic encephalopathy. his hct stabilized and he had no more episodes of active bleeding. he was extubated on , but his ms continues to wax and wane. he is currently completing a 10 day course of vancomycin for ?gpc in sputum. he also completed an 8 day course of levo/flagyl for sbp ppx given his ascites. also during the micu course, abdominal us showed diffusely coarsened and heterogeneous hepatic echotexture, consistent with cirrhosis. no focal lesions identified. small amount of perihepatic ascites. patent portal veins, with flow in the appropriate direction. he had a tte that showed only mild mr. jad a swam placed; numbers did not implicate a primary cardiac cause for his initial hypotension. abd ct showed showed mesenteric edema, some diverticuli. mri of head showed mild to mod age-inappropriate brain atrophy. he was transferred to the floor when hct was stable; ms is still waxing and , and he is still not able to adequately take po's. past medical history: alcoholism, kidney stones, etoh cirrhosis. social history: 1 ppd smoking hx and known alcoholic- unclear when last drink, lives alone with no known family family history: nc physical exam: vs: 99.5 110/78 75 20 104 gen: not completely clear speech, a&o x 2 (knows year, knows in hospital, ?knows president), mild distress, tearful at times heent: perrl, some yellow saliva/exudate on roof of mouth neck: with right ij, no lad, no jvd appreciated lungs: cta from anterior exam cv: distant heart sounds, nl s1/s2, no m/r/g abd: soft, distended, ?fluid wave, no hsm, nt, no reb/guard extr: 2+ pitting edema in le (with pneumoboots), dp 1+ bilaterally neuro: ms as above, grip, can lift legs off bed, 3-4/5 strength le pertinent results: abd u/s (): impression: 1) diffusely coarsened and heterogeneous hepatic echotexture, consistent with cirrhosis. no focal lesions identified. small amount of perihepatic ascites. 2) patent portal veins, with flow in the appropriate direction. egd (): impression: grade ii varices were noted in the lower esophagus but last 4 cm of esophagus appeared fibrotic with no varices, consistent with possible prior endoscopic therapy. no bleeding noted from the esophagus. mostly old, and some fresh blood in the stomach - ?bleeding from proximal stomach. erythema and congestion in the whole stomach compatible with portal gastropathy and hypoalbuminemia. otherwise normal egd to second part of the duodenum. l le u/s (): impression: there is a crescenteric-shaped thrombus within the left common femoral vein, which is only partially occlusive. acuity of this can not be determined, and this may be an acute thrombus. these correspond to the findings on recent ct scan. ct torso/pelvis (): impression: 1) 3.4-cm aneurysm arising from the proximal left common iliac artery. 2) apparent peripheral filling defect within the left superficial femoral vein. while this could represent artifact, an ultrasound could be performed to evaluate for the presence of thrombus in this patient with history of left femoral vein catheterization. 3) diverticulosis with no ct evidence of diverticulitis. 4) sludge and stones within a nondistended gallbladder. 5) moderate amount of intra-abdominal ascites with a nodular liver contour, findings suggestive of cirrhosis. 6) small bilateral pleural effusions with associated atelectasis. 7) emphysema. 8) bilateral low-attenuation lesions within both kidneys, likely representative of simple cysts. a focal area of dense calcification is also present adjacent to a cystic area of low attenuatiuon within the posterior right kidney. 04:38am blood freeca-1.03* 05:36am blood freeca-1.19 04:38am blood glucose-127* lactate-9.0* na-144 k-4.9 cl-115* calhco3-17* 09:48am blood lactate-3.0* 04:05pm blood lactate-1.8 08:11am blood lactate-1.3 07:37am blood type-art temp-35.3 rates-12/ peep-5 fio2-100 po2-303* pco2-45 ph-7.23* calhco3-20* base xs--8 aado2-364 req o2-65 intubat-intubated 09:48am blood type-art temp-36.4 po2-107* pco2-37 ph-7.35 calhco3-21 base xs--4 intubat-intubated 04:05pm blood type- temp-38.2 tidal v-50 peep-5 po2-104 pco2-36 ph-7.35 calhco3-21 base xs--4 intubat-intubated vent-controlled 04:45pm blood type-art temp-36.4 rates-18/2 tidal v-500 peep-5 fio2-50 po2-82* pco2-35 ph-7.34* calhco3-20* base xs--5 -assist/con intubat-intubated 08:03am blood type-art temp-36.7 rates-14/3 tidal v-500 peep-5 fio2-50 po2-89 pco2-38 ph-7.48* calhco3-29 base xs-4 -assist/con intubat-intubated 02:30pm blood type-art temp-35.8 rates-0/9 tidal v-500 peep-5 fio2-50 po2-93 pco2-36 ph-7.47* calhco3-27 base xs-2 intubat-intubated 03:17am blood hcv ab-negative 04:10am blood asa-neg ethanol-19* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 04:33am blood asa-neg ethanol-10 acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:17am blood afp-6.2 05:36am blood -positive titer-1:40 03:17am blood hbsag-negative hbsab-positive hbcab-negative hav ab-positive 07:21pm blood cortsol-14.0 09:38pm blood cortsol-13.5 10:01pm blood cortsol-14.2 07:21pm blood tsh-0.85 05:09am blood caltibc-130* ferritn-816* trf-100* 06:33am blood albumin-3.0* calcium-7.0* phos-5.2* mg-1.2* 02:02pm blood calcium-8.1* phos-3.1# mg-1.8 07:21pm blood calcium-7.5* phos-2.6* mg-1.6 05:26am blood calcium-7.9* phos-2.6* mg-1.7 05:48am blood calcium-7.9* phos-3.0 mg-1.7 05:46am blood calcium-7.7* phos-4.5 mg-1.9 03:17am blood lipase-12 06:04am blood lipase-224* 05:55am blood lipase-219* 06:24am blood lipase-235* 05:50am blood lipase-191* 05:50am blood lipase-147* 04:10am blood amylase-23 04:33am blood amylase-21 06:33am blood alt-16 ast-47* alkphos-93 totbili-2.2* 07:21pm blood alt-15 ast-46* alkphos-62 totbili-1.9* 03:17am blood alt-16 ast-61* alkphos-68 amylase-14 totbili-1.4 dirbili-0.8* indbili-0.6 05:50am blood alt-22 ast-47* alkphos-128* amylase-115* totbili-1.5 06:19am blood alt-20 ast-41* ld(ldh)-266* alkphos-120* totbili-1.6* 04:10am blood urean-25* creat-1.2 na-145 k-4.2 cl-115* hco3-14* angap-20 04:33am blood urean-26* creat-1.2 06:33am blood glucose-127* urean-24* creat-1.1 na-143 k-5.3* cl-111* hco3-18* angap-19 09:03am blood glucose-124* urean-27* creat-1.1 na-144 k-4.4 cl-114* hco3-21* angap-13 02:02pm blood glucose-109* urean-34* creat-1.3* na-146* k-4.2 cl-117* hco3-20* angap-13 04:10am blood glucose-127* urean-28* creat-1.0 na-146* k-3.6 cl-119* hco3-24 angap-7* 05:06am blood glucose-131* urean-28* creat-1.0 na-146* k-3.7 cl-119* hco3-24 angap-7* 06:21pm blood glucose-107* urean-28* creat-1.1 na-146* k-3.4 cl-113* hco3-26 angap-10 04:14am blood glucose-131* urean-29* creat-1.1 na-145 k-2.9* cl-115* hco3-25 angap-8 05:00am blood glucose-92 urean-15 creat-1.2 na-143 k-2.3* cl-109* hco3-29 angap-7* 05:18am blood glucose-110* urean-16 creat-1.4* na-144 k-3.4 cl-111* hco3-28 angap-8 06:02am blood glucose-104 urean-15 creat-1.5* na-144 k-4.0 cl-111* hco3-26 angap-11 05:50am blood glucose-85 urean-22* creat-1.9* na-138 k-4.3 cl-106 hco3-27 angap-9 06:19am blood glucose-89 urean-20 creat-1.8* na-138 k-3.8 cl-106 hco3-25 angap-11 05:46am blood urean-15 creat-1.7* k-3.9 04:10am blood fibrino-150 04:33am blood fibrino-140* 06:33am blood fibrino-213# 05:26am blood fibrino-304 04:10am blood pt-19.0* ptt-36.7* inr(pt)-2.3 04:10am blood plt ct-113* 04:33am blood pt-19.3* ptt-46.2* inr(pt)-2.4 04:33am blood plt ct-110* 04:10am blood pt-14.8* ptt-31.4 inr(pt)-1.4 04:10am blood plt ct-92* 05:06am blood pt-15.4* ptt-30.6 inr(pt)-1.5 06:19am blood pt-14.8* inr(pt)-1.4 06:19am blood plt ct-180 05:18am blood neuts-79.8* lymphs-12.1* monos-6.0 eos-1.8 baso-0.3 06:02am blood neuts-78.2* bands-0 lymphs-12.6* monos-6.7 eos-2.1 baso-0.3 05:48am blood neuts-75.6* lymphs-15.5* monos-6.3 eos-2.4 baso-0.2 05:50am blood neuts-66.6 lymphs-22.4 monos-5.6 eos-4.6* baso-0.7 04:10am blood wbc-28.5* rbc-2.51* hgb-8.1* hct-25.6* mcv-102* mch-32.2* mchc-31.5 rdw-21.2* plt ct-113* 04:33am blood wbc-27.1* rbc-2.54* hgb-8.3* hct-25.7* mcv-101* mch-32.7* mchc-32.4 rdw-20.8* plt ct-110* 06:33am blood wbc-20.5* rbc-4.42*# hgb-13.4*# hct-40.4# mcv-92# mch-30.3 mchc-33.1 rdw-18.6* plt ct-76* 06:00pm blood wbc-9.4 rbc-3.77* hgb-11.4* hct-32.9* mcv-87 mch-30.3 mchc-34.7 rdw-19.5* plt ct-95* 11:31pm blood wbc-9.7 rbc-3.73* hgb-11.5* hct-32.9* mcv-88 mch-30.7 mchc-34.9 rdw-19.3* plt ct-104* 05:26am blood wbc-9.1 rbc-3.76* hgb-11.2* hct-33.6* mcv-89 mch-29.7 mchc-33.3 rdw-19.3* plt ct-106* 08:12pm blood hct-35.7* 07:14pm blood hct-36.2* 05:18am blood wbc-16.2* rbc-3.40* hgb-10.7* hct-31.3* mcv-92 mch-31.5 mchc-34.2 rdw-19.0* plt ct-93* 06:02am blood wbc-14.1* rbc-3.44* hgb-10.9* hct-32.2* mcv-94 mch-31.8 mchc-34.0 rdw-19.2* plt ct-99* 05:50am blood wbc-8.6 rbc-3.10* hgb-9.5* hct-29.0* mcv-94 mch-30.7 mchc-32.8 rdw-19.1* plt ct-138* 05:50am blood wbc-8.0 rbc-3.07* hgb-9.6* hct-29.3* mcv-95 mch-31.2 mchc-32.8 rdw-18.7* plt ct-148* 06:19am blood wbc-8.3 rbc-2.99* hgb-9.5* hct-28.2* mcv-94 mch-31.7 mchc-33.6 rdw-19.0* plt ct-180 05:46am blood hct-28.7* brief hospital course: 1. ugib/cirrhosis: the patient presented from and an outside hospital after suffering a severe upper gi bleed, hypotension, and hypovolemia. he was resuscitated with prbc and ivf, and sent to the micu. the etiology was considered likely variceal in nature, given the briskness of his bleed, and history of heavy etoh use. he had had multiple egd's at showing varices, portal gastropathy, but required no egd-interventions (ie. cautery or clipping). of note, hepatitis a titers were positive. he was started on lactulose, ppi, nadolol, spironolactone and lasix. the latter two were discontinued given declining renal function. his hct remained stable on the floor thereafter, with levels in the high 20's to low 30's. he was completd on a course of levofloxain and flagyl for sbp ppx in the setting of an ugib. he was discharged with liver follow-up. 2. confusion: he was seen by neurology while in the micu who felt that the differential diagnosis for this patient included, alcoholic encephalopathy, anoxic brain injury, or hepatic encephalopathy. his eeg, head mri and head ct were negative. his mental status improved, with sedation avoidal and treatment of his liver disease, as noted above. 4. fevers (uti and le dvt): while in the micu, he was treated with a course of vancomycin for gram positive cocci in his sputum, and he received a course of levo/flagyl for sbp prophylaxis. once on the floor, he continued to have persistent low grade fevers. multiple urine/blood/peritoneal fluid cultures were negative. a ct of the torso did not show any source. however, a clot in the left common femoral vein, which was confirmed by ultrasound, was seen. further, his urine cultures later grew out vre. regrading the clot, an ivc filter was placed (given the fact he was not a anticoagulate candidate and the high probability of the acuity of the clot because of recent femoral line placement). he was started on a short course of linezolid for the uti. it was unclear if the clot or the uti were the cause of his fevers. 5. arf: the patient had normal renal function at baseline. he evidenced an acute decline in his gfr after a ct contrast dye exposure and his creatinine peaked in the low 2.0's. it improved thereafter. he had a possible atn (with fena at 6%) and was managed with gentle hydration. 6. alcoholism: he had nos signs of withdrawal over his course. he was seen by the addiction service, social work and was advised to enter a detoxification center upon discharge from his rehab facility. medications on admission: meds on transfer: nadolol 20 vanco 1 haldol protonix ativan dulcolax ssi meds on admission: ativan 0.5 prn, lasix 40 qday, remeron 15 qday, aldactone 25 qday, naprosyn prn discharge medications: 1. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 2. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 3. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 5. multivitamin capsule sig: one (1) cap po daily (daily). 6. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. linezolid 600 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 4 days. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: 1) variceal hemorrhage. 2) alcoholic cirrhosis. secondary diagnosis: 3) vancomycin-resistant enterococcal urinary tract infection. 4) common femoral vein thrombosis. discharge condition: fair/stable. discharge instructions: 1) please call your doctor or return to the er if you have any nausea, vomiting, fevers, chills, dizziness, dark stools, diarrhea, bleeding, or any other concerning symptoms. 2) take your medications as instructed. followup instructions: 1) please arrive on the following date to see your new liver doctor. your liver doctor will restart your aldactone and lasix when your kidney function returns to normal: provider . where: lm center phone: date/time: 9:00 2) please see your primary doctor (maurukas,rimas j. ) in the next 2-3 weeks. your hematocrit (blood level) should be checked at least weekly for a month after you leave your rehab, to ensure it is stable. 3) we recommend you enter an alchohol detoxification center once you leave the physical rehab facility. the social workers at the rehab facility can help you with this. md, Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Other endoscopy of small intestine Other endoscopy of small intestine Interruption of the vena cava Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Insertion of other (naso-)gastric tube Transfusion of packed cells Transfusion of other serum Transfusion of platelets Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Tobacco use disorder Urinary tract infection, site not specified Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Acute kidney failure, unspecified Acquired coagulation factor deficiency Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Portal hypertension Alcohol abuse, unspecified Acute respiratory failure Other shock without mention of trauma Personal history of urinary calculi Esophageal varices in diseases classified elsewhere, with bleeding Hematemesis Hepatic encephalopathy Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Injury to bladder and urethra, without mention of open wound into cavity Metabolic encephalopathy Other disorders of plasma protein metabolism Other specified intestinal malabsorption Viral hepatitis A without mention of hepatic coma Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: vomiting blood major surgical or invasive procedure: esophagogastroduodenoscopy with banding of varices history of present illness: 55 y/o m w/hx of alcoholic cirrhosis and grade ii esophageal varices, w/recent micu admission for ugib, who presented to osh with hematemesis. he reports that he was in his usoh and feeling well until this evening. he was drinking iced coffee with his daughter and began to feel vaguely nauseous. he was at his daughter's house, and so he went home. when he stood up, he felt very "hot", and then he vomited approximately cup of bright red blood. he called ems and was taken to . for other review of systems, he occasionally has a mild increase in his abdominal girth with some associated tenderness, but none recently. he denies any fevers or chills. he has some occasional lower extremity edema in the rle * at , he was afebrile, tachycardic to 123, bp 95/49. his labs there were significant for a hct of 19.4 (from 29 2 days ago in liver clinic), platelets 150, wbc 14. his creatinine was 1.4 (1.0 on recent check in liver clinic). his inr was 2.1. he also had a lipase of 243. he received vit k 10 mg sq, protonix 40 mg iv, octreotide bolus and gtt, 3.5 l ns. he was transfused 2 u prbcs. he had several episodes of vomiting black emesis with clots and was subsequently medflighted to . * in our ed, he remained tachycardic but has a stable bp in the 120s. labs were drawn and revealed a hct of 25, inr 1.5, plt 117. creatinine was 1.0. he had an ng lavage which did not clear after 2l. he was admitted to the micu. . micu course: ugib - egd done showing non bleeding varices, 3 bands placed. resuscitated with fluid but still tachycardic; tsh checked, .77, 2.5. received 4 units rbc in (+2 at ) c hct on txf (28.2-30.9), 1 unit ffp. tx c ppi iv, octreotide drip, levofloxacin for sepsis prophylaxis in cirrhotics with variceal bleed . cirrhosis - nadolol, lactulose held in setting of low bp and acute bleed. lactulose started once hct stable. ruq u/s c dopplers done to assess portal flow. pt. creatinine stable 0.9-1.0; not likely hepatorenal in micu. . on questioning, pt. denies any abdominal pain, nausea, vomiting, hematemesis, only has had 1 bm since arrival to hospital. has appetite, drinking clear fluids currently. past medical history: past med hx: 1. alcoholic cirrhosis: had 3 week hospital stay here in , where he presented with hematemesis. was intubated in micu, had egd x3 which showed grade ii esophageal varices (not bleeding, had scarring in cm of distal esophagus which were felt consistent with prior endoscopic therapy), and portal gastropathy. actual source of bleeding never found, pt never had endoscopic intervention here. had abd u/s at that time which showed patent portal vein. also had a swan at the time which per report did not reveal a cardiac cause of his hypotension. tte normal. 2. left femoral dvt, rx w/ivc filter (clot was felt to be due to femoral cordis) 3. vre uti during hosp social history: soc hx: was a heavy drinker until prior hospitalization in . smoked 2 ppd x 20 yrs, now smokes 10 cigs/day. lives at home alone, daughter lives one mile away. family history: no history of liver disease physical exam: t: 98.4 bp: 129/72 p: 104 r: 12 o2 sat: 98% ra gen: awake, alert and oriented male in no acute distress heent: nc, at. ngt in place. sclerae mildly icteric. perrl. mmm. neck: supple, no lad. lungs: mild inspiratory crackles at r base, o/w cta bilaterally. cv: tachycardic, regular, no m/r/g. abd: mildly distended, nontender, no fluid wave. + bs. ext: trace r ankle edema, o/w no peripheral edema, good distal pulses bilaterally skin: warm and dry. erythema over superior chest, no palmar erythema. neuro: moving all extremities well. no asterixis. pe on txf from micu: vs - 98.8, 82, 119/52, 17, 98% ra heent - sclerae anicteric, conjunc. pink, eomi lungs - cta at apices, bases abd - soft, nt, + hepatmegaly (8-9 cm in length by percussion), + spider angiomas over sternum, spleen not palpable heart - rrr, s1, s2 ext - +palmar erythema, trace edema to ankles b/l, pneumoboots on neuro - a* o * 3, no asterixis pertinent results: labs at : wbc 14 (67 polys/2 bands), hct 19 (mcv 100), plt 150 na 142, k 5.1, cl 108, bicarb 25, bun 28, creat 1.4, glc 104 calcium 8.2, albumin 2.1, total protein 5.4 tot bili 0.8, alk phos 134, alt 26, ast 25, amylase 29, lipase 243 . 02:25am blood wbc-15.1*# rbc-2.80* hgb-8.9* hct-25.9* mcv-93 mch-31.8 mchc-34.4 rdw-17.4* plt ct-117* 06:00am blood wbc-13.0* rbc-2.50* hgb-8.0* hct-23.8* mcv-95 mch-31.9 mchc-33.6 rdw-18.0* plt ct-105* 05:53am blood wbc-9.7 rbc-3.31* hgb-10.4* hct-30.2* mcv-91 mch-31.3 mchc-34.4 rdw-17.0* plt ct-91* 08:00pm blood hct-32.2* 06:00am blood wbc-7.9 rbc-3.36* hgb-10.8* hct-30.4* mcv-90 mch-32.0 mchc-35.4* rdw-16.7* plt ct-96* . 02:25am blood pt-15.0* ptt-29.4 inr(pt)-1.5 02:25am blood plt ct-117* 06:00am blood pt-13.6* ptt-28.8 inr(pt)-1.2 06:00am blood plt ct-96* . 02:25am blood glucose-98 urean-29* creat-1.0 na-143 k-5.6* cl-114* hco3-22 angap-13 06:00am blood glucose-109* urean-30* creat-1.0 na-144 k-4.6 cl-113* hco3-24 angap-12 06:00am blood glucose-87 urean-11 creat-0.8 na-138 k-3.7 cl-108 hco3-23 angap-11 . 02:25am blood albumin-2.6* 06:00am blood calcium-8.3* phos-3.7 mg-1.6 . 05:53am blood free t4-0.7* 06:00am blood tsh-0.77 . ruq u/s c doppler: the liver has a heterogenous echotexture and nodular surface contour suggestive of underlying cirrhotic change. no focal mass lesion demonstrated. doppler assessment of the hepatic vasculature shows patent left, right and main portal veins with normal directional flow. the left middle and right hepatic veins and inferior vena cava are patent with normal spectral waveform on doppler. right, left, and main hepatic arteries are demonstrated with a good systolic upstroke. there is a moderate amount of intra-abdominal ascites, which appears simple on . the common bile duct is prominent in diameter at 7 mm but there is no intrahepatic biliary dilatation. a number of small echogenic gallstones are noted in the dependent portion of the gallbladder, which is nondistended and non-thickened. the splenic and superior mesenteric veins are patent on color doppler flow. brief hospital course: ugib - this was thought likely to portal gastropathy/esophageal varices. he has not been banded in the past. since his ng lavage did not clear after 2 l, persistent coffee grounds, dark brown liquids, he was transferred to the micu. he received ivf, 4 units of prbcs and he remained hd stable. he underwent egd in the morning after admission to the micu as described above under hpi. he was transferred to the floor after he had been hd stable c no further episodes hematemesis, brbpr, and c a stable hematocrit. on the floor, he had one episode of brbpr but remained hd stable c a stable crit. he was continued on his levaquin regimen started in the micu for a 7 day course (day , ). he was taken off the octreotide drip and switched to po protonix. he was discharged with a plan for egd with banding on monday, , c dr. . . cirrhosis: according to discharge summary from , pt was supposed to be on nadolol, lactulose, protonix but pt reported that he is only taking nortriptyline. he was started on nadolol on transfer to the floor. he was maintained on lactulose. an abdominal u/s c dopplers was done (see above). he did not become hepatorenal. he was discharged with prescriptions for lactulose and nadolol. . tca use: the pt. came in using nortryp.; this was d/w his pcp, . . he was started on this for peripheral neuropathy etoh use. he reported minimal paresthesias in his feet and no recent etoh use; it was thought better to stop this medication in this context. . thyroid studies: in the micu, the question was raised that he may be hyperthyroid given his elevated hr despite fluid resuscitation. a tsh and free t4 were checked. one tsh level was low, another normal. a free t4 level was low. his hr came down on transfer to the floor and we did not pursue further workup for hyperthyroidism given his low t4. . ivc filter: a discussion was had c the ir resident who was involved in the placement of his ivc filter; a trapease filter as he has is usually a permanant filter. medications on admission: nortriptyline discharge medications: 1. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. disp:*30 tablet(s)* refills:*0* 2. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day). disp:*2700 ml(s)* refills:*2* 3. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 5 days. disp:*5 tablet(s)* refills:*0* 4. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: primary 1. upper gastrointestinal bleed 2. alcoholic cirrhosis discharge condition: good discharge instructions: you should contact your pcp or go to the emergency room if you continue to have any more episodes of bloody vomiting, bloody stools, bright red blood in the stool, light headedness, dizziness, chest pain, shortness of breath. you should take all your medications as prescribed and keep all your appointments with health care providers. followup instructions: you have an appointment with dr. on monday, at 10:00 am for an egd with banding. you should not eat anything after midnight the night before the procedure. you will need to arrange for a ride home after the procedure on . the appointment is listed below: provider: suite gi rooms where: gi rooms date/time: 10:00 provider: . where: building (/ complex) endoscopy suite phone: date/time: 10:00 you also have the following other appointments listed below: provider: where: cc clinical center radiology phone: date/time: 8:30 Procedure: Endoscopic excision or destruction of lesion or tissue of esophagus Transfusion of packed cells Transfusion of other serum Diagnoses: Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Esophageal varices in diseases classified elsewhere, with bleeding Alcoholic polyneuropathy

allergies: patient recorded as having no known allergies to drugs attending: addendum: addendum to discharge summary adm: - dis: this is an addendum regarding discharge medications. patient should be in the same outpatient dose of lisinopril 2.5mg qd. i spoke with nursing staff at nursing facility today in order to make them aware of this change. fax of this d/c summary plus addendum will be faxed directly to the facility . chief complaint: cc: major surgical or invasive procedure: ddd pacemaker device. history of present illness: hpi: 84 year old female with htn, hypercholesterolemia, dementia presents from nursing home after they noted that her heart rate was in the 30's. she was noted to be in complete heart block, on arrival to hospital, sbp decreased to 80's systolic and she was started on dopamine gtt at 13 cc/hr. past medical history: htn hypercholesterolemia dementia with agitation hypothyroidism depression syncope social history: soc hx: lives in nursing home. (+) tobacco 1ppd x 50 yrs, quit > 15 family history: family history: sister cva in her 60s. father cva in his 70s. physical exam: phys exam: 98.1f hr 60 bp 151/64 rr 14 100%/intubated gen: sedated, intubated, responsive to pain heent: perrl, intubated cv: distant s1, s2, ?systolic murmur chest: external pacer in place with dsg c/d/i pulm: diffuse rhonchi and occasional wheeze bilaterally abd: (+) bs, soft, obese, nontender ext: wwp, faint dp pulses b/l, 2+ pitting le edema b/l pertinent results: 09:36pm blood wbc-13.5*# rbc-3.89* hgb-11.3* hct-32.5* mcv-84 mch-29.1 mchc-34.8 rdw-15.6* plt ct-222 07:35am blood wbc-10.4 rbc-3.81* hgb-11.4* hct-31.7* mcv-83 mch-30.0 mchc-36.0* rdw-15.6* plt ct-222 05:18am blood neuts-79.2* lymphs-14.0* monos-3.0 eos-3.7 baso-0.1 09:36pm blood pt-12.6 ptt-24.9 inr(pt)-1.1 05:42am blood pt-13.3 ptt-27.2 inr(pt)-1.2 07:15am blood pt-12.6 ptt-25.0 inr(pt)-1.1 09:36pm blood glucose-148* urean-22* creat-1.0 na-136 k-4.5 cl-101 hco3-24 angap-16 07:35am blood glucose-107* urean-14 creat-0.8 na-136 k-4.2 cl-100 hco3-27 angap-13 09:36pm blood alt-28 ast-28 ck(cpk)-57 alkphos-77 totbili-1.0 05:42am blood ck-mb-notdone ctropnt-0.04* 05:42am blood tsh-6.6* 05:42am blood free t4-0.8* 09:41pm blood type-art po2-428* pco2-38 ph-7.43 calhco3-26 base xs-1 12:13pm blood type-art temp-37.2 fio2-40 po2-94 pco2-36 ph-7.48* calhco3-28 base xs-3 intubat-not intuba echo conclusions: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is moderate aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is severe mitral annular calcification with a moderate inflow gradient (in part due to significant regurgitation). moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. chest x ray: chest: a single semi-upright ap view at 9:30 p.m. is compared to previous examination earlier from the same day. since the previous exam the interstitial edema has decreased. there is an endotracheal tube with the tip approximately 4.5 cm proximal to the carina. there is a new single lead pacemaker with the lead overlying the right ventricle. there is no evidence of pneumothorax. there are probable pleural calcifications in left lower lung. there is focal opacity in right upper lobe which may represent pneumonia. brief hospital course: brief hospital course: a/p: 84 year old female with htn, hyperlipidemia, recently diagnosed pneumonia treated with antibiotics, found by nursing home to have hr 30's, found to be in complete heart block. . 1. cv: rhythm: patient was taken to the cath lab, intubated for agitation, and a external screw-in pacemaker was placed. unclear source of complete heart block, given she r/o for ischemia, more likely worsening conduction system with age. a permanent ddd pacemaker was placed on with no complications. patient should have a follow up appointment with device clinic in 1 week. pump: patient on admission appeared volume overloaded, and her lasix dose was increased from 40 po day to 40 iv q day. patient responded well, and later on was transitioned back to her home dose40 po/day echo on echo on .ef >55%mod as, mod mr and severe pulmonary artery systolic htn on echo. ischemia: patient rule out for mi, enzymes negative. bp: patient was initially hypotensive on admission, and was started on dopamine. after procedure, she was transfer to ccu and dopamine was weaned off over the following 12 hours. cad: patient was continued on aspirin, statin, and ace was re-started once patient was transfer to the floor. 2. pulm: patient was extubated succesfully in the morning of . patient did well after extubation. . 3. id: pneumonia, was treated at nh with erythromycin. chest x ray on admission compatible with right upper lobe pneumonia. patient was switched to azytromycin- ceftriaxone. sputum final showed sparse oropharingeal flora. per id recomendation, and given good clinical conditions, antibiotics were stopped on . per electrophisiology recs, she received vancomycin for 48 hours after procedure, since patient will be d/c after 24h, she will receive 1 more day of keflex. . 4. hypothyroidism: patient with high tsh and low free t4 on admission. levothyroxine dose was increased from 75 to 100mcg/day. . 5. dementia: continue namenda. . 6. fen: cardiac heart diet monitor electrolytes and replete prn. medications on admission: lipitor 20 qhs lasix 40 po qday lisinopril 2.5 po qday mvi os-cal 500mg qday asa 81 qday namenda 10 qday levoxyl 75 mcg qday tylenol prn erythromycin 333 tid (for pna) discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for fever. 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. memantine 5 mg tablet sig: two (2) tablet po qday (). 5. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 6. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 7. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q4h (every 4 hours) as needed for wheeze. 8. keflex 250 mg capsule sig: one (1) capsule po four times a day for 1 days. 9. multivitamin capsule sig: one (1) capsule po once a day. 10. os-cal 500 mg tablet sig: one (1) tablet po once a day. 11. lisinopril 2.5 qd discharge disposition: extended care facility: healthcare - discharge diagnosis: complete heart block community acquired pneumonia hypothyroidism discharge condition: good discharge instructions: please take your medications as prescribed. please follow up your appointments as schedule. a pacemaker device was implanted durint this hospitalization. your levothyroxine dose was increased during your hospital stay. if shortness of breath, chest pain, or any other symptoms that may concern you please call your pcp or come to the emergency department. followup instructions: please call your pcp for follow up appointment in about 2 weeks. please recheck tsh in 1 month. provider: clinic phone: date/time: 11:00 md Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Pure hypercholesterolemia Mitral valve disorders Unspecified essential hypertension Unspecified acquired hypothyroidism Other chronic pulmonary heart diseases Atrioventricular block, complete Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cc: major surgical or invasive procedure: pacemaker placement ddd history of present illness: hpi: 84 year old female with htn, hypercholesterolemia, dementia presents from nursing home after they noted that her heart rate was in the 30's. she was noted to be in complete heart block, on arrival to hospital, sbp decreased to 80's systolic and she was started on dopamine gtt at 13 cc/hr. past medical history: htn hypercholesterolemia dementia with agitation hypothyroidism depression syncope social history: soc hx: lives in nursing home. (+) tobacco 1ppd x 50 yrs, quit > 15 family history: family history: sister cva in her 60s. father cva in his 70s. physical exam: phys exam: 98.1f hr 60 bp 151/64 rr 14 100%/intubated gen: sedated, intubated, responsive to pain heent: perrl, intubated cv: distant s1, s2, ?systolic murmur chest: external pacer in place with dsg c/d/i pulm: diffuse rhonchi and occasional wheeze bilaterally abd: (+) bs, soft, obese, nontender ext: wwp, faint dp pulses b/l, 2+ pitting le edema b/l pertinent results: 09:36pm blood wbc-13.5*# rbc-3.89* hgb-11.3* hct-32.5* mcv-84 mch-29.1 mchc-34.8 rdw-15.6* plt ct-222 07:35am blood wbc-10.4 rbc-3.81* hgb-11.4* hct-31.7* mcv-83 mch-30.0 mchc-36.0* rdw-15.6* plt ct-222 05:18am blood neuts-79.2* lymphs-14.0* monos-3.0 eos-3.7 baso-0.1 09:36pm blood pt-12.6 ptt-24.9 inr(pt)-1.1 05:42am blood pt-13.3 ptt-27.2 inr(pt)-1.2 07:15am blood pt-12.6 ptt-25.0 inr(pt)-1.1 09:36pm blood glucose-148* urean-22* creat-1.0 na-136 k-4.5 cl-101 hco3-24 angap-16 07:35am blood glucose-107* urean-14 creat-0.8 na-136 k-4.2 cl-100 hco3-27 angap-13 09:36pm blood alt-28 ast-28 ck(cpk)-57 alkphos-77 totbili-1.0 05:42am blood ck-mb-notdone ctropnt-0.04* 05:42am blood tsh-6.6* 05:42am blood free t4-0.8* 09:41pm blood type-art po2-428* pco2-38 ph-7.43 calhco3-26 base xs-1 12:13pm blood type-art temp-37.2 fio2-40 po2-94 pco2-36 ph-7.48* calhco3-28 base xs-3 intubat-not intuba echo conclusions: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is moderate aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is severe mitral annular calcification with a moderate inflow gradient (in part due to significant regurgitation). moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. chest x ray: chest: a single semi-upright ap view at 9:30 p.m. is compared to previous examination earlier from the same day. since the previous exam the interstitial edema has decreased. there is an endotracheal tube with the tip approximately 4.5 cm proximal to the carina. there is a new single lead pacemaker with the lead overlying the right ventricle. there is no evidence of pneumothorax. there are probable pleural calcifications in left lower lung. there is focal opacity in right upper lobe which may represent pneumonia. brief hospital course: a/p: 84 year old female with htn, hyperlipidemia, recently diagnosed pneumonia treated with antibiotics, found by nursing home to have hr 30's, found to be in complete heart block. . 1. cv: rhythm: patient was taken to the cath lab, intubated for agitation, and a external screw-in pacemaker was placed. unclear source of complete heart block, given she r/o for ischemia, more likely worsening conduction system with age. a permanent ddd pacemaker was placed on with no complications. patient should have a follow up appointment with device clinic in 1 week. pump: patient on admission appeared volume overloaded, and her lasix dose was increased from 40 po day to 40 iv q day. patient responded well, and later on was transitioned back to her home dose40 po/day echo on echo on .ef >55%mod as, mod mr and severe pulmonary artery systolic htn on echo. ischemia: patient rule out for mi, enzymes negative. bp: patient was initially hypotensive on admission, and was started on dopamine. after procedure, she was transfer to ccu and dopamine was weaned off over the following 12 hours. cad: patient was continued on aspirin, statin, and ace was re-started once patient was transfer to the floor. 2. pulm: patient was extubated succesfully in the morning of . patient did well after extubation. . 3. id: pneumonia, was treated at nh with erythromycin. chest x ray on admission compatible with right upper lobe pneumonia. patient was switched to azytromycin- ceftriaxone. sputum final showed sparse oropharingeal flora. per id recomendation, and given good clinical conditions, antibiotics were stopped on . per electrophisiology recs, she received vancomycin for 48 hours after procedure, since patient will be d/c after 24h, she will receive 1 more day of keflex. . 4. hypothyroidism: patient with high tsh and low free t4 on admission. levothyroxine dose was increased from 75 to 100mcg/day. . 5. dementia: continue namenda. . 6. fen: cardiac heart diet monitor electrolytes and replete prn. . medications on admission: lipitor 20 qhs lasix 40 po qday lisinopril 2.5 po qday mvi os-cal 500mg qday asa 81 qday namenda 10 qday levoxyl 75 mcg qday tylenol prn erythromycin 333 tid (for pna) discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for fever. 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. memantine 5 mg tablet sig: two (2) tablet po qday (). 5. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 6. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 7. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q4h (every 4 hours) as needed for wheeze. 8. keflex 250 mg capsule sig: one (1) capsule po four times a day for 1 days. 9. multivitamin capsule sig: one (1) capsule po once a day. 10. os-cal 500 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: healthcare - discharge diagnosis: compleat heart block community acquired pneumonia hypothyroidism discharge condition: good discharge instructions: please take your medications as prescribed. please follow up your appointments as schedule. a pacemaker device was implanted durint this hospitalization. your levothyroxine dose was increased during your hospital stay. if shortness of breath, chest pain, or any other symptoms that may concern you please call your pcp or come to the emergency department. followup instructions: please call your pcp for follow up appointment in about 2 weeks. please call pacemaker and device clinic at ( to make an appointment in 1 week. please recheck tsh in 1 month. Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Pure hypercholesterolemia Mitral valve disorders Unspecified essential hypertension Unspecified acquired hypothyroidism Other chronic pulmonary heart diseases Atrioventricular block, complete Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance

past medical history: includes bph and mild exercise intolerance. past surgical history: of renal cyst aspiration, hernia repair, cataract surgery, and colonoscopy and biopsy. medications: include aspirin 81 mg every day. allergies: no known drug allergies. social history: includes no tobacco use and alcoholic drinks a day with no drug use. review of symptoms: otherwise noncontributory. physical exam: revealed a 71 inch, 157 pound male with a pulse of 68, blood pressure of 147/92 in no apparent distress with clear lungs with a murmur in left sternal border with abdomen that is soft and nontender. no extremity edema. hospital course: patient presented as above and underwent a transurethral resection of the prostate for bph on . this was a large resection, and postoperatively was noted to have a great deal of hematuria requiring brisk cbi immediately postoperatively. because of the brisk cbi and requiring bag changes approximately every 30 minutes, patient was monitored overnight for 1-to-1 nursing care in the icu. medically, however, patient remained stable throughout the hospital course, and patient's hematocrit postoperatively was in the 30s (stable at 30 at discharge). patient did not require any transfusions. the patient's foley was removed on postoperative day #2 after urine was noted to be fruit punch color off of cbi. patient was then observed for another day of hospitalization, and reported urinating well. but initially urinated several clots. the urine color then became much lighter in color after urination of clots. patient reported sensation of complete emptying upon discharge, and also reported a very strong stream and good satisfaction of his urination. therefore, upon discharge on postoperative day #3, patient was ambulating, voiding, without significant pain, and tolerating pos without difficulty. discharge condition: good. discharge diet: regular. discharge medications: tylenol 650 mg p.o. q.4h. p.r.n. pain, colace 100 mg p.o. b.i.d. no antibiotics were given upon discharge because 3 days of ciprofloxacin had been given in the hospital. followup: will be with dr. in weeks. discharge activities: no restrictions. , Procedure: Other transurethral prostatectomy Diagnoses: Acute posthemorrhagic anemia Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hemorrhage complicating a procedure Other specified cardiac dysrhythmias

allergies: latex attending: chief complaint: vomiting & dark diarrhea major surgical or invasive procedure: upper endoscopy history of present illness: this is a 84 year old male with a history of cad (s/p cypher to rca in ), recent aaa repair in , htn, hyperlipidemia, copd, pud who presents from his nh on with vomitting, abdominal pain and dark stools. he notes that several days ago, he began to have nausea, vomitting, loose stools and abdominal pain. due to these symptoms he has had limited po intake. he was brought to the ed due to persistent loose stools and abdominal pain. . in the ed: vs 97.2 102 101/66 20 100% ra. he had a cta that showed a duodenitis and absence of dissection. he was given cipro 400mg iv x1, flagyl 500mg iv x1 given for duodenitis. he was initially admitted with a hct to 30, and then the following am noted to have hct to 22. he was given 1 unit prbc for this and transfered to the micu, though he was hemodynamically stable throughout. plan was for patient to undergo an egd, but this procedure was held due to a coagulopathy with an inr to 2.3. he was given 5mg po vitamin k and 2 units of ffp (inr down to 1.6). during his blood product transfusion, he developed chest pain that was left sided, and associated with mild sob. his ecg revealed inferolateral st depressions. his chest pain self-resolved. troponins trended from 0.04 to peak of 0.11, most recently down to 0.1 so no longer being followed. cks and ck-mb have been flat throughout. thought to be consistent with demand ischemia. cardiology was consulted and recommended conservative management with holding asa and continuing bb. . in the micu, patient received a total of 6 units prbcs, and eventually hematocrit began to stabilize and increase over the last 24 hours. additionally became hypertensive, currently on bb, started on hydralazine for easy on/off if he develops hemodynamically significant re-bleed. at this time, patient is transfered to the medicine floor with plan for egd in the morning pending stable inr (1.4 yesterday). . at this time, patient is feeling well. no bm for several days, feels he has more energy. no nausea or vomiting. his only complaint is his chronic arthritis for which he requests tylenol. no fevers, chills, abdominal pain, chest pain, shortness of breath. past medical history: past medical history: 1. coronary artery disease, status post mi in . 2 vessel disease s/p successful pci to mid-rca, ehco: ef 45% with no significant valvular disease () 2. hypertension. 3. hyperlipidemia. 4. paroxysmal atrial fibrillation. 5. history of abdominal aortic aneurysm. 6. history of deep venous thrombosis. 7. chronic obstructive pulmonary disease: fev1 70%, fev/fvc 79% 8. peptic ulcer disease. 9. history of esophagitis. 10. history of gastrointestinal bleeding. 11. diverticulosis. 12. renal insufficiency. 13. lumbosacral radiculopathy. 14. depression. 15. history of hip fracture. . past surgical history: 1. status post stent graft surgery for abdominal aortic aneurysm. 2. status post filter placement for history of dvt. 3. status post hip replacement. 4. status post aaa repair. social history: lived with wife of 60 years at home, but currently at rehab. supportive family with 1 daughter, 2 granddaughter and great-granddaughters. retired professor . denies tobacco, etoh, drugs. at home, he uses a walker for ambulation. family history: noncontributory physical exam: vs 98.1 134/82 72 18 100%@ra gen: awake, reluctantly converstant, admits being confused heent: dry oropharynx, cnii-xii otherwise intact pulm: b cta cv: s1& s2 appreciated without murmur abd: non tender to palpation, non distended, bs present. old bruising on left abdomen. several surgical scars. ext: no edema, 2+ distal pulses pertinent results: 10:15am pt-20.5* ptt-30.3 inr(pt)-1.9* 10:15am plt count-521* 10:15am neuts-63.4 lymphs-30.4 monos-4.1 eos-0.8 basos-1.3 10:15am wbc-10.7 rbc-3.40* hgb-10.1* hct-30.6* mcv-90 mch-29.7 mchc-33.0 rdw-16.6* 10:15am albumin-3.1* calcium-8.9 phosphate-2.8 magnesium-2.2 10:15am ck-mb-notdone 10:15am ctropnt-0.04* 10:15am lipase-16 10:15am alt(sgpt)-11 ast(sgot)-24 ck(cpk)-90 alk phos-51 tot bili-0.3 10:15am estgfr-using this 10:15am glucose-93 urea n-53* creat-1.7* sodium-143 potassium-5.5* chloride-112* total co2-22 anion gap-15 10:22am hgb-10.5* calchct-32 10:22am lactate-2.1* k+-5.2 02:48pm lactate-1.3 echo: conclusions the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is infero-lateral hypokinesis. the remaining lv segments appear hyperdynamic and therefore the overall left ventricular systolic function is preserved (lvef = 55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the lvef has improved. cta cap: impression: 1. no evidence of aortic dissection or endograft leak s/p aortic aneurysm endograft repair. 2. focal thickening in the duodenum with some adjacent fat stranding, suggestive of duodenitis. 3. interval improvement in the left lower lobe consolidation. 4. air in the bladder. correlate for recent catheterization. otherwise, may represent infection. correlate with urinalysis. egd findings: findings: esophagus: normal esophagus. stomach: mucosa: diffuse continuous moderate inflammation of the mucosa with no bleeding was noted in the antrum. duodenum: mucosa: diffuse continuous marked inflammation of the mucosa with no bleeding was noted throughout the duodenum. excavated lesions a single cratered non-bleeding 20mm ulcer was found in the proximal bulb. a small visible vessel was present in the center of the ulcer. clipping was attempted, but three endoquick clips were non-adherent. some oozing was noted after the clipping attempt, 4cc of epinephire were injected at the ulcer border at three separate sites. impression: moderate inflammation in the antrum marked inflammation in the duodenum ulcer in the proximal bulb otherwise normal egd to third part of the duodenum brief hospital course: # gi bleed: patient presented with 4 day history of vomiting and melena without any po intake and abdominal pain. on his first night he displayed no symptoms. the following morning, pt's inr was found to be 2.3. hematocrit dropped to 22 from 30.2 egd cancelled. 2 u ffp transfused followed by 2 units prbcs in preparation for egd. during administration of 1st unit of blood, called to bedside for a trigger: patient had chest pain with st depression in i, ii, avf, v3-6. resolved with sl nitroglycerin. lipitor 80mg, lopressor 25mg po tid restarted. after discussion with cardiology & geriatrics (primary) 325mg asa started. intermediate hct drawn after 1.5 units prbc administered showing 21.2. at this point the unit was consulted. no blood per rectum, no hemtatemesis. patient has no new complaints at this time. during his icu admission, the patient received 5 units prbcs. initially, he did not have an appropriate hct bump, but then he began to bump appropriately and was hemodynamically stable for transfer to the floor. he had no further episodes of melena or chest pain. his cardiac enzymes began to trend downwards. his hct goal was greater than 30 given dynamic ecg changes and likely ischemia. he was then transferred back to the floor since he remained hemodynamically stable and bumping appropriately to prbcs with no further transfusions. egd done which showed non-bleeding ulcer in duodenal bulb with visible vessel that was not able to be clipped. it was injected with epinephrine. no further bleeding while admitted. h. pylori igg was checked and was found to be positive prior to discharge. patient was discharged on 2 week course of triple therapy for h. pylori. # pneumonia: patient admitted with picc line in place from mssa pneumonia. nafcillin course completed on , no signs or symptoms of pneumonia on this admission. picc line was discontinued prior to discharge. # hypertension: the patient was initially maintained on home regimen of amlodipine, hydralazine and lopressor until transfer to the micu. his lopressor was decreased to 12.5 mg tid given hr in the 50s on telemetry. his hydralazine was ultimately decreased to 50mg tid. he was started on lisinopril for bp control in the setting of recent mi. bp well-controlled at the time of discharge. # anxiety: the patient was initially maintained on home regimen of effexor & xanax. # aaa repair: assessed and cleared by surgery that examined the ct and felt there were no issues with the graft. # chronic back pain: the patient continued home oxycodone 5mg po q4hrs prn pain and neurontin 100mg po bid. # stage ckd: the patient's cr was below baseline of 1.7-2 during admission after fluid administration and low po intake over the last few weeks. his baseline cr 1.7-2, secondary to hypertension. # cad: patient maintained on home beta blocker and anti-hypertensives. home aspirin was held during the acute bleed. otherwise as above. it was also held at the time of discharge per primary attending until seen by gi given how large the patient's bleed had been. restarting this medication should be discussed with the patiet's primary care physician as an outpatient. # coagulopathy: inr was 2.3 at the time of admission. improved with vitamin k, ffp and increased nutrition. was likely due to malnutrition and was stable and improved prior to discharge. # code status: patient request dnr/dni status with dr. . ordered entered and confirmed . medications on admission: simvastatin 20 mg po qday aspirin 325 mg po qday pantoprazole 40 mg po bid albuterol 90 mcg/actuation aerosol 2 puff ih q6h prn dyspnea alprazolam 1 mg po qhs venlafaxine 225 mg po qday ferrous sulfate 325 mg po qday gabapentin 100 mg po tid docusate sodium 100 mg po bid senna 8.6 mg po bid bisacodyl 10 mg pr qhs:prn constipation hydralazine 50 mg po q6h metoprolol tartrate 25 mg po tid amlodipine 10mg po qday furosemide 20 mg po qday oxycodone 5 mg po q4h prn pain nafcillin 2g iv q6h, completed discharge medications: 1. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 2. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 4. outpatient lab work please draw cbc and chemistry panel including na, k, hco3, cl, bun, cr and call into dr. at . 5. alprazolam 1 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 6. venlafaxine 75 mg capsule, sust. release 24 hr sig: three (3) capsule, sust. release 24 hr po qpm (once a day (in the evening)). 7. venlafaxine 75 mg capsule, sust. release 24 hr sig: two (2) capsule, sust. release 24 hr po qam (once a day (in the morning)). 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). disp:*45 tablet(s)* refills:*2* 9. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): please take this while you are taking oxycodone. disp:*60 capsule(s)* refills:*2* 11. hydralazine 25 mg tablet sig: two (2) tablet po tid (3 times a day). 12. amoxicillin 500 mg tablet sig: two (2) tablet po twice a day for 2 weeks. disp:*56 tablet(s)* refills:*0* 13. clarithromycin 500 mg tablet sig: one (1) tablet po twice a day for 2 weeks. disp:*28 tablet(s)* refills:*0* 14. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*10 tablet(s)* refills:*0* 15. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 16. lisinopril 10 mg tablet sig: 1.5 tablets po daily (daily). disp:*45 tablet(s)* refills:*2* 17. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 18. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. discharge disposition: home with service facility: family & services discharge diagnosis: upper gi bleed duodenal ulcer h. pylori positive nstemi coronary artery disease hypertension chronic kidney disease discharge condition: hemodynamically stable with stable hematocrit discharge instructions: you were admitted with a gi bleed. you were given blood and had an upper endoscopy that showed ulcers in your stomach. you were also found to be h. pylori positive as below. you should take protonix twice a day to help heal your ulcer and to prevent additional ulcers from forming. you are also being prescribed two weeks of two antibiotics to erradicate the h. pylori. please take these as directed. it is very important that you follow up with the gastroenterologist for further evaluation and management. if you notice an increase in the number of dark stools you are having, if you notice blood in your stools, or if you develop chest pain, shortness of breath, abdominal pain, change in your urinary habits, or any other symptom that is concerning to you, please call your doctor to the emergency room immediately. several of your medications have been changed: 1. simvastain: please take 80mg daily 2. hydralazine: please take this three times daily 3. please do not take aspirin, ibuprofen or other non-steroidal anti-inflammatory medications until you discuss this with your gastroenterologist given that these medicines can predispose you to gi bleeding. 4. you have been started on a medication called lisinopril for your hypertension. please take this as directed. 5. your metoprolol dose has changed from 25 mg three times daily to 12.5 mg three times daily. 6. you are also positive for h. pylori which is likely causing your ulcers. you will be treated with two weeks of antibiotics (amoxicillin and clarithromycin). please take these as directed. 7. we are holding your lasix for now. please discuss restarting this with your primary care physician. you should have lab work done this upcoming which should be called into your primary care doctor's office. followup instructions: please keep the following appointments: provider: () lmob (nhb) phone: date/time: 11:45 provider: , md phone: date/time: 12:15 provider: , md phone: date/time: 3:20 gastroenterology: provider: , md phone: date/time: 2:00 primary care: provider: , phone: date/time: 10:30 Procedure: Endoscopic control of gastric or duodenal bleeding Transfusion of packed cells Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Aortocoronary bypass status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Duodenitis, without mention of hemorrhage Helicobacter pylori [H. pylori]

pt. has allergies to latex. pt. remains a/a/o and denies of chronic back pain which he has utilized his oxycodone 5mg po thwice through this shift. pt. has been afebrile. pt. is nsr 60-70's with no noted ectopy. b/p has been stable ranging 120-150's/60-80's. pulses are weak but palable. no edema noted. pt. has been given two units of prbc's during this shift. pt. has bumped from 22-23.7 after first units and second unit is just finishing and hct to be drawn at 0800. pt. had episode of chest pain and ekg changes on the fllor prior to admission to icu. pt. has had no further c/o chest pain. pt. will have followup ekg today. troponin ar slightly elevated at 0.11 pt. remains clear throughout. few crackles were noted in right base. resp rate is controlled and o2 sats remain >95% pt. remains npo at this time. pt. have sips and ice chips. abd. is beningn in assessment with bowel sounds easily audible x4 qaudrants. no stool noted this shift. pt. voids per urinal, ample amt's. skin remains intact, with piv's all intact, secured,and functioning well. pt. has old ecchymotic areas to abd. that pt. states there still there from my aaa repair. Procedure: Endoscopic control of gastric or duodenal bleeding Transfusion of packed cells Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Aortocoronary bypass status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Duodenitis, without mention of hemorrhage Helicobacter pylori [H. pylori]

pt. has allergies to latex. pt. remains a/a/o and required two oxtcodone doses throughout this shift for c/o abd/back pain. pt. is afebrile. pt. has been nsb/sr 54-60's with no noted ectopy. b/p 140-170/60-80's. pulses palpble. hct is now 28.5 slightly down from 30.5. am labs are pending. lungs are clear/dim and resp rate controlled and sats >95% on room air. pt. remains npo at this time. abd. is benign in assessment and no stool noted this shift. bowel sounds are present. pt. continues to void ample amt's of clear yellow urine. skin remains unremarkable with two old ecchymotic areas noted on abd. pt. also has tow #18 piv's to right ac and right hand. pt. has single lumen picc to left ac. Procedure: Endoscopic control of gastric or duodenal bleeding Transfusion of packed cells Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Aortocoronary bypass status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Duodenitis, without mention of hemorrhage Helicobacter pylori [H. pylori]

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hematemesis major surgical or invasive procedure: ivc filter placement egd brief hospital course: addendum to hospital course: hematemesis: the patient??????s hematocrit remained stable. h pylori was negative. the patient did have a tarry melanotic stool on , however, his hematocrit remained very stable in the 35-37 range, and so this was thought to represent old blood that the patient was passing. he should have an outpatient colonoscopy and perhaps evaluation of his small bowel to evaluate for any source of bleeding. infectious disease: the patient??????s wbc came down significantly on bactrim and metronidazole. he remained afebrile without diarrhea or dysuria. he should continue to complete a 7 day course of bactrim (ending ) and a 14 day course of metronidazole (ending ). dvt: the patient has a filter in place. if the decision is made to remove the filter, this will have to be done within 2 weeks of placement (). interventional radiology should be called to arrange this. he received 1 mg sc vitamin k on for an inr of 7.3 (repeat 4.9). his inr before discharge was 1.8. at this point, the decision was made to hold coumadin despite the patient??????s atrial fibrillation. this can be re-addressed on an outpatient basis with the patient??????s pcp. pulmonary: the patient was continued on albuterol and atrovent nebulizer treatments. he had no further evidence of fluid overload, no oxygen requirement and required no more lasix. if he develops shortness of breath or evidence of fluid overload, small doses of lasix (20mg po) should be considered. psych: the patient was seen by psychiatry to evaluate his capacity and suicidal risk. the patient was noted to have no evidence of psychosis, delirium, dementia. although he did report some symptoms of depression and suicidal thoughts, he was not at risk of suicide acutely. at one point, the patient requested to go home for 3 days prior to going to rehab. although he was secretive about reason for wanting to go home, it was determined that he convincingly denies that this involves any suicidal or otherwise dangerous activity. renal: the patient??????s creatinine increased somewhat from 1.1-1.4 but this was below his baseline of 1.5-1.7. he has been stable at 1.4. cad: the patient was continued on asa, plavix and metoprolol. his blood pressure was still somewhat high in the 140-150s, and he may need another to control his bp to be started if he is still hypertensive as an outpatient. contact: daughter: home () work (wknd and even): work (weekdays): (ext 325) full code discharge medications: 1. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd (once a day). 2. venlafaxine hcl 75 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 3. venlafaxine hcl 75 mg tablet sig: three (3) tablet po qpm (once a day (in the evening)). 4. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 5. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 6. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). 7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). 8. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 7 days. 10. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 days. 11. percocet 5-325 mg tablet sig: one (1) tablet po every hours. 12. seroquel 25 mg tablet sig: one (1) tablet po at bedtime. discharge disposition: extended care facility: - discharge diagnosis: epistaxis presumed urinary tract infeciton and clostridium difficile colitis deep venous thrombosis status post inferior vena cava filter erosive esophagitis status post right hip orif coronary artery disease s/p stent diastolic cardiac dysfunction discharge condition: good discharge instructions: please complete 7 day course of bactrim 1 tab po bid for presumed uti and flagyl 500 mg po tid (14 day course) for presumed c. diff colitis. please call your doctor or return to ed if you have temperatures > 101.5, severe chest pain, shortness of breath, bleeding or if your symptoms worsen. followup instructions: follow up with your pcp weeks. provider: scan where: radiology phone: date/time: 2:30 provider: breathing tests where: phone: date/time: 3:45 provider: , .d. where: date/time: 4:00 md Procedure: Interruption of the vena cava Transfusion of packed cells Diagnoses: Acidosis Urinary tract infection, site not specified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Intestinal infection due to Clostridium difficile Hematemesis Abdominal aneurysm without mention of rupture Epistaxis

history of present illness: this is a 79-year-old male with a history of coronary artery disease status post right coronary stent, deep venous thrombosis, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, abdominal aortic aneurysm, peptic ulcer disease, hypertension presenting from with confusion, hematemesis, and high white count. the patient was recently admitted from to for a right hip open reduction internal fixation status post a fall. he was also treated with levofloxacin from to for presumed urinary tract infection. on admit he complained of several bouts of diarrhea over the past few days prior to admission as well as fevers and chills. he has a history of recurrent aspiration pneumonia but did not complain of a cough. the day prior to admit he complained of abdominal pain diffusely with bloody emesis times one concurrent with a nosebleed. the morning of admission he was found to be diaphoretic, pale, and his white count was elevated to 34. in the emergency department he received vancomycin, ceftriaxone, and flagyl empiric. his hematocrit was found to be 29 and decreased to 17. after one unit of packed red cells it was improved to 26. he was guaiac negative and trace guaiac positive brown stool. nasogastric lavage was clear with flecks of blood. chest x-ray was negative. abdominal ct showed no acute process. his systolic blood pressure in the emergency department dropped to the 80s which was responsive to intravenous fluid boluses. his heart rate also transiently decreased to the 40s with an atrial arrhythmia. he was given two liters of normal saline as well as two units of packed red cells. past medical history: coronary artery disease status post non-st elevation myocardial infarction status post right coronary artery stent in with two- vessel disease, diastolic dysfunction, ejection fraction 60 percent deep venous thrombosis on coumadin status post right hip open reduction internal fixation in paroxysmal atrial fibrillation mild chronic obstructive pulmonary disease abdominal aortic aneurysm repair diverticulosis peptic ulcer disease/gastroesophageal reflux disease hypertension hyperlipidemia depression carotid stenosis osteoarthritis benign prostatic hypertrophy status post transurethral resection of the prostate chronic renal insufficiency with baseline creatinine of 1.6 to 1.8 medications: 1. lopressor 50 mg p.o. b.i.d. 2. atorvastatin 10 mg q.d. 3. venlafaxine 150 mg q. a.m., 225 mg q. p.m. 4. aspirin 325 mg q.d. 5. protonix 40 mg q.d. 6. colace 100 mg b.i.d. 7. atrovent nebulizer and albuterol nebulizer p.r.n. 8. calcium carbonate 500 mg p.o. t.i.d. 9. vitamin d 400 units q.d. 10. alprazolam 1 to 2 mg q. h.s. p.r.n. 11. trazodone 25 mg q. h.s. p.r.n. 12. senna 13. percocet one to two tabs p.o. q. 4 to 6 hours p.r.n. 14. coumadin 3 mg q. h.s. 15. levofloxacin 250 mg q.d. finish course . allergies: no known drug allergies. pertinent laboratory data on admit: his white count was 34.5, hematocrit 29, 17, and then 26, inr 1.3, bun 67, creatinine 1.8, anion gap 15, cardiac enzymes negative times three, haptoglobin normal. urinalysis showed positive nitrites, moderate bacteria, trace leukocyte esterase, 11 to 20 white blood cells, 0 red blood cells, lactate 6 and on repeat 2.2. ct of the abdomen and pelvis showed bibasilar atelectasis with relative sparing of subpleural region. abdominal aortic aneurysm unchanged to prior study. chest x-ray: no acute cardiopulmonary process. ekg in emergency department during a bout of hypotension showed depressions anterolaterally with resolution of depressions on the floor. hospital course by problem: hematemesis: the patient was transfused a total of four units of packed red blood cells and continued to have a stable hematocrit checked every six hours. egd was done by gastroenterology which showed no active bleeding and was consistent with erosive esophagitis. he was continued on protonix 40 mg q.d. likely, his hematemesis was secondary to his episode of epistaxis the day prior to admit. h. pylori is pending. infectious disease: patient's white count was 34 on admit. he had low-grade temperatures to 99 and 100 degrees fahrenheit. he was started empirically on a course of p.o. flagyl to cover for clostridium difficile as the patient was recently on levofloxacin and complained of diarrhea prior to admit. his urinalysis was also a positive. on admit he was started on ceftriaxone as well as vancomycin. this was switched to bactrim before discharge. cultures are pending. deep venous thrombosis: the patient has a history of a deep venous thrombosis in on coumadin with a goal inr of 2 to 3. he was given two doses of vitamin k at before transfer. his inr on admit was 1.3. as the patient could not be anticoagulated on the first night, inferior vena cava filter was placed and after the normal egd, his coumadin was resumed. pulmonary: the patient is on albuterol and atrovent nebulizers. he was 7 to 8 liters positive during the course of this stay and mildly fluid overloaded. he required two liters oxygen by nasal cannula and responded well to lasix during his diastolic cardiac dysfunction. he will be discharged on 20 mg p.o. q.d. renal: patient's creatinine improved to baseline and anion gap resolved, likely from a non-gap metabolic acidosis from his prior diarrhea. coronary artery disease status post stent: he was continued on his aspirin and plavix. fluids, electrolytes, and nutrition: the patient's diet was advanced and he tolerated it well before discharge. contact: wife. full code. disposition: the patient will be discharged back to for continued rehabilitation after his open reduction internal fixation. discharge status: good. discharge medications: 1. coumadin 3 mg p.o. q. h.s. 2. protonix 40 mg p.o. q.d. 3. aspirin 81 mg p.o. q.d. 4. plavix 75 mg p.o. q.d. 5. percocet one to two tabs p.o. q. 4 to 6 hours p.r.n. 6. flagyl 500 mg p.o. t.i.d. times 12 days 7. bactrim one tablet p.o. b.i.d. times seven days 8. trazodone 12.5 mg p.o. q. h.s. p.r.n. 9. albuterol and atrovent nebulizers q. 6 hours p.r.n. 10. venlafaxine 150 mg p.o. q. a.m., 225 mg q. p.m. 11. lipitor 10 mg p.o. q.d. , dictated by: medquist36 d: 11:26:52 t: 15:31:50 job#: Procedure: Interruption of the vena cava Transfusion of packed cells Diagnoses: Acidosis Urinary tract infection, site not specified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Intestinal infection due to Clostridium difficile Hematemesis Abdominal aneurysm without mention of rupture Epistaxis

history of present illness: the patient was initially evaluated in dr. office on . he has a known aneurysm. he underwent aortogram with coil embolization to the right internal iliac artery which he tolerated well. he now returns for an endovascular aneurysm repair. past medical history: 1. hypercholesterolemia. 2. chronic obstructive pulmonary disease. 3. hepatitis. 4. chronic low back pain. 5. right hip pain. 6. echocardiogram in showed left atrial dilatation, left ventricular hypertrophy, with normal systolic function. 7. electrocardiogram and stress in was without electrocardiogram changes. 8. he has a history of peptic ulcer disease with symptoms over six to eight years. past surgical history: 1. transurethral resection of prostate in . 2. a cystoscopy in and . 3. hemorrhoidectomy in . 4. appendectomy in . allergies: he has no known drug allergies. medications on admission: darvon, effexor 2.25 mg p.o. q.d., xanax 1 mg p.o. p.r.n., cardura 4 mg p.o. at bedtime. physical examination: blood pressure 166/86, pulse 75, respirations 20. the general appearance revealed an overweight russian-speaking gentleman in no acute distress. his heent examination was unremarkable. his heart had a regular rate and rhythm, distant heart sounds. no extra murmur, rubs or gallops. chest revealed distant lungs sounds bilaterally in all lung fields. no adventitious sounds. abdomen was round, soft, and nontender. no bruits were noted. no organomegaly was noted. the abdominal aorta was not prominent. the extremities showed edema bilaterally with palpable posterior tibialis pulses. preoperative laboratory: hematocrit of 41.5, creatinine 1.5, pt and inr were normal. radiology/imaging: electrocardiogram showed inverted t waves in i, avl, v5, and v6; unchanged from . hospital course: the patient is now admitted endovascular abdominal aortic repair. the patient was admitted to the preoperative holding area. on , he underwent an endovascular abdominal aortic aneurysm repair without incident. he was transferred to the postanesthesia care unit in stable condition with dopplerable dorsalis pedis and posterior tibialis bilaterally. postoperatively, he remained hemodynamically stable. his postoperative hematocrit was 34.6. his bun was 16, creatinine 1.5, potassium 4.2, magnesium 2.2. he had a palpable dorsalis pedis bilaterally. bowel sounds were present. lungs were clear to auscultation. he continued to do well and was transferred to the surgical intensive care unit for continued monitoring and care. vascular on call was called to see the patient at 3:30 a.m. on postoperative day one for complaints of chest pain. vital signs were blood pressure of 121/51, pulse 72, respiratory rate 19, oxygen saturation 96% on room air. lung examination and cardiac examination were unremarkable. abdomen remained soft and nontender. pulse examination remained unchanged. an electrocardiogram was obtained. there were no acute ischemic electrocardiogram changes. serial creatine kinase, mb, and electrocardiogram were obtained. electrolytes were obtained. hematocrit was obtained. results revealed hematocrit was stable at 31.8. electrolytes showed a potassium of 5.1, bun 19, creatinine 1.5, ionized calcium 1.12. creatine kinase total was 1400. mbs were 16, 10, and 7. troponin was less than 0.3. serial electrocardiograms returned to baseline. the patient remained hemodynamically stable with a temperature maximum of 101.2. incentive spirometry was begun. perioperative kefzol was continued. he remained in the vascular intensive care unit. on postoperative day two he defervesced. he ruled out for myocardial infarction and was delined and transferred to the regular nursing floor. his foley was discontinued, but the patient failed to void and required the foley to be replaced. on the day of transfer he had a temperature maximum of 100.4 to 98.7. groin dressings were clean, dry and intact. abdomen was soft, nontender, and nondistended. foley was in place. culture and sensitivity and urinalysis were sent for evaluation. the patient was continued on kefzol. urology was consulted with regard to failure to void in a patient with known transurethral resection of prostate. discharge disposition: the patient was evaluated by physical therapy and felt that he would benefit from a short stay in rehabilitation for increasing endurance and mobility. the patient was requested to be screened by transitional care unit. medications on discharge: 1. cardura 4 mg p.o. q.d. 2. ancef 1 g intravenous q.8.h. 3. percocet tablets one to two tablets q.4h. p.r.n. for pain. 4. heparin 5000 units subcutaneous b.i.d. 5. ocean spray to both nostrils p.r.n. 6. xanax 0.5 mg p.o. q.h.s. 7. flexeril 10 mg p.o. q.d. 8. dulcolax suppository p.r.n. 9. colace 100 mg p.o. b.i.d. 10. dulcolax tablets 5 mg to 10 mg p.o. p.r.n. discharge diagnoses: 1. abdominal aortic aneurysm. 2. status post endovascular stent. 3. fever secondary to unclear etiology; urine and culture and sensitivity pending at the time of dictation. 4. failure to void with a history of transurethral resection of prostate; genitourinary consulted. , m.d. dictated by: medquist36 Procedure: Endovascular implantation of other graft in abdominal aorta Other endovascular procedures on other vessels Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Retention of urine, unspecified Abdominal aneurysm without mention of rupture Aneurysm of iliac artery

allergies: latex attending: chief complaint: intermittant abdominal and back pain for 10 days major surgical or invasive procedure: abdominal aortic aneurysm s/p repair history of present illness: 83 yo m s/p evar in by dr. for an infrarenal aaa. he has been lost to follow up since that time. he has been c/o intermittant abdominal and back pain for the last 10 days, with an acute increase in pain at around 6pm this evening. he was seen by his pcp and a nc ct was obtained, showing enlargement of the aaa from ~ 5x5 to ~ 7x7. his symptoms were thought to be due to constipation and he was sent home recommendations to see dr. in clinic asap. a repeat nc ct was done this evening, due to his cri, which showed the enlarged aaa with extravasation of high-density fluid anteriorly. the aaa also appears to now involve the renal arteries b. he arrived in the ed hypertensive with sbp >200. we have since given him labetalol and he is now on a nitro gtt for bp control, goal sbp <100. he is currently mentating. we have discussed the gravity of this situation and he wishes us to proceed with an attempt at operative repair. past medical history: 1. coronary artery disease, status post mi in . 2 vessel disease s/p successful pci to mid-rca 2. hypertension. 3. hyperlipidemia. 4. paroxysmal atrial fibrillation. 5. history of abdominal aortic aneurysm. 6. history of deep venous thrombosis. 7. chronic obstructive pulmonary disease. 8. peptic ulcer disease. 9. history of esophagitis. 10. history of gastrointestinal bleeding. 11. diverticulosis. 12. renal insufficiency. 13. lumbosacral radiculopathy. 14. depression. 15. history of hip fracture. past surgical history: 1. status post stent graft surgery for abdominal aortic aneurysm. 2. status post filter placement for history of dvt. 3. status post hip replacement. social history: home: lives with wife of 60 years at home; supportive family with 1 daughter, 2 granddaughter and great-granddaughters : retired math professor denies tobacco, etoh, drugs family history: noncontributory physical exam: vs: t 98.8 hr 56 bp 100/56 gen: nad. a&ox3. heart: , . now brady in the 50's. lungs: diminshed bases b/l. abdomen: + guarding. ttp diffusely. + palpable mass mid-abdomen. pulses: palpable femoral pulses b. no peripheral edema. labs: trop-t: <0.01 ck: 35 mb: notdone 144 109 23 / ------------- 109 4.5 26 1.7 \ ca: 9.8 mg: 2.2 p: 2.6 alt: 5 ap: 62 tbili: 0.5 alb: 3.9 ast: 12 lip: 17 143 103/ ------- 100 4.2 27 \ freeca:1.18 lactate:1.3 ph:7.42 hgb:13.4 calchct:40 pt: 13.4 ptt: 30.6 inr: 1.1 abd./pelvis ct: new stranding and high-attenuation fluid surrounding large abdominal aortic aneurysm, which is slightly increased in size since very recent exam of . of note, the stent endograft has migrated significantly inferiorly since previous contrast-enhanced scan of . while no evidence of intramural hemorrhage, active endoleak or extravasation of contrast is seen, these findings are concerning, and may represent impending leak or rupture. alternatively, the inflammation surrounding the aortic aneurysm could represent a process such as aortitis (though no evidence of such was seen as recently as three days before). pertinent results: 07:20am blood wbc-7.9 rbc-3.51* hgb-9.8* hct-30.8* mcv-88 mch-28.1 mchc-32.0 rdw-15.1 plt ct-257 04:51am blood wbc-8.0 rbc-3.31* hgb-9.6* hct-28.6* mcv-86 mch-29.0 mchc-33.5 rdw-15.3 plt ct-251 04:52am blood wbc-6.8 rbc-3.43* hgb-9.8* hct-29.7* mcv-86 mch-28.5 mchc-33.0 rdw-15.0 plt ct-222 02:10am blood wbc-7.5 rbc-3.69* hgb-10.5* hct-31.7* mcv-86 mch-28.4 mchc-33.0 rdw-14.8 plt ct-235 03:00am blood wbc-8.6 rbc-3.56* hgb-10.3* hct-30.7* mcv-86 mch-28.8 mchc-33.4 rdw-14.9 plt ct-219 02:42am blood wbc-9.4 rbc-3.60* hgb-10.7* hct-31.0* mcv-86 mch-29.8 mchc-34.5 rdw-14.9 plt ct-206 03:11am blood wbc-8.3 rbc-3.41* hgb-9.9* hct-29.4* mcv-86 mch-29.1 mchc-33.8 rdw-15.1 plt ct-168 01:08am blood wbc-8.6 rbc-3.21* hgb-9.1* hct-28.2* mcv-88 mch-28.4 mchc-32.3 rdw-14.8 plt ct-126* 04:24am blood wbc-10.4 rbc-2.97* hgb-8.6* hct-26.7* mcv-90 mch-29.1 mchc-32.4 rdw-14.3 plt ct-124* 02:05am blood wbc-10.7 rbc-3.43* hgb-10.0* hct-29.6* mcv-86 mch-29.2 mchc-33.9 rdw-14.3 plt ct-155 08:30am blood wbc-12.1* rbc-3.63* hgb-10.6* hct-31.3* mcv-86 mch-29.3 mchc-34.0 rdw-13.6 plt ct-197 03:18am blood hgb-9.4*# hct-27.9*# 12:50am blood wbc-9.8 rbc-4.42* hgb-12.6* hct-37.7* mcv-85 mch-28.6 mchc-33.5 rdw-13.3 plt ct-229 12:50am blood neuts-69.3 lymphs-23.6 monos-4.8 eos-1.4 baso-0.8 07:20am blood plt ct-257 07:20am blood pt-13.2 ptt-28.6 inr(pt)-1.1 04:51am blood plt ct-251 04:52am blood plt ct-222 02:10am blood plt ct-235 03:00am blood plt ct-219 02:42am blood plt ct-206 02:42am blood pt-12.7 ptt-31.1 inr(pt)-1.1 03:11am blood plt ct-168 03:11am blood pt-12.1 ptt-34.3 inr(pt)-1.0 09:45am blood pt-12.2 inr(pt)-1.0 01:08am blood plt ct-126* 04:24am blood plt ct-124* 04:24am blood pt-14.7* ptt-38.8* inr(pt)-1.3* 04:24am blood pt-14.7* ptt-38.8* inr(pt)-1.3* 02:05am blood plt ct-155 02:05am blood pt-15.7* ptt-41.1* inr(pt)-1.4* 08:30am blood plt ct-197 08:30am blood pt-16.1* ptt-35.8* inr(pt)-1.4* 03:18am blood pt-15.1* ptt-40.9* inr(pt)-1.3* 12:50am blood plt ct-229 10:05am blood glucose-125* urean-34* creat-1.8* na-141 k-4.1 cl-104 hco3-32 angap-9 07:20am blood glucose-112* urean-38* creat-2.0* na-141 k-4.0 cl-105 hco3-30 angap-10 04:51am blood glucose-124* urean-45* creat-2.2* na-141 k-3.5 cl-106 hco3-29 angap-10 04:52am blood glucose-92 urean-47* creat-2.3* na-140 k-3.7 cl-107 hco3-25 angap-12 02:10am blood glucose-104 urean-49* creat-2.5* na-142 k-3.9 cl-111* hco3-25 angap-10 03:00am blood glucose-98 urean-49* creat-2.6* na-142 k-4.2 cl-112* hco3-21* angap-13 04:38pm blood creat-2.7* 02:42am blood glucose-141* urean-45* creat-2.8* na-141 k-4.6 cl-111* hco3-22 angap-13 03:11am blood glucose-116* urean-40* creat-2.6* na-140 k-4.2 cl-113* hco3-21* angap-10 01:08am blood glucose-79 urean-34* creat-2.6* na-139 k-4.1 cl-112* hco3-19* angap-12 04:24am blood glucose-76 urean-32* creat-2.2* na-140 k-4.5 cl-115* hco3-20* angap-10 02:05am blood glucose-91 urean-28* creat-2.2* na-142 k-4.4 cl-116* hco3-22 angap-8 08:30am blood glucose-198* urean-22* creat-1.6* na-142 k-4.7 cl-114* hco3-23 angap-10 12:50am blood glucose-109* urean-23* creat-1.7* na-144 k-4.5 cl-109* hco3-26 angap-14 09:45am blood alt-4 ast-20 ld(ldh)-229 alkphos-37* totbili-0.6 08:30am blood ck(cpk)-65 12:50am blood alt-5 ast-12 ck(cpk)-35* alkphos-62 totbili-0.5 12:50am blood lipase-17 08:30am blood ck-mb-notdone ctropnt-0.01 12:50am blood ctropnt-<0.01 12:50am blood ck-mb-notdone 10:05am blood calcium-8.6 phos-3.0 mg-1.9 07:20am blood calcium-8.0* phos-3.5 mg-2.0 04:51am blood calcium-8.2* phos-3.5 mg-2.2 04:52am blood calcium-8.3* phos-3.5 mg-2.1 02:10am blood calcium-8.2* phos-2.8 mg-2.2 04:32pm blood mg-2.2 03:00am blood calcium-8.3* phos-3.0 mg-2.3 02:42am blood calcium-8.5 phos-3.7 mg-2.3 03:11am blood calcium-8.2* phos-4.3 mg-1.9 09:45am blood albumin-2.2* 01:08am blood calcium-8.2* phos-3.5 mg-1.8 04:24am blood calcium-7.7* phos-3.6 mg-1.7 chest (portable ap) 12:47 am findings: single portable upright chest radiograph is reviewed without comparison. cardiomediastinal silhouette is unchanged, with lobulated contour to the descending thoracic aorta which appears to correlate to thoracic saccular aneurysm seen on prior ct from . minimal scarring in the right mid lung is unchanged. emphysema is unchanged. there is no new airspace opacity. there is no pleural effusion or pneumothorax, though note, a portion of the left hemithorax and costophrenic sulcus is excluded. impression: 1. increased prominence of lobulated contour of the descending aorta, suggestive of interval growth of known saccular aneurysm at this site. 2. no evidence of pneumonia. ct pelvis w&w/o c 1:04 am comparison: and . ct abdomen: bullous emphysematous changes at the lung bases, right greater than left are unchanged. right basilar atelectasis has increased. liver and gallbladder are normal. there is mild dilatation of the extrahepatic common bile duct, measuring up to 13 mm. no sign of stone or other obstructing lesion is seen. pancreas is fatty replaced, and atrophic. spleen is normal. the stomach and intra-abdominal loops of bowel are normal. there is no sign of bowel obstruction. kidneys are atrophic bilaterally, with unchanged small cystic lesions too small to definitively characterize. contrast is excreted symmetrically. there is no hydronephrosis. large infrarenal abdominal aortic aneurysm is again seen. the aneurysm has slightly increased in size, measuring 7.3 x 6.9 cm. the endovascular stent graft is again identified below the renal arteries, with limbs extending into both common iliac arteries. stent graft is unchanged in position from . however, note is made that when compared to previous contrast- enhanced study of , the stent has shifted significantly in position, at least 3 cm inferiorly. while there is no definite evidence of leak or extravasation of contrast from the stent, and there is no increased density seen within the aneurysm sac, there is now a moderate amount of inflammatory stranding seen around the aneurysm sac. there is also dense fluid (48 on non-contrast imaging) seen tracking along the left aspect of the aneurysm sac (2:47). there is no free intraperitoneal air, or abnormal intra-abdominal lymphadenopathy. ct pelvis: pelvic loops of large and small bowel are normal, though lower pelvis evaluation is limited by streak artifact from right hip prosthesis. there is no free pelvic fluid or abnormal pelvic or inguinal lymphadenopathy. aneurysm coil in the right internal iliac artery is unchanged. osseous structures: right hip prosthesis is unchanged. ill-defined sclerotic lesion in the right iliac bone is unchanged. mild degenerative changes in the lumbar spine are stable. impression: new stranding and high-attenuation fluid surrounding large abdominal aortic aneurysm, which is slightly increased in size since very recent exam of . of note, the stent endograft has migrated significantly inferiorly since previous contrast-enhanced scan of . while no evidence of intramural hemorrhage, active endoleak or extravasation of contrast is seen, these findings are concerning, and may represent impending leak or rupture. alternatively, the inflammation surrounding the aortic aneurysm could represent a process such as aortitis (though no evidence of such was seen as recently as three days before). ecg study date of 9:22:24 am artifact is present. sinus rhythm. there are non-diagnostic q waves in the inferior leads. diffuse non-specific st-t wave changes. compared to the previous tracing early transition is no longer present. chest (portable ap) 3:46 pm indication: dobbhoff placement. comparison: . frontal chest radiograph: there has been interval removal of the endotracheal tube. the dobbhoff tube is seen with tip projecting over the proximal duodenum. right-sided central venous line is in unchanged position. otherwise, no significant change seen compared to prior study with persistent bibasilar opacities and small bilateral pleural effusions. impression: dobbhoff tube seen with tip projecting over the proximal duodenum. otherwise, no significant change from prior. ecg study date of 11:45:24 am sinus rhythm. non-specific inferolateral t wave flattening. compared to the previous tracing of the q wave is absent in lead iii and less pronounced in lead avf. t wave flattening is new. brief hospital course: 83 yo m s/p evar in by dr. for an infrarenal aaa. he has been lost to follow up since that time. he has been c/o intermittant abdominal and back pain for the last 10 days, with an acute increase in pain at around 6pm this evening. he was seen by his pcp and a nc ct was obtained, showing enlargement of the aaa from ~ 5x5 to ~ 7x7. his symptoms were thought to be due to constipation and he was sent home recommendations to see dr. in clinic asap. a repeat nc ct was done this evening, due to his cri, which showed the enlarged aaa with extravasation of high-density fluid anteriorly. the aaa also appears to now involve the renal arteries b. he arrived in the ed hypertensive with sbp >200. we have since given him labetalol and he is now on a nitro gtt for bp control, goal sbp <100. he is currently mentating. we have discussed the gravity of this situation and he wishes us to proceed with an attempt at operative repair. patient was admitted for open aaa repair and further management. hd1 patient was taken to or by dr. for repair of ruptured aaa. patient tolerated procedure well. post-operatively patient was transfered to the icu for recovery. patient sedated and intubated. patient rousable and responsive. patient placed on levo and cipro for antibiotics. npo. on riss for blood sugar control. vitals signs stable on pressors (levophed gtt.), low dose beta blocker. labs stable. pod1 remains in icu, intubated, sedated on propofol and fentanyl drips. antibiotics switched to ancef and cipro. afebrile. remains npo. poor urine output- hydrated. plans to wean to extubate, wean off drips. pod2 remains in icu, intubated but weaning, sedated. continues to require ivf. given 1 unit of prbc. afebrile. npo. pod3 remains in icu, intubated-continues to wean, minimally sedated. diuresed with lasix. remains on cipro. transfused 1 unit prbc. adequate uop. afebrile. riss. pod4 remains in icu. vent weaned and extubated. reamins on fentanyl drip for pain management. hypertensive- increased beta blocker.good uop. continues on cipro. pod5 remains in icu. awake, extubated, afebrile. diuresed with lasix-adequate uop. resumed some home meds. tube feeds via ngt. cipro d/c'd. riss. pod6 remains in icu, hypertensive- started on nitro gtt, increased antihypertensives. afebrile. dob off placed, tube feeds increased- well tolerated. gentle diuresis. plan to transfer to stepdown. resumed most home meds. riss. pod7 speech and swallow eval-ok to start pos as tolerated, thickened liquids. remains in icu. nitro gtt for hypertension. diuresed with lasix. afberile. physical therapy referral. transferred to vicu 5. pod8 vicu status, vss, afebrile. diuresed. pulmonary toilet. no acute events. pod9 vicu status, vss, afberile. increasing diet. no acute events. pod10 vicu staus, vss, afberile. dat. pt re-consult, ambulate. diuresed. dispo planning. pod11 floor status, vss, afebrile. d/c foley. rehab screen for dispo.afebrile. no acute events. restarted cipro for citrobacter freundii complex that grew from urine cx on . pod12 discharged to rehab ( of ) in good condition. will d/c on cipro for 2 wks. fu for dr. already set up. medications on admission: oxycodone 5mg q4prn amlopidine 5mg qd lisinopril 25 (20 + 5) mg qd metoprolol 12.5 mg alprazolam 1 mg qhs gabapentin 300/200 mg omeprazole 20 mg qd simvastatin 20 mg qd venlafaxine xr 225 mg qhs senokot tab qhs discharge medications: 1. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 4. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed. 5. gabapentin 100 mg capsule sig: two (2) capsule po hs (at bedtime). 6. gabapentin 100 mg capsule sig: one (1) capsule po q am (). 7. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 9. venlafaxine 75 mg capsule, sust. release 24 hr sig: three (3) capsule, sust. release 24 hr po daily (daily). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 11. hydralazine 50 mg tablet sig: two (2) tablet po q6h (every 6 hours). 12. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 13. albuterol sulfate 2.5 mg/3 ml solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed. 14. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 15. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 2 weeks. 16. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). 17. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 18. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. discharge disposition: extended care facility: of discharge diagnosis: abdominal aortic aneurysm s/p repair cad htn hyperlipidemia paf h/o dvt with ivc filter copd pud with gib esophagitis diverticulosis renal insufficiency lumbosacral radiculopathy depression discharge condition: good discharge instructions: division of vascular and endovascular surgery abdominal aortic aneurysm (aaa) surgery discharge instructions what to expect when you go home: 1. it is normal to feel weak and tired, this will last for weeks ?????? you should get up out of bed every day and gradually increase your activity each day ?????? you may walk and you may go up and down stairs ?????? increase your activities as you can tolerate- do not do too much right away! 2. it is normal to have incisional and leg swelling: ?????? wear loose fitting pants/clothing (this will be less irritating to incision) ?????? elevate your legs above the level of your heart (use pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated 3. it is normal to have a decreased appetite, your appetite will return with time ?????? you will probably lose your taste for food and lose some weight ?????? eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do: ?????? no driving until post-op visit and you are no longer taking pain medications ?????? you should get up every day, get dressed and walk, gradually increasing your activity ?????? you may up and down stairs, go outside and/or ride in a car ?????? increase your activities as you can tolerate- do not do too much right away! ?????? no heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? you may shower (let the soapy water run over incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? take all the medications you were taking before surgery, unless otherwise directed ?????? take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? call and schedule an appointment to be seen in 2 weeks for staple/suture removal what to report to office: ?????? redness that extends away from your incision ?????? a sudden increase in pain that is not controlled with pain medication ?????? a sudden change in the ability to move or use your leg or the ability to feel your leg ?????? temperature greater than 101.5f for 24 hours ?????? bleeding from incision ?????? new or increased drainage from incision or white, yellow or green drainage from incisions followup instructions: provider: , md phone: date/time: 1:30 provider: , md phone: date/time: 3:20 Procedure: Enteral infusion of concentrated nutritional substances Resection of vessel with replacement, aorta, abdominal Transfusion of packed cells Diagnoses: Anemia, unspecified Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Other and unspecified hyperlipidemia Old myocardial infarction Unspecified disorder of kidney and ureter Personal history of venous thrombosis and embolism Urinary complications, not elsewhere classified Abdominal aneurysm, ruptured Mechanical complication of other vascular device, implant, and graft Allergy to latex

history of present illness: is the former 3 kg product of a 36 and 6/7 weeks gestation pregnancy, born to a 40 year-old, g3, p1 now 2 woman. prenatal screens: blood type 0 positive, antibody negative, rubella immune, rpr nonreactive, hepatitis b surface antigen negative, group beta strep status unknown. the mother's obstetrical history is notable for an intrauterine fetal demise at 32 weeks gestation which occurred in . this pregnancy was uncomplicated with planned early delivery secondary to concern with the prior intrauterine fetal demise. the mother was taken to elective cesarean section on . the infant emerged with spontaneous respirations. she required oxygen, bulb suctioning as part of her resuscitation. apgars were 7 at 1 minute and 8 at 5 minutes. she was admitted to the nicu due to respiratory distress. physical examination: upon admission to the neonatal intensive care unit, weight was 3000 grams; length was 49 cm; head circumference was 34 cm. general: non dysmorphic, near term female in moderate respiratory distress. heent: anterior fontanel soft and flat; non dysmorphic facies; palate intact. neck and mouth normal. mild nasal flaring. chest: mild subcostal retractions. good breath sounds bilaterally. no adventitious sounds. cardiovascular: well perfused. regular rate and rhythm. femoral pulses normal. normal s1 and s2. no murmur. abdomen soft, nondistended, no organomegaly, no masses. bowel sounds active. anus patent. genitourinary: normal female genitalia. spine straight, normal sacrum. skin normal. no rashes. extremities: moving all, hips stable. neurologic: active, alert, reactive to stimuli. tone normal and symmetric, moving all extremities. suck, root, gag intact. facies symmetric. hospital course: 1. respiratory: had respiratory distress consistent with retained fetal lung fluid. she did require 400 cc of nasal cannula oxygen flow for the first few hours after birth. by day of life 1, she was in room air and she continued in room air for the rest of her neonatal intensive care unit admission. she had an episode of spontaneous apnea and bradycardia associated with a feeding on day of life 2. therefore, she remained for an additional 5 day observation. during that time, she has not had any further episodes of apnea and bradycardia. at the time of discharge, she is breathing comfortably in room air with a respiratory rate of 30 to 50 breaths per minute. 1. cardiovascular: has maintained normal blood pressure and heart rates. no murmurs have been noted. baseline heart rate is 130 to 160 beats per minute with a recent blood pressure of 71/42 mmhg, mean arterial pressure of 52 mmhg. 1. fluids, electrolytes and nutrition: was initially n.p.o. and maintained on iv fluids. enteral feeds were started on day of life 1 and were advanced to full volumes. at the time of discharge, she is breast feeding or taking similac 20 formula ad lib. weight on the day of discharge is 2.755 kg with a corresponding head circumference of 34 cm and a length of 49.5 cm. 1. infectious disease: due to the unknown etiology of the respiratory distress and the unknown group beta strep status of the mother, was evaluated for sepsis upon admission to the nicu. a complete blood count was within normal limits and a blood culture was obtained prior to starting iv ampicillin and gentamycin. the blood culture was no growth at 48 hours and the antibiotics were discontinued. 1. hematology: is blood type 0 positive and is direct antibody test negative. hematocrit at birth was 44.3%. she did not receive any transfusions of blood products. 1. gastrointestinal: had a peak serum bilirubin occur on day of life 4 with a total of 13.4 mg/dl. her repeat bilirubin on day of life 5 was down to 12.3 mg/day of life total. a serum bilirubin obtained on the day of discharge is 10.6/0.3. 1. neurologic: has maintained a normal neurologic exam during admission. there are no concerns at the time of discharge. 1. sensory: audiology: hearing screening was performed with automated auditory brain stem responses. passed in both ears on . condition on discharge: good. discharge disposition: home with the parents. primary pediatrician: dr. , ., , , telephone number . care and recommendations: 1. ad lib p.o. feeding; breast feeding or similac 20 formula. 2. no medications. 3. car seat position screening was performed. was observed in her car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia. 4. state newborn screen was sent on . there has been no notification of abnormal results to date. 5. immunizations: hepatitis b vaccine was administered on . 6. immunizations recommended: synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria: (1) born at less than 32 weeks; (2) born between 32 weeks and 35 weeks with two of the following: day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. follow up: 1. appointment with dr. within 3 days of discharge. discharge diagnoses: 1. prematurity at 36 and 3/7 weeks gestation. 2. transitional respiratory distress. 3. suspicion for sepsis, ruled out. , md Procedure: Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Primary apnea of newborn Neonatal bradycardia 35-36 completed weeks of gestation Other preterm infants, 2,500 grams and over Transitory tachypnea of newborn

allergies: pcn->rash pmh: esophageal ca diagnosed has completed course of chemo/xrt, pvd, iddm, polio as child, ue dvt, recent bladder infection. meds: nph. cipro(bladder infection) Procedure: Venous catheterization, not elsewhere classified Diagnoses: Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified protein-calorie malnutrition Atrial fibrillation Atrial flutter Other septicemia due to gram-negative organisms Acute and subacute bacterial endocarditis Malignant neoplasm of other specified part of esophagus

history of present illness: the patient is a 76 year-old male with a history of esophageal cancer, type 2 diabetes, who presented to the emergency department with a chief complaint of weakness. the patient has been in declining health since secondary to his esophageal cancer and has noted decreasing po intake secondary to mucositis over the last few months. the patient has also complained of increasing bilateral lower extremity edema over the last month and has been seen by his primary care physician in the past for intravenous fluid administration. on the day of presentation the patient once again presented originally to his primary care physician, . , requesting intravenous fluid administration. the patient was thought to be significantly dehydrated on examination and was therefore referred to the emergency department for evaluation. in the emergency department the patient was noted to have a heart rate in the 140s with progressive hypoxia to as low as 77% on a nonrebreather. the patient was subsequently immediately admitted to the intensive care unit for progressive hypoxia. review of systems: positive for a cough for the last three to four weeks, which was worse when he attempted to eat or drink anything, as well as a low grade temperature and chills for the last two days. the patient also has noted significantly increasing leg edema over the last few weeks. at the time of admission to the emergency department, the patient tripped and fell and hit his head on his way into the emergency department. past medical history: 1. esophageal cancer treated with local radiation therapy, 5fu, cisplatin diagnosed in . 2. status post billroth 2 in the secondary to peptic ulcer disease. 3. type 2 diabetes mellitus times ten years. 4. polio as a child. 5. questionable abruption of many deep venous thrombosis. 6. recurrent bladder infections. allergies: penicillin causes a rash. medications: nph. social history: tobacco use in the past, but quit in the and reports a three pack per day history times twenty years prior to this. the patient denies any alcohol use. family history: the patient has a son who has been diagnosed with renal cell carcinoma. the patient's primary care physician is . and he is followed by oncologist dr. . physical examination: vital signs, temperature 99.4. heart rate 140. blood pressure 122/75. respiratory rate 16. sating 98% on room air and then subsequently 77% on 100% face mask. general, ill appearing, elderly thin male. heent right temple with ecchymosis, pupils are equal, round and reactive to light. extraocular movements intact. poor dentition. cardiovascular tachycardic, no murmurs. pulmonary diffuse rales. abdomen soft, midline surgical scar. rectal examination guaiac negative. extremities 3+ bilateral lower extremity edema to the knees. laboratory: white blood cell count 7.7, hematocrit 29.7, platelets 225, sodium 127, potassium 4.4, chloride 94, bicarb 27, bun 18, creatinine 0.7, glucose 288. free calcium 1.05. arterial blood gas 7.48/30/67/lactate equals 1.8. chest x-ray bibasilar infiltrates in the dependent regions. ct of the head no evidence of bleed or mass, but low attenuation left cerebellar area. ct of the chest, diffuse infiltrate consistent with congestive heart failure, but no evidence of pe. electrocardiogram, atrial flutter at 150 beats per minute. hospital course: the patient was noted to have marked hypoxia at the time of admission, which was originally thought to be secondary to a pe, however, his ct angiogram was negative. the ct scan also demonstrated evidence of an alveolar process, which was felt to be congestive heart failure versus pneumonia. given the lack of fever, sputum or increased white blood cell counts and given the patient's symptoms of increasing lower extremity edema, it was felt to be most likely secondary to congestive heart failure. however, the patient was also noted to have a supraventricular tachycardia versus atrial flutter of unclear etiology. the patient was treated with intravenous diltiazem push without change in his pulse, however, his systolic blood pressure did drop to the 70s. therefore an emergent cardiology consult was obtained and cardioversion was attempted with conscious sedation. further diuresis was put on hold pending potential cardioversion. however, cardioversion was attempted with 200 jewels and then 300 and 360 jewels without success resulting in a rhythm of multifocal atrial tachycardia. cardiology consult subsequently recommended attempting rate control with an esmolol drip, initiating gentle diuresis and obtaining a portable echocardiogram to assess function and valvular disease. the patient was placed on an esmolol and a neo-synephrine drip, which were titrated as needed to keep a mean blood pressure of greater then 60 and a rate less then 100. the patient was treated with lasix for gentle diuresis and cardiac enzymes were cycled to evaluate for the potential of myocardial ischemia as an initiating event. the patient's multifocal atrial tachycardia persisted and an echocardiogram was obtained. the echocardiogram demonstrated 4+ mr with a flail mitral leaflet and a normal end systolic dimensions. a vegetation could not be definitively ruled out. given that blood cultures obtained at the time of admission were subsequently demonstrating gram positive coxae in pairs and chains it was felt the patient was most likely suffering from endocarditis. by this time the patient was hemodynamically stable, however, with persistent mat. given the acute onset of mitral regurgitation vasodilator therapy such as ace inhibitor and nitroglycerin were initiated as tolerated. the possibility of surgical correction was discussed with the patient and his family who stated that they did not want surgery under any circumstances. therefore it was determined to attempt medical management of the patient's acute mitral regurgitation and endocarditis. as the patient underwent gentle diuresis his oxygen saturations began to improve and his supplemental oxygen needs were slowly titrated down. the patient's neo-synephrine drip was titrated off and the patient was started on captopril .i.d. an infectious disease consult was obtained to help in the management of endocarditis. the infectious disease consult recommended removing the patient's port-a-cath so that the infection would be easier to cure with antibiotics. they felt the most likely bug responsive was staph aureus versus enterococcus versus strep viridans versus a coag negative staph and therefore requested treatment with penicillin. given the patient's history of a penicillin allergy desensitization to the drug was initiated per protocol. the patient's blood culture results demonstrated enterococcus, which was ampicillin sensitive and therefore the patient was placed on penicillin therapy intravenously with gentamycin for synergy for two weeks after therapy. over the next few hospital days the patient's captopril dose was titrated up as tolerated and his supplemental oxygen requirement was titrated down. the patient's heart rate remained tachycardic, which is felt to be likely a compensatory response given the patient's poor forward flow secondary to acute mitral regurgitation. on the patient was felt to be stable enough to be transferred to the floor. the patient had been off of pressor therapy for the last 48 hours and was tolerating low doses of ace inhibitor for afterload reduction. however, on the evening following transfer to the flor the patient became suddenly tachycardic and hypotensive with a blood pressure in the 70s and a heart rate in the 150s. the patient was treated with 5 mg intravenous lopressor times three with some decrease in his heart rate, but little change in the blood pressure. the patient was subsequently given a normal saline bolus of 250 cc times three and then loaded on digoxin therapy. the patient appeared to respond well to the beta blocker with a decrease in his heart rate, however, additional fluid therapy did little to help the patient's blood pressure and resulting in a significantly worsened oxygen requirement. therefore the patient was treated once again with lasix and over the next few hospital days a careful balance was maintained between controlling the patient's heart rate and not dropping his blood pressure too low. the patient was therefore continued on standing doses of captopril, lopressor and digoxin as well as prn lasix doses, which were titrated up as tolerated over the next few hospital days. the patient maintained a systolic blood pressure in the high 80s to low 90s, however, he tolerated this blood pressure well with adequate urine output and normal mentation. a picc line was placed for long term administration of antibiotic therapy. given the length (two weeks) of gentamycin therapy for synergy against enterococcus the concern for ototoxicity was raised and an audiology consult was obtained. audiology recommended that the patient already had some hearing loss prior to admission for which he was seeking amplification therapies and recommended as little gentamycin as possible with follow up audiology testing following release from the hospital. following transfer to the floor the patient's rhythm converted from a multifocal atrial tachycardia to atrial fibrillation. the patient was currently on digoxin and lopressor for rate control and the patient's heart rate was maintained in the 90s to low 100s. the possibility of cardioversion as a potential therapeutic option was discussed with cardiology who recommended that it was possible that his hemodynamics may improve with cardioversion to normal sinus rhythm. given the state of the patient's mitral valve endocarditis it was unlikely that the patient would be able to maintain his heart rate and normal sinus rhythm successfully. in addition, cardiology recommended that consideration be given to starting the patient on coumadin therapy and this was echoed by the patient's primary oncologist. therefore the patient was started on low dose coumadin therapy with a goal inr of 2.0 to 2.5. at this point given the difficulty of maintaining the patient with adequate blood pressure and heart rate a family meeting was obtained in order to evaluate the patient and families goals in the setting of the medical problems. the results of the family meeting suggested that the family and the patient were hoping that the patient would improve enough to go to a rehab and they did want to complete antibiotic therapy for the current endocarditis. however, the family and the patient all understood the tenuous state of the patient's current health and that while our current medical therapies might provide the patient some degree of improvement. they were incapable of curing the patient's primary problem and would likely only help with short term benefits. however, the patient and his family once again reiterated their desire not to undergo surgical correction of his valvular disease. over the next few hospital days the patient continued to improve very slowly with mild decreases in his lower extremity edema and subjective decreases in shortness of breath and fatigue. however, the patient continued to demonstrate mild setbacks such as on when the patient was transferring from bed to chair and became acutely short of breath with a subsequent heart rate in the 150s, systolic blood pressure in the 60s and a drop in his oxygen saturations to 80 to 85%. at this point, however, the patient was treated with intravenous lopressor 5 mg times two doses with a subsequent drop in his heart rate to the 100s and a bump in his systolic blood pressure to the 190s. therefore it was demonstrated that the patient did well when his lopressor was administered despite low blood pressures, because his blood pressure acutely responsive to his heart rate. therefore his captopril was increased to a dose of 50 mg t.i.d., his beta blocker was increased to a dose of 37.5 mg t.i.d. and digoxin was continued on a q.o.d. basis. in addition, the patient was started on a daily dose of lasix at 20 mg po q day and was monitored for the appropriateness of that dose for continued effective gentle diuresis. over the next few hospital days the patient's medications were titrated as needed while the patient was screened for rehabilitation. the patient was seen by physical therapy and was able to transfer from bed to chair and even improved well enough to walk a few steps. at the time of discharge the patient's lopressor had been titrated up to 62.5 mg t.i.d., which his blood pressure was able to tolerate. in addition, the patient was continued on captopril 50 mg t.i.d., digoxin every other day and lasix 40 mg po b.i.d. a therapeutic inr was obtained on coumadin at 1 mg po q day. although the patient consistently demonstrated a blood pressure with a systolic in the low 80s, the patient maintained adequate urine output and excellent mentation. therefore it was felt that the most important therapeutic intervention was to maintain the patient's heart rate at approximately 100 and therefore the patient's beta blocker should not be held unless his blood pressure was low enough to cause low urine output or mental status changes. the patient was transferred to rehabilitation on the 20th with thirty more days of antibiotic therapy remaining via his picc line and a stable cardiac regimen obtained for management of his acute mitral regurgitation. condition on discharge: the patient was discharged to rehab in guarded, but stable condition. discharge medications: lopressor 62.5 mg po t.i.d. hold for systolic blood pressure less then 70, coumadin 1 mg po q day, nph 6 units subq b.i.d., digoxin 0.125 mg po q o day, captopril 15 mg po t.i.d., ampicillin 2 grams intravenous q 4 hours times thirty days, gentamycin 60 mg intravenous q 12 hours times thirty days, protonix 40 mg po q day, nutra shakes one po t.i.d. with meals, tylenol 650 mg po q 4 to 6 hours prn, regular insulin sliding scale, lasix 30 mg po b.i.d. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified protein-calorie malnutrition Atrial fibrillation Atrial flutter Other septicemia due to gram-negative organisms Acute and subacute bacterial endocarditis Malignant neoplasm of other specified part of esophagus

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p etoh ablation of interventricular septum for hypertrophic obstructive cardiomyopathy major surgical or invasive procedure: ethanol ablation of myocardial interventricular septum history of present illness: patient is a 63 yo male with pmh significant for hypertrophic cardiomyopathy, copd, hypertension and recently diagnosed afib admitted after undergoing etoh ablation of the interventricular septum. the patient has had doe with chest pressure since 1 year. says that he used to get sob and cp while walking up only a slight incline. he denies symptoms at rest. he does have periodic leg edema which he treats with diuretics. he sleeps on two pillows for comfort. denies claudication, pnd, lightheadedness. gives h/o occasional palpitations of about few seconds since 1 year. in early , pt had cp and diaphoresis at rest which subsided after some time. next day he went to play golf but soon developed sob and cp and had to be admitted to . troponin was borderline positive/ck's negative and he was transferred to for cardiac catheterization which revealed a significant subaortic valve pressure gradient that increased with valsalva. he was found in atrial fibrillation during the admission and discharged on coumadin which he stopped taking on . he now came in for ethanol ablation of the myocardial interventricular septum. past medical history: 1)hypertrophic cardiomyopathy (diagnosed 3 years ago) 2)hypertension 3)copd 4)low back pain secondary to herniated disc 5)atrial fibrillation (newly diagnosed) 6)s/p cataract surgery 7)remote knee surgeries 8)thalasemia minor social history: patient is single and lives alone. he has two chdilren. pt smoked 1ppd x 40-50yrs and quit 10 yrs ago. 1-2 beers/day family history: mother w/mi physical exam: vitals bp 142/73 hr 40-50 (irregular) rr 14 o2 sat ?? gen: conscious and cooperative, in nad heent: jvd elevated to about 10cm, perrl, eomi, neck supple chest: cta bilaterally cvs: s1 s2 muffled. ?systolic murmur at lsb. abd: soft, non-tender, non-distended, bs+ neuro: a&ox3, no fnd ext: cath wound on rt groin. no hematoma or bruit. peripheral pulses+ pertinent results: labs 07:22pm blood wbc-6.0 rbc-5.12 hgb-10.8* hct-31.7* mcv-62* mch-21.1* mchc-34.1 rdw-15.7* plt ct-107* 07:22pm blood wbc-6.0 rbc-5.12 hgb-10.8* hct-31.7* mcv-62* mch- 07:22pm blood ck(cpk)-338* 21.1* mchc-34.1 rdw-15.7* plt ct-107* 07:22pm blood ck-mb-61* mb indx-18.0* ctropnt-0.54* 06:08am blood ck(cpk)-743* 06:08am blood ck-mb-128* mb indx-17.2* ctropnt-3.48* 06:30am blood wbc-8.2 rbc-4.81 hgb-10.1* hct-29.7* mcv-62* mch-21.0* mchc-34.0 rdw-15.6* plt ct-96* 06:30am blood glucose-86 urean-14 creat-1.0 na-141 k-3.5 cl-104 hco3-30 angap-11 . echo () - pre septal ablation the left atrium is markedly dilated. there is symmetric left ventricular hypertrophy. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is systolic anterior motion of the mitral valve leaflets with a severe (peak 60-70mmhg) resting left ventricular outflow tract obstruction. following administration of 0.5ml definity (diluted 1.5ml to 8.5ml saline), there was prominent enhancement of the basal septum abutting the mitral valve . the right ventricular free wall did not appear to enhance . echo () - post septal ablation following administration of alcohol (total 2.7ml), there was intense enhancement of the basal interventricular septum in the area abutting the of the mitral valve. persisted, but the lvot gradient declined to <30mmhg peak. overall left ventricular systolic function remained intact.there was no pericardial effusion . brief hospital course: mr. ethanol ablation of myocardial interventricular septum on after which he was transferred to the ccu for monitering for development of heart block. . 1. hypertrophic obstructive cardiomyopathy patient's initial heart rate was in the 40's and irregular (atrial fibrillation). a temporary pacing line was put in at the time of the procedure so that he could be paced if he developed complete heart block and became symptomatic. on the second day his hr picked up and by the 3rd day his temporary pacing line was removed. pt was also started on toprol xl 100mg twice daily and verapamil sr 240 twice daily. he also experienced an episode of chest pain on the 2nd day. given his recent cardiac cath with normal coronoray arteries and unchanged ekg the pain was most likely due to his hocm and he was given morphine. he also experienced 3-4 episodes of groin bleeding at the site of his cath wound. each time manual pressure was applied for about 10 min followed by a pressure dressing. later his heparin was discontinued. pt was transferred to the step down unit for where he did fine. there were no more episodes of groin bleeding and the area was soft without any audible bruit. . 2) atrial fibrillation he was started on heparin drip given his high chads score for risk of stroke due to his atrial fibrillation. however due to repeated groin bleeding at the site of his cath wound heparin was stopped. he was started on coumadin 2.5mg daily. his toprol and verapamil given for hocm also helped in rate control. . 3) hypertension patient was continued on diovan 160mg twice daily. his toprol xl and verapamil were also adjusted to control his bp. lasix which had been stopped on admission was continued on day 4. . 4)fen potassium was continued as his k on admission was 3.1. he was continued on potassium chloride and slowly his potassium improved. he was given healthy cardial diet with low sodium. . 5)disposition the patient is being discharged home. he needs to follow up with his primary care physician, (dr. and with the coumadin clinic. if he develops syncope, palpitations or persistent chest pain he should immediately contact his cardiologist. medications on admission: 1)toprol xl 100mg twice a day 2)diovan 160mg twice a day 3)verapamil sr 240mg twice a day 4)furosemide 80mg daily every morning (sometimes takes up to 160mg depending on weight) 5)doxazosin 8mg daily every evening 6)klor-con 10meq er, 2 tablets twice a day 7)aspirin 81mg daily every morning 8)coenzyme q 10, 150mg daily every morning 9)vitamin c 1000mg daily every morning 10)vitamin d 1000 iu daily every morning 11)folic acid 400mcg daily every morning 12)mvi 13)glucosamine/chondroiton one daily every morning 14)coumadin 2.5mg daily every morning, last dose 15)albuterol prn 16)advair diskus prn discharge medications: 1. metoprolol succinate 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po bid (2 times a day). disp:*60 tablet sustained release 24hr(s)* refills:*2* 2. verapamil 240 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). disp:*60 tablet sustained release(s)* refills:*2* 3. furosemide 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). tablet, chewable(s) 5. valsartan 160 mg tablet sig: one (1) tablet po daily (daily). 6. doxazosin 8 mg tablet sig: one (1) tablet po at bedtime. 7. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 8. advair diskus 250-50 mcg/dose disk with device sig: one (1) inhale inhalation twice a day. 9. outpatient work pt, ptt, inr please send results to , . 10. coumadin 2.5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: ethanol ablation of myocardial interventricular septum for hypertrophic obstructive cardiomyopathy atrial fibrillation, new onset secondary: hypertension copd discharge condition: stable discharge instructions: if you experience syncope, shortness of breath, chest pain or any other symptoms that concern you, please call your pcp or return to the er. . please take all medications as prescribed. please follow up with all appointments. followup instructions: please make a follow up appointment with dr. in 3 months. you will also need a repeat echo at that time. . please get your blood drawn and have the results sent to your pcp , . . you have an appointment with your pcp , on wed at 1:30. please get your labs drawn prior to your appointment. . please follow up with dr. in the clinic ( in one month. Procedure: Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach Insertion of temporary transvenous pacemaker system Injection or infusion of other therapeutic or prophylactic substance Cardiac mapping Diagnoses: Other primary cardiomyopathies Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrial fibrillation Other thalassemia

history of present illness: this is a 55-year-old male with a past medical history significant for diabetes, hypertension, hypercholesterolemia, neuropathy, chronic renal insufficiency, coronary artery disease, who underwent a left bka and a right -dp bypass graft and cabg. three days prior to admission, he presented with right third toe discoloration. this has become progressive over the past three days. he denies rest pain secondary to severe neuropathy. he has recently developed linear changes between the toes, as well. he has not been able to move forefoot and toes for years. this is not an acute change. denies constitutional symptoms. past medical history: 1. diabetes. 2. hypertension. 3. hypercholesterolemia. 4. neuropathy. 5. chronic renal insufficiency. 6. coronary artery disease. past surgical history: 1. left bka which was done in . 2. a right -dp done in . 3. coronary artery bypass done in . social history: the patient is a former smoker, rare tobacco use. he is married and lives with his wife. allergies: denies any known drug allergies. medications on admission: 1. enteric-coated aspirin 81 mg qd. 2. lasix 20 mg . 3. lipitor 40 mg qd. 4. cartia xl 240 mg qd. 5. avapro 150 mg qd. 6. alphagan eyedrops. 7. cosopt eyedrops. 8. insulin - 30 u of nph + 8 of r in the morning; of n + of r q pm. physical exam - vital signs: 99.8, 78, 176/66, 18, 95% on room air. general appearance: alert, in no acute distress. chest exam: lungs are clear to auscultation. heart: regular rate and rhythm. there are no murmurs. abdominal exam: unremarkable. rectal: without masses or prolapse extremity exam: shows left bka. the right forefoot is mottled, with the first toe and tips of the second, third toe blue. the carotids are palpable bilaterally without bruits. the femorals are palpable bilaterally, 2+. the right popliteal is biphasic, dopplerable signal. the graft at the ankle is monophasic. the right dp is monophasic signal. pt is monophasic signal. hospital course: the patient was initially evaluated in the emergency room and admitted to the vascular service for continued care. the patient was continued on heparinization. venous mappings were obtained of the upper extremities and lower extremities for potential consideration of revascularization. rehydration and mucomyst protocol were initiated. the patient underwent arteriogram with attempted lytic therapy of the graft thrombosis without success. psychiatry was consulted for second opinion regarding surgical intervention for foot salvage versus amputation. they were in agreement that the patient would require an amputation. the patient underwent a right bka on . he tolerated the procedure well and was transferred to the pacu in stable condition. the patient was followed perioperative by dr. of the cardiology service. the patient had ekg without ischemic changes. serial cks were 163, 159 and 160. there were no ck-mbs or troponin levels drawn since total cks were flat. the remaining hospital course was unremarkable. physical therapy was requested to see the patient. he will require rehab. prior to discharge to home, the patient was followed by service. he did require adjustment in his insulin regime for episodes of hyperglycemia. cardiology recommended that the patient needs to consider starting an ace inhibitor, and zestril 5 mg was started. on postoperative day #3, the patient ran a t-max of 100.8. duplex of the right extremities was obtained. there was no dvt. chest x-ray did show some left lower lobe atelectasis and cardiomegaly, but no definite pneumonia. the patient's hyperglycemia improved. the patient was pancultured at the time of the temperature elevation, and these cultures were all negative. the patient was seen by infectious disease, and recommendations regarding antibiotic therapy and length of therapy. they felt there was no obvious source of infection for the fever. they felt that the suspected cause of the fever was related to his atelectasis. recommended dc antibiotics. reculture patient if he respikes. the patient continued to show improvement. the patient was discharged to rehab in stable condition. antibiotics were restarted on for a short course of 7 days, and then they should be discontinued. vancomycin, levofloxacin and flagyl were begun. at the time of discharge, the patient was on no antibiotics. the patient should follow-up with dr. in 2 weeks after discharge. skin clips will remain in place in the amputated stump until seen in follow-up. wound care is dry sterile dressing with ace wrap qd. the patient should be cultured if he spikes again. discharge medications: 1. aspirin, enteric-coated, 81 mg qd. 2. atorvastatin 40 mg qd. 3. brimonidine tartrate ophthalmic 0.15% 1 drop left eye qd. 4. dorzolamide 2% and timolol 0.5% combined ophthalmic drop 1 ou . 5. diltiazem er 240 mg qd. 6. pentamidine 20 mg . 7. metoprolol 2.5 mg . 8. aspirin 325-650 mg q 4-6 h prn fever. 9. oxycodone/acetaminophen tablets q 4-6 prn pain. 10.insulin, sliding and fixed scale as follows: nph - 46 u at breakfast and 8 u at bedtime. regular insulin sliding scales before meals and at bedtime as follows: breakfast insulin sliding scale: glucose less than 100 - no insulin; 101-150 - 4 u; 151-200 - 6 u; 201-250 - 8 u; 251-300 - 10 u; 301-350 - 10 u; 351-400 - 12 u; greater than 400 - 12 u. lunch sliding scale: glucose less than 100 - no insulin; 101-150 - 4 u; 151-200 - 6 u; 201-250 - 8 u; 251-300 - 9 u; 301-350 - 9 u; 351-400 - 11 u; greater than 400 - 13 u. dinner time sliding scale: glucose less than 100 - no insulin; 101-150 - 4 u; 151-200 - 6 u; 201-250 - 8 u; 251-300 - 11 u; 301-350 - 13 u; 351-400 - 13 u; greater than 400 - 13 u. bedtime sliding scale: glucose less than 250 - no insulin; 251-300 - 2 u; 301-350 - 4 u; 351-400 - 6 u; greater than 400 - 8 u. discharge diagnoses: 1. right foot ischemia, nonreconstructable, status post right below-knee amputation. 2. diabetes, insulin dependent, uncontrolled, corrected. , m.d .02.914 dictated by: medquist36 Procedure: Injection or infusion of thrombolytic agent Other amputation below knee Diagnoses: Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Polyneuropathy in diabetes Pulmonary collapse Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled Diabetes with neurological manifestations, type I [juvenile type], uncontrolled Diabetes with renal manifestations, type I [juvenile type], uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled Gangrene

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: doe x 2 months major surgical or invasive procedure: cabg x 3 (lima->lad, svg->om, svg->diag), mvrepair (28mm band) history of present illness: 55 y/o with known cad, cypher stent to lcx , now with recurrent angina. past medical history: cad s/p lcx cypher stent h/o rheumatic fever htn lipids physical exam: nad hr 70, b/p 128/68 admission exam unremarkable. pertinent results: 06:10am blood hct-25.4* 06:05am blood wbc-5.6 rbc-3.48* hgb-7.9* hct-24.0* mcv-69* mch-22.7* mchc-32.9 rdw-18.3* plt ct-144* 06:05am blood plt ct-144* 05:16am blood pt-13.4* ptt-27.0 inr(pt)-1.2* 06:10am blood k-4.2 06:05am blood glucose-113* urean-13 creat-0.8 na-135 k-3.8 cl-99 hco3-30 angap-10 brief hospital course: he was taken to the operating room on where he underwent a cabg x 3 and mvrepair. he was transferred to the sicu in critical but stable condition. he was extubated later that same day. he was found to be in svt and started on an esmolol drip. his svt resolved and he was weaned from his vasoactive drips. he was transferred to the floor on pod #3. he continued to do well post operatively and was ready for discharge home on pod #5. medications on admission: toprol, quinapril, hctz, lipitor, plavix, tricor, asa discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days. disp:*10 tablet(s)* refills:*0* 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 5 days. disp:*20 capsule, sustained release(s)* refills:*0* 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 5. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 7. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. quinapril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. tricor 145 mg tablet sig: one (1) tablet po once a day. 10. toprol xl 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: cad s/p lcx cypher stent h/o rheumatic fever htn lipids discharge condition: good. discharge instructions: call with fever, redness or drainage from incision or weight gain more than 2 pound sin one day or five in one week. shower, no baths, no lotions, creams or powders to incisions. no lifting more than 10 pounds in one day or five in one week. followup instructions: dr. 4 weeks dr. 2 weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Open heart valvuloplasty of mitral valve without replacement Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Unspecified essential hypertension Other and unspecified angina pectoris

allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: called to evaluate for altered mental status major surgical or invasive procedure: endotracheal intubation, now extubated history of present illness: 77 year-old woman with pmh of l internal carotid aneurysm, complex partial seizures, currently weaning off dilantin who presented with disorientation, not following commands or recognizing people and wandering around; now s/p intubation. family reports that pt has a hx of seizures for about 15 years, on dilantin. she has never had gtc seizures. her seizures are characterized by confusion, not following commands. because she has been seizure-free for the last 7 years she was started on a dilantin wean recently and family thinks she might not be taking her meds any more. pt was well until around 3:30 am; she was working as a nurse when she suddenly became disoriented, wondering around, would not respond to questions or recognize her colleagues. there is no hx of weakness. family reports that her seizures in the past have had similar presentations. she was brought to ed where she was moving all extremities symmetrically with eyes open, not following commands. as she was too agitated for brain imaging, she was intubated and started on propofol. family thinks it was about an hour between initiation of symptoms and intubation. she received zosyn and vancomycin. a head ct showed previous aneurysm but no acute process. family denies any recent illness. ros: family denies that pt had visual difficulty, hearing changes, difficulty speaking, language problems, memory difficulty, difficulty swallowing, vertigo, unsteady gait, paresthesias, sensory loss,weakness, or falls. the patient denied fever, wt loss, appetite changes, cp, palpitations, doe, sob, cough, wheeze, nausea, vomiting, diarrhea, constipation, abd pain, fecal incont, dysuria, nocturia, urinary incontinence, muscle or joint pain, hot/cold intolerance, polyuria, polydipsia, easy bruising, depression, anxiety, stress, or psychotic sx. past medical history: -l internal carotid aneurysm -lung ressection many years ago found not to be malignant -asthma -heart attack in her 70's -?chf -complex partial seizures as above -arthritis social history: np, works at corner, widowed, 5 children, denies tobbaco, occasional alcohol use family history: asthma; sons think her father could have had seizures physical exam: per admitting resident t-89 bp-173/110 hr-100 rr-21 100o2sat intubated gen: lying in bed, intubated heent: nc/at, moist oral mucosa neck: supple, normal rom, supple, no carotid or vertebral bruit cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: clear to auscultation bilaterally abd: +bs soft, nontender ext: no edema neurologic examination: mental status: intubated on propofol, could follow commands such as open your eyes cranial nerves: pupils equally round and reactive to light, 3 to 2 mm bilaterally. corneal +; normal doll's. facial movement symmetric. tongue midline motor: she moves all extremities symmetrically spontaneously sensation: she retracts to noxious stimuli symmetrically in all extremities reflexes: b t br pa pl right 1 1 1 1 0 left 1 1 1 1 0 toes were mute bilaterally. coordination: finger-nose-finger normal, heel to shin normal, rams normal. gait: unable to examine pertinent results: 06:05am blood wbc-10.5 rbc-4.09* hgb-12.1 hct-38.5 mcv-94 mch-29.6 mchc-31.5 rdw-15.3 plt ct-165 09:19pm blood wbc-10.7 rbc-4.17* hgb-12.4 hct-38.6 mcv-93 mch-29.8 mchc-32.2 rdw-15.6* plt ct-183 02:14am blood wbc-10.2# rbc-4.12* hgb-12.4 hct-38.2 mcv-93 mch-30.1 mchc-32.5 rdw-15.8* plt ct-189 05:10am blood wbc-3.8* rbc-4.28 hgb-13.0 hct-39.3 mcv-92 mch-30.3 mchc-33.0 rdw-15.6* plt ct-194 09:19pm blood neuts-68.3 lymphs-23.6 monos-3.7 eos-3.9 baso-0.6 02:14am blood neuts-70.0 lymphs-24.1 monos-3.3 eos-1.9 baso-0.6 06:05am blood plt ct-165 06:05am blood pt-12.1 ptt-28.6 inr(pt)-1.0 02:14am blood plt ct-189 05:10am blood pt-13.3 ptt-24.6 inr(pt)-1.1 05:10am blood fibrino-285 09:19pm blood esr-36* 06:05am blood glucose-114* urean-14 creat-0.7 na-139 k-3.4 cl-109* hco3-21* angap-12 02:14am blood glucose-138* urean-10 creat-0.7 na-142 k-4.0 cl-109* hco3-20* angap-17 05:59pm blood glucose-135* na-142 k-3.6 cl-107 05:10am blood urean-18 creat-0.7 02:14am blood alt-36 ast-43* ck(cpk)-146 alkphos-103 totbili-0.8 05:59pm blood ck(cpk)-158 02:14am blood ck-mb-2 05:59pm blood ck-mb-2 ctropnt-0.01 06:05am blood calcium-8.2* phos-2.8 mg-2.0 02:14am blood albumin-3.5 calcium-8.3* phos-2.4*# mg-1.4* 05:59pm blood mg-1.4* 09:19pm blood crp-145.7* 05:10am blood digoxin-1.3 02:14am blood phenyto-16.6 05:10am blood phenyto-1.4* 05:10am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 05:22pm blood type-art po2-194* pco2-29* ph-7.50* caltco2-23 base xs-0 10:55am blood type-art temp-37.1 tidal v-500 peep-5 fio2-100 po2-556* pco2-34* ph-7.47* caltco2-25 base xs-2 aado2-131 req o2-32 -assist/con intubat-intubated 05:22pm blood lactate-2.6* k-3.4* 10:55am blood glucose-176* lactate-3.7* na-145 k-3.1* 06:46am blood lactate-3.9* 05:17am blood glucose-122* lactate-4.8* na-146 k-4.4 cl-106 calhco3-22 05:22pm blood freeca-1.19 10:55am blood freeca-1.10* urine 05:45am urine color-yellow appear-clear sp -1.017 05:45am urine blood-neg nitrite-neg protein-25 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-neg 05:45am urine rbc-0 wbc-0-2 bacteri-occ yeast-none epi-0-2 07:38am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg joint fluid 02:27am joint fluid wbc-* rbc-* polys-87* lymphs-6 monos-7 02:27am joint fluid crystal-few shape-rhomboid locatio-intrac birefri-pos comment-c/w calciu eeg impression: this 24-hour video eeg telemetry captured no pushbutton activations. no electrographic seizures or interictal epileptiform discharges were seen. the background was slow and disorganized throughout the recording, suggestive of a moderate encephalopathy, and some superimposed leftsided slowing suggested subcortical dysfunction in that region. eeg impression: this is an abnormal non-continuous extended routine eeg due to slowing and disorganization of the background with brief bursts of generalized slowing suggestive of a mild to moderate encephalopathy. medications, toxic/metabolic disturbances, and infections are common causes. no epileptiform discharges or electrographic seizures were seen in this study. this study captured no pushbutton activations. wrist (left) x-ray there is abnormal widening of the scapholunate interval measuring 7 mm consistent with sl ligament rupture. there are also degenerative changes involving the radioscaphoid joint and of the first cmc joint. there is mild generalized demineralization. no acute fractures or dislocations are seen. there is mild swelling about the soft tissues of the wrist. brief hospital course: ms. was admitted to neurology icu for evaluation and management of seizures. she was closely monitered and underwent frequent neuro checks. hospital course; neuro she was intubated in ed for airway protection. the most likey cause of seizure in this patient was medication taper of dilantin as outpatient recently. she was not febrile and had no signs of infectious precipitant. she underwent ct scan of head with cta which did not show evidence of acute pathology, however did show aneurysm of size 3mm in left ica in caverous sinus area. this was thought to be incidental and did not correlate with the clinical presentation. she was loaded with dilantin and continued on 100 mg tid with no further clinical events. she was monitored on continuous eeg with results as described above. pulm she was rapidly extubated on night and closely monitered. her respiratory status was stable after extubation. however she complained of throat pain and some tenderness. it was thought to be related to recent intubation. she underwent neck x ray which showed prominent soft tissue swelling about the neck, however, this may be partially due to the patient's body habitus. the epiglottis was not enlarged and there was no prevertebral soft tissue swelling. rheum she complained of left wrist pain, shortly after transfer out of icu. the wrist appeared swollen and tender. she was seen by hand surgery and underwent joint tap which showed positive birifringent rhomboid crystals consistent with a diagnosis of pseudo-gout. she received a short course of unasyn which was discontinued after a gram stain of the fluid was negative and a fluid culture has shown no growth to date. she was treated with colchicine and ibuprofen 800 mg tid with good relief of her symptoms. an x-ray of her wrist revealed a widening of the scapholunate interval consistent with ligament rupture. this was reviewed with the hand surgery team who believed this was a chronic finding and unlikely to be related to her presentation. id she was afebrile and did not show signs of infection. she had an elevated esr and crp which was believed to be related to her pseudogout. medications on admission: -ic albuterol 4mg -omeprazole 20mg daily -allopurinol 200mg daily -ic digoxin 0.25g daily -metoprolol 50mg daily -ic tramadol 50mg daily -diclofenac 50mg tid -dilantin 100mg daily (currently on taper) discharge medications: 1. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 2. phenytoin 50 mg tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day). disp:*180 tablet, chewable(s)* refills:*2* 3. allopurinol 100 mg tablet sig: two (2) tablet po daily (daily). 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po once a day. 5. diclofenac potassium 50 mg tablet sig: one (1) tablet po three times a day. 6. tramadol 50 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: epilepsy pseudogout discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted after an episode of confusion and disorientation which was likely a seizure. it is likely this occurred due to the recent discontinuation of your anti-epileptic medication. phenytoin was resumed and you should continue this medication as prescribed. also, you were found to have pseudogout in your left wrist. please take nsaids as needed for pain control (such as ibuprofen 600-800 mg three times daily for the next 3-5 days as needed) and follow up with your pcp weeks. followup instructions: please follow up with your neurologist, dr. as scheduled; provider: , md phone: date/time: 8:30 provider: , m.d. phone: date/time: 10:15 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Arthrocentesis Diagnoses: Congestive heart failure, unspecified Asthma, unspecified type, unspecified Cerebral aneurysm, nonruptured Old myocardial infarction Encephalopathy, unspecified Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy Chronic diastolic heart failure Acute gouty arthropathy

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: acute pancreatitis. presumed pancreatic injury from percutaneous biopsy. major surgical or invasive procedure: exploratory laparotomy, wide drainage of pancreatic leak placement of a combined gastrostomy/jejunostomy tube (mic tube). history of present illness: this unfortunate 24-year-old lady had hepatitis b and was being worked up for this with a biopsy of her liver. it is uncertain to my why she required this biopsy. the patient had this done in the midline position 2 days prior to this procedure. in the interim, she became very sick and was treated at another hospital. she developed abdominal and went to nsmc- ed where workup was significant for lipase of and amylase of 1351. ct showed diffuse hypoattenuation of the liver, suggestive of infiltration, and small amount of ascites. she was admitted with a diagnosis of acute pancreatitits. on evening of , she became febrile and tachycardic. repeat laboratories showed wbc 29.3 (from 20.0), amylase 3894 (from 1351), and lipase >2400 (from ). repeat ct showed increase in intraperitoneal fluid, pelvic fluid, and bilateral pleural effusions she was transferred to our facility the day of this operation. in the interim, she developed clear-cut acute pancreatitis and was gravely ill. we found her to be profoundly dehydrated with all the sequelae of raging acute pancreatitis. what was worrisome, however, was her abdominal exam which showed peritonitis. in reviewing the reports, there was apparently a percutaneous biopsy attempt of the left lateral sector of the liver. it was pretty clear that there was a traumatic injury to the pancreas through this biopsy precipitating acute pancreatitis. i was very concerned that there was a ductal leak injury given her clinical state with a rigid abdomen with peritoneal signs. past medical history: hbv x 5 years social history: has 2 young children. no etoh or tobacco physical exam: vitals - t 100.3, bp 139/64, hr 121, rr 18, o2 sat 98% 2l nc general - well-appearing female, speaking full sentences, no acute distress heent - perrl, eomi, op clr, mmm, no lad cv - rrr, syst flow mur chest - ctab abdomen - subxiphoid biopsy set dressed, c/d/i; abdomen diffusely tender with voluntary guarding extremities - no edema pertinent results: bcx-p s/bcx-p; ucx-neg ucx -> neg; bld cx -> pending; bld fungal cx -> pend; or swab-gpc (broth only)- pending . 07:24am blood wbc-28.1* rbc-3.91* hgb-11.5* hct-33.6* mcv-86 mch-29.5 mchc-34.3 rdw-14.8 plt ct-293 06:30am blood wbc-13.3* rbc-3.41* hgb-9.7* hct-29.8* mcv-87 mch-28.4 mchc-32.5 rdw-14.8 plt ct-413 06:30am blood glucose-102 urean-5* creat-0.4 na-138 k-4.0 cl-103 hco3-28 angap-11 06:30am blood alt-25 ast-32 ld(ldh)-379* amylase-170* totbili-0.4 07:24am blood alt-35 ast-25 alkphos-49 amylase-2045* totbili-1.1 07:24am blood lipase-2662* 06:30am blood lipase-190* 06:30am blood calcium-7.5* phos-2.6* mg-2.6 . 05:50am blood wbc-14.9* rbc-3.27* hgb-9.3* hct-28.3* mcv-87 mch-28.5 mchc-32.9 rdw-15.3 plt ct-673* 05:05am blood glucose-87 urean-10 creat-0.7 na-137 k-4.5 cl-101 hco3-26 angap-15 05:50am blood alt-72* ast-34 ld(ldh)-303* alkphos-99 amylase-223* totbili-0.4 05:50am blood lipase-286* 05:05am blood calcium-8.7 phos-4.1 mg-2.7* 06:50am blood albumin-3.0* . ct abdomen w/contrast 1:12 pm impression: marked improvement post-drainage of fluid collection in the abdomen. decrease in amount of fluid seen in the pelvis as well. tiny amount of fluid is seen near the pancreatic tail and lesser sac. the celiac, superior mesenteric, and inferior mesenteric arteries are patent. the portal vein, and superior mesenteric veins and splenic veins are patent. . ercp procedures: a plastic pancreatic stent was removed from the ampulla with a snare. impression: peg stent in the major papilla a plastic pancreatic stent was removed from the ampulla with a snare. otherwise normal ercp to second part of the duodenum . brief hospital course: she was admitted on //07 with a presumed pancreatic leak and peritoneal signs, fever, elevated wbc, tachycardic. # pancreatitis: she was npo and started on ivf resuscitation. she was receiving morphine for pain control. she went to the or later that evening for exploratory laparotomy; wide drainage of pancreatic bed for pancreatic leak; placement of a combined gastrostomy/jejunostomy tube (mic tube). on pod 2, she was extubated. she continued to have fevers for several days post-op, with a tm 103.4. blood cultures were negative. she was found to be mrsa+, likely colonized. c.diff was negative. urine grew out e.coli and she was started on cipro for a uti. she continued to have a wbc and intermittent fevers. she went for a ercp for stent removal on . her wbc trended down, she was not having fevers and clinically was stable. her lfts, amylase and lipase continued to trend down and did not bump with po intake. her pancreatitis seemed to resolve. #abd/gi: she had 2 jp drains in place and a gj feeding tube. her midlin incision was c/d/i. the staples were removed on pod 11 and steri strips placed. the other drains will remain in place for now. # tachycardia: normal response to acute pancreatitis, improved with ivf resuscitation and as fevers trended down. . # chronic hbv - monitor clinically . # fen: she was npo, ivf. she was started on trophic tubefeedings on pod 4 and started on clear liquids on pod 5. her lytes were repleted prn. her diet was advanced over the next few days. she was able to tolerate food and her tubefeedings were discontined. . proph - sq heparin - ppi while npo . medications on admission: none discharge medications: 1. hydromorphone 2 mg tablet sig: one (1) tablet po q3-4h (every 3 to 4 hours) as needed for 2 weeks. disp:*30 tablet(s)* refills:*0* 2. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 3 days. disp:*6 tablet(s)* refills:*0* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: pancreatic leak tachycardia peritonitis fever uti discharge condition: good tolerating diet abdomen soft pain controlled discharge instructions: please call your doctor or return to the er for any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomitting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomitting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your skin, or the whites of your eyes become yellow. * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. = = = = = ================================================================ please resume all regular home medications and take any new meds as ordered. you are being discharged on cipro for a uti. please complete the full course of antibiotics. . continue to ambulate several times per day. followup instructions: please follow-up with dr. in 1 weeks. call ( to schedule an appointment. Procedure: Arterial catheterization Other gastroenterostomy without gastrectomy Other laparotomy Endoscopic retrograde cholangiopancreatography [ERCP] Removal of pancreatic tube or drain Diagnoses: Urinary tract infection, site not specified Accidental puncture or laceration during a procedure, not elsewhere classified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Tachycardia, unspecified Acute pancreatitis Other specified peritonitis Home accidents Other specified diseases of pancreas

history of present illness: this is a 65 year old female with a past medical history notable for diabetes mellitus, hypertension, coronary artery disease status post myocardial infarction and coronary artery bypass graft, right lower lobectomy, asthma and congestive heart failure, who presents complaining of cough times one week, malaise and fatigue. the patient had a low grade temperature of 99.6 f., at home. the patient denied any lower extremity edema or weight gain. the patient's peak flows at home were in the 150 range. the patient was recently admitted to the hospital until for similar complaints of shortness of breath and cough. at that time, she was treated with steroids, azithromycin and nebulizers for a presumed bronchitis exacerbation. in the emergency room, the patient was treated with a combivent nebulizer, solu-medrol intravenously, levaquin and lasix. past medical history: 1. diabetes mellitus type 2. 2. neuropathy. 3. hypertension. 4. coronary artery disease status post inferior myocardial infarction in ; status post coronary artery bypass graft in ; most recent catheterization in with an ejection fraction of 40%; left internal mammary artery with 40% disease and right coronary artery with 90% disease. 5. status post right lower lobectomy for question of tuberculosis disease at age 16. 6. asthma. 7. congestive heart failure. 8. fibromyalgia. 9. osteoarthritis. 10. low back pain secondary to spinal stenosis. allergies: penicillin and tetracycline. medications at time of admission: 1. aspirin 325 mg a day. 2. prednisone taper. 3. protonix 40 mg a day. 4. trandolapril 2 mg a day. 5. nph 34 units in the morning and 26 units at night. 6. subcutaneous insulin. 7. albuterol inhaler. 8. fluticasone inhaler. 9. valium p.r.n. 10. sotalol 80 mg twice a day. 11. nystatin swish and swallow. social history: the patient lives at home independently. she has around 12 siblings. she has a 30 pack history of tobacco but quit in . she does not use any alcohol. physical examination: temperature 99.5 f.; pulse 96; blood pressure 110/60; respiratory rate 24; pulse oximetry 95% on two liters. in general, a sad tearful female with a flat affect. heent: pupils are equal, round and reactive to light. mucous membranes were moist. neck is supple without any jugular venous distention. chest: crackles at the lung bases about of the way up. cardiovascular: regular rate, no murmurs. abdomen is soft. extremities are warm without edema with good pulses. neurological is alert and oriented times three. laboratory: data at the time of admission is white blood cell count of 10.3 with 70% neutrophils, hematocrit of 39.7, platelets of 226. sodium 134, potassium 4.4 hemolyzed, chloride 95, bicarbonate 29, bun 24, creatinine 1.4 with baseline of 1.0, and glucose of 120. chest x-ray shows blunting of the left costophrenic angle, right middle and lower lobe pneumonia. ekg with normal sinus rhythm at a rate of 95, old q waves in the inferior leads with no acute st changes. hospital course: 1. hypoxic hypercarbic respiratory failure: the patient was initially admitted to the medical floor for treatment of her multi-lobar pneumonia. she initially maintained an oxygen saturation of greater than 95% on three liters of nasal cannula, however, developed hypoxia to 80% with saturation of 90% on non-rebreather, in the setting of a narrow complex tachycardia while she was on the floor. however, the patient remained hypoxic at about 96% on a nonrebreather; therefore she was transferred to the fenard intensive care unit. in the intensive care unit her arterial blood gas revealed a ph of 7.16, a pco2 of 74 and po2 of 94 with abnormal mental status. the patient's culture data revealed a methicillin resistant staphylococcus aureus pneumonia and the patient's antibiotic regimen was changed to vancomycin. there was also a question of aspiration. the patient was initially tried on a trial of bi-pap, however, she did not tolerate this very well and her mental status decreased to the point of requiring intubation. initially there was significant confusion regarding her code status, as on a previous admission it was documented that she wanted to be resuscitated but did not want to be intubated. so, after discussion with various of her attendings and given her clinical status, the decision was made to intubate the patient as she was in acute respiratory distress. the patient continued to require high ventilatory support and had adult respiratory distress syndrome physiology. 2. tachycardia: the patient, just prior to her transfer to the intensive care unit, had a tachycardia that was presumed to be either an atrial tachycardia versus an nrt. she decreased her rate from the mid 200s to 100 after receiving diltiazem 20 mg intravenously and was followed closely in the intensive care unit. she had multiple episodes of tachycardia and the electrophysiology service was consulted as well as the electrophysiology physician, , occasionally her rhythm would break with idenosine and occasionally with diltiazem and eventually she was on a diltiazem drip. there was a question of amiodarone loading as well. of note, her sotalol, which she had been maintained on as an outpatient, had been discontinued during her hospital course as she had started to develop renal failure. 3. hypotension: the patient remained hypotensive after she was intubated and was not fluid responsive. her maps were around 50. she was started on norepinephrine and vasopressin and the etiology was thought to be sepsis although it then also became cardiogenic later in her hospital course. 4. acid base: the patient had a mixed respiratory and metabolic acidosis. she was given intravenous fluids and her respiratory status was maintained with a ventilator, although it was very difficult to correct her acid base status given her overwhelming sepsis as well as her worsening renal failure. 5. acute renal failure: the patient had worsening renal failure likely secondary to acute tubular necrosis with anuria. cvh was debated upon, however, ultimately a change in the patient's code status did not require use of this node of volume removal. disposition: after extensive discussion with the family, initially the patient was clearly full code as she was intubated, ventilated and on pressors, however, after two to three family meetings and multi-system organ failure including cardiovascular, pulmonary, renal with overwhelming sepsis, methicillin resistant staphylococcus aureus pneumonia and progressive overall worsening, it was decided that goal for care would change from "do not resuscitate" "do not intubate" followed by comfort measures only status. the patient had multiple family members who came to see her prior to her demise. the patient expired at 03:55 a.m. on . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Paroxysmal ventricular tachycardia Acute respiratory failure Cardiac arrest Methicillin susceptible pneumonia due to Staphylococcus aureus Chronic obstructive asthma with (acute) exacerbation

allergies: codeine / bactrim ds attending: chief complaint: fevers major surgical or invasive procedure: right ij placement history of present illness: 40 m with hiv (cd 4=664 in and 189 on ) but no history of opportunistic infections who presents with 2 days of fevers to 102 for which he took tylenol. he had a cough productive of clear sputum and back pain secondary to a deep cutaneous abscess. he presented to the ed on with fever and abscess. the abscess was i&d'd and he was given fluids for tachycardia and oxacillin for abscess. he then abruptly dropped his bp to 60's, a sepsis protocol was initiated and a total of 5 l fluid were given. a central line was placed, vanc, ceftriaxone and dilaudid were given in the ed. admitted to the for closer monitoring of hypotension and tachycardia. blood cultures from grew mrsa x 2. surgery following. id consulted for antibiotic therapy and ?indications for propylaxis given low cd4. past medical history: 1. hiv: diagnosed in , on zdv/3tc/nevirapine (per omr note but patient denies ever being on haart), currently no meds, followed by dr 2. seasonal allergies 3. right hand tendonitis 4. s/p t and a 5. right knee cellulitis (mssa, ) 6. h/o strep pharyngitis, hsv, skin abscesses (per omr) social history: lives alone, currently single, smokes 1 ppd x 12 years, past ecstacy and ketamine use family history: non-contributory physical exam: tm=102.1 tc=98.6 p=95 (92-104) bp=110/65 (110/65-124/59) rr=21 100% ra gen - alert, no acute distress, lying on r side, unable to move secondary to vac dressing heent - perrl, extraocular motions intact, anicteric, moist mucous membranes, poor dentition neck - 10 cm jvd, no cervical lymphadenopathy, submandibular lymphadenopathy chest - right upper lobe crackles, decreased breath sounds at the bases bilaterally r>l cv - normal s1/s2, rrr, no murmurs, rubs, or gallops abd - soft, nontender, nondistended, with normoactive bowel sounds back - no costovertebral angle tenderness; lower back with vac dressing draining 2 cm incised lesion extr - no clubbing, cyanosis, or edema. 2+ dp pulses bilaterally neuro - alert and oriented x 3, cranial nerves intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact pertinent results: mri : essentially stable appearance of soft tissue edema/inflammation without evidence of osteomyelitis or drainable abscess collection. slightly heterogeneous signal within the dependent portions of the iliac bones is non- specific, and most likely represents hematopoietic marrow. ct abdomen : no intra-abdominal fluid collections. ct chest : multiple nodular and focal patchy opacities bilaterally of different sizes, many of which show evidence of cavitation. the largest of these within the right upper lobe although all lobes are affected. these findings are consistent with septic emboli. 2. elevation of the right hemidiaphragm. tiny right-sided pleural effusion which is layering posteriorly. 3. gastric varices. mri pelvis : no evidence of intraosseous infection. cxr ap: increased right pleural effusion with right lower lobe atelectasis vs. pna. increased pulmonary edema vs. diffuse infection. cxr ap: left upper lobe, right upper lobe infiltrates suggestive of pma. diffuse intersitital opacities suggestive of pulmonary edema vs. infxn 07:35am wbc-12.9* lymph-8* abs lymph-1032 cd3-82 abs cd3-845 cd4-18 abs cd4-189* cd8-59 abs cd8-613 cd4/cd8-0.3* 07:35am plt count-240 07:35am wbc-12.9* rbc-5.24 hgb-14.6 hct-42.8 mcv-82 mch-27.9 mchc-34.1 rdw-12.1 07:35am neuts-84.4* lymphs-8.3* monos-6.6 eos-0.4 basos-0.4 07:35am cortisol-25.6* 07:35am albumin-3.9 calcium-9.0 phosphate-2.9 magnesium-1.5* uric acid-3.8 07:35am lipase-12 07:35am alt(sgpt)-23 ast(sgot)-21 ld(ldh)-147 alk phos-102 amylase-28 tot bili-0.9 07:35am glucose-111* urea n-11 creat-0.8 sodium-132* potassium-4.2 chloride-94* total co2-27 anion gap-15 08:06am lactate-2.3* 10:31am blood wbc-4.1 rbc-4.34* hgb-11.5* hct-35.3* mcv-81* mch-26.5* mchc-32.7 rdw-14.6 plt ct-419 07:35am blood wbc-12.9* lymph-8* abs -1032 cd3%-82 abs cd3-845 cd4%-18 abs cd4-189* cd8%-59 abs cd8-613 cd4/cd8-0.3* 05:00am blood wbc-3.7* lymph-42 abs -1554 cd3%-91 abs cd3-1408 cd4%-29 abs cd4-454 cd8%-57 abs cd8-888* cd4/cd8-0.5* 05:50am blood alt-46* ast-30 ck(cpk)-20* alkphos-131* totbili-0.2 10:06am blood alt-57* ast-41* ld(ldh)-174 alkphos-127* amylase-39 totbili-0.2 03:28am blood vanco-14.5* brief hospital course: 1. sacral abscess - abscess was incised and drained in the ed. surgery consult obtained, and this was felt to be subcutaneous abscess rather than pilonidal cyst. wound cultures grew out mrsa. pt placed on vancomycin, ultimately for a 4-week course. wound vac was placed, with surgery following and doing dressing changes. wound vac discontinued prior to discharge per surgery team; wet-to-dry dressings were performed, and eventually dry gauze dressings. no evidence of further infection, with abscess appearing to be healing well by discharge. pt will follow up with dr. in surgery in 4 weeks. 2. mrsa sepsis - pt was admitted to the from the ed on a non-rebreather mask, hypotensive on a levophed drip which was weaned off and the patient remained stable, transferred from to the floor on . on arrival, pt's cvp continued to be low (), with further fluid resuscitation resulting in adequate bp. levophed drip was stopped 48 hours later, and bp remained stable throughout rest of course. pt had multiple further blood cultures for surveillance purposes, which were negative. last positive blood culture was on . pt on vanco for 4 week course after first negative blood culture. vancomycin trough levels were persistently low, with continual uptitrating of the dose, up to 1750mg iv q12, and then ultimately was 1000mg iv q8h with a therapeutic trough level. 3. pneumonia - pt noted to have multiple patchy opacities on cxr and chest ct, some of these lesions were noted to be cavitating. id was involved early in the course of hospital stay. 3 afb smears were negative, pcp via sputum induction was negative, legionella urinary antigen was negative, cryptococcus negative. a ppd was placed, which was negative, as well. cxr showed right pleural effusion with right lower lobe atelectasis vs. pneumonia. this was evaluated with u/s probe and it was determined that the fluid collection was too small to be tapped. findings on ct scan were consistent with septic emboli, so a tte and then tee were performed, both of which were negative for any vegetations. per id, it is thought that these are septic emboli, likely of mrsa, from some intravascular source but not valvular vegetations. the appearance of these nodules, in their cavitations is consistent with staph pneumonia, possibly from hematogenous spread. pt was placed on 4 week course of vanco, and he continued to improve overall, feeling well by the time of discharge. he maintained good o2 sats and showed no respiratory distress. a followup ct scan was arranged prior to discharge, and pt will follow up in clinic to determine if the vancomycin may be discontinued. 4. fevers - fevers persisted even with the vancomycin on board. pt's cultures were consistently negative and no changes noted on repeat chest imaging. pt clinically was well-appearing in the last week or so before discharge, but was still having fevers. other sources of fever were searched for: an abdominal ct showed no fluid collections or occult abscesses; an mri of the sacral area near the abscess ruled out osteomyelitis. it was thought that perhaps his subtherapeutic vanco dose might be responsible for this. however, no further causes of infection were found, and pt was clinically well. pt remained afebrile for > 4 days prior to discharge. 5. hiv - cd4 count low 189, but pt had an acute infectious process going on. repeat cd4 count when pt more stable was 454. bactrim prophylaxis was stopped. pt will follow up with dr. in of next year. no haart while in house. 6. hsv - pt had some oral hsv and completed a 7-day course of famciclovir with resolution of symptoms. 7. gastric varices - varices were found incidentally on ct scan. lfts were mildly elevated. pt asymptomatic. abd ct scan did not comment on any liver abnormalities. an outpatient egd appointment was arranged to better assess these varices, as well as a subsequent liver clinic appointment. 8. ppx: h2 blocker, sq heparin 9. full code. 10. dispo: patient will be discharged to home with vna for picc care, as well as help with dressing changes. medications on admission: none discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. zolpidem tartrate 5 mg tablet sig: two (2) tablet po hs (at bedtime) as needed for insomnia. 5. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 6. oxycodone hcl 5 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 7. vancomycin hcl 500 mg recon soln sig: 1250 (1250) mg intravenous q12h (every 12 hours) for 11 days: last day of treatment in . patient may need longer duration of therapy to be determined by outpatient infectious disease doctor. :*22 doses* refills:*0* 8. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous qd () as needed: to picc. 9. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours). 10. saline heparin flushes per vns protocol 11. picc line care discharge disposition: home with service facility: home therapies discharge diagnosis: primary diagnoses: mrsa sacral abscess mrsa bacteremia septic pulmonary emboli hiv secondary diagnoses: gastric varices, seen on ct scan seasonal allergies right hand tendonitis s/p t and a right knee cellulitis (mssa, ) h/o strep pharyngitis, hsv, skin abscesses (per omr) discharge condition: stable. pain well controlled. wound healing well. discharge instructions: please call your doctor and return to the hospital for fever/chills, increasing warmth, pain, redness, or swelling from the abscess, general malaise, diarrhea, or any other concerns you may have. please go to all of your appointments. followup instructions: you have the following appointments: 1) provider: scan where: cc clinical center radiology phone: date/time: 10:15 this is on the . please do not eat any solid food 3 hours beforehand. ***before this appointment, please call ( to update your information. 2) md where: lm disease phone: date/time: 10:30 provider: , md where: lm disease phone: date/time: 10:30 3) dr. - surgery - to take a look at your abscess , 1:00pm; in building (surgical subspecialties); phone number ( 4) , dr. nurse practitioner provider: , rnc where: phone: date/time: 11:00 5) provider: , m.d. where: phone: date/time: 9:50 6)provider: ,md where: building ( complex) phone: date/time: 10:00 ***you need to arrive at 9 am. provider: west,room five gi rooms where: gi rooms date/time: 10:00 this is for evaluation of your liver 7) liver clinic appointment: to follow up with liver scan at 9 am dr. Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Excisional debridement of wound, infection, or burn Other incision with drainage of skin and subcutaneous tissue Diagnoses: Unspecified pleural effusion Severe sepsis Infection with microorganisms resistant to penicillins Methicillin susceptible Staphylococcus aureus septicemia Septic shock Methicillin susceptible pneumonia due to Staphylococcus aureus Acute osteomyelitis, other specified sites Other pulmonary embolism and infarction Asymptomatic human immunodeficiency virus [HIV] infection status

allergies: 20/20 / iodine; iodine containing / keflex attending: chief complaint: symptomatic carotid stenoses. major surgical or invasive procedure: l internal carotid artery stenosis s/p angioplasty and stenting pacemaker and icd lead revision history of present illness: 80 year old with significant carotid artery stenoses revealed by mra. noted to have significant l-ica stenoses beyond the bifurcation with mild stenosis at the bifurcation. on the right hand side, moderate to severe stenosis at the bifurcation and in the proximal r-ica. these stenoses have become symptomatic with recent ?tia. obstructions: left 90%, right 60-70%. past medical history: 1. icd: biventricular icd placed for vt indication. 2. cad: last cath : d1 ostial 30%, lcx 30% isrs, totally occluded rca. 3 prior mi's. stent to lcx in , ptca of lad in , stent to rca in early (now occluded). 3. h/o lbbb 4. desc aortic aneurysm (2.3 x 1.5 cm ) 5. chf, syst and diast (ef 30%) 6. asbestosis on home o2 7. djd s/p r tkr 8. mild cri 9. s/p appy social history: pt is a jehovah's witness no etoh /tob lives with his wife in an apartment in family history: htn, cad, dm physical exam: v/s: afeb, 75, 108/59, 14, comfortable on ra i/o: 1738/1040 (+698), overnight -1340. tele: no events. gen: a/ox3, pleasant, nad. cv: rrr, nl s1/s2, no m/r/g. no carotid bruit. pulm: ctab abd: +bs, s/nt/nd extr: no c/c/e. neuro: cnii-xii intact pertinent results: ,: radiology detail - ccc record # indications: 80 year old man with carotid artery stenosis. evaluation of the vasculature requested. technique: multiplanar t1, t2, and susceptibility images of the brain were obtained. no contrast was administered. mr angiography of the circle of was performed with acquisition of two- and three- dimensional time-of-flight images. mr angiography of the neck was also performed with two- and three-dimensional time- of- flight images of the major arteries. findings: on the brain images, there is no evidence of hydrocephalus, mass effect, or shift of the normally midline structures. the ventricles, cisterns, and sulci are unremarkable. there are patchy areas of increased t2 signal in the pons. there are also widespread patchy areas of increased t2 signal in the subcortical white matter of both cerebral hemispheres. these signal abnormalities are consistent with chronic small vessel ischemic infarcts. also, in the posterosuperior right frontal cortex, there is a small area of increased t2 signal in the cortex consistent with a chronic infarction. a similar small infarct in the head of the left caudate nucleus is also observed. no susceptibility artifact is seen. the visualized vascular flow voids are present. the osseous structures, soft tissues, and sinuses are unremarkable. mr angiography of the circle of shows no evidence of stenosis in the major vessels. along the proximal right posterior cerebral artery, there is a tiny focus of increased signal intensity on the two-dimensional time-of-flight images. in the source images, there is no suggestion of an aneurysm at that site. this small focus appears to be an artifact. there is no definite evidence of an aneurysm. mr angiography of the carotid and vertebral arteries in the neck is significant for a severe stenosis beyond the bifurcation in the left proximal internal carotid artery. only mild carotid narrowing is seen at the left carotid bifurcation. the left carotid bifurcation is more superiorly located than the right, and accordingly, three-dimensional time- of-flight images understandably did not entirely cover this area. the severe left proximal internal carotid stenosis is best visualized on the two-dimensional time- of- flight images. on the right side, on both the two- and three-dimensional time-of- flight images, a probable moderate to severe right carotid stenosis at the bifurcation, and moderate to severe right proximal internal carotid stenosis is also seen. impression: the head mri shows evidence of widespread patchy increased t2 signal. these are are consistent with chronic small vessel ischemic infarcts. the mr angiogram of the circle of shows no definite evidence of stenosis or aneurysm. the mr angiogram of the neck is significant for a severe left internal carotid artery stenosis beyond the bifurcation, with mild stenosis at the bifurcation. on the right, there is evidence of moderate to severe stenosis at the bifurcation and in the proximal internal carotid artery. procedure date: ,: radiology detail - ccc record # history: 80 y/o man s/p bivalve icd placement. r/o rv lead dislodgement. comparison: . chest ap: the tip of the right ventricular lead appears to have rotated into the right atrium. the right atrial and coronary sinus leads are in unchanged position. cardiac and mediastinal and hilar contours are stable in appearance. pulmonary vasculature is normal. the lungs are clear. there are no pleural effusions. osseous and soft tissue structures are unremarkable. impression: displacement of right ventricular icd lead into the right atrium. procedure date: ,: radiology detail - ccc record # history: defibrillator lead change. chest, pa and lateral: the heart is normal in size. a difibrillator is present on the left anterior chest wall, and there are two rv leads and a single ra lead. there is no pneumothorax. there are no signs of failure and there are no focal infiltrates. nodular calcifications in the left mid lung zone are likely related to previous granulomatous disease. there is no mediastinal adenopathy. there is no effusion or bone destruction. procedure date: brief hospital course: admitted for stent placement in the left ica. pt. returned from cath with 1.5 mcg/kg/min of phenylephrine, successfully weaned. pt. experienced brief bouts of non-specific bilateral radiating numbness but with consistently normal cnii-xii exam; likely transient vagal depression nature. the patient also has a biventricular icd implanted, which was interrogated prior to the stent procedure. it was determined that the rv lead/icd had become dislodged. the defibrillator function was disabled, leaving the device operating as an ra/lv ddd pacer. cxr indicated that the rv lead had ascended into the ra. the pacer function began to be impaired by erroneous sensing, with pacing occuring on the st segment leading to brief aberrant nsvt runs. ep put the icd into (sense-only) mode, and the patients leads were then percutaneously resited satisfactorily as confirmed by repeat cxr. icd function was tested and found to be satisfactory. the patient did well after carotid stenting and icd lead revision and was subsequently discharged home with assistance in stable and improved condition. medications on admission: 1. lasix 20mg po qd 2. glucophage 500mg po bid 3. glyburide 5mg po qd 4. prevacid 30mg po qd 5. lisinopril 20mg po qd 6. asa 325mg po qd 7. oxycodone 5mg po q4-6h:prn pain 8. plavix 75mg po qd 9. simvastatin 40mg po qd 10. digoxin 0.125mg po qd 11. setraline 50mg po qd discharge medications: 1. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day): do not stop this medicine until speaking with dr. . disp:*30 tablet(s)* refills:*2* 2. aspirin 325 mg tablet sig: one (1) tablet po qd (once a day). 3. sertraline hcl 50 mg tablet sig: one (1) tablet po qd (once a day). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. digoxin 125 mcg tablet sig: one (1) tablet po once a day. 6. glyburide 5 mg tablet sig: one (1) tablet po once a day. 7. glucophage 500 mg tablet sig: one (1) tablet po twice a day. 8. prevacid 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 9. zocor 40 mg tablet sig: one (1) tablet po once a day. 10. oxycodone hcl 5 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 11. percocet 5-325 mg tablet sig: one (1) tablet po every hours as needed for pain. disp:*10 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: 1. l internal carotid artery stenosis s/p angioplasty and stenting 2. dislodged pacemaker and icd lead s/p revision 3. congestive heart failure 4. diabetes mellitus discharge condition: stable and improved discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 2l -contact your primary care physician should you experience any lightheadedness, dizziness, shortness of breath or chest pain. -do not restart your lisinopril without checking with dr. . the visiting nurse will call his office next week after checking your blood pressure. followup instructions: 1. please call to schedule an appointment next week with dr. at ( to follow up for your pacemaker. 2. contact dr. office to schedule an appointment at ( to be seen the same day as dr. . Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Other operations on heart and pericardium Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Other nonoperative cardiac and vascular measurements Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Paroxysmal ventricular tachycardia Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified angina pectoris Mechanical complication of automatic implantable cardiac defibrillator Old myocardial infarction Asbestosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: gallstone pancreatitis major surgical or invasive procedure: none history of present illness: patient is a 45 year old female transferred from on for treatment of pancreatitis. patient presented to after a syncopal episode. postive reports of r abdominal and back pain after eating fatty meals in the past. at , lipase 7474m antkase 2,490, alt 402, ast 463, bili 1.5, alk phos 130, wbc 17. ct demonstrated cholecystitis, cholelithiasis, intrahepatic ductal dilatation and pacreatitis with surrounding phlegmon. she improved on cefotetan, imopenem and hydration. on , patient symptoms became acutely worse and developed grey- sign. repeat ct demonstrated increase in abdominal fluid, increase in pancreatic inflamation, increase of phlegman, new pleural effusions. patient arrived to intensive care unit . past medical history: none social history: denies etoh, tobacco or idu family history: denies cad, cancer, or gallstones physical exam: 99.2 158/70 89 24 94% 5l diaphoretic dry mmm tachy regular dull @ bases bilaterally, poor inspiratory effort tense echymosis over flanks bilaterally, tender, distended, no rebound mild lowere extremity edema pertinent results: 08:06pm lactate-1.0 07:12pm glucose-155* urea n-19 creat-0.5 sodium-153* potassium-3.8 chloride-113* total co2-30* anion gap-14 07:12pm alt(sgpt)-42* ast(sgot)-21 alk phos-90 amylase-80 tot bili-0.4 07:12pm lipase-33 07:12pm calcium-7.9* phosphate-2.1* magnesium-2.5 07:12pm wbc-14.9* rbc-3.35* hgb-8.4* hct-27.3* mcv-81* mch-25.1* mchc-30.8* rdw-16.8* 07:12pm neuts-75* bands-0 lymphs-15* monos-8 eos-2 basos-0 atyps-0 metas-0 myelos-0 07:12pm pt-14.2* ptt-19.7* inr(pt)-1.3 brief hospital course: on arrival to medical intensive care unit, patient was stable and supportive measures were continued. imipenan was continued. patient remained stable and was started on tpn and transferred to the surgical intensive care unit on . patient continue to improve in both clinical appearance and in lab values and was transferred to the floor . sugars were monitored and patient required insulin. patient was advanced low fat diet on which she tolerated well. a consult was obtained for patients new onset of diabetes. a cholecystectomy was planned during the hospital admission was but then cancelled secondary to a large pseudocyst demonstrated on ct. patient was discharged on with surgical and follow upl medications on admission: none discharge medications: 1. lantus 100 unit/ml solution sig: eight (8) units subcutaneous at bedtime. disp:*30 * refills:*2* 2. humalog 100 unit/ml solution sig: per sliding scale unit subcutaneous with meals. disp:*100 * refills:*2* 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*50 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: insulin dependent diabetes gallstone necrotizing pancreatitis cholelithiasis discharge condition: good discharge instructions: take medications as perscribed. call doctor or report to emergency if develop abdominal pain, naseau or vomiting followup instructions: patient to call and make appointment with dr. office in one month. office will arrange for patient to have repeat ct scan that am. clinic- 10 am with dr. patient to follow up with dr. office regarding diabetic nutrition education classes. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Calculus of gallbladder with other cholecystitis, without mention of obstruction Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Acute pancreatitis Cyst and pseudocyst of pancreas Calculus of gallbladder with acute cholecystitis, without mention of obstruction

mrs was transfer from to nsicu for increase inflammation of pancreatitis. no allergies. no pass surgical or medical history. neuro; a+ox3. mae. follow commands. pca use appropriately of abd pain. perla. good gag and cough reflex. cv; nsr without ectopy. bp 110-130/40-50. temp max 100.9. warm, dry/clampy, edema at ankles and feet +1. resp; clear lung sound in upper lobes. dimish at bases. 3-4 l nc. encourage deep breathing and coughing when awake. gu/gi; soft distended abd. +bsx4. no bm. no flatus. slight pain on ruq with medium palpation (no pain on light palpation) - no radiating abd pain. no bruising visible. foley patent - clear/yellow urine - greater >40 cc/hr. skin intact. am lab done. plan; continue to monitor. possible transfer to floor. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Calculus of gallbladder with other cholecystitis, without mention of obstruction Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Acute pancreatitis Cyst and pseudocyst of pancreas Calculus of gallbladder with acute cholecystitis, without mention of obstruction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cocaine and heroine overdose major surgical or invasive procedure: right internal jugular vein central line placement intubation and extubation on history of present illness: the patient is a 33 year old african-american male with a history of polysubstance abuse who was found by the police in his car with a needle in his antecubital vein, incoherent and combative. he was subsequently brought to where he admitted to cocaine, heroin and marajuana use but denied etoh. the patient was initially extremely combative and required up to 20 mg iv haldol and 4 + mg ativan for sedation. after receiving sedation, he then became somnolent with an inability to manage his own secretions and was intubated for airway protection. his serum tox in the ed was negative with a urine tox positive for cocaine and opiates. past medical history: l meniscal tear chylamydia heroin/cocainehcv gential herpes anxiety eczema social history: the patient smokes 1.5 packs of cigarettes per day. he recently has used 30 to 50 bags of heroine in the past. low alcohol. positive cocaine use. positive crack use. positive heroine drug abuse. the patient claims about 3 g a day for cocaine use in past history. family history: the patient claims mother and father are alive and healthy. the patient has no siblings. physical exam: tc=97.9 p=100 bp=170/100 rr=18 100% o2 on ra gen - intubated, sedated heent - perla heart - rrr, no m/r/g lungs - ctab (anteriorly) abdomen - soft, nt, nd, + bs, no hepatosplenomegaly ext - no c/c/e, + 2 d. pedis bilaterally skin - tattoos, needle marks evident throughout upper extremities pertinent results: 03:29pm ck(cpk)-663* 03:29pm wbc-8.1 rbc-4.80 hgb-12.2* hct-37.3* mcv-78* mch-25.4* mchc-32.7 rdw-13.0 03:29pm plt count-204 02:43pm type-art po2-131* pco2-49* ph-7.38 total co2-30 base xs-3 intubated-not intuba 01:13pm type-art po2-71* pco2-52* ph-7.34* total co2-29 base xs-0 01:00pm type-art rates- tidal vol-600 o2-50 po2-179* pco2-55* ph-7.34* total co2-31* base xs-2 -assist/con intubated-intubated 06:26am type-art po2-347* pco2-57* ph-7.32* total co2-31* base xs-1 05:00am urine hours-random 05:00am urine hours-random 05:00am urine gr hold-hold 05:00am urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-pos amphetmn-neg mthdone-neg 05:00am urine color-yellow appear-clear sp -1.023 05:00am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-neg urobilngn-1 ph-5.0 leuk-neg 02:30am glucose-93 urea n-10 creat-1.0 sodium-144 potassium-4.0 chloride-103 total co2-25 anion gap-20 02:30am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg ecg study date of 10:01:34 am sinus rhythm. since the previous tracing of the rate has decreased. the mild j point and st segment elevation are now back to a pattern similar to that of . chest (portable ap) 3:15 am impression: no definite acute cardiopulmonary process. brief hospital course: impression: the patient is a 33 year old male with h/o psa who presented after cocaine/heroine intoxication s/p intubation post sedation now extubated and aox3. 1. polysubstance abuse: - the patient clearly overdosed on heroine and cocaine. on further questioning, the patient was unable to provide more details regarding the event. - addiction consult was placed but patient did not want to participate in referral. - the patient exhibited no further symptoms of withdrawal throughout his stay. 2. respiratory status: - as mentioned, the patinet required intubation secondary to sedation and inability to clear his secretions. - the patient was given lasix in the ed for what they thought was flash pulmonary edema. his cxr showed ?rl infiltrate but was felt not to be significant given his clinical picture. - he self-extubated himself and continued to sat well off of o2. 3. id- ?rl infiltrate - patient did not spike fevers with no wbc with questionable rl infiltrate on cxr. there was no evidence to support a pneumonia and thus the patient was not treated with antibiotics. 4. hepatitis c: - the patient has received no prior treatment and his lfts were within normal limits. 5. mental status change: - the patient arrived to the ficy very sedated. this was most likely due to the 20 mg iv haldol and 4 mg ativan the patient received in the ed. the patient was not fully cooperative on physical exam but alert and oriented times three. the patient was discharged from the with no further events once he remained stable and was able to tolerate po intake and asked to follow up with his primary care physician. medications on admission: none. discharge medications: none. discharge disposition: home discharge diagnosis: heroin and cocaine overdose. discharge condition: stable. discharge instructions: please return to the er if you feel more confused or develop more shortness of breath. followup instructions: please call ( to schedule an appointment with your primary care doctor, dr. . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Drug detoxification Diagnoses: Tobacco use disorder Congestive heart failure, unspecified Unspecified viral hepatitis C without hepatic coma Opioid type dependence, continuous Acute respiratory failure Accidents occurring in other specified places Accidental poisoning by heroin Accidental poisoning by central nervous system stimulants Accidental poisoning by psychodysleptics [hallucinogens] Drug withdrawal Poisoning by heroin Cocaine dependence, continuous Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta Cannabis dependence, continuous Poisoning by psychodysleptics (hallucinogens)

history of present illness: the patient is a 66-year-old male with a history of a cerebrovascular accident with residual right-sided weakness who presented after having severe acute onset of headache the night before admission. the patient's wife stated he had no trauma or precipitating factors. the patient vomited three times overnight. denied any fever, chills, nausea, chest pain, shortness of breath or visual changes. the patient awoke this morning with increased right leg weakness and continuous headache and now new onset of neck pain notably with flexing. the patient currently states that he only has a headache. past medical history: hypertension. hypercholesterolemia. cerebrovascular accident in . medications: 1. lisinopril 40 q. day. 2. lipitor 40 q. day. 3. minoxidil 2.5 q. day. 4. atenolol 10 q. day. 5. triamterene hydrochlorothiazide 37.5/25 one q. day. allergies: no known allergies. physical examination: he was afebrile. heart rate in the 60's. blood pressure 235/97. sats 97 percent on room air. generally, in no acute distress, pleasant. heent: no lymphadenopathy. positive tenderness to paraspinal area. positive pain on flexion. cardiovascular: regular rate and rhythm. pulmonary: chest clear to auscultation bilaterally. abdomen soft, non-tender, non-distended. extremities: no clubbing, cyanosis or edema. neurological: awake, alert and oriented times three. long and short term memory intact. recalls two out of three and three out of three with prompting. following three step commands. finger-to-nose normal bilaterally. rapid alternating movements intact bilaterally. his strength was in all muscle groups. his reflexes were 2 plus throughout and his toes were upgoing. radiology: ct shows likely a caudally positioned subarachnoid hemorrhage, the causes of which could be a ruptured aneurysm, arteriovenous malformation or tumor. the patient had several scans, mri's of the brain and neck and a conventional angiogram, all of which were negative for any arteriovenous malformation or aneurysm or more atypical source of hemorrhage such as a vascular malformation. the patient had his angiogram on , which showed an occluded left vertebral artery and showed no evidence of an aneurysm. the right vertebral artery ended in the pica distribution and provided multiple dural/muscular collaterals to the left vertebral artery. hospital course: on the patient was awake, alert and oriented times three. extraocular movements were full. no nystagmus. the face was symmetric. no pronator drift. ip's were full. wiggles toes bilaterally. it was stable. diet was advanced and he remained stable. the patient had a repeat head ct on , that showed no new hemorrhage and no extension of his existing hemorrhage. neurologically he was stable. he had a repeat mri of the cervical spine that was negative for any vascular malformation. his head ct remained stable. he had a chest x-ray that showed no pneumonia. on he was opening his eyes, sleepy, preferred to keep his eyes closed. knew his name, following commands, moving all extremities with good strength. the patient spiked a temperature on to 102. fully cultured. continued on day two of levofloxacin and flagyl for question of aspiration pneumonia. the patient had repeat chest x-ray on , that showed improvement of the left lower lobe opacity. the patient had a non-contrast head ct on , that showed a right internal capsule infarct likely due to small vessel disease. the patient was assessed by speech and swallow and must remain npo. patient was unable to cooperate with swallow evaluation due to his mental status. his vital signs remained stable. he had been afebrile. he was sleepy but easily arousable, oriented times one to two. motor strength: his grasp on the left was ; on the right he was 4 plus out of 5. his ip's were 5 out of 5. he remained sleepy but arousable. he had a peg tube placed on , without any complications and will restart on his tube feedings. his sodium level has been steadily climbing with a high level 156. today, , it is 163. he is receiving 700 cc of free water down his feeding tube four times a day with repeat sodium pending for . discharge medications: include: 1. metoprolol 50 p.o. b.i.d. 2. lisinopril 20 p.o. q. day. 3. minoxidil 10 p.o. b.i.d. 4. albuterol nebs one inhaler q. 6h. p.r.n. 5. lansoprazole oral suspension 300 mg per ng q. day. 6. heparin 5000 subcu q. 12h. 7. atorvastatin 40 q. day. 8. the patient also had dyazide one p.o. q. day which was discontinued due to his high sodium. when his sodium levels return to normal level, that should be restarted for blood pressure control. condition on discharge: stable. follow up: follow up with dr. in one month with a repeat head ct. , Procedure: Enteral infusion of concentrated nutritional substances Arteriography of cerebral arteries Percutaneous [endoscopic] gastrojejunostomy Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Occlusion and stenosis of vertebral artery without mention of cerebral infarction Subarachnoid hemorrhage Pneumonitis due to inhalation of food or vomitus

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: lethargy x 2 days major surgical or invasive procedure: none history of present illness: 82 yo m w/ h/ body dementia, parkinson's dz, htn, and h/o falls who p/w increasing lethargy x 2 days. moved to on due to progressive dementia s/p multiple falls. was stable at until the past 2 days when note was made of increasing difficulty w/ ambulation and difficulty swallowing. had swallow training today and kept coughing, per daughter. daughter and wife, no diarrhea. incontinent of urine at baseline but no foul smell recently. last fall approximately 5 days ago per wife. is nonverbal at baseline. however, family noticed he was very sleepy on arrival to ed and had an absent look about him but is now interacting with them more through touch since initial resuscitation. in ed, o2 sats dropped into 80s, and he initially required 100% nrb. sbp dropped from 120's to 90s. the patient was evaluated by the micu and placed on sepsis protocol. he received 4l ns. after receiving ivf, his bp stabilized. o2 sat eventually stabilized at 98% on 5l nc. the micu team felt that he did not require icu level of care so he was admitted to the medicine service for further observation past medical history: htn body dementia h/o falls parkinson's disease social history: lives at . dependent of all adls and incontinent of stool/urine at baseline. married and has daughter who visits him regularly. no significant h/o tob and only occasional etoh (none currently). family history: m w/ h/o alzheimer's disease physical exam: t 103.0 (rectal) hr 84 bp 119/82 rr 25 o2 98% 5l nc gen: elderly, in nad heent: perrla (3->2mm), sclera anicteric cv: rrr, no m/r/g, soft s1/s2 pulm: diminished bs at both bases, no wheeze/ronchi/rhales abd: nabs, soft, nt/nd, no masses/hsm extr: no le edema, warm/dry neuro: awake, alert, non-conversant pertinent results: cxr: tortuous aorta, no infiltrates . head ct: right subdural hemorrhage, primary isodense, suggesting subacute/chronic. no shift of midline structures. brain atrophy and areas of chronic lacunar infarction. head ct: head ct without iv contrast: again demonstrated within the right subdural space is a heterogeneous fluid collection, which is predominantly hypodense in attenuation with small foci of hyperattenuation noted. the appearance of this subdural hematoma is not significantly changed since the prior examination. there is associated mass effect upon the adjacent right cerebral cortex, which is unchanged since the prior examination, and only minimal right to left midline shift is again demonstrated, which also is unchanged since the prior examination. there are no new areas of intra- or extra-axial hemorrhage noted. the ventricles and sulci are stable in size, and there is no evidence of hydrocephalus. periventricular white matter hypodensities are again noted along with focal hypodensities within the basal ganglia, findings consistent with chronic microvascular and lacunar infarction. visualized paranasal sinuses and left mastoid air cells are clear. post- surgical changes within the right mastoid air cells are again demonstrated with an air fluid level, unchanged in the interval. impression: overall, stable appearance of subacute/chronic right subdural hematoma. no new areas of hemorrhage identified. . admission labs: 06:00pm urine rbc-* wbc-21-50* bacteria-mod yeast-none epi-0-2 06:00pm urine blood-lg nitrite-pos protein->300 glucose-tr ketone-tr bilirubin-sm urobilngn-1 ph-5.5 leuk-sm 06:00pm urine color-yellow appear-hazy sp ->1.030 06:21pm lactate-2.8* k+-4.7 06:30pm pt-15.4* ptt-27.7 inr(pt)-1.6 06:30pm plt smr-normal plt count-143* 06:30pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 06:30pm neuts-90.0* bands-0 lymphs-7.8* monos-2.1 eos-0 basos-0.1 06:30pm wbc-21.1*# rbc-5.52 hgb-17.0 hct-48.1 mcv-87 mch-30.9 mchc-35.4* rdw-13.6 06:30pm albumin-4.2 calcium-9.8 phosphate-2.7 magnesium-2.2 06:30pm ck-mb-6 ctropnt-<0.01 06:30pm alt(sgpt)-22 ast(sgot)-73* ck(cpk)-799* alk phos-81 amylase-23 tot bili-1.8* 06:30pm glucose-131* urea n-49* creat-1.4* sodium-142 potassium-5.4* chloride-105 total co2-20* anion gap-22* brief hospital course: he was initially stable on the floor, without fever or hypotension. then, in am of , he decompensated with temp to 101.6, rigors, and hypotension with sbp of 80's. additionally, his oxygen dropped to 78% on ra -> 97% on 100% nrb -> 97% on 3l nc. he was initially stabilized with 4l of ns boluses, but hypotension persisted to 70's systolic. dopamine was started. hypoxia persisted with sats in 80's on 100% nrb. a respiratory code was called, and he was intubated by anesthesia. abg done at codewhile on 100% nrb was 7.43/31/132, lactate of 2.0. he was transferred to the ccu for further treatment. . in the ccu he required one pressor for less than 24 hours. his hypotension was felt to be due to vasodilation from sepsis in combination with hypovolemia. his culture data only revealed gram negative rods in his urine, and vanc, levo and flagyl were continued. he was intubated for hypoxic respiratory failure. the etiology of his hypoxemia was unclear. his rapidly deteriorating neurolgic function from parkinsons' he may have aspirated, although, he did not have radiologic evidence of a pneumonia. his hypoxemia may have been due to acidosis and v/q mismatching. lenis did not reveal evidence of dvt. he was extubated successfully on . he had moderate secretions and received aggressive chest pt, but maintained adequate o2 sats on shovel mask. additionally, he was started on low dose beta-blocker for hypertension and treated with free water boluses for hypernatremia. during his icu stay he was less responsive to stimuli and a repeat ct scan revealed unchanged size and mass effect from subdural hematoma. his mental status improved to baseline according to family after weaning sedation. he developed lue edema and on a lue doppler was performed which showed occlusive thrombosis of both brachial veins and the axillary vein, and nearly completely occlusive thrombosis of the subclavian vein. pt. had not been receiving sc heparin because of his known subdural hematoma and risk for increased bleeding and mass effect, and a decision was made not to anti-coagulate him, even given the doppler results. stim test was performed, with decreased cortisol response, and pt. was pulsed with 7 days of fludrocortisone and hydrocortisone. during his ccu stay, he was started on tube feeds. a discussion was begun with the family regarding long-term nutrition and possible peg placement. he was about 8 l positive on day of transfer, and had been receiving lasix qd. pt was transfered from ccu to the floor on with resolved urosepsis. pt remained afebrile but un-responsive. he finished vanc/levo/flagyl x 10 days. his wbc continued to be elevated. family discussion was held and patient was made cmo. pt was started on morphine drip titrated to comfort. pt's breathing became more agonal over next few days and he peacefully expired on @ 10:18 am. family was notified and were able to say their final goodbyes while patient was still in the hospital. . # sdh: - appears to be subacute to chronic. stable. repeat ct last: unchanged subdural hematoma/hypodense collection, unchanged/persistent mass effect on right cerebelar cortex, minimal right to left midline shift. no hydrocephalus, no new hemorrhages. chronic lacunar and microvascular infarcts. neurosurg was re- consulted but unable to say whether burr hole procedure will reverse mental status changes, drainage in ~ 4 weeks is still recommended, once acute events stabilized. . # ue dvt - hold off on anticoagulation for now given sdh . # failed stim - initially tx with 7 d steroids; stable electrolytes/bp. . # ppx: pneumoboots, ppi . # fen: ngt, tube feeds were continued until pt was made cmo; supplemented with ivfs d5 1/2ns with 20 k. # full code: family met with the providers and decided to make cmo. . # communication: (daughter): cell (no messages), home , work medications on admission: mvi sinemet 25/100 1 tab po bid discharge medications: none discharge disposition: expired discharge diagnosis: 1. urosepsis 2. end stage parkinson's disease discharge condition: deceased discharge instructions: none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Unspecified fall Personal history of tobacco use Paralysis agitans Acute respiratory failure Septic shock Encounter for palliative care Dementia in conditions classified elsewhere without behavioral disturbance Other and unspecified coagulation defects Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Dementia with lewy bodies

history of present illness: the patient is a 35-year-old gentleman with no past medical history who recently taking aspirin 81 mg by mouth once per day three weeks prior to presentation to decrease potential cardiac risks. the patient reports that two weeks ago he had scant bright red blood on his toilet paper after a soft bowel movement. none again until the day of admission when he had ten soft bowel movements; all brown and streaked with blood. the patient denies lightheadedness or syncope. he denies nausea or vomiting. her reports that he was consuming alcohol at a social event last night, and he ate out at a fast food location this past week. the patient denies any history of anal trauma. he denies abdominal pain, dizziness, or weakness. he reports some fatigue. no chest pain. no palpitations. no shortness of breath. no known history of hemorrhoids. no history of easy bruising or bleeding disorders. the patient reports that he occasionally has back pain. past medical history: 1. hypercholesterolemia; under no treatment. 2. gastroesophageal reflux disease; for which he occasionally uses prilosec. medications on admission: aspirin 81 mg by mouth once per day (started two weeks ago as stated). allergies: the patient denies any known drug allergies. family history: no family history of colon cancer. social history: the patient lives with his wife who is a nurse . the patient denies any use of illicit substances. the patient denies any use of tobacco and reports occasional use of alcohol (a few drinks on the evening prior to admission). physical examination on presentation: vital signs on admission revealed the patient's temperature was 95 degrees fahrenheit, his heart rate was 105, his blood pressure was 150/82, his respiratory rate was 12, and his oxygen saturation was 100% on room air. in general, the patient was alert sitting up on the gurney with an athletic build and good coloring. head, eyes, ears, nose, and throat examination revealed the sclerae were anicteric. the mucous membranes were moist. the patient's neck was supple. no carotid bruits. cardiovascular examination revealed the patient had a regular rate. there was 1/6 systolic murmur at the left sternal border. no rubs or gallops. radial and dorsalis pedis pulses were 2+ bilaterally and equal. the patient's lungs were clear to auscultation. the abdomen was soft and distended. there were positive bowel sounds. no bruits. no masses. there was a soft tissue 0.5-cm in diameter mass at one o'clock above the umbilicus. the patient's extremities were warm with some varicose veins present on the leg. no clubbing, cyanosis, or edema. neurologic examination revealed cranial nerves ii through xii were grossly intact. his gait was not assessed. rectal examination revealed normal tone and guaiac-positive stool. orthostatics were not assessed prior to intravenous fluid hydration. pertinent laboratory values on presentation: pertinent laboratories on admission revealed the patient had a normal white blood cell count, normal platelets, and his hematocrit was 40%. his prothrombin time, partial thromboplastin time, and inr were all within normal limits. electrolytes were all within normal limits. pertinent radiology/imaging: in the emergency department, the patient had a nasogastric lavage which was negative, and gastric contents were of food. electrocardiogram revealed a normal sinus rhythm with normal axis and normal intervals. there was a single t wave inversion in v1 and biphasic t waves in v3. there was a q wave in iii. no st elevations or depressions. no known previous electrocardiogram for comparison. concise summary of hospital course: our impression was that this was a 35-year-old otherwise healthy gentleman with bright red blood per rectum multiple times in one day and a history of significant blood on toilet paper two weeks ago with recent use of aspirin. the differential was a lower gastrointestinal bleed, most likely diverticulosis or hemorrhoids, given the clinical history and lack of crampy pain or support for colitis or irritable bowel disease. the patient has no history to support the idea of ulceration or upper gastrointestinal bleeding. no family history of colon cancer. the patient was initially managed with fluid resuscitation. serial hematocrit levels were monitored, and all stools were guaiaced. the patient was kept nothing by mouth for an esophagogastroduodenoscopy and colonoscopy. the patient was not orthostatic or symptomatic. the patient was initially admitted to the floor and the gastroenterology service was following him closely. on the night of admission, the patient persistently had bright red blood per rectum every hour. he became orthostatic and lightheaded. the patient's hematocrit decreased into the 20s, and he was transferred to the medical intensive care unit for further monitoring. he was transfused 2 units of packed red blood cells and given 3 liters of normal saline, and his blood pressure normalized to 120/84. subsequent nasogastric lavages were all negative. esophagogastroduodenoscopy revealed a short segment of esophagus, schatzki ring. a tagged red blood cell scan revealed no active gastrointestinal bleed. a colonoscopy revealed diverticulosis of the cecum and ascending colon as likely source of bleeding. no active bleeding site was found, but his hematocrit remained stable over 48 hours. the patient denied any complaints. the patient had no abdominal pain. on the day of discharge, it was presumed that diverticular disease was the source of his bleeding with no subsequent bleeds. the patient was maintained on a high-fiber diet. he was continued on protonix 40 mg by mouth once per day. the patient was recommended to have a follow-up esophagogastroduodenoscopy for esophageal biopsies given the short segment of esophagus seen on the esophagogastroduodenoscopy during his admission. discharge disposition: all electrolytes were within normal limits, and he was discharged to home hemodynamically stable. discharge diagnoses: 1. gastrointestinal bleed. 2. anemia secondary to blood loss. 3. diverticulosis. 4. esophagus. discharge instructions/followup: 1. the patient was instructed to call for an appointment to follow up with a gastroenterologist in six months for a repeat esophagogastroduodenoscopy with dr. and/or dr. . 2. the patient was instructed to follow up with his primary care physician. medications on discharge: protonix 40 mg by mouth once per day. condition at discharge: the patient was hemodynamically stable with a normal blood pressure (130 systolic) without lightheadedness or evidence of gastrointestinal bleeding. his hematocrit was stable at 32%. discharge status: discharge status was to home. , m.d. dictated by: medquist36 d: 12:50 t: 10:57 job#: Procedure: Other endoscopy of small intestine Colonoscopy Diagnoses: Esophageal reflux Pure hypercholesterolemia Acute posthemorrhagic anemia Diverticulosis of colon with hemorrhage Ulcer of esophagus without bleeding

history of present illness: the patient is a 74-year-old gentleman with a history of type 2 diabetes, coronary artery disease (status post myocardial infarction), and cerebrovascular accident who originally presented on from hospital with painless jaundice and a 55-pounds weight over the past year here for endoscopic retrograde cholangiopancreatography. the patient noticed gradual jaundice since . no abdominal pain, nausea, vomiting, fevers, or chills. positive dark urine, and light stools, pruritus, and fatigue. an abdominal computed tomography on from the outside hospital was reported to have shown moderate ascites, a large liver and spleen, and dilation of the biliary tree, with a question of intrahepatic malignancy. an abdominal ultrasound at the outside hospital on showed splenomegaly, ascites, gallbladder wall thickening, and dilated ducts in the liver. a magnetic resonance imaging on at the outside hospital showed dilation of the biliary tree and a 4-cm lesion in the left lobe of the liver. endoscopic retrograde cholangiopancreatography on performed at showed an intraductal mass, and plastic stent placed. the mass was brushed and cells were sent to cytology which were positive for adenocarcinoma. additionally, the patient was found to have an increased creatinine while admitted. creatinine in was noted to be 0.9. then on , creatinine was noted to be 2 after a computed tomography scan at the outside hospital. on admission to the hospital on , creatinine was noted to be 8.1. the patient was treated multiple times with kayexalate for a high potassium. a paracentesis was performed on which showed no evidence of spontaneous bacterial peritonitis. on , a quinton catheter was placed in the right femoral vein, and the patient underwent hemodialysis. during the course of hemodialysis the patient became hypotensive in the 80s/40s, and was subsequently volume resuscitated with 2.2 liters of fluids. his blood pressure did not increase, and the patient began to experience shortness of breath. the patient was originally saturating 96% on room air but then desaturated to 93% on 2 liters of oxygen and then 95% on 4 liters of oxygen. additionally, the patient was wheezing. thus, the patient was transferred to the medical intensive care unit. an arterial blood gas was taken and showed a ph of 7.41, a pco2 of 28, and a po2 of 72. once the patient was transferred to the medical intensive care unit, his blood pressures dropped to the 60s. a right internal jugular was placed, and the patient was started on levophed. fresh frozen plasma was given prior to line placement as the patient's inr was 1.7. additionally, the patient was started on ampicillin, gentamicin, and flagyl for presume cholangitis. past medical history: (past medical history is significant for) 1. coronary artery disease; status post myocardial infarction. a catheterization performed in showed no significant coronary artery disease. 2. an echocardiogram performed in showed diastolic dysfunction without systolic dysfunction and left atrial enlargement. 3. non-insulin-dependent diabetes mellitus. 4. cerebrovascular accident with a right facial droop. 5. left hydronephrosis; chronic ? 6. mild spinal stenosis at l4-l5. 7. left anterior temporal lobe small arachnoid cyst. medications on admission: spironolactone. allergies: no known drug allergies. social history: alcohol once per month. tobacco times 20 years; quit four years ago. no intravenous drug abuse. one to two cups of coffee once per day. a retired truck driver. family history: family history was not significant for gastrointestinal problems or cancer. physical examination on presentation: physical examination on admission to the medical intensive care unit revealed vital signs of 93/29, heart rate was 83, respiratory rate was 10, and oxygen saturation was 96% oxygen saturation on 4 liters nasal cannula. temperature was 95.8 (hypothermic). in general, the patient was markedly jaundiced and appropriately conversational. head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. pupils were equal, round, and reactive to light. scleral icterus. a jaundiced oropharynx. spider angiomas on the face. chest examination revealed crackles at the bases bilaterally/anteriorly. mild expiratory wheezes. cardiovascular examination revealed a regular rate and rhythm. a holosystolic murmur heard at the left fifth intercostal space midclavicular line. the abdomen was soft and nontender. distended. positive fluid wave. unable to assess organ size. a right femoral quinton catheter. extremity examination revealed no edema. dorsalis pedis pulses were 2+ bilaterally. positive asterixis bilaterally. pertinent laboratory values on presentation: laboratories on admission to the medical intensive care unit revealed white blood cell count was 7 (down from 10.2), hematocrit was 28.6, and platelets were 90. prothrombin time was 15.9, partial thromboplastin time was 37.1, and inr was 1.7. urinalysis revealed brown/cloudy. specific gravity was 1.016, large blood, 100 protein, moderate bilirubin, trace leukocytes, greater than 50 red blood cells, 6 to 10 white blood cells, few bacteria, and amorphous crystals. sodium was 137, potassium was 4.5, chloride was 100, bicarbonate was 16, blood urea nitrogen was 86, creatinine was 7.9, and blood glucose was 105. lipase was 72 and amylase was 25. calcium was 7.8, phosphate was 6.9, and magnesium was 2.1. albumin was 3. alt was 47, ast was 82, total bilirubin was 27.2, and alkaline phosphatase was 145. microscopic examination from ascites taken from revealed no growth, no polymorphonuclear leukocytes, no organisms seen on gram stain, 55 white blood cells, and 3045 red blood cells. cytology from ascites taken from was negative for malignant cells. brush on endoscopic retrograde cholangiopancreatography taken from was positive for malignancy cells adenocarcinoma. urine cultures from and revealed no growth. pertinent radiology/imaging performed at : 1. endoscopic retrograde cholangiopancreatography performed on revealed intraductal mass, stent placed. 2. abdominal ultrasound on revealed sludge in the gallbladder, negative sign, liver shrunken with increased echogenicity, enlarged spleen, and portal vein was patent. 3. magnetic resonance imaging of the abdomen performed on (although limited by the patient's claustrophobia), revealed massive ascites, left greater than right small bilateral pleural effusions, liver nodularity (consistent with cirrhosis), 3.6-cm x 4.8-cm mass with increased signal in segment 4a liver, spleen mildly enlarged, varices along the stomach (portal hypertension), gallbladder with no stones and no ductal dilatation. 4. a chest x-ray on revealed right internal jugular in place and pulmonary edema. no infiltrate. no pneumothorax. hospital course by issue/system: in summary, the patient is a 74-year-old gentleman with diabetes, coronary artery disease, and cerebrovascular accident who presented with painless jaundice and a 55-pound weight loss, status post endoscopic retrograde cholangiopancreatography with stent, now with cirrhosis and acute renal failure and probable cholangiocarcinoma. the patient was transferred to the medical intensive care unit with hypotension and shortness of breath. 1. hypotension issues: hypotension was treated with pressors (levophed). the patient was weaned off levophed with gentle fluid boluses. mean arterial pressure remained in the 50s to 60s, and the patient mentated well throughout his hospital course in the medical intensive care unit. hypotension was most likely secondary to sepsis. 2. pulmonary issues: the patient remained stable on 4 liters nasal cannula and was saturating well. the patient's pulmonary status was monitored closely while receiving fluid boluses for blood pressure so as to prevent a flare of pulmonary edema. albuterol nebulizers were given for wheezing. shortness of breath differential diagnoses included cirrhosis, renal failure, ascites (atelectasis), possible congestive heart failure or fluid overload. 3. coronary artery disease/congestive heart failure issues: no aspirin was given at this time as the patient was coagulopathic with an increased inr. no beta blocker were given during this time as the patient was hypotensive. mild congestive heart failure was seen on chest x-ray on . the patient received an echocardiogram on which revealed an ejection fraction of 75% to 80%; although the patient was on levophed at the time of this echocardiogram. findings included left atrium was mildly dilated, left ventricular wall thickness and cavity size were normal, hyperdynamic, right ventricular size and motion were normal, aortic valve leaflets were thickened, no regurgitation, trivial tricuspid regurgitation, and borderline pulmonary artery systolic hypertension. no effusions. 4. gastroenterology issues: intraductal mass was positive for adenocarcinoma by cytology. palliative care for this patient. the patient's treatment options and prognosis were discussed at length with the patient and his family. total bilirubin and liver function tests were checked daily to assess for obstruction. if these values were to increase significantly, could possibly replace stent with a more permanent stent via endoscopic retrograde cholangiopancreatography to relieve obstruction. total bilirubin tended to decrease throughout his hospital stay. the patient also has cirrhosis of unclear etiology. 5. renal issues: acute renal failure; question as to etiology - acute tubular necrosis; status post contrast for computed tomography versus hepatorenal syndrome. the patient received three days of hemodialysis. no fluid was removed in hemodialysis. renal consultation team is following the patient. fractional excretion of sodium was 1%. 6. infectious disease issues: the patient was originally started on ampicillin, gentamicin, and flagyl for presumed cholangitis causing a septic picture with increased white blood cells, hypotension, and hypothermia. this antibiotic regimen was changed to vancomycin, ceftazidime, and flagyl so as to provide more protection for the kidneys. cultures were negative or pending to date. blood cultures from were pending. urine cultures from and showed no growth. ascites from showed no growth. 7. hematologic issues: the patient remained coagulopathic secondary to liver disease. the patient was oozing from intravenous site. thus, the patient was given three days of subcutaneous vitamin k to correct for the increased inr. the patient received two units of packed red blood cells while in the medical intensive care unit for a hematocrit of less than 30. the patient also received one unit of fresh frozen plasma prior to internal jugular central vein line placement on . 8. fluids/electrolytes/nutrition issues: the patient received fluid boluses for a decreased blood pressure; yet remained saturating well on 4 liters nasal cannula oxygen and had no complaints of chest discomfort. electrolytes were repleted as needed. the patient was given a full diet upon his request. 9. access issues: the patient has a right internal jugular central line which was placed on , and a right femoral quinton catheter which was placed on , as well as two peripheral intravenous lines. 10. code status: the patient's code status was changed from full code to do not resuscitate/do not intubate. the patient and the patient's family expressed a wish to not be started on pressors if the patient's blood pressure were to fall. 11. social issues: multiple family meetings were held with the patient and his family. his son is the main contact person. additionally, the patient's brother flew in from and was able to meet with the patient and spend time with him. discharge disposition: currently, the patient is in the medical intensive care unit awaiting a private bed on the floor. the patient will most likely either be discharged to the floor in a private bed or go home soon with some kind of hospice care or visiting nurse assistance; pending social work evaluation and discussions with the family and the patient. condition at discharge: condition on discharge was fair. discharge status: the patient was to be discharged pending a private room on the floor, or the patient and his family wish for care at home. discharge diagnoses: 1. cirrhosis. 2. probably cholangiocarcinoma. 3. acute renal failure. 4. diabetes. 5. coronary artery disease/congestive heart failure. medications on discharge: have yet to be decided. the patient will most likely go home with antibiotics for presumed cholangitis and other comfort medications. discharge instructions/followup: 1. the patient was to follow up with his primary care doctor if needed. 2. the patient was also to follow up with social work for home hospice care if desired. , m.d. dictated by: medquist36 d: 22:36 t: 22:51 job#: Procedure: Venous catheterization, not elsewhere classified Hemodialysis Venous catheterization for renal dialysis Percutaneous abdominal drainage Endoscopic insertion of stent (tube) into bile duct Other closed [endoscopic] biopsy of biliary duct or sphincter of Oddi Diagnoses: Acidosis Hyperpotassemia Acute kidney failure with lesion of tubular necrosis Cirrhosis of liver without mention of alcohol Unspecified septicemia Hydronephrosis Cholangitis Malignant neoplasm of extrahepatic bile ducts

allergies: penicillins attending: chief complaint: shortness of breath major surgical or invasive procedure: none history of present illness: 60 yo f with ra (only on plaquenil), htn, pulm fibrosis, pvd, oa, tobacco use presents to ed with 2-3 wk h/o malaise, dry cough, and progressive sob. denies any f/c/ns. nearly intubated in the ed for hypoxic respiratory failure (o2 sats 80s, rr 40s), with significant wheeze. however, with iv steroids and continuous albuterol nebs, improved and stablilized, though still tachypnic with wheeze. cta demonstrated no pe, though large mass (taking up much of rul, some of rml that compresses the rul and rml bronchi, with ?extension into the pretrachial/subcarinial space vs associated lymphadenopathy, innumerable bilateral nodules and thick interstitial markings. in addition, hypodensities were visualized in the liver. started on empiric levo/azithro in the ed. ed course also notable for mat as high as 170 bpm, in part exacerbated by albuterol, with rate-related lateral ischemic changes (st dep v3-v6, lateral twi). ruling out for mi with serial neg cardiac enzymes. past medical history: ra pulmonary fibrosis pvd tobacco use (>20 years) oa htn prior cardiomyopathy, with ef now 55% (was 30-40% , etiology unknown) recent p-mibi, with no perfusion defects, no , 58% s/p appy s/p cervical fusion s/p lumbar fusion oa social history: very relgious, former heavy smoker. family history: n.c. physical exam: t 97.9 hr 127 bp 138/63 rr 25 98% nrb gen: female, sitting up, tachypnic, w/ acc muscle use heent/neck: +jvd, +cervical lad, eomi, mm dry, cv: irregular, tachy, no m/r/g pul: diffuse wheezes, poor a/m b/l abd: soft, nt, nd. ext: no edema, from pertinent results: 02:22pm type-art temp-37.0 rates-/30 o2-60 po2-118* pco2-40 ph-7.36 total co2-24 base xs--2 intubated-not intuba 03:02am blood wbc-17.2* rbc-3.61* hgb-9.9* hct-31.9* mcv-88 mch-27.5 mchc-31.1 rdw-15.0 plt ct-95* 03:02am blood glucose-150* urean-56* creat-1.2* na-145 k-4.5 cl-111* hco3-25 angap-14 09:40am blood type-art temp-36.4 o2 flow-4 po2-70* pco2-51* ph-7.26* calhco3-24 base xs--4 intubat-not intuba brief hospital course: pt was admitted to the in respiratory distress. ct/angiogram results showed a large right lung mass, likely to be lung cancer, with metastasis to the left lung and liver. the prognosis of this cancer was discussed with the patient and her sister, , her healthcare proxy. the patient's respiratory distress seemed to improve, her blood gases demonstrated that she was tiring out. on and family meetings were held to discuss the patient's progress and dismal prognosis. at this time the patient was made dnr/dni but treatment was continued. later on in the night, the patient became hypotensive and increasingly short of breath. after speaking with , her healthcare proxy, comfort measures were started with morphine. shortly thereafter, she became more hypoxic and bradycardic. the patient had no corneal reflexes, and had no heart sounds or breath sounds for one minute. time of death was 7:10pm. the family was present. autopsy consent was granted. medications on admission: lopressor oxycontin vioxx plaquenil fosamax mvi discharge medications: expired discharge disposition: home facility: expired discharge diagnosis: pneumonia metastatic lung cancer discharge condition: deceased discharge instructions: deceased followup instructions: deceased md Procedure: Venous catheterization, not elsewhere classified Diagnoses: Other primary cardiomyopathies Malignant neoplasm of liver, secondary Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Peripheral vascular disease, unspecified Acute respiratory failure Postinflammatory pulmonary fibrosis Malignant neoplasm of other parts of bronchus or lung Rheumatoid arthritis Secondary malignant neoplasm of lung Bronchopneumonia, organism unspecified Neoplasm of uncertain behavior of larynx

allergies: morphine attending: chief complaint: bilateral femoral periprosthetic shaft fractures major surgical or invasive procedure: 1. open reduction, internal fixation with percutaneous plating and reduction of right periprosthetic fracture. 2. open reduction, internal fixation with percutaneous plating technique, minimally invasive technique of left femoral periprosthetic fracture. history of present illness: ms. is a 73-year-old female patient who fell from standing resulting in bilateral femur fractures which were periprosthetic. on the left side, she has a hip hemiarthroplasty and total knee, and on the right side she has a hip hemiarthroplasty. the presence of implants precludes the performance of intramedullary nailing. the procedure of choice at this point is plating which we will perform through a percutaneous technique in order to minimize the morbidity to this elderly and very frail patient. past medical history: cva 2.5yrs ago seizure disorder h/o urosepsis/uti hypertension osteoporosis pancreatic insufficiency h/o depression/anxiety h/o alcoholic liver disease hypothyroidism chronic renal insufficiency - baseline cre 1.4-1.8 h/o hyperkalemia h/o amenia social history: non-contributory family history: non-contributory physical exam: on discharge: afebrile, all vital signs stable gen: alert and oriented, no acute distress lungs: clear to auscultation bilaterally cardiac: regular rate and rhythm abd: +bowel sounds, benign extremities: bilateral lower weight bearing: non weight bearing x8wks incision: no swelling/erythema/drainage dressing: clean/dry/intact +/fhl/at +silt 2+ pulse, wiggles toes capillary refill brisk brief hospital course: ms. presented to the emergency department from hospital with bilateral leg pain. she was evaluated by the orthopaedics department and found to have bilateral periprostetic femur fractures. she is s/p bilateral total hip replacements. reduction was attempted, but unsucessful. she was placed in bilateral leg braces for stabilization. she was admitted to the medicine service and cleared for surgery. on , she was prepped and brought down to the operating room for surgery. intra-operatively, she was closely monitored and remained hemodynamically stable. she tolerated the procedure well without any difficulty or complication. post-operatively, she was extubated and transferred to the pacu for further stabilization and monitoring. she was then transferred to the floor for further recovery. on pod #1, she was transfused 2 units of prbc for postoperative anemia. she then remained hemodynamically stable and her pain was controlled. she progressed with physical therapy to improve her strength and mobility. she continues to make steady progress without any incidents. she was discharged to a rehabilitation facility in stable condition. she was instructed to call dr. office at for a follow up appointment in 2 weeks after hospital discharge. medications on admission: buspirone aspirin fosamax synthroid darvocet keppra mvi effexor xr prevacid norvasc pancrease discharge medications: 1. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 2. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 3. venlafaxine 75 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po daily (daily). 4. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 5. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 7. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. 8. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 12. enoxaparin 30 mg/0.3 ml syringe sig: one (1) syringe subcutaneous q24h (every 24 hours) for 4 weeks. 13. insulin regular human 100 unit/ml solution sig: ssir injection asdir (as directed). 14. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 15. buspirone 5 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for anxiety. 16. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. discharge disposition: extended care facility: senior healthcare of discharge diagnosis: bilateral periprosthetic femur shaft fractures discharge condition: stable discharge instructions: keep the incision clean and dry. you may apply a dry sterile dressing as needed for drainage or comfort. if you are experiencing any increased redness, swelling, pain, or have a temperature >101.5, please call your doctor or go to the emergency room for evaluation. you may not bear weight on either leg. your skin staples/sutures may be removed 2 weeks after surgery. resume all of your home medication and take all medication as prescribed by your doctor. continue your lovenox injections as prescribed for preventing blood clots. please call dr. office @ for a follow up appointment in 2 weeks after hospital discharge. feel free to call our office with any questions or concerns. physical therapy: activity: out of bed w/ assist right lower extremity: non weight bearing x8wks left lower extremity: non weight bearing x8wks treatments frequency: as stated above followup instructions: please call dr. office for a follow-up appointment 2 week after hospital discharge. md, Procedure: Open reduction of fracture with internal fixation, femur Open reduction of fracture with internal fixation, femur Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Unspecified acquired hypothyroidism Other convulsions Chronic kidney disease, unspecified Dysthymic disorder Osteoporosis, unspecified Unspecified late effects of cerebrovascular disease Knee joint replacement Fall from other slipping, tripping, or stumbling Peri-prosthetic fracture around prosthetic joint Hip joint replacement

allergies: morphine/latex neuro: pt alert but disoriented. asked if she is dying (ed documentation states this also) easily oriented. forgetful. able to state name and dob. total 0.5mg iv hydromorphone given since admit to unit. Procedure: Open reduction of fracture with internal fixation, femur Open reduction of fracture with internal fixation, femur Diagnoses: Urinary tract infection, site not specified Unspecified essential hypertension Unspecified acquired hypothyroidism Other convulsions Chronic kidney disease, unspecified Dysthymic disorder Osteoporosis, unspecified Unspecified late effects of cerebrovascular disease Knee joint replacement Fall from other slipping, tripping, or stumbling Peri-prosthetic fracture around prosthetic joint Hip joint replacement

discharge medications: 1. docusate 100 mg twice a day. 2. sliding scale insulin. 3. lansoprazole 30 mg q. day. 4. erythromycin optic ointment 0.5 in affected eye three times a day. 5. the patient is also receiving simethicone 80 mg four times a day. this dose should shortly be weaned and discharged in the outpatient setting. 6. reglan 10 mg intravenous q. six hours. 7. lactulose 30 ml p.o. three times a day. 8. fentanyl patch 25 micrograms q. 72 hours transdermal. 9. flagyl 500 mg p.o. three times a day. the patient should continue on flagyl, today being day seven, for an additional seven days, completing a 14 day course for current clostridium difficile. 10. ambien 5 mg p.o. at night. 11. ativan 0.5 mg p.o. q. six hours. 12. hydrocortisone cream 1%, one application twice a day to patient's back. 13. lasix 60 mg intravenously q. eight hours for further diuresis. once the patient has diuresed an additional 1.5 liters, the patient may be stopped on this and switched to original lasix dose p.o. 14. the patient is also written for percocet one to two pills p.o. q. four to six hours p.r.n. back pain. dr., 12-981 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other enterostomy Insertion of endotracheal tube Temporary tracheostomy Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Pneumonitis due to inhalation of food or vomitus Intestinal infection due to Clostridium difficile Hematemesis Ulcerative colitis, unspecified Conjunctival hemorrhage

history of present illness: the patient is a 76 year old gentleman presenting to emergency department on complaining of 24 hours of dizziness, shortness of breath, cough, fever and respiratory distress. patient was noted to have a significant past medical history of upper gi bleed and was status post one episode of coffee ground emesis the night prior to admission. patient was found to be in mild respiratory distress with bilateral rhonchi, hypoxia and hypercapnia. patient became significantly more hypoxic and hypercapnic and anesthesia was called for potential difficult airway and patient was successfully intubated. patient remained hemodynamically stable. in the emergency department patient was noted to have a temperature of 101.9, blood pressure 118/50, heart rate 119, o2 sat 77%, respiratory rate between 30 and 35. patient received sublingual nitroglycerin times one, noted drop in blood pressure to systolic of 77 over diastolic of 54. given 5 liters iv fluids. subsequent abg of 7.48, 38, 39 in room air. given 100% nonrebreather and increased o2 sat to 85%. patient was then electively intubated. chest x-ray showed predominantly chf with bilateral pneumonia consistent with aspiration pneumonia. subsequent abg was 7.36, 45, 96. patient was put on assist control 14/400, peep 12, 100%. patient was noted to have bloody sputum with suctioning. no acute gi bleed. patient received cat scan of head which showed no bleed. patient was subsequently admitted to the medical icu. patient subsequently received ffp times two units and one bag of platelets. past medical history: head and neck squamous cell cancer in status post xrt and radical neck dissection. cva in . recent admission for gi bleed and hemoptysis. thrombocytopenia. ulcerative colitis. basal cell cancer of the scalp. status post head injury in the status post metal plate insertion. allergies: no known drug allergies. medications: prednisone taper which ended , protonix 40 q.day, fioricet p.r.n., hydrocortisone enema 100 q.h.s. p.r.n., colace 100 b.i.d., sulfasalazine 1000 mg t.i.d. social history: distant tobacco history. patient currently nonsmoker. nondrinker. past history of etoh abuse. no illicit drugs. patient recently widowed. family history: significant for prostate cancer in father and uterine cancer in sister. physical examination: on presentation to medical icu temperature was 101.9, pulse 101, blood pressure 116/69, respiratory rate 12, 96%. patient was intubated, sedated and unresponsive. pupils equal, round, and reactive to light. mucous membranes moist. right ij placed in e.d. in place. regular rate s1, s2, 2/6 systolic ejection murmur. lungs showed diffuse crackles with occasional rhonchi. et tube in place with some diffuse bloody secretions. abdomen distended with decreased bowel sounds. extremities were warm, 1+ distal pulses, 1+ pitting edema way up patient's calves. laboratory data: subsequent ekg showed sinus tach at 110, 0 axis, right bundle branch block, slight depression in 4 and 5. hospital course: the patient was admitted to micu with the diagnoses of severe hypoxia, bilateral pneumonia, chf versus aspiration pneumonia, resolving hemoptysis, fever and elevated white count at 21.0. patient was started on levofloxacin and flagyl, pan cultured. was given propofol for sedation. patient's chest x-ray day subsequent to admission was consistent with aspiration pneumonia. gram positive cocci. was continued on levaquin and flagyl. vancomycin was added for coverage. pulmonary. bilateral pneumonia persisted right worse than left. he was continued on levaquin, flagyl and vancomycin. medical icu team had difficulty oxygenating patient further contributing to patient's respiratory failure from aggressive volume depletion in the emergency department and early icu course. patient was in excess of 18 liters positive. patient was placed on assist control, tidal volume 500, peep 16, pressure support 25, fio2 50%. patient slowly making gradual decrease in fio2 to 40%. patient had decrease in peep to 14. patient continued on course of antibiotics for aspiration pneumonia. patient was noting to continually desat with decrease in peep requiring increase in ventilatory support. patient received moderate benefit from aggressive chest p.t. and recruitment maneuvers. at or around hospital day 16 patient was switched from assist control to pressure support of 10, peep 16, fio2 40%. patient continued to have thick yellow secretions, coarse breath sounds bilaterally. chest x-ray slowly improving. right interstitial consolidations. patient eventually tolerated decrease of pressure support to 12, peep 12, continuing to wean. patient was deemed slow to wean from vent settings and ent was consulted to do an o.r. trach for patient secondary to patient's neck dissection and xrt for skin cancer. on or around patient was at pressure support of 12, peep 7 , fio2 40%, remaining extremely sensitive to changes in pressure support. drops from pressure support of 14 to 13 would make patient tachypneic pulling low tidal volumes. patient remained slow to wean. patient was decreased on his sedation of ativan and fentanyl drips and slowly began to wean from pressure support of 12 to eventual goal of pressure support of 8 over a period of 12 days. on patient was decreased to pressure support of 8.5 and 40% and was started on trach collar trial for one hour. patient continued at pressure support of 8.5 and 40% for multiple hours without previous tachypnea episodes. patient was gotten out of bed to chair and had multiple successful trach collar trials ranging from 15 minutes to 1 1/2 hours. patient was aggressively diuresed with lasix with a goal of 0.5 to 1 liter net negative on fluid balance per day. diuresis was somewhat limited secondary to recurrent bouts of hypotension with systolic in the 90s, thus delaying diuresis. over the course of the hospital stay from to today, , patient is now net only 1.5 liters positive in fluids and responding to lasix. infectious disease. throughout his hospital course patient continued to have low grade fevers in the range from 100 to 101.0. patient occasionally spiked fevers as high as 102.8. patient was put on ceftriaxone and vancomycin. patient's white counts were in the high teens and subsequently decreased. all cultures, blood and urine, were negative. further all cath tips sent for culture were negative. patient was given abdominal ct and sinus ct to look for source. sinus ct was positive for right maxillary sinusitis. abdominal ct was negative for infectious source. patient was continued on antibiotics. ent was consulted for sinusitis and suggested increase head of bed, intranasal spray, no acute management necessary at this time. on or around patient was found to be c.diff positive in the stool. patient was started on flagyl. all blood cultures, wound cultures and sputum cultures remained negative. patient without any new elevations in white count or temperature spikes for the 10 days prior to discharge. patient's hematocrit ranged from the high 20s in the beginning of his hospital stay and began to very slowly drift down throughout the hospital course. patient had no source of obvious bleeding, although he was noted to have ob positive stool. patient was transfused two units of blood with an inappropriate bump in patient's hematocrit. patient's hematocrit only increased from 23 to 25 status post two units. patient's hematocrit tended to be stable with slight decrease. patient eventually trended down from hematocrit of 26 to a slow decrease over subsequent days to hematocrit of 23. patient was transfused two additional units of blood, bringing patient's hematocrit to an appropriate bump. patient's hematocrit was noted to be 31. from patient's hematocrit has remained around 31 and remained stable. no active bleeding prior or since noted. neurologically despite negative head ct in the emergency department, throughout patient's course with decreasing sedation, patient continued to not move any extremities. did appear to track and somewhat understand responses, although he was nonvocal in response. icu staff remained concerned while sedation was completely turned off for a period of four days on or about . patient was given repeat head ct which was negative for bleed. approximately four days after shutting off sedation patient was noted to move all extremities, although was noted to be weak. subsequent day patient was found to be able to follow simple commands, squeezing hands, blinking eyes, etc. trach done in o.r. was done on . patient was also sent to interventional radiology on to receive a pej, percutaneous jejunal tube, for nutritional support. prior patient had been on a combination of tpn and tube feeds. at time of discharge on patient currently has a left subclavian day seven and previously described pej tube also day seven. both insertion sites are clean, dry and intact and devoid of any signs of infection. throughout patient's course he was kept on prophylaxis including pneumoboots, subcu heparin and prevacid. patient currently taking colace, erythromycin eyedrops, reglan, gas-x, flagyl day seven, lactulose, miconazole cream, ativan, fentanyl patch and ambien. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other enterostomy Insertion of endotracheal tube Temporary tracheostomy Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Pneumonitis due to inhalation of food or vomitus Intestinal infection due to Clostridium difficile Hematemesis Ulcerative colitis, unspecified Conjunctival hemorrhage

history of present illness: this is a 76 year-old man with a history of prior strokes, anxiety disorder, cranial plate after trauma in world war ii, head and neck cancer and recent respiratory failure secondary to aspiration pneumonia with difficulty being weaned from the ventilator. he presents from rehab as he is in pulmonary rehab at this time. while he was in a rehab facility he was noted by an employee to have an episode of unresponsiveness unclear how long. his eyes "back as well." at 7:30 a.m. his eyes rolled back again and he was brought to . on arrival he had a thirty second generalized tonic clonic seizure observed with post ictal confusion. he received dilantin one gram and prepped for an lp and then lp was tried, however, unobtainable. he was then noted to be waking up and doing better and with no further seizure activity. we admitted him to the intensive care unit at that point. after ct scan showed several attenuations consistent with a stroke of an undetermined age, but no hemorrhage. on admission we also performed a ct scan with contrast as the original ct was without contrast. this ct was negative. we also performed an electroencephalogram, which showed occasional generalized single spikes with no focal abnormalities. we continued his dilantin at 150 mg intravenous t.i.d. and continued to check levels. his dilantin level on discharge was 4.7, however, this is corrected for his albumin at 11.8. at that point we decided to increase his dilantin to 200 mg t.i.d. throughout his hospital admission he had no further seizure episodes. he was noted to have persistent thrombocytopenia and hematology/oncology was consulted. he was noted to have numerous episodes of thrombocytopenia in his last three hospital visits and each time his platelets were increased over the hospital stay. his differential per hematology/oncology included drug induced and itp. itp was unlikley given the smear and he had normal fibrinogen, lack of fever and no change in kidney function. in the patient appeared to improve due to discontinuing numerous medications including zantac and clonidine. in the platelet count was also low, but came out nicely. heparin induced thrombocytopenia and itp were still in the differential. he was on heparin 5000 units subq t.i.d. on admission and we stopped that. his platelets rose to 77 on discharge and remained stable. the patient was tapped on saturday after platelet transfusion. his lp had an opening pressure of 16, white cells of 2, reds of 120, 85 glucose and 65 protein, gram stain was negative. he had no other signs of meningitis on examination. his pulmonary status remained stable throughout his admission. at first he was somewhat agitated and he necessitated low dose ativan and propofol overnight for the first night, however, he did not have any other problems and was sating well. arterial blood gas on discharge was ph 7.46, po2 50, o2 82. laboratories on discharge: white blood cell count 7.6, hemoglobin 8.9, hematocrit 27.5, platelets 78, sodium 140, potassium 3.5, chloride 100, co2 31, bun 18, creatinine .7, glucose of 134, calcium was 8.3, phosphorus 3.1, magnesium was 1.8. dilantin level was 4.7, but corrected to 8 for his albumin, which was 2.6. on discharge his neurological examination he was alert and answering questions and following commands. pupils are equal, round and reactive to light. extraocular movements showed slight decrease in abduction left greater then right. motor examination he moved all extremities symmetrically, full strength. no drift. reflexes were symmetric. tone was normal. from a neurological perspective he was seizure free. we increased his dilantin and this should be followed in a few days at rehab. from a gastrointestinal perspective he is on prophylaxis. when admitted he had hematest positive stools. hematocrit on admission was 32 and on discharge was 27.5. as an outpatient he should have further evaluation for this, but otherwise he is clinically stable. we discussed this with the sicu team and they felt that outpatient workup was in order being that he was clinically stable. his renal function had good output, normal bun and creatinine. in regard to his hematology/oncology, he was on heparin and his platelets have increased. the patient will be ready for discharge today to rehab. prior to discharge we will assure intravenous access and possible picc placement. discharge medications: dilantin 200 mg nasogastric t.i.d., metoprolol 25 mg nasogastric b.i.d., lansoprazole 30 mg nasogastric q day, sliding scale insulin, lasix 40 mg q day nasogastric, mvi one per nasogastric q day, salsalate 500 mg nasogastric b.i.d., colace 100 mg nasogastric q day, ipratropium bromide nebulizers q 12 hours, albuterol one treatment q twelve hours, senna one tab nasogastric q.h.s., trazodone 50 mg po q.h.s. prn sleep, _______________ .5 mg intravenous q 4 to 6 hours prn. his diet is promote with fiber full strength, 95 milliliters per hour, check residuals q 4 hours and hold if greater then 100 milliliter residual. his anticipated goals is to wean off vent. final diagnoses: 1. seizure. 2. respiratory failure. 3. thrombocytopenia. 4. anemia. he is to follow up with his physician at or dr. as well as nurse i spoke with on the phone prior to discharge. further questions regarding any medical issues should be referred to the cicu team here, dr. . he was also followed by dr. hematology/oncology and neurology dr. . dr., 13-279 dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Other convulsions Acute respiratory failure Tracheostomy status

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: black stools and weakness x 7 days. major surgical or invasive procedure: esophagogastroduodenoscopy history of present illness: 87 yo f w/ h/o chf, htn, afib, and h/o recent fall resulting in a compression transferred from for c/o black stools w/ hct 16.3 and inr 32.3 due to no available icu beds at . patient was af, bp 130/44 and hr 87. she received 2 u prbc, 40 iv protonix, and 10 mg iv vit k for this. on arrival to er, hct 25.2 and inr 2.1. bp 150/54 and hr 70. patient received additional 5 mg sq vit k, in addition to 2 u ffp. ng lavage was done and yielded coffee ground emesis w/ the first 250 cc, followed by a pink-tinged fluid with the second 250 cc. on hx patient reports no po x 2 weeks due to nausea w/o c/o pain w/ eating. she has never had black stools in the past. she is on coumadin and her level was low 3 weeks ago (per her report) and thus her coumadin was increased. patient denies any diarrhea w/ the black stool. she is n but no v, and she denies abd pain. no h/o nsaids and no h/o pud. no brbpr or hematemesis. she also denies c/o lh, cop, or sob. however, she has been completely exhausted for the past week. past medical history: ## chf ## htn ## afib on coumadin ## h/o compression fx due to fall ## s/p recent fall (2 wks ago) social history: + h/o tob: pk yr hx, quit 25 yrs ago. no etoh x 4 yrs, occasional in the past. married and has 1 daughter. contact for emergencies: (sister). family history: nc physical exam: t 99.1 hr 71 bp 155/65 rr 18 o2 92% ra (100% on 4l nc) genrl: in nad, pleasant heent: perrla (3->2 mm), mmm, op clear, ngt in place (120 cc lavage continues to produce coffee grounds) neck: no jvd cv: rrr, no m/r/g pulm: cta bilaterally abd: nabs, soft, nt/nd, no masses/hsm rectal: black, guiac positive stool surrounding anus extr: no neuro: a, o x 3, strength and soft touch sensation grossly in ue/le pertinent results: 02:42pm wbc-16.8* rbc-2.81* hgb-9.0* hct-25.2* mcv-90 mch-31.9 mchc-35.6* rdw-16.0* plt count-281 02:42pm neuts-82.8* lymphs-13.3* monos-3.5 eos-0.3 basos-0.2 02:42pm pt-17.5* ptt-26.8 inr(pt)-2.1 02:42pm glucose-115* urea n-45* creat-1.0 sodium-141 potassium-3.7 chloride-101 total co2-30 anion gap-14 . 05:03am blood wbc-11.7* rbc-3.53* hgb-11.4* hct-32.7* mcv-93 mch-32.2* mchc-34.8 rdw-15.5 plt ct-325 05:03am blood plt ct-325 05:03am blood glucose-91 urean-21* creat-1.0 na-139 k-4.2 cl-99 hco3-31 angap-13 05:03am blood mg-1.8 . cxr : medical condition: 87 year old woman with bibasilar crackles w/ h/o chf reason for this examination: r/o chf history: bibasilar crackles, rule out chf. chest, single ap view. no previous chest x-rays on pacs record for comparison. the lungs are hyperinflated. there is moderate to moderately severe cardiomegaly. there is subsegmental atelectasis and/or scarring at both bases. there is minimal blunting of both costophrenic angles. there is no chf or frank consolidation. i doubt the presence of an infectious infiltrate. there is right upper hilar peribronchial cuffing. linear atelectasis or scarring noted in the right mid zone. an ng tube is present, tip over proximal stomach. there is osteopenia and an old ununited left clavicle fracture. impression: hyperinflation and cardiomegaly. right upper hilar peribronchial cuffing. no chf. doubt acute infectious infiltrate. . ct head w/o contrast 4:59 pm ct head w/o contrast reason: r/o ich medical condition: 87 year old woman with recent head trauma, inr 35 reason for this examination: r/o ich contraindications for iv contrast: none. ct head indication: recent head trauma, inr 35. no prior studies are available for comparison. technique: non-contrast head ct. findings: there is no intraparenchymal or extra-axial hemorrhage. there is no shift of normally midline structures, mass effect or hydrocephalus. there is mild prominence of the ventricles and sulci consistent with age-related involutional change. encephalomalacic changes are demonstrated in the anterior and medial portions of the frontal lobes bilaterally. there is also encephalomalacic change demonstrated in the left occipital lobe. periventricular white matter hypodensities are also noted consistent with chronic small vessel ischemic change. the visualized paranasal sinuses and osseous structures are within normal limits. impression: 1. no intracranial hemorrhage or mass effect. 2. encephalomalacic changes in the bifrontal lobes and left occipital lobe. . cxr : atrial fibrillation modest nonspecific intraventricular conduction delay modest st-t wave changes with probable qt interval prolonged although is difficult to measure - are nonspecific but clinical correlation is suggested for possible in part metabolc/drug effect. no previous tracing available for comparison intervals axes rate pr qrs qt/qtc p qrs t 78 0 118 446/479 0 -21 107 . patient: ref.phys.: birth date: (87 years) instrument: gif xq140 gastroscope id#: asa class: p2 medications: cetacaine topical spray meperidine 25mg midazolam 1mg procedure: the procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. a physical exam was performed. the patient was administered conscious sedation anesthesia. the patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. careful visualization of the upper gi tract was performed. the procedure was not difficult. the patient tolerated the procedure well. there were no complications. findings: esophagus: lumen: a small size hiatal hernia was seen. excavated lesions a single non-bleeding 6mm ulcer was found in the gastroesophageal junction. stomach: contents: old blood was seen in the stomach. no sites of active bleeding were identified. duodenum: normal duodenum. impression: blood in the stomach ulcer in the gastroesophageal junction small hiatal hernia brief hospital course: 87 yo f w/ h/o chf, htn, fib, and h/o recent fall transferred from osh w/ likely ugi in setting of elevated inrx (on coumadin). . ## ugi: the patient's hct was 16.3 with inr 32.3 at osh. the patient received 2 units of pr bc, protonix 40 mg iv, and 10 mg iv vit k at the osh. due to no icu availability, the patient was transferred to . on arrival to , her hct was 25.2 with inr 2.1. she received additional mg sc vit k and 2 u ffp. ng lavage showed coffee ground emesis followed by a pink-tinged fluid. ct of head was neg for bleeds. the patient was started on protonix 40 mg iv bid and observed overnight in the micu, and gi did not feel that urgent egd was necessary as the patient was hemodynamically stable with stable hct after blood transfusion. the patient was transferred to the floor in a hemodynamically stable and hct was stable at 33.2. egd was performed on which showed an ulcer at ge junction and old blood in the stomach without signs of active bleeding. the patient was switched to po protonix after the procedure and hct continued to remain stable at the time of discharge. the patient is to follow up with dr. , her pcp, decide on when to restart coumadin and close monitor of inr when she gets placed on coumadin again. . ## chf: after a total of 4 units of prbc transfusion, the patient became hypoxemic and required supplemental o2 to keep o2 sat above 92. her lung exam was consistent with pulmonary edema. she was given iv lasix and her hypoxemia resolved. once satting 95-97% on ra, she was restarted on her outpatient po lasix regimen. . ## afib: held beta blocker initially given ugib. once stable hemodynamically, outpatient atenolol 100mg qday and amlodipine 5mg qday were restarted for rate control. no coumadin was given during this hospitalization. gi felt that she can be restarted on coumadin but with close monitor of inr with goal of . . ## htn: no antihypertensives given while in the micu. received lasix iv for pulmonary edema and gradually added her outpatient antihypertensives, atenolol, amlodipine, and lasix. . ## s/p recent fall: head ct w/o bleed or shift. the patient did not have other musculoskeletal pain anywhere. . ## leukocytosis: no clear sources and the patient remained afebrile. wbc continued to trend down and at the time of discharge, wbc was 11.7. ua/ucx and bcx and cxr were negative for infection. . ## ppx: pneumoboots, ppi - pt recommended outpatient pt as the patient became deconditioned during this hospitalization. the patient was discharged home with pt services. . ## fen: cardiac diet. repleted 'lytes/prn. . ## full code (confirmed w/ patient) medications on admission: coumadin 1 mg po qd lasix 40 mg po qam, 20 mg po qpm atenolol 100 mg po qd amlodipine 5 mg po qd discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 2. furosemide 40 mg tablet sig: one (1) tablet po qam. disp:*30 tablet(s)* refills:*2* 3. furosemide 20 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). disp:*30 tablet(s)* refills:*2* 4. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. atenolol 50 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. ativan 0.5 mg tablet sig: tablet po once a day as needed for anxiety for 10 days. disp:*5 tablet(s)* refills:*0* discharge disposition: home with service facility: home health care discharge diagnosis: principal: 1. upper gi bleed. 2. gastric ulcer. 3. blood loss anemia. secondary: 1. atrial fibrillation. 2. heart failure (ef unknown) 3. hypertension. 4. vertebral compression fracture. discharge condition: stable. hematocrit stable at 32.7. discharge instructions: return to the emergency department or call your primary care physician if you develop chest pain, shortness of breath, blood in your stools, abdominal pain, nausea, vomiting, bloody sputum, or any other worrisome symptoms. do not take coumadin until you see you primary care physician tells you so. you may resume all your blood pressure medications as previously prescribed. we've added protonix 40mg twice a day for your stomach ulcer. you have a follow-up appointment with dr. on , thursday at 10:50 am. discuss with your primary care physician about starting calcium, vitamin d, and possibly bisphophonates for osteoporosis. followup instructions: 1. provider: , . phone number: . date/time: at 10:50am. 2. outpatient h. pylori antibody assay - to be performed by dr. . 3. please ask dr. to start you on calcium and vitamin d supplementation for osteoporosis. she may also add another medication callled a bisphosphonate for this as well. Procedure: Other endoscopy of small intestine Transfusion of packed cells Transfusion of other serum Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Atrial fibrillation Long-term (current) use of anticoagulants Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 1. status post fall from roof at work. 2. t3 burst fracture with evidence of complete spinal cord injury and spinal instability. 3. c6, c7 spinous process fracture, t1 spinous process fracture, t2 spinous process fracture and t4 spinous process fracture. 4. left displaced distal radius fracture. 5. sternal manubrial fx. dissociation major surgical or invasive procedure: 1. anterior fusion t2 to t4 with application of interbody cage and morselized autograft . 2. posterior c5 to t9 arthrodesis . 3. posterior c5 to t9 nonsegmental instrumentation . 4. corpectomy of t3 with from the posterior approach decompression from t2-3 to t3-t4 . 5. posterior decompression laminectomy, medial facetectomy t1-2 to t3-4 . 6. right posterior iliac crest bone graft with application of morselized autograft . 7. application of morselized allograft . 8. closed reduction of left distal radius fracture . 9. tracheostomy . 10. percutaneous endoscopic gastrostomy 11. inferior vena caval filter 12. transesophageal echocardiogram 13. percutaneous drainage of fluid collection by interventional radiology . history of present illness: 45year old, spanish speaking male s/p fall from roof while working. fell 15-20 feet. landed on head. no loc. unable to feel or move le, sensation below nipples on arrival. given 2.5g salumedrol in field by ems. past medical history: none social history: from . in united states for work. living with cousin and her husband. wife and children live in . family history: noncontributory pertinent results: 05:25pm glucose-114* lactate-1.5 na+-143 k+-3.9 cl--107 tco2-24 05:22pm wbc-11.3* rbc-4.47* hgb-14.0 hct-38.0* mcv-85 mch-31.3 mchc-36.8* rdw-13.1 05:22pm fibrinoge-226 05:22pm fibrinoge-226 01:04am blood wbc-25.2* rbc-3.71* hgb-11.3* hct-31.8* mcv-86 mch-30.6 mchc-35.6* rdw-14.8 plt ct-143* 02:01am blood wbc-26.5*# rbc-3.02* hgb-9.0* hct-25.9* mcv-86 mch-30.0 mchc-34.9 rdw-15.0 plt ct-637* 02:20am blood wbc-10.8# rbc-2.84* hgb-8.2* hct-25.0* mcv-88 mch-29.0 mchc-32.9 rdw-15.0 plt ct-686* 03:32am blood wbc-8.4 rbc-3.11* hgb-9.6* hct-26.9* mcv-87 mch-30.9 mchc-35.7* rdw-15.3 plt ct-341 03:32am blood plt ct-341 03:32am blood glucose-101 urean-21* creat-0.6 na-136 k-3.7 cl-105 hco3-23 angap-12 03:30am blood alt-126* ast-54* ck(cpk)-304* alkphos-187* totbili-0.6 04:32am blood lipase-60 05:22pm blood ck-mb-15* mb indx-2.1 05:22pm blood ctropnt-<0.01 01:11am blood ck-mb-31* mb indx-1.7 ctropnt-<0.01 03:32am blood calcium-8.2* phos-3.8 mg-2.0 10:10am blood hbsag-negative hbsab-negative hbcab-negative hav ab-positive igm hav-negative 09:17pm blood hiv ab-negative 05:22pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:10am blood hcv ab-negative : mrsa screen : bl cx -> mr s. aureus coag neg : sputum: p. aeruginosa, k. pneumoniae, m. catarrhalis : acinetobacter pansens. : c. diff neg, bl//sputum neg, vanco trough 5.8 : lfts elevated, wbc 14.6, hct 28, vanco trough 6.9 : wbc 26.5, na 132, bal gs -/cx p : cl tip cx p., vanco trough 15.4 : vanco 9.9 bal: g+ cocci pairs/clusters, g- rods. id p : acinetobacter in sputum : afb neg x 3 : leg. urine neg : o&p: neg : mrsa neg (nasal) back cx: gs - , cx- radiology: ct head: no evidence of intracranial hemorrhage or mass effect. ct c-spine: burst fracture of the t3 vertebral body. multiple fractures of the posterior elements of c6, c7, t1, and t2. no impingement on the bony cervical spinal canal. ct thorax: burst fracture of t3, retropulsion of fragments into canal. multiple fractures of the distal cervical and upper thoracic posterior elements. no aortic injury seen, sternal dislocation. no abd/pel injury. old fx in the inferior ribs bilaterlly. ct pelvis: no fractures of the lumbar spine, sacrum, or pelvis are identified. mri c/t spine: t2-t3 fx-disloc c intraspin/pll disrupt. c txn of cord. intraspinal hematoma. r wrist/elbow/shoulder: 1. r colles fx. 2. r ulnar styloid pr. : ct thorax: bilat pl. eff., pneumonia : l lung atelectasis improved; new opacification r lung ? lg aspiration; incr small r pleural effusion r wrist post-cast port cxr: worsening llung air space opacity, ?asp pna : ruq us neg ct torso: diffuse ground glass opacities, ? pna, wedge shaped kidney infarcts : tee >55%, nl. mri: demonstrating no definite discitis/osteomyelitis. small irregularly enhancing region in what appears to be right sided epidural space at t2/t3 level, as described above, which could be postoperative scar or a phelgmon. two additional peripherally enhancing fluid collections, one in the posterior epidural space at t2 level; the larger one in the posterior paraspinal soft tissues at approximately the same level, as described above, which may represent postoperative seromas versus abscess. : ir percutaneous drainage of subcutaneousx tissue brief hospital course: 45 year old spanish speaking male admitted to t/sicu status post fall from 15-20 feet at work. landed on head with resultant injuries including, traumatic burst fracture of the t3 vertebral body with retropulsion of multiple fragments posteriorly as well as angulation of the spinal canal at this level, fracture of the posterior elements of t1 and t2 -> s/p fusion, right transverse distal radial fracture, sternal manubrial fracture dissociation, and a head laceration. patient underwent c5-t10 posterior spinal fusion with l1-l4 posterior decompression as well as open reduction and internal fixation of his right wrist fracture . he was given 7 liters of crystalloid and 1200 cc of red blood cells in the operating room during the spinal fusion. see operative reports for procedure details. patient tolerated both procedures reasonably well but was found to be hypotensive after spinal fusion and was transfused 2 additional units of packed red blood cells when transported back to the trauma/sicu after surgery. he was placed on spinal precautions and given a brace to wear after extubation. the patient's respiratory status was managed on a ventilator. on , patient was transfrused 2 units of packed red blood cells and was febrile to 104 with a whit blood cell count to 16.4 he was started on vancomycin and zisyn for broad spectrum coverage. physical and occupational therapy were consulted on and followed patient throughout hospital course with satisfactory results. on , patient was taken to operating room for orif of right distal radius fracture without event. see operative reports for procedure details. infectious disease was consulted for continued fevers and recommended standard fever workup including pan culture, d/c lines fpr 2 days with central line exchange, stool studies, sputum cultures (patient underwent multiple bronchial alveolar lavages for sputum collection), and strongyloides. please see microbiology results above for details. an ascaris worm was removed from patient's nostril in entirety and sent to pathology for identification. id followed patient throughout hospital stay and recommendations were followed. levoquin was added to antibiotic regimen on . vanco/zosyn discontinued on . patient is to continue levaquin until for sputum culture positive for acintobacter 10/24 per id recommendations. on , arterial line was reinserted and received 2 untis prbc for hematocrit of 23 and ct of spine was performed to eval for abscesses. please see results section for details. nutrition followed patient throughout course and recommendations followed regarding tube feeds/tpn. on social work wrote letter to mexican vice consul in regarding patient's status and was instrumental in obtaining family contact and visas. social work was actively involved in patient's care throughout stay. on had spontaneous breathing trail but tired after 4 hours and was placed back on mechanical ventilation. please note patient had multiple fever spikes throughout course, was pan cultured with each spike > 102. please see above culture data for details. on the final spike before discharge, he underwent an interventional radiology drainage of a superficial fluid collection over t2 and t3. fluid was cultured and found to be without infection. he was also tested for tuberculosis, hepatitis a/b/c, cmv, hiv, legionella, which were all negative. afb was negative x 3. on he underwent tracheostomy, peg, and ivc filter placement for spinal cord injury with prolonged respiratory dependency, malnutrition and right risk for venous embolic disease. see operative reports for details. he tolerated that procedure without complication. initially after tracheostomy, the patient's respiratory status was managed with assist control ventilation. however, as he recovered and gained muscle strength, he was weaned over to cpap with pressure support and remained stable throughout the rest of his hospital stay. his pressure support was slowly weaned to 5. forehead staples removed on and arterial line was removed. on , a fiberoptic endoscopic evaluation of swallowing was performed which showed mild oral pharyngeal dysphagia with minimal aspiration. with recommendation to repeat swallowing evaluation at rehab facility. on patient underwent a tee which showed no evidence of subacute bacterial endocardiditis. on , patient complained of a visual field defect and ophthalmology was consulted with no recommendations for intervention. thoughts were consistent with traumatic maculopathy which should slowly improve. patient should follow up in clinic as an outpatient in weeks. patient remained stable, cooperative, and cordial throught duration of hospital stay. he was afebrile for > 48 hours before discharge. medications on admission: none discharge medications: 1. brace sig: one (1) at all times. disp:*1 * refills:*0* 2. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 3. artificial tear with lanolin 0.1-0.1 % ointment sig: one (1) appl ophthalmic prn (as needed). 4. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed. 6. ranitidine hcl 15 mg/ml syrup sig: one (1) po bid (2 times a day). 7. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed. 8. acetaminophen 160 mg/5 ml solution sig: po q4h (every 4 hours) as needed for fever>101.5. 9. ibuprofen 100 mg/5 ml suspension sig: one (1) po q6h (every 6 hours) as needed for fever>101.5. 10. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4-6h (every 4 to 6 hours) as needed. 11. enoxaparin 40 mg/0.4 ml syringe sig: one (1) subcutaneous q 24h (every 24 hours). 12. potassium chloride oral 13. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 14. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for agitation. 15. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 days: through . disp:*4 tablet(s)* refills:*0* 16. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 17. calcium gluconate 2 gm / 100 ml d5w iv prn please administer for ionized calcium less than 1.12 18. magnesium sulfate 2 gm / 100 ml d5w iv prn mg<2.0 19. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift discharge disposition: extended care facility: - discharge diagnosis: 1. traumatic burst fracture of the t3 vertebral body with retropulsion of multiple fragments posteriorly as well as angulation of the spinal canal at this level. status post fusion. 2) fracture of the posterior elements of t1 and t2 . status post fusion 3) right transverse distal radial fracture. status post orif. 4) sternal manubrial fracture. dissociation discharge condition: good discharge instructions: go to an emergency room if you experience new and continuing nausea, vomiting, fevers (>101.5 f), chills, or shortness of breath. also go to the er if your wound becomes red, swollen, warm, or produces pus. if you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. narcotics can cause constipation. please take an over the counter stool softener such as colace or a gentle laxative such as milk of magnesia if you experience constipation. be sure to take your complete course of antibiotics. you may resume your regular diet as tolerated. you may resume all of your previously prescribed medications. you may take showers. you should wear your back brace at all times. followup instructions: with dr. in orthopedic spine clinic in 1 month. please call to make that appointment. location 2, deaconness. with dr. in general orthopedic surgery for right radial fracture and shoulder pain in 2 weeks. call to make that appointment. with clinic for visual field defect in weeks. call to make that appointment. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnostic ultrasound of heart Interruption of the vena cava Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Other exploration and decompression of spinal canal Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Dorsal and dorsolumbar fusion of the anterior column, anterior technique Closure of skin and subcutaneous tissue of other sites Excision of bone for graft, other bones Transfusion of packed cells Dorsal and dorsolumbar fusion of the posterior column, posterior technique Closed reduction of fracture without internal fixation, radius and ulna Repair of vertebral fracture Other cervical fusion of the posterior column, posterior technique Aspiration of other soft tissue Insertion of interbody spinal fusion device Fusion or refusion of 9 or more vertebrae Infusion of vasopressor agent Diagnoses: Pneumonia due to other gram-negative bacteria Open wound of scalp, without mention of complication Bacteremia Infection and inflammatory reaction due to other vascular device, implant, and graft Seroma complicating a procedure Other and unspecified alcohol dependence, unspecified Traumatic shock Closed fracture of T1-T6 level with complete lesion of cord Closed fracture of C5-C7 level with unspecified spinal cord injury Accidental fall from or out of building or other structure Closed Colles' fracture Closed fracture of T7-T12 level with unspecified spinal cord injury Ascariasis Closed dislocation, sternum Visual field defect, unspecified Pain in joint, shoulder region Acute alcoholic hepatitis

*allergies: sulfas, isoproterenol in brief: pt admit from hosp w/ increased o2 needs. was on bipap w/known pna on levo/flagyl/vanco @ . came to er, became increasingly lethargic,. chest ct ruled out pe. rll consolidation noted. electively intubated. surgery lbka. neuro: pt alert and able to follow commands. nods yes and no to verbal questions. pearl 3mm brisk. mae. pain indicated and noted w/ grimacing, not able to identify specific cause of pain and agitation. gave 2mg midazolam and 650 tylenol w/ good results. pain in mouth when taking temp and suctioning d/t oral ulcers. et sxn q1-2h for thick,tan secretions. cardiac: nsr w/ occasional ectopy (pvc's, pac's). hr 66-81, sbp 125-151 w/ nbp as a-line was dc'd yesterday. last hct 26.0, awaiting morning lab results. resp: vented on pcv 40%/14/5peep. attempting to wean pt off vent. last shift changes were made and abg's 7.15/84/131/31, so old setting (pvc) was resumed for this shift. since no a-line, no abg labs taken this am. mixed venous instead, lab results pending. ls very coarse throughout w/ pleural friction in lll, chest tube in place to suction w/ leak, md's aware. rr 19-34, o2sat 95-100. gi/gu: tf promote w/ fiber running @ goal 60cc/hr, 10cc residual undigested food. +bs, hypoactive. foley in place, output 40-80cc/hr yellow urine w/ sediment. stool x1 this shift, sm amt brown, loose stool. no softeners given this shift. bs 140fs and 127 am labs, no coverage this shift. id: temp 97.5-98.3, last wbc 21.7, awaiting am lab results. vanco trough 18.7, vanco given @ 0200, next dose 1400. nystatin powder used for reddened perianal area and vaginal area, both sensitive for pt when cleaning. sites appear to be improving w/ use of nystatin. sputum cx sent. skin: lbka wound approximated, c&d, open to air. r big toe blackened, but good peripheral pulse. bilateral ue edema. remove chest tube site covered w/ dsd clean and intact. current chest tube dressing wnl. open wound on lue covered w/ dsd. broken down coccyx area covered w/ duoderm. redened perianal area (yeast infection) being treated w/ nystatin powder w/ improving results. fluconazol x1 given last shift. oral ulcers, painful for pt, put vaseline on lips. psychosocial: team to attempt to contact son regarding condition and possible changen in code status. Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Injection of antibiotic Injection into thoracic cavity Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Long-term (current) use of steroids Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Long-term (current) use of insulin Pressure ulcer, lower back Emphysema (subcutaneous) (surgical) resulting from procedure Hypovolemia Atherosclerosis of native arteries of the extremities with gangrene Below knee amputation status Empyema with fistula Emphysematous bleb Candidiasis of vulva and vagina

*allergies: sulfas, isoproterenol neuro: pt alert, able to follow commands, mae, complaint of pain and discomfort x 1, given 2mg midaz w/ good results. cardiac: nsr w/ some ectopy (pvc's rare, pac's occas). hr 61-78, sbp 118-149. hct 22.3 down from 24.9. no blood products given. bs 76-102, no coverage needed at this time. resp: vented on pcv 40%/25/5peep, rr 18-31, o2sat 94-100. attempting to wean pt off vent, but f20 was tried today and ph was 7.18, set back to old setting f25 and last ph 7.32. pt not tolerating vent changes at this time. chest tube in place w/ leak, md's aware. replaced drainage system as it was full, new drainage system in place. trach to be placed soon as pt and fam have agreed. gi/gu: tf promote w/ fiber at goal 60cc/hr. foley in place, output yellow w/ sediment 35-60cc/hr, then given lasix 40mg and output <200 for several hours. loose, brown stool x2 (med + lg), held colace. +bs. id: temp 97.9-98.8, wbc 21.0. nystatin powder for fungal infection in groin and perianal area. pt remains on antibiotics. next vanco @ 0800. skin: perianal rash treated w/ double guard, coccyx abrasion clean and covered w/ duoderm, old chest tube dressing site d&i, current chest tube site also d&i. oral ulcers painful for her when taking temp. frequent oral care, moist swabs and vasaline on lips. psychosocial: son, daughter and grand daughter were in to visit yesterday, but through speaking w/ her, i'm not sure she remembers. fam agreed to trach, but no change in code status at this time. Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Injection of antibiotic Injection into thoracic cavity Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Long-term (current) use of steroids Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Long-term (current) use of insulin Pressure ulcer, lower back Emphysema (subcutaneous) (surgical) resulting from procedure Hypovolemia Atherosclerosis of native arteries of the extremities with gangrene Below knee amputation status Empyema with fistula Emphysematous bleb Candidiasis of vulva and vagina

*allergies: sulfa, isoproterenol in brief: pmh anemia, arrhythmias, copd, diabetes, gi bleed, osteoporosis, paf, peripheral neuropathy secondary to dm, gerd, mrsa. below knee bypass graft, r breast mastectomy. admitted after increasing o2 needs @ hospital. on bipap, known pna. on flagyl/levo/vanco. came into er d/t increasing lethargy. chest ct ruled out pe. rll consolidation. they electively intubated on propofol sedation. : lbka neuro: pt sedated, localizes pain. becomes very restless w/ treatment and moving the pt. in bed. mae. sensitive oral cavity from ulcers. pt has fentanyl gtt @ 2.5ml/hr, versed @ 1ml/hr, bolus before movement for pt comfort. cardiac: nsr w/ frequent ectopy (multiform pvc's, svpb's). hr 68-82 w/ 3 episodes of tachy >100, quickly settled. sbp 116-136, map 62-83. resp: vented a/c 35%/400/20/5. team hoping to wean to ps soon. ls coarse throughout. ett tube rotated, 23 at the lip. rr 20-24, o2sat 96-99. noon abg's 7.37/62/80/37. goal to taper steroids to her normal daily levels. gi/gu: tf promote w/ fiber @ goal of 60cc/hr. tolerating well at this point. +bs. foley output 10-50cc/hr. pt receiving free water boluses q4h of 250cc's, to decrease na level (last 144). bs 169 given 2u regular insulin. scant amount of stool, brown, loose, guiac neg. id: temp 97.2-97.9, some sediment in urine, cont antibiotics. skin: abrasion on coccyx cleaned and dressed w/ duoderm. necrotic areas on r big toe open to air. stapled wound from recent lbka wnl, covered w/ gauze for scant drainage, lambs wool for comfort. oral cavity w/ ulcers and wounds on lips. iv sites and a-line site wnl. psychosocial: son has been calling frequently, but not this shift. house staff would like to speak w/ him regarding code status. Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Injection of antibiotic Injection into thoracic cavity Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Long-term (current) use of steroids Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Long-term (current) use of insulin Pressure ulcer, lower back Emphysema (subcutaneous) (surgical) resulting from procedure Hypovolemia Atherosclerosis of native arteries of the extremities with gangrene Below knee amputation status Empyema with fistula Emphysematous bleb Candidiasis of vulva and vagina

*allergies: sulfas, isoproterenol in brief: pmh anemia, arrhythmias, copd (steroid and o2 dependent), , gi bleed, osteoporosis, paf, peripheral neuropathy secondary to dm, gerd, mrsa. below knee bypass graft, mastectomy. admitted w/ increasing o2 needs from hosp. on bipap, known pna. on levo/flagyl/vanco. came into er d/t increasing lethargy. chest ct ruled out pe. rll consolidation. electively intubated. surgery: lbka neuro: pt sedated w/ fentanyl 25mcg/hr and versed 1mg/hr. bolus for moving pt as it caused her discomfort. pt responds to pain and touch, does not follow commmands. able to mae. cardiac: nsr w/ frequent pavs, episodes of pvc's. hr 63-78, sbp 118-150, map 68-94. pedal pulses easily palpable in r foot and popliteal. pt w/ lbka, popliteal pulse weak. last hct 28, 1600 ca 7.6, md's aware but no repleation, waiting for albumin level as add on. resp: ls coarse through out, vented a/c 30%/400/20/5, rr 18-24, o2sat 96-97. last abg's 7.37/56/80/34. failed sbt yesterday am. not able to breath on ps. gi/gu: tf promote w/ fiber @ goal 60cc/hr, bag changed this shift. pt w/ foley, output 22-100 (100cc's following 80mg lasix), not responding well to the lasix. +bs, 5cc's residual, undigested food. mds asked us to hold the 250cc bolus q4h since last na was 135. pt had one large brown, loose stool (c.diff cx sent) and one small brown loose stool, inserted mushroom cath, held colace. bs 205-72, on insulin gtt running @ 2u/hr at this time. id: temp 97.5-98.2, wbc 15.7. pt w/ pna and ?uti. on zosyn/vanco/azythro. skin: black necrotic area on r big toe, open to air. lbka wound approximated, stapled, wnl, covered w/ dsd. oral ulcers, breakdown on lips. oral care done and vasaline to lips. breakdown on coccyx covered w/ duoderm. bilateral upper extremity edema. iv sites wnl. want to order kinaire bed if pt is going to remain sedated and intubated for much longer. psychosocial: son called yesterday for update, given poc. Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Injection of antibiotic Injection into thoracic cavity Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Long-term (current) use of steroids Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Long-term (current) use of insulin Pressure ulcer, lower back Emphysema (subcutaneous) (surgical) resulting from procedure Hypovolemia Atherosclerosis of native arteries of the extremities with gangrene Below knee amputation status Empyema with fistula Emphysematous bleb Candidiasis of vulva and vagina

*allergies: sulfas, isoproterenol in brief: pt admitted w/ increased o2 needs from hosp. there, was on bipap, had known pna, on levo/flagyl/vanco. came into er, became increasingly lethargic. chest ct ruled out pe. rll consolidation noted. electively intubated. neuro: pt lethargic but alert, able to follow commands and nod head to answer questions. no complaints of pain. 1mg midazolam x2 this shift as pt gets agitated d/t discomfort when moving her in bed at times. cardiac: nsr w/ frequent ectopy (pvc's, pac's, irregular rate). hr 71-86, sbp 148-162, map 76-91. last shift, pt had 12v run of v-tach, self adjusted. last hct 24.8 resp: pt vented current setting pcv 50%/14/peep5. rr 19-30, o2sat 100, last abg's @ 1800 7.36/49/157/29. sxn q1-2h thick tan secretions. plan is to cont to wean vent settings. chest tube posterior lower lobe. draining to suction, leak (md's aware), draining straw colored fluid in small amounts. gi/gu: tf promote w/ fiber @ 60cc/hr. +bs. med brown, soft stool early in shift, 3 lg loose previous shift so held softeners. last shift, stool heme +. foley in place, 50-240cc/hr, yellow w/ sediment. bs 148, no coverage needed, glargine 15u fixed dose given. id: temp 98.1-99.2, last wbc 20.6. vanco changed to q12h w/ trough to be collected before next pm dose. c.dif cx sent last shift, awaiting results. skin: pt on kinair bed. lbka wound approximated and wnl, no drainage. iv sites intact. r big toe black. breakdown on coccyx, cleaned and covered w/ duoderm. very pink and painful rash around anus on all sides, covered w/ doubleguard. open soar on left arm covered w/ duoderm but can't remove at this point as it would damage the skin further. old chest tube site covered w/ dsd wnl, tube site still in clean and dry wnl. psychosocial: no contact w/ family today. son called yesterday. Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Injection of antibiotic Injection into thoracic cavity Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Long-term (current) use of steroids Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Long-term (current) use of insulin Pressure ulcer, lower back Emphysema (subcutaneous) (surgical) resulting from procedure Hypovolemia Atherosclerosis of native arteries of the extremities with gangrene Below knee amputation status Empyema with fistula Emphysematous bleb Candidiasis of vulva and vagina

allergies: sulfa (sulfonamides) attending: chief complaint: increased sob major surgical or invasive procedure: tracheal intubation mechanical ventilation chest tube placement x 2 arterial cannulation central venous cannulation bronchoscopy tracheostomy peg tube placement pleurodesis history of present illness: 85 year old woman admitted with a chief complaint of hypoxia. she was admitted to after 10 day hospitalization at for left below the knee amputation. she has a history of steroid use for oxygen dependent copd. on arrival at , her o2 sat was 97% on 2l. she has had a steadily increasing oxygen requirement since, progressing to the point on the day of admission of being on bipap 14/8 15l. when her mask is removed for even a few seconds, she desaturates to the low 70s. she has been evaluated for her hypoxia by various coverage physicians over the weekend and was treated with nebulizer treatments and lasix with little improvement. she also had a cxr on which showed a left lower lobe pneumonia for which she is on ceftriaxone, flagyl, and vancomycin. on the day of admission, she was tachypneic, more hypoxic, with decreased responsiveness, and was sent in for evaluation. on exam in the ed, she was noted to have decreased air movement with rhonchi and faint wheezes which improved with nebulizer treatments. her cxr was not impressive. an ekg showed multifocal atrial tachycardia and mild lateral st depressions. she was initially placed on bipap in the ed; after nebulizer treatments, she improved and was put back on nasal cannula. she then again got worse in the ed, and an abg was 7.25/94/66. the patient was thus intubated in the ed for worsening respiratory failure and sent to the . past medical history: type 2 diabetes hypertension gout osteoporosis chronic obstructive pulmonary disease, steroid dependent, oxygen-dependent, (fvc 1.89,fev1 0.83, fev1/fvc 44, dlco: severely reduced) paroxysmal atrial fibrillation anemia peripheral neuropathy secondary to diabetes gastroesophageal reflux disease history of mrsa hyperthyroidism past surgical history: right below knee popliteal bypass graft with nonreversed saphenous vein and a left popliteal bypass graft with saphenous vein angiogram on . mastectomy in . picc line placement . left bka social history: the patient is a resident at rehabilitation. there is no smoking or alcohol history. family history: noncontributory physical exam: t 100.8 hr 106 bp 163/69 o2sat 90% ac tv 400 x 20 peep 5 fio2 0.5 gen: patient intubated, responsive and sedated heent: perrl, sclera anicteric, op with ulcers, mmm lungs: diffuse tubular sounds ant/lat cardiac: irregularly irregular no murmurs abdomen: soft nt nabs ext: left bka, surgical wound intact, staples in place; right le no edema, black necrotic right big toe. right dp +2 at ankle neuro: sedated pertinent results: admission labs: cbc: wbc-21.1*# rbc-3.64* hgb-10.2* hct-33.3* mcv-91 mch-27.9 mchc-30.6* rdw-17.9* plt ct-646* diff: blood neuts-81.8* lymphs-13.3* monos-3.5 eos-0.8 baso-0.6 coags: pt-13.3 ptt-37.1* inr(pt)-1.2 chem 10: glucose-86 urean-28* creat-1.0 na-147* k-4.2 cl-103 hco3-38* calcium-7.9* phos-2.6* mg-2.0 abg: type-art temp-37.0 rates-40/ fio2-50 po2-66* pco2-94* ph-7.25* calhco3-43* base xs-9 intubat-not intuba comment-ventimask other: lactate-1.1 cardiac enzymes: ck(cpk)-14* ck-mb-notdone ctropnt-0.06* -> ck(cpk)-14* ck-mb-1 ctropnt-0.04* thyroid tests: tsh-0.10* free t4-0.7* t4-3.3* discharge labs: imaging: admission cxr: 1. worsening of right upper lobe opacity near the future, which are somewhat linear. although it could represent subsegmental atelectasis, cannot rule out the presence of pneumonia. 2. background emphysema and pulmonary fibrosis as well as pulmonary artery hypertension. 3. bilateral small pleural effusions are stable. admission cta chest: 1. no evidence of central pulmonary embolism. 2. right lower lobe consolidation/atelectasis; this likely represents pneumonia in the correct clinical setting. 3. stable mediastinal lymphadenopathy, most prominent in the ap window and precarinal distribution. 4. severe fibrotic, bronchiectatic, and cystic changes consistent with the known history of copd. no pneumothorax as was demonstrated on the prior ct. 5. several smaller focal areas of consolidation bilaterally, the most prominent of which in the left lower lobe, just superior and anterior to the dominant area of consolidation. while these may represent multifocal areas of infection or fibrotic change, followup should be obtained to exclude malignancy. 6. small left-sided pleural effusion. 7. mild prominence of the central main pulmonary artery, likely consistent with the given history of pulmonary arterial hypertension. head ct : there is no evidence for hemorrhage. the ventricles, sulci, and cisterns demonstrate no effacement. the white matter junction is preserved. there are multiple hypodensities seen in the subcortical and deep white matter as well as both thalami that are the sequelae of chronic small arterial ischemia. there is a frothy fluid within both maxillary sinuses, sphenoid sinuses, and right mastoid air cells that may indicate sinusitis. the osseous structures are unremarkable. cxr : very large left-sided pneumothorax with signs of tension. chest ct : findings: the large left hydropneumothorax, mostly air filled was also shown on plain chest radiographs earlier today. since it shifts the mediastinum rightward and everts the left hemidiaphragm, it may be causing hemodynamic tension as well. the left lung is tethered to the chest cage by many pleural adhesions. right lower lobe consolidation is improving and edema has resolved. emphysema is severe. a 6- cm bulla marginates the left major fissure and smaller bullae are seen elsewhere . the airways are patent up to the segmental bronchi. there is no right pleural or any pericardial effusion. subcentimeter mediastinal nodes not meet ct size criteria for lymphadenopathy. extensive atherosclerotic coronary artery calcifications are noted, along with substantial aortic valvular calcification. there is no pericardial effusion. in the upper abdomen, the imaged liver, spleen, adrenals, and kidneys are unremarkable. a 24-mm gallstone is noted without evidence of cholecystitis. there are no suspicious bone findings. et tube and ng tube are in good position with the ng tube terminating in the body of the stomach and the et tube well above the carina. impression: 1. large left hydropneumothorax could be under tension and hemodynamically significant. 2. severe emphysema including a 6 cm bulla along the left major fissure. 3. improving right lower lobe consolidation. 4. decreasing pulmonary edema. cxr pm: compared with the examination obtained approximately 6 1/2 hours earlier, a left chest tube has been inserted, with its tip ending in the apex. the left pneumothorax has markedly diminished and is now small, best seen at the left lateral costophrenic angle. the mediastinum is now midline. the endotracheal tube is in satisfactory position. a nasogastric tube descends into the abdomen. there is a background of chronic lung disease and emphysema. scattered nonspecific opacities are present bilaterally. cxr : left lung appears to be completely re-expanded. the left apical pleural tube is relatively short intrathoracic and the tip of the basal tube is not its entire course is extrathoracic. little if any left pleural effusion or pleural air. mild pulmonary edema is unchanged. heart size is normal, although larger than it was prior to chest tube insertion. tip of the et tube is in standard placement and a nasogastric tube passes into the stomach and out of view. dr. was paged to discuss these findings at the time of dictation. cxr : one of the two left basal pleural tubes have been withdrawn approximately 6 cm now projecting over the cardiac apex and left hemidiaphragm. the other tube is unchanged in position, tip just to the left of the midline at the level of the left hemidiaphragm. no appreciable left pneumothorax. small left pleural effusion may have increased. small right pleural effusion unchanged. subcutaneous emphysema in the chest wall and neck is still severe but improving. heart size remains top normal. heterogeneous opacification in the lungs is probably a combination of pulmonary edema, multifocal pneumonia and emphysema. tracheostomy tube in standard placement. gram stain (final ): pmns and <10 epithelial cells/100x field. no microorganisms seen. smear reviewed; results confirmed. respiratory culture (final ): oropharyngeal flora absent. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. yeast. sparse growth. enterobacter cloacae. rare growth. identification and sensitivities performed on culture # 203-0763r . staph aureus coag +. rare growth. sensitivities performed on culture # 203-1121r . brief hospital course: assessment: 85yo woman with chronic obstructive pulmonary disease, admitted with respiratory failure, intubated in the ed, likely secondary to multilobar pneumonia, chronic obstructive pulmonary disease, and congestive heart failure, complicated by a pneumothorax. hospital course is discussed below by problem: 1. respiratory failure - her initial respiratory failure was thought to be multifactorial, secondary to multilobar pneumonia, chronic obstructive pulmonary disease with very poor baseline function, and congestive heart failure. she was treated with vancomycin, zosyn, and azithromycin for 14 days for broad coverage given that she had recently been living in health care facilities. dfa for influenza and urinary legionella antigen were both negative. sputum cultures only grew yeast, which was thought to be contamination. most recent sputum cultures grew e coli, thought to be a contaminant as well, as the patient has been afebrile, with resolving leukocytosis, unremarkable chest x-ray, and no other symptoms of a pneumonia. she then developed a low grade temperature and with 2/16 sputum culutres with 2+ gnr and with a history of enterobacter, she was restarted on a 10 day course of meropenem to be finished at rehabilitation. her sputum culture grew gram positive cocci and she was started on a course vancomycin, to complete a 10 day course of vancomycin and 10 day course of meropenem. her vancomycin had been supratherapeutic and was being monitored daily for dosing purposes. she was day fo vancomycin on , she still remained supratherapeutic on day of discharge at 31 (on day ). her chronic obstructive pulmonary disease was treated with albuterol and atrovent, though she was not very responsive to these medications. she was also given a dose of solumedrol 125mg iv, with a subsequent prednisone taper that was ongoing at the time of discharge. she was diuresed intermittently throughout the hospitalization (see below) she was intubated in the emergency room and had a tracheostomy on . her ventilator weaning was complicated by a cuff leak, requiring 30mmhg pressure to seal. this improved, and she has done well on pressure control. she has also had several trach collar trials, during which she tires within 10-15 minutes. 2. pneumothorax - on the morning of , the patient's chest x-ray showed a vertical linear opacity consistent with pneumothorax. a chest ct at the time confirmed a large pneumothorax involving most of her left lung. this was thought to occur secondary to positive pressure with preexisting severe bullous disease, and likely occurred the night prior to the chest x-ray, as she began to have low blood pressure responding to iv fluids that night. thoracic surgery was called, and in concert with interventional pulmonology, they placed a chest tube in the apex of the left lung. she was determined to still have an element of pneumothorax at her left lung base, so a second chest tube was placed. the apical chest tube was displaced slightly and caused subcutaneous emphysema, but it was effective and was able to be clamped and removed on without complications. the basilar chest tube manifested an inspiratory leak which resolved until the patient's tracheostomy, at which time the leak recurred. as such, the thoracic team performed pleurodesis x 3 () with doxycycline. the chest tube was set to suction and the inspiratory leak resolved. the chest tube was clamped and removed without complications. a chest x-ray after chest tube removal showed no pneumothorax. however, that night she became increasingly tachypneic, and a cxr in the morning showed recurrence of the pneumothorax. another chest tube was placed, with a significant amount of resulting subcutaneous emphysema (head to toe) and no significant change in the pneumothorax. a second chest tube was thus placed, which resulted in some improvement in the pneumothorax. her course was also complicated by a bronchopleural fistula, requiring pressure control ventilation. her fistula gradually resolved, and she has been able to be adequately supported on pressure control ventilation. since that time, her subcutaneous emphysema has gradually improved. her chest tubes were put to water-seal on , then were clamped on , and daily cxrs have revealed no evidence of recurrent ptx. the chest tubes were sequentially clamped and then removed with serial chest xrays revealing no pneumothorax. the pt is to follow up with thoracics surgeon dr. after discharge. 3. hypotension - she had an episode of hypotension in the setting of her pneumothorax. initially, it responded to fluid boluses and, given that the patient had been aggressively diuresed previously, was thought to be secondary to hypovolemia. this was likely just a contributing factor to hypotension caused by pneumothorax. it resolved after chest tube placement. once she was normotensive, her metoprolol was restarted. 4. fluid status - on admission, the patient was volume overloaded. she responded well to lasix 40mg iv. this was held in the setting of hypotension (with her pneumothorax), and was thought to be hypovolemic at that time. she has been intermittently volume overloaded, with good response to lasix. over the past 4 days prior to discharge the pt was euvolemic, not requiring any lasix. 5. mental status - early in the hospitalization, the patient was noted to have decreasing responsiveness. this was likely related to her sedation, as once the sedation was lessened, she became very appropriate and responsive. she also has had difficulty in regulating sleep/wake cycles. primary team has been moderately succesful in improving this with pm ambien, gabapentin, nortriptyline, and haldol. 6. yeast infection - she had urine cultures sent that showed only yeast, and vaginal discharge consistent with yeast. she was treated with one dose of fluconazole with resolution of her symptoms. 7. atrial tachycardia - she had a rhythm consistent with multifocal atrial tachycardia, most likely secondary to her underlying pulmonary issues. her metoprolol was restarted and the tachycardia resolved. 8. atrial fibrillation with rapid ventricular response - ms. has known paf, but she had increasingly frequent episodes of rvr to the 150s, with stable blood pressures. her metoprolol and diltiazem dosages were increased, with some effect, but she continued to have these episodes with maximal doses. she was placed on an esmolol drip, which helped ms. to revert to nsr at a dose of 100mcg/min, but experienced recurrent episodes on the drip. the electrophysiology service was consulted, who recommended started amiodarone. she was po loaded, and placed on 200mg po bid, in addition to her previous dose of diltiazem. her comorbid lung and thyroid conditions were noted in terms of managing with amiodarone, but this was thought to be the most appropriate treatment option. daily ekgs were obtained to assess for prolonged qt. the pt was switched from diltiazem to metoprolol as the pt has been noted to have better rate control with bb than ccb. the pts amiodarone was weaned down to 200 mg po qd prior to discharge. she developed episodes of atrial fibrillation while on amiodarone and cardiology was consulted and she was started on a low dose heparin drip for possible dccv if she became hypotensive. long term anticoagulation is to be determined as an outpatient the pt will need ekg's to assess for qt prolongation. her outpt pcp will also need to assess reinitiation of coumadin; pt seems to be a likely fall risk per nursing. her heparin gtt was discontinued on day of discharge. 9. diabetes - she was monitored with fingersticks. initially, she was treated with an insulin drip, but she was later switched to a sliding scale. her bs were generally well controlled. 10. urinary tract infection - urine culture grew e. coli and enterobacter clocae on . she was treated with a 7 day course of meropenem. 9. hypertension - other than during her brief episode of hypotension, she was treated with her outpatient metoprolol and diltiazem. the pts medications wer changed to metoprolol and amiodarone. 10. peripheral vascular disease - plavix and aspirin was continued. vascular surgery was consulted to assess her gangrenous toe, but the decision was made to defer any interventions until such time as her respiratory status had significantly improved. the pt is to follow up with vascular surgery 1 month after discharge to f/u her dry gangrene. she had no post-operative complications stemming from her recent left bka. 11. hyperthyroidism - she was continued on methimazole. her tsh was high and free t4 low. this needs to be readdressed as an outpatient, as her current status was likely complicated by her stay in the icu, and should be assessed once in an outpatient setting. nutrition - she was treated with tube feeds, initially by orogastric tube, then by peg once she had the tracheostomy. communication - her son, , lives in , and can usually be reached at . code status - full medications on admission: atrovent neb flagyl 500mg iv q8 ceftriaxone 1gm iv daily monistat derm lasix 40mg po q8 vancomycin 1gm iv daily fosomax 70mg q sat asa 325mg daily tapazole 5mg po daily lopressor 75mg q8 plavix 75mg daily cardizem 30mg po q8 colase 100mg 60mg daily nuerontin 100mg robitussin 200mg heparin sc riss mvi prednisone 2.5mg daily nortrptyline 25mg qhs zantac 150mg serevent 50 probenecid 500mg accolate 10mg daily discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. methimazole 5 mg tablet sig: one (1) tablet po daily (daily). 4. ipratropium bromide 18 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 5. zafirlukast 20 mg tablet sig: 0.5 tablet po daily (). 6. docusate sodium 150 mg/15 ml liquid sig: thirty (30) ml po bid (2 times a day) as needed. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. zantac 150 mg capsule sig: one (1) capsule po once a day. 9. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 10. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 11. insulin glargine 100 unit/ml solution sig: fifteen (15) units subcutaneous at bedtime. 12. insulin regular human 100 unit/ml solution sig: sliding scale units based on fs see attached sheet for details. injection four times a day. 13. multi-vitamin tablet sig: one (1) tablet po once a day. 14. fosamax 70 mg tablet sig: one (1) tablet po once a week: once weekly on sat. 15. 60 mg tablet sig: one (1) tablet po once a day. 16. nortriptyline 25 mg capsule sig: one (1) capsule po hs (at bedtime). 17. lorazepam 0.5-1 mg iv q6h:prn use before haldol for agitation 18. fluticasone 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). 19. amiodarone 200 mg tablet sig: one (1) tablet po once a day. 20. morphine sulfate 1-4 mg iv q2h:prn 21. ferrous sulfate 300 mg/5 ml liquid sig: five (5) cc po daily (daily). 22. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 23. gabapentin 250 mg/5 ml solution sig: one hundred (100) mg po bid (2 times a day). 24. olanzapine 5 mg tablet sig: one (1) tablet po hs (at bedtime). 25. haloperidol 1 mg tablet sig: one (1) tablet po tid (3 times a day) as needed. 26. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q1hr () as needed. 27. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 28. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). 29. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for toe pain. 30. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po once a day. 31. meropenem 1 g recon soln sig: one (1) intravenous twice a day for 2 days. disp:*4 grams* refills:*0* 32. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po three times a day. disp:*135 tablet(s)* refills:*2* discharge disposition: extended care facility: - discharge diagnosis: primary: 1. pneumonia 2. copd with bullous disease on home oxygen 3. pneumothorax 4. atrial tachycardia 5. atrial fibrillation secondary: 1. dm ii 2. peripheral vascular disease with necrotic toes 3. hyperthyroidism 4. anemia 5. hypertension discharge condition: stable. discharge instructions: please follow up with all of your doctors, including your pcp as well as your vascular surgeon regarding your necrotic toes. please weight yourself daily, if you notice a significant increase in your weight more than 3lb daily, please call your pcp for possible change in medications. please note several changes have been made in your medication regimen. for details, see the following changes: 1. you should continue your antibiotics for the prescribed length of time. 2. please continue to take your aspirin, plavix, and lopressor as you have been doing. you are on a new medication called amiodarone. 3. your serevent has been discontinued as it would be difficult to take with the tracheostomy tube. instead place take albuterol ih 6 puffs q4 hours in addition to the atrovent ih 6 puffs q4 hours. 4. please continue your other medications as you have been doing as well. if you develop any chest pain, palpitations. shortness of breath, fevers, chills, nauseas, vomiting, diarrhea or other concerning health problems, please call your pcp or come directly to the ed. followup instructions: 1). please follow up with your pcp within two weeks of discharge. 2). please follow up with thoracics dr. 3). please follow up with dr. (vascular surgeon) on at 9:45 am, suite 5c, Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Other intubation of respiratory tract Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Injection of antibiotic Injection into thoracic cavity Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Long-term (current) use of steroids Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Acute and chronic respiratory failure Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Long-term (current) use of insulin Pressure ulcer, lower back Emphysema (subcutaneous) (surgical) resulting from procedure Hypovolemia Atherosclerosis of native arteries of the extremities with gangrene Below knee amputation status Empyema with fistula Emphysematous bleb Candidiasis of vulva and vagina

allergies: sulfa (sulfonamides) attending: chief complaint: right foot gangrene major surgical or invasive procedure: amputation of right first toe amputation history of present illness: transfreered rehabfor suspicion of gangrenous ulcer on right foot. had recent complicated admission tobidmc for pna,chf,respiratory failure,ptx,hypoand hypertension and a fib with pvp. before transfer, she did not have any reported infectious prodrome,fever,chills,or erythema. no reported respiratory status and pt cannot report difficulaty breathing. past medical history: type 2 diabetes hypertension gout osteoporosis chronic obstructive pulmonary disease, steroid dependent, oxygen-dependent, (fvc 1.89,fev1 0.83, fev1/fvc 44, dlco: severely reduced) paroxysmal atrial fibrillation anemia peripheral neuropathy secondary to diabetes gastroesophageal reflux disease history of mrsa hyperthyroidism past surgical history: right below knee popliteal bypass graft with nonreversed saphenous vein and a left popliteal bypass graft with saphenous vein angiogram on . mastectomy in . picc line placement . left bka social history: the patient is a resident at rehabilitation. there is no smoking or alcohol history. family history: noncontributory physical exam: nad ncat/ mmm/op clear, carotid pulse +2 irregular . no murumurs soft/nt/nd radila pusle 2+ b/l. dp 2+ b/l, pt 1+ b/l, popliteal 2+r right foot bandaged . gangrene of 1st digit sacral ucler pertinent results: foot ap,lat & obl right 10:35 pm foot ap,lat & obl right reason: assess for osteomyelitis medical condition: 85 year old woman with r toe 1 gangrene reason for this examination: assess for osteomyelitis study: right foot three views performed on . history: this is an 85-year-old woman with right first toe gangrene. evaluate for osteomyelitis. findings: no prior studies available for comparison. there are extensive vascular calcifications identified. there is a soft tissue defect seen over the distal aspect of the right first toe. however, no definite cortical destruction is seen to indicate radiographic signs of osteomyelitis. lateral radiograph is suboptimal as a portion of the first digit has been excluded from the image. impression: soft tissue defect overlying the distal aspect of the first digit without definite radiographic evidence for acute osteomyelitis. chest (portable ap) reason: question chf medical condition: 85 year old woman s/p ptx, s/p removal of cts, now with increasing dyspnea and increased secretions reason for this examination: question chf history: 85-year-old female with dyspnea. comparison: ct chest , and multiple chest radiographs in . ap portable chest: endotracheal tube is in appropriate position approximately 7 cm above the carina. a left-sided picc line terminates in the proximal svc. compared to most recent prior chest radiograph, , there has been interval improvement in small bilateral pleural effusions. chronic bilateral increased interstitial markings persist consistent with chronic interstitial lung disease. there is improvement in vascular congestion, and there is no evidence of chf currently. the heart size and cardiomediastinal contours are unchanged given differences in position. impression: improvement in small bilateral pleural effusions. chronic interstitial lung disease. no chf. 09:21pm blood wbc-14.2* rbc-3.14* hgb-10.1*# hct-30.5* mcv-97 mch-32.0 mchc-33.0 rdw-16.9* plt ct-518* 03:28am blood wbc-14.1* rbc-3.04* hgb-9.6* hct-29.7* mcv-98 mch-31.5 mchc-32.3 rdw-17.0* plt ct-535* 03:57pm blood wbc-12.1* rbc-2.90* hgb-9.2* hct-28.2* mcv-97 mch-31.9 mchc-32.8 rdw-16.6* plt ct-504* 03:45am blood wbc-17.4* rbc-2.94* hgb-9.3* hct-29.2* mcv-99* mch-31.7 mchc-31.9 rdw-16.7* plt ct-505* 09:21pm blood pt-11.7 ptt-23.8 inr(pt)-1.0 09:21pm blood plt ct-518* 03:28am blood pt-12.0 ptt-24.3 inr(pt)-1.0 03:28am blood plt ct-535* 03:57pm blood plt ct-504* 03:45am blood pt-12.4 ptt-23.4 inr(pt)-1.1 03:45am blood plt ct-505* 09:21pm blood glucose-130* urean-47* creat-0.8 na-138 k-5.3* cl-97 hco3-35* angap-11 03:28am blood glucose-89 urean-44* creat-0.8 na-140 k-5.0 cl-99 hco3-37* angap-9 03:57pm blood glucose-134* urean-35* creat-0.8 na-140 k-5.2* cl-100 hco3-35* angap-10 03:45am blood glucose-125* urean-31* creat-0.8 na-137 k-5.3* cl-98 hco3-36* angap-8 09:21pm blood calcium-9.8 phos-4.1 03:28am blood albumin-2.8* calcium-9.4 phos-4.4 mg-2.0 03:57pm blood calcium-8.9 phos-4.5 mg-1.8 03:45am blood calcium-9.0 phos-4.7* mg-1.8 09:40pm blood type- ph-7.32* 08:40am blood type-art po2-195* pco2-90* ph-7.25* calhco3-41* base xs-8 10:50am blood type-art po2-78* pco2-64* ph-7.37 calhco3-38* base xs-8 09:40pm blood glucose-136* 08:40am blood glucose-177* 10:50am blood glucose-191* k-5.5* brief hospital course: pt directly admitted to sicu due to all her comorbid conditions.pt placed on trach mask. pt palced on vancomycin as precautioanry measure for underlying osteomyelitis. a fxr was ordered and showed soft tissue destruction but no osteomyelitis. labs were sent. pt palced on g-tube to gravity and left npo. on hd 2, pt pre-oped for or. pt underwent a right hallux amputation. offical operative report can be read in the chart. pt tolerated the procedure well and was transfered back to the sicu in stable condition. infectious disease was consulted to assess if there were any other underlying infectious causes of elevated white count. they felt that the increase could be attributed to the long term steroid use. a ua and sputum culture were obtained as precautionary measure. pt d/c back to on hd 3. vanco was d/c. instructions sent to have pt seen by pcp for decreasing steroid dose. pt is to follow up with dr in 2 weeks. medications on admission: lasix lopressor aldectone neurontin amio tramadol fluconasol prednision lisinopril prevacid riss cardizam atroven albuterol tobramax nortiptyline lantus zfilikast methemazole plavix asa colase senna discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 2.5 tablets po bid (2 times a day). 2. furosemide 40 mg iv bid 3. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po daily (daily). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 6. methimazole 5 mg tablet sig: one (1) tablet po qd (). 7. zafirlukast 20 mg tablet sig: 0.5 tablet po qd (). 8. fexofenadine 60 mg tablet sig: one (1) tablet po qd (). 9. nortriptyline 25 mg capsule sig: one (1) capsule po hs (at bedtime). 10. tobramycin 300 mg/5 ml solution for nebulization sig: inhalation (2 times a day). 11. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 12. gabapentin 100 mg capsule sig: two (2) capsule po bid (2 times a day). 13. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 14. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 15. fluconazole 50 mg tablet sig: one (1) tablet po q24h (every 24 hours). 16. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). 17. diltiazem hcl 90 mg tablet sig: one (1) tablet po qid (4 times a day). 18. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation qid (4 times a day). 19. albuterol 90 mcg/actuation aerosol sig: four (4) puff inhalation q6h (every 6 hours). 20. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 21. insulin regular human subcutaneous discharge disposition: extended care facility: & rehab center - discharge diagnosis: gangrene of right hallux discharge condition: stable discharge instructions: please continue medicatiosn as directed. you will not be on any antibiotics. please monitor patients white count. she is chronically elevated. this may be due to her steriods. please check with her priamry care doctor to see if the steriod level can be decreased followup instructions: please monitor pateint in rehab. she can follow up with dr in 2 weeks. Procedure: Amputation of toe Diagnoses: Anemia, unspecified Esophageal reflux Unspecified essential hypertension Unspecified protein-calorie malnutrition Chronic airway obstruction, not elsewhere classified Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Rheumatic heart failure (congestive) Ulcer of other part of foot Long-term (current) use of insulin Osteoporosis, unspecified Atherosclerosis of native arteries of the extremities with gangrene Diseases of tricuspid valve Gastrostomy status Tracheostomy status Rheumatic mitral insufficiency

history of present illness: patient is a 70-year-old male with recurrent nasal-ethmoid adenocarcinoma, who underwent a craniofacial resection for ethmoid cancer with lateral rhinotomy. past medical history of this cancer also had surgery x2 for this problem twice in the past. allergies: no known allergies. physical examination: on physical exam, blood pressure was 147/66, pulse 110. in general, elderly man in no acute distress, walks with a cane. heent: positive clear rhinorrhea bilateral nares. pupils are equal, round, and reactive to light. eoms full. no lymphadenopathy, no thyromegaly. chest was clear to auscultation. cardiac: regular, rate, and rhythm, no murmurs, rubs, or gallops. abdomen is soft, nontender, nondistended, negative masses, negative hepatosplenomegaly. extremities: no clubbing, cyanosis, or edema. his strength is in all muscle groups. medications preoperative: 1. ranitidine. 2. vioxx. 3. folic acid. he was admitted status post a subfrontal craniotomy with resection of the nasal-ethmoid carcinoma. surgeons were , caradonnar, and . he had no complications from the surgery. he was monitored in the intensive care unit overnight. his vital signs remained stable. he was afebrile. he remained intubated and sedated. he awoken to painful stimuli. his pupils were pin point and brisk. he had cough and gag intact, withdraw extremities to nailbed pressure. his vital signs were stable. his lungs were clear. on postoperative day #1, he still continued to be intubated. was awake, following commands bilaterally. his ip strength was . he had antigravity strength in both his upper and lower extremities. his dressing was clean, dry, and intact. he had no evidence of csf leak and his vital signs were stable. patient was extubated on . his vital signs were stable. he was afebrile. he opened his eyes spontaneously. he is moving all extremities with good strength. his dressing was clean, dry, and intact. eoms were full. he was transferred to the floor on postoperative day #2. his vital signs were stable. he is afebrile. pupils are 2.5 down to 2 and brisk. his grasp was strong, he was following commands. he had no evidence of csf leak. his dressing was clean, dry, and intact. he did have some periods of agitation, and was receiving haldol for that and he had a sitter while he was in the intensive care unit. his sitter was discontinued before he went to the floor. he had a swallow evaluation which showed that he was ............. and had aspirating on thin liquids. he was made npo. on , he was awake, alert, and oriented times three with bilateral drift. grasps were 4+/5. ips are . his eyes were swollen shut. his smile was symmetric. he was seen by physical therapy and occupational therapy and found to require rehab. on , he had a repeat swallow evaluation which he passed. he was started on a soft solid diet with some nectar thick liquids, and was ready for discharge to rehab. his vital signs remained stable. his incision was clean, dry, and intact. discharge medications: 1. heparin 5,000 units subq q12h. 2. famotidine 20 mg po bid. 3. metoprolol 25 po bid, hold for systolic blood pressure less than 110, heart rate less than 55. 4. folic acid 1 mg po q day. 5. acetaminophen 650 po q4h prn. 6. hydromorphone 1-2 mg po q4h prn. condition on discharge: stable. discharge instructions: he should have his staples removed on postoperative day #10, and follow up with dr. at in six weeks. , md dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Excision of lesion or tissue of cerebral meninges Pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance Excision of lesion of skull Frontal sinusectomy Ethmoidectomy Diagnoses: Rheumatoid arthritis Secondary malignant neoplasm of bone and bone marrow Secondary malignant neoplasm of other parts of nervous system Secondary malignant neoplasm of other respiratory organs Malignant neoplasm of ethmoidal sinus

history of present illness: the patient is a 71-year-old gentleman with a past medical history of ethmoid cancer resected at in . he had a repeat resection here on by ear/nose/throat and neurosurgery. postoperative course was uneventful. the patient had no cerebrospinal fluid leak. he passed a swallow evaluation and was discharged to rehabilitation on . he began having mental status changes and seizure activity on the day of admission. he became unresponsive. he had a fever to 102 and was transferred here for further management. past medical history: 1. chronic obstructive pulmonary disease. 2. rheumatoid arthritis. physical examination on presentation: on physical examination his temperature was 97.9, blood pressure was 124/55, heart rate was 72, respiratory rate was 20, and oxygen saturation was 97%. head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. extraocular movements were full. he had bilateral orbital edema. his cardiovascular status revealed a regular rate and rhythm. normal first heart sounds and second heart sounds. no murmurs, rubs, or gallops. pulmonary examination was clear to auscultation bilaterally. the abdomen was soft, nontender, and nondistended. no masses. extremity examination revealed no clubbing, cyanosis, or edema. on neurologic examination, he did not open his eyes. he did grasp hand bilaterally. pertinent radiology/imaging: a chest x-ray showed some mild fluid overload; slightly improved. no infiltrates. hospital course: he was seen by the ophthalmology service and ruled out for orbital cellulitis. he had a lumbar puncture and a magnetic resonance imaging with evidence of an epidural versus subdural frontal collection. on the patient was taken to the operating room for exploration and drainage of a frontal collection. a drain was in place, and the patient was monitored in the intensive care unit postoperatively where he had severe facial swelling, and his eyes were swollen shut. postoperatively, he was awake and following commands. he was moving all extremities to commands. the fluid collection was sent for a culture. he was seen by infectious disease service. he was placed on vancomycin 1 g q.12h. and ceftazidime 2 g q.8h. for initial antibiotic coverage. the gram stain showed gram-positive cocci and gram-negative rods from the abscess. the patient had a bone flap removed. therefore, there was a skull defect. the patient will require six weeks of intravenous antibiotic coverage. his drain was removed on postoperative day four (on ), and he was transferred to the regular floor after being seen by physical therapy and occupational therapy. he was also re-evaluated by the swallow service. he passed the swallow with some modifications. he needs to be on a nectar-thick ground solid diet. pills need to be crushed and pureed. he needs to maintain aspiration precautions. he should be full upright for all meals, alternating between bites and sips, and two to three swallows for each bite and sip. his dressing was removed, and his incision was clean, dry, and intact. he had a peripherally inserted central catheter line placed on . he currently continues on gentamicin 100 mg intravenously q.12h. and ceftazidime 2 g intravenously q.8h. he was growing proteus from the culture from his surgery. the patient was to be discharged on ceftazidime 2 g intravenously q.8h. and ciprofloxacin 500 mg p.o. q.12h.; together for a total of six weeks. discharge instructions/followup: 1. the patient was to follow up with dr. at in four to six weeks. 2. the patient should also have his staples removed at rehabilitation in 14 days postoperatively. 3. the patient should also be fitted for a helmet due to the bone defect once at rehabilitation. medications on discharge: (medications at the time of discharge included) 1. pantoprazole 40 mg p.o. q.24h. 2. metoprolol 25 mg p.o. twice per day. 3. sodium chloride nasal spray four times per day as needed. 4. ceftazidime 2 g intravenously q.8h. 5. folic acid 1 mg p.o. once per day 6. gentamicin 100 mg intravenously q.12h. (peak and trough levels are pending). condition at discharge: the patient's condition on discharge was stable. discharge status: to rehabilitation. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Spinal tap Incision of lung Reopening of craniotomy site Other myectomy Diagnoses: Other postoperative infection Chronic airway obstruction, not elsewhere classified Bacteremia Rheumatoid arthritis Other disorders of neurohypophysis Intracranial abscess Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft Malignant neoplasm of bones of skull and face, except mandible

history of present illness: the patient is a 74-year-old white male with a history of significant for high-grade esophageal dysplasia who presented to on , for elective thoracoscopic and laparoscopic esophagogastrectomy. past medical history: hypertension. depression. medications on admission: hydrochlorothiazide 50 mg daily, atenolol 25 mg daily, lipitor 10 mg daily, fluoxetine 20 mg, prilosec, multivitamin, aspirin 81 mg once daily. allergies: none. social history: the patient has a remote smoking history. he quit in . he denied alcohol and recreational drug use. family history: noncontributory. review of symptoms: he reports feeling well on the day of surgery. he denied recent fever, chills, nausea, vomiting, shortness of breath, chest pain, or light-headedness. physical examination: vital signs: temperature 97.9, heart rate 80, blood pressure 168/89, respirations 12, oxygen saturation 96 percent on room air. general: the patient was alert and oriented. he was comfortable. heent: pupils equal, round and reactive to light. no scleral icterus. no jugular venous distension. no lymphadenopathy. no thyromegaly. chest: clear to auscultation bilaterally. heart: regular, rate, and rhythm without murmur. abdomen: nondistended, soft, nontender to palpation. extremities: distal neurovascular intact. hospital course: the patient presented to on , for elective laparoscopic and thoracoscopic esophagogastrectomy and placement of a feeding jejunostomy tube for high-grade esophageal dysplasia. the patient underwent the procedure on . the patient tolerated the procedure well. after recovery in the postanesthesia care unit, he was transferred in stable condition to the surgical intensive care unit intubated. on postoperative day 1, he remained intubated and was in stable condition. he did require two fluid boluses for low urine output. on postoperative day 2, the patient continued to remain clinically stable but intubated. he continued to be weaned from his vent, and on postoperative day 3, he presented with a temperature spike for which blood cultures, urine culture, and sputum culture were obtained. he also went into rapid atrial fibrillation and was promptly converted to sinus rhythm with intravenous lopressor, which he would remain on. he continued to be weaned from his vent and was extubated on postoperative day 3, which he tolerated well. he continued on tube feeds, which were advanced to goal. on postoperative day 4, he began to get out of bed with physical therapy. on postoperative day 5, he was transferred to the floor in stable condition. he underwent a swallow study which was negative for leak. his chest tube remained draining serosanguineous fluid. he was started on sips, which he tolerated well. on postoperative day 7, he was advanced to a clear-liquid diet, which he tolerated well. he continued to ambulate easily and often. on postoperative day 8, he was advanced to a regular diet, which he tolerated well. his chest tube was discontinued; however, he did have a fever spike to 102 degrees. blood cultures, urine culture, and chest x-ray were obtained. chest x-ray was suggestive for right middle lobe/right lower lobe. he was started on zosyn. on postoperative day 9, he was noted to have increased erythema with exudate from around his - drain site. vancomycin was started. his neck incision was partially opened but revealed no signs of infection at the incision site. he continued to remain stable and afebrile, tolerating a regular diet, and ambulating often. his vancomycin and zosyn were discontinued on postoperative day 12. on postoperative day 12, his - drain from his neck was removed, which he tolerated well. on postoperative day 13, he was discharged to home in good condition afebrile and vital signs within normal limits. he was ambulating easily. he was given a seven-day supply of levaquin. follow up: the patient is to follow-up with dr. within the next few days after discharge. he is to call dr. office at for a follow-up appointment. discharge medications: protonix 40 mg once daily, percocet 1- 2 tab p.o. q.4-6 hours as needed, ambien 5 mg p.o. q.h.s., levaquin 500 mg p.o. daily x 7 days, metoprolol 50 mg p.o. t.i.d., hydrochlorothiazide 25 mg p.o. once daily, lipitor 10 mg p.o. once daily, aspirin 81 mg p.o. once daily, fluoxetine 20 mg p.o. once day, multivitamin, albuterol ipratropium inhaler as needed. major surgical/invasive procedures: laparoscopic thoracoscopic esophagogastrectomy with placement of a feeding jejunostomy tube. condition on discharge: good. discharge instructions: the patient is to keep the wound area clean and dry. he is to take his medications as prescribed. he is to seek medical attention if he experiences fevers, chills, nausea, vomiting, or increased neck, chest, or abdominal pain. , dictated by: medquist36 d: 11:25:32 t: 15:56:37 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other total gastrectomy Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Suture of laceration of bronchus Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Unspecified essential hypertension Atrial fibrillation Depressive disorder, not elsewhere classified Accidental puncture or laceration during a procedure, not elsewhere classified Emphysema (subcutaneous) (surgical) resulting from procedure Unspecified anomaly of upper alimentary tract Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

allergies: iodine; iodine containing / penicillins / shellfish attending: chief complaint: stemi major surgical or invasive procedure: cardiac catheterization history of present illness: pt is a 68 yo woman with pmh of tobacco use, ra presents to ed today with chest pain, found to have inferior/posterior stemi with rv involvement. patient was in her usoh until 2 week pta when developed sub-sternal chest pressure w/ radiation down both arms while raking leaves. she rested after onset of pain, and pain resolved after 5 minutes. 1 week prior to presentation, patient again experienced these sxs after having "an emotional phone call". again, pt rested and pain resolved after minutes, but she was nervous about pain, so presented to on . at that time she was r/o for mi with negative cardiac enzymes and underwent stress echo that was negative after going 7 minutes on protocol, achieving 91% of maximum hr. therefore patient was discharged. she then again had a similar episode of this pain last night, associated w/ n/v x 1, but then was able to fall asleep without sxs. pt then reports this evening, developed same type of substernal chest pressure, but more severe. patient states she was baking pies when had onset of sub-sternal chest pressure, + radiation down arms b/l, associated with n/v x 1 and diaphoresis. onset of sxs was 7:30pm. therefore pt called ambulanace and presented to . on presentation to , pt was initially given ntg gtt and morphine. found to have ekg with st elevations in inferior leads with reciprical st depressions in avl, v1-v2. r sided ekg demonstrated st elevations in v4, indicating rv involvment. therefore nitro gtt d/ced, started on ivf - received a total of 1 l fluid bolus in ed. also started on heparin gtt, integrilin gtt, and given plavix load 300mg x 1 in ed. also received benadryl, solumedrol, pepcid prior to cardiac cath given hx of dye allergy. patient presented to cath lab at 10:06 pm (therefore time of onset of pain to cath lab was approximately 2.5 hours). in cath lab, patient found to have lesion in rca extending into pda and pl - patient had 1 x stent placed in rca-to-pda, jailing the pl, which was then rescued with balloon angioplasty (timi 3 flow demonstrated). also noted to have 50% lad lesion after d1, 70% l cx lesion, 40% proximal rca lesion. hemodynamics were noted to be co 3.48, ci 2.02, pcwp 20, ra mean 15, pap 46/22, rv 46/8. cath course c/b some bradycardia, thought vagal response, responded to atropine. also had hypotension with sbp = 90's intra-cath, given fluid boluses for total of 1.8l in cath (2.8l total with 1l fluid bolus in ed). post cath pt noted to have small groin hematoma. post cath ekg notable for resolution of st elevations, q waves in leads iii and avf. patient had resolution of pain in cath lab. currently patient feels well. denies any chest pain/pressure, sob, diaphoresis, nausea, any other complaints. ros also negative for orthopnea, pnd, le edema. past medical history: rheumatoid arthritis social history: smokes 1-1.5 ppd x 55 years (quit on thursday - got nicotine patch), rare etoh, no drug use. lives alone, 2 daughters live nearby, also has 2 sons. family history: mother alive and well, father died in his 60's in a car accident, has 6 brothers, no fh of cad or dm physical exam: vitals - afebrile, hr 89, bp 101/85, rr 12, o2 90-92% on ra (not sob) -> 96% 2l nc general - lying supine, awake, alert, pleasant, nad heent - perrl, eomi, dry mm neck - could not assess jvp as pt lying flat, no carotid bruit b/l cvs - rrr, nl s1, s2, no m/r/g lungs - cta anteriorly and laterally - could not assess posterior lung fields as pt lying supine abd - soft, nt/nd, + bs groin - r sided groin w/ some eccymoses, mildy tender to palpation, ?small hematoma although difficult to assess, no bruit ascultated ext - no le edema b/l, 2+ dp pulses b/l neuro - a+o x 3, from x 4 ext . ekg on presentation: st elevations in leads ii, iii, avf with reciprical st depressions in avl, v1-v2. r sided ekg with st elevation in v4. . post cath ekg: resolution of st elevation, q waves noted in iii, avf pertinent results: 09:20pm wbc-12.4* rbc-4.75 hgb-14.7 hct-42.6 mcv-90 mch-31.0 mchc-34.5 rdw-15.1 09:20pm neuts-50.9 lymphs-41.1 monos-5.5 eos-2.2 basos-0.4 09:20pm plt count-279 09:20pm pt-11.6 ptt-19.2* inr(pt)-1.0 09:20pm glucose-156* urea n-24* creat-1.0 sodium-135 potassium-3.0* chloride-95* total co2-25 anion gap-18 09:20pm ld(ldh)-224 ck(cpk)-87 09:20pm ctropnt-0.01 09:20pm ck-mb-notdone . cxr (): prominence of bilateral vasculature, which may represent early volume overload versus mild chf. . c.cath (): 1. selective coronary angiography of this right dominant system revealed two vessel coronary artery disease. the lmca was patent. the lad had 50% stenosis after d1. the lcx had 70% om2 stenosis. the rca had proximal 40% and 100% stenoses distally at the crux. 2. resting hemodynamics demonstrated elevated right and left sided pressures (mean ra pressure was 15mmhg, mean pcwp 20mmhg). there was evidence of moderate pulmonary hypertension. the cardiac index was normal at 2.02 l/min/m2. 3. successful ptca/stenting of the distal rca with a 3.0x18mm cypher des posted to 3.5mm in the proximal portion with excellent results (see ptca comments). . tte (): 1.the left atrium is normal in size. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 3. right ventricular chamber size is normal. right ventricular systolic function is normal. 4.the aortic valve leaflets are mildly thickened. no aortic regurgitation is seen. 5.the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. 6.there is borderline pulmonary artery systolic hypertension. 7.there is no pericardial effusion. brief hospital course: assessment/plan: patient is a 68 yo woman with pmh tobacco use, presents with inferior/posterior stemi with rv involvement. . # cardiac: a. ischemia: patient presents with inferior/posterior stemi with rv involvement. course complicated by some hypotension noted in cath lab, responsive to ivf boluses. pcwp noted to be 20 intra-cath. initially monitored with swan-ganz catheter. received integrilin gtt x 18 hours. cardiac enzymes trended down. continued on asa 325mg qd, plavix 75mg qd, lipitor 80mg qd. started on a beta blocker and discharged on toprol xl. started on ace-i and discharged on lisinopril. further lipid management deferred to outpatient setting. discharged to follow up with cardiology, may need ett-mibi in the future. encouraged smoking cessation. . b. pump: patient with ef=65%, no wall motion abnormalities noted on stress echo done at on . intra cath hemodynamics consistent with mild fluid overload, with pcwp=20, ra=15, pap=46/22. tte on with ef 70-75%, no wall montion abnormality, 1+ mr, and borderline pa systolic hypertension. euvolemic on exam upon discharge. discharged on beta blocker and ace-inhibitor as above. . c. rhythm: patient was in nsr. given rv involvement, was felt to be high risk for arrythmia. no signs of nodal block on ekg. had asymptomatic run of nsvt with stable vital signs. maintained and discharged on beta blocker. . # hematoma: small hematoma noted in groin site post-cath. remained hemodynamically stable, improved to just ecchymosis by discharge. hct stable. . # rheumatoid arthritis: patient on prednisone as outpatient. continued on prednisone with prn tylenol for pain. . # code status: full . medications on admission: prednisone 5mg hctz 50mg qd advil discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. prednisone 5 mg tablet sig: one (1) tablet po bid (2 times a day). 5. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* discharge disposition: home discharge diagnosis: inferoposterior st elevation mi right groin hematoma discharge condition: good discharge instructions: please take all of your medications as prescribed. if you experience chest pain, shortness of breath, or other concerning symptoms, please call your doctor or go to the er. followup instructions: 1) pcp: . , at 2:30pm, (. 2) cardiology: dr. , at 10:00am, (. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Angiocardiography of right heart structures Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Hematoma complicating a procedure Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute myocardial infarction of inferoposterior wall, initial episode of care

allergies: iodine; iodine containing / penicillins / shellfish attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catherization with bare metal stent to mid and distal right coronary artery. history of present illness: history of presenting illness: 72 yo woman with h/o cad s/p imi (lad had 50% stenosis after d1, lcx had 70% om2 stenosis, rca with proximal des) presents with chest pain 2 hours. per the patient, she was taking a shower when she noticed some chest tightness at 8:30am. she took some nitroglycerin and her chest pain seemed to resolve. 15 minutes later the pain returned and continued to progress. she described it as a severe pressure, substernal that radiated to both arms (l>r). she denied any sob, nausea, vomitting, diarrhea, fevers, chills, cough, diaphoresis. she decided to come to the ed for further evaluation. in the ed, she had the following vital signs: 98.2 80 85/62 12 98%nrb. her ekg revealed st elevations in the inferior leads and reciprocal depressions in the lateral leads. she was sent to the cath lab for revascularization. in the cath lab, she underwent angiography which showed no obstructive disease in the lmca, lad, lcx. it did show 99% stenosis of the distal rca secondary to a clot. they also noticed a mid rca lesion of approximately 90%. they aspirated the clot in the distal rca placed 2 bare metal stents in the distal and the mid-rca. her pain, st elevations, and hypotension all resolved promptly after this intervention. she was sent to the ccu for further management. in the ccu, the patient remained chest pain free. she denies any symptoms and claimed she felt much better. . on review of systems, she denies any prior history of joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. all of the other review of systems were negative. past medical history: past medical history: 1. cardiac risk factors: tobacco abuse (60 pack year) 2. cardiac history: -cabg: none -percutaneous coronary interventions: comments: cath report : 1. selective coronary angiography of this right dominant system revealed two vessel coronary artery disease. the lmca was patent. the lad had 50% stenosis after d1. the lcx had 70% om2 stenosis. the rca had proximal 40% and 100% stenoses distally at the crux. 2. resting hemodynamics demonstrated elevated right and left sided pressures (mean ra pressure was 15mmhg, mean pcwp 20mmhg). there was evidence of moderate pulmonary hypertension. the cardiac index was normal at 2.02 l/min/m2. 3. successful ptca/stenting of the distal rca with a 3.0x18mm cypher des posted to 3.5mm in the proximal portion with excellent results (see ptca comments). final diagnosis: 1. two vessel coronary artery disease. 2. elevated filling pressures. 3. successful stenting of the rca. -pacing/icd: 3. other past medical history: rheumatoid arthritis with moderate joint deformity requiring chronic prednisone and methotrexate therapy. spinal stenosis with radiculopathy. chronic back pain social history: -tobacco history: 1 ppd for 60 years -etoh: none -illicit drugs: none -used to work as a farmer, grew up in novascotia family history: no family history of early mi. mom - deceased, alzheimer's. father - deceased at 54 y.o. in a car accident, has 6 brothers and 1 sister, no fh of cad or dm. 1 brother died of gastric cancer. one brother has . physical exam: vs: t=98.2 bp=144/88 hr=94 rr=20 o2 sat=100% nrb general: overweight elderly woman in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. neck: supple with jvp wnl. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. groin without hematoma, ttp, or bruit. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: dp pulses 2+ bl, pertinent results: admission: 10:55am blood wbc-13.7* rbc-4.24 hgb-13.2 hct-40.0 mcv-94 mch-31.0 mchc-32.8 rdw-17.2* plt ct-355 10:55am blood pt-12.2 ptt-22.5 inr(pt)-1.0 10:55am blood neuts-58.8 lymphs-31.4 monos-6.0 eos-2.9 baso-0.9 10:55am blood glucose-124* urean-18 creat-0.7 na-140 k-3.7 cl-105 hco3-26 angap-13 10:55am blood ck(cpk)-44 08:19pm blood ck(cpk)-278* 05:27am blood ck(cpk)-250* 07:00am blood ck(cpk)-119 10:55am blood ctropnt-<0.01 08:19pm blood ck-mb-35* mb indx-12.6* ctropnt-0.38* 05:27am blood ck-mb-31* mb indx-12.4* ctropnt-0.36* 07:00am blood ck-mb-7 ctropnt-0.26* 07:00am blood calcium-8.7 phos-3.3# mg-2.0 11:02am blood k-3.5 discharge: 07:00am blood wbc-12.2* rbc-3.60* hgb-11.4* hct-33.9* mcv-94 mch-31.8 mchc-33.7 rdw-17.1* plt ct-252 07:00am blood plt ct-252 07:00am blood glucose-74 urean-18 creat-0.7 na-142 k-3.9 cl-106 hco3-30 angap-10 ekg : sinus rhythm with two to three millimeter st segment elevation in the inferior leads and one millimeter st segment elevation in leads v4-v6. st segment depression of one to two millimeters in leads v1-v2 and st segment depression of two millimeters in lead avl. this is consistent with a large area of nterolateral, inferior and posterior myocardial infarction. compared to the previous tracing of acute injury pattern in the inferior-posterior region is new. echo : the left atrium and right atrium are normal in cavity size. there is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior and inferolateral segements. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a promient fat pad. impression: mild focal lv systolic dysfunction consistent with inferior ischemia/infarction. no pathologic valvular abnormality seen. mild pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , mild inferior and inferolateral hypokinesis is seen on the current study. cardiac catheterization : 1. cardiac catheterization in this right dominant system revealed single vessel coronary artery disease. the lmca, lcx, and lad were without significant obstructive coronary artery disease. the rca had a 90% stenosis in the mid-portion, and a 99% stenosis with thrombus in the distal portion. 2. resting hemodynamics revealed normal blood pressure of 121/72 mmhg. 3. successful ptca, manual aspiration thrombectomy, and placement of a 4.0x12mm vision bare-metal stent in the mid rca and a 3.5x12mm vision bare metal stent in the distal rca were performed. final angiography showed normal flow, no apparent dissection, and a 5% residual stenosis in the mid rca. (see ptca comments.) final diagnosis: 1. one vessel coronary artery disease. 2. placement of bare metal stents in the mid and distal rca. brief hospital course: 72 yo woman with h/o cad (lad had 50% stenosis after d1, lcx had 70% om2 stenosis, rca with proximal des) presents with inferior stemi due to late stent thrombosis (4 years later), now s/p bms x 2 in mid and distal rca. . # stemi: patient with inferior stemi that was successfully treated with thrombectomy and pci with 2 bms placed one in the 99% occluded distal rca and another in the 90% occluded mid rca lesion. pt also with hypotension on presentation suggestive of cardiogenic shock, which has since resolved after pci in mid and distal rca. this may also have been secondary to nitroglycerin. pt was treated with integrillin for a total of 18 hours, started and continued on aspirin 325mg po daily, supplemental o2, plavix loaded and then 75mg po daily, and simvastatin increased from 20mg po daily to 80mg po daily. heart rate was kept near 60 and bp<140/90, by adding metoprolol 12.5mg po tid as pressures allow and uptitrated to 25mg po tid. the ccu team strongly encouraged smoking cessation (spent 15 minutes with pt who has been precontemplative, but now will consider quitting). tte showed normal systolic global function (ef 55%) but with inferior hypokinesis c/w imi. pt was continued on a low sodium diet and physical therapy was consulted. the pt had some episodes of mild ectopy with a few runs of nsvt. the patient remained cp free since the catheterization for the remainder of the admission. the patient was scheduled to see in cardiology on . . # rheumatoid arthritis: no active issuses. continued prednisone 5mg po daily. pt to continue weekly mtx tx at home. continued gabapentin for chronic pain. medications on admission: gabapentin 100 mg po tid prednisone 5 mg po daily metoprolol tartrate 25mg po bid folic acid 1 mg po daily simvastatin 20 mg po daily aspirin ec 81 mg po daily acetaminophen 325-650 mg po/ng q6h:prn pain hctz 25mg po daily calcium/vitamin d vitamin b12 discharge medications: 1. tylenol ex str arthritis pain 500 mg tablet sig: 1-2 tablets po three times a day as needed for pain: no substitutions. disp:*270 tablet(s)* refills:*2* 2. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch transdermal once a day for 6 weeks. disp:*30 patches* refills:*1* 5. nicotine 7 mg/24 hr patch 24 hr sig: one (1) patch transdermal once a day for 2 weeks. disp:*14 patches* refills:*0* 6. simvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain: take up to 3 tablets 5 minutes apart, call 911 if you still have chest pain after 3 tablets. . disp:*25 tablet, sublingual(s)* refills:*0* 8. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 9. cyanocobalamin 50 mcg tablet sig: one (1) tablet po once a day. 10. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 11. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 12. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). 13. metoprolol succinate 50 mg tablet sustained release 24 hr sig: 1.5 tablet sustained release 24 hrs po once a day. disp:*45 tablet sustained release 24 hr(s)* refills:*2* 14. calcium oral 15. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 16. outpatient lab work please check cbc on wednesday and call results to dr. at . diag 280.0 discharge disposition: home discharge diagnosis: st elevation myocardial infarction coronary artery disease . secondary: rheumatoid arthritis gastric ulcer discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you had a heart attack because the stent in your right coronary artery was partially clotted and because of a new blockage in the same artery. the artery was fixed and 2 new bare metal stents have been placed. you will need to take aspirin and plavix every day for at least one month and probably longer to keep the stents open. do not stop taking aspirin and plavix unless dr. tells you not to. you will see your new cardilogist and should go to cardiac rehab when dr. tells you it is ok. please stop smoking to prevent another heart attack and to make your new medicines more effective. this is the single most important thing you can do for your health. medication changes: 1. start taking aspirin (increase to 325 mg) and plavix every day to keep the stent from clotting off 2. increase the simvastatin to 80 mg daily 3. change the short acting metoprolol to long acting (succinate) and take 1.5 tables daily 4. stop taking hydrochlorothiazide 5. do not take motrin or aleve for your arthritis pain, take the high dose tylenol instead. 6. start using a nicotine patch to help you quit smoking. you will take 14mg every day for 6 weeks, then the dose is decreased to 7mg for an additional 2 weeks. 7. take nitroglycerin for chest pain as described in the handout. if you take this medicine, make sure to call dr. . 8. stop taking prilosec (the purple pill) as this can interfere with the plavix. you can take ranitidine instead twice daily. please talk to dr. about this. . your blood count went down after the procedure. we would like you to check the blood count again on wednesday . you can go to the hospital at . followup instructions: primary care: , p. phone: date/time: office will call you with an appt. . cardiology: dr. phone: date/time: wednesday at 11:30am. . gastroenterology: : phone: ( date/time: please keep any scheduled appts. . rheumatology: provider: , md phone: date/time: 10:30 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Long-term (current) use of steroids Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Cardiogenic shock Acute myocardial infarction of other inferior wall, initial episode of care Other complications due to other cardiac device, implant, and graft Rheumatoid arthritis Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Spinal stenosis, unspecified region

allergies: iodine-iodine containing / penicillins / shellfish / latex / bee pollen attending: chief complaint: nausea and vomitting and altered mental status. major surgical or invasive procedure: whole brain radiation. history of present illness: 73f w/ metastatic lung cancer to brain, on radiation therapy, here with severe nausea and vomiting since this morning; sent from rad clinic with severe hypertension and nausea/vomiting concerning for increased intracranial pressure. she was recently admitted to from with hypoxia and back pain; nausea and vomiting. patient's symptoms completely resolved with dexamethasone, complicated by steroid-induced psychosis. also initiated whole-brain radiation while in-house and continued to see rad onc following discharge. she had been on a dexamethasone taper following discharge. currently on 2g . . pt somnolent but arousable. states that she has not had any other symptoms, including headaches, changes in vision, dizziness, weakness, or numbness. reports exhaustion from not being able to sleep for 1.5d due to vomiting and nausea. states that she was vomiting "all day yesterday" and "every half hour" this morning. pt reports fatigue and sleepiness. pt a&o to "hospital, somewhere near , year --, 20-- don't know". . in the ed, triggered for hypertension. initial vitals were: 16:30 0 98.9 65 170/111 16 97% 2l nasal cannula. bp --> 16:45 225/119 --> 17:00 179/100 patient was somnolent but arousable. neuro exam somewhat limited by pt's lack of participation, pupils pinpoint cn 2-12 intact. lungs: bibasilar crackles. ekg: normal sinus rhythm, hr 70, left shifted axis, normal intervals. 1mm pr depression in v2, v2. peaked t waves v2, v3. t wave inversion v1. consistent with prior. labs: show elevated k to 5.6, hemolyzed. repeat lab -> k 4.0. ct head w/out contrast: vasogenic edema unchanged, but right parietal hyperdense lesion is more conspicuously hyperdense and slightly increased in size than on the prior. this degree of increased hyperdensity would not be expected in the interval and raises concern for intralesional hemorrhage. . neurosurgery consulted: feel that pt's n/v related to wbxrt and decadron taper. recommended no acute neuro intervention. increase dexa to at least 6mgq6h standing. she was started on dexamethasone 6mg iv q6hrs. on re-exam, pt's bp improved to 140s/80s w/ only dexamethasone. pt is sleeping peacefully. past medical history: 1. coronary artery disease -s/p inferior/posterior stemi with rv involvement with bms to distal rca. repeat bms x 2 to same rca lesion in 2. stage iv lung cancer metastatic to brain 3. hyperlipidemia 4. rheumatoid arthritis 5. hypertension 6. lumbar djd 7. basal cell carcinoma of the nose social history: she is widowed and lives alone in senior housing. she has four children, two daughters and two sons. one son lives out of state but the others are local. originally from . she smoked one pack a day of cigarettes for the past 60 years and continues to smoke. alcohol rare. her daughter, may be reached at . her daughter may be reached at . family history: mother died of disease. father died at age 54 from an mva. she has six brothers, one deceased from cancer ?prostate, another had alzheimer's disease. one sister alive and well. physical exam: admission physical exam: vitals: afebrile 149/84 92 14 95% ra general: alert, orientedx1-2, no acute distress heent: sclera anicteric, mmm, oropharynx clear. perrla neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally. mild bibasal crackles. cv: regular rate and rhythm, normal s1 + s2, sem ii/vi nonradiating abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing. 1+ pitting edema on lower extremity to shins bilateral. . discharge physical exam: vitals: 95.4, 142/84, 53, 20, 96%ra i/o: 780/470 + large bm this am physical exam: general: a&o x 2, no acute distress heent: sclera anicteric, mmm, oropharynx clear. perrl. neck: supple, no jvd, no lad lungs: clear to auscultation bilaterally. cv: rrr, normal s1 + s2, sem ii/vi nonradiating abdomen: soft, nt/nd, bowel sounds (+), no rebound/guarding, no hsm ext: warm, well perfused, 2+ pulses, no clubbing. no edema. pertinent results: labs at discharge: 06:20am blood wbc-13.6* rbc-4.13* hgb-12.4 hct-37.1 mcv-90 mch-30.0 mchc-33.4 rdw-16.6* plt ct-316 06:20am blood pt-12.1 ptt-22.1 inr(pt)-1.0 06:20am blood glucose-117* urean-32* creat-0.7 na-135 k-4.9 cl-99 hco3-25 angap-16 06:20am blood calcium-9.3 phos-4.2 mg-2.3 . studies & imaging: ecg: baseline artifact. sinus rhythm with atrial premature beats. left axis deviation. left anterior fascicular block. inferior myocardial infarction, age indeterminate. compared to the previous tracing of the atrial premature beats are new. rate pr qrs qt/qtc p qrs t 70 154 76 388/405 66 -55 46 . ct head w/o con: increased size of the hyperattenuated focus with a more amorphous appearance raises suspicion for a possible intralesional hemorrhage of the right parietal metastasis. otherwise, unchanged degree of vasogenic edema in the right parietal lobe. the other masses demonstrated on the previous mr are not well identified on this nonenhanced ct study. . ecg: sinus rhythm with premature atrial and ventricular complexes. marked left axis deviation. inferior myocardial infarction of indeterminate age. delayed r wave progression. compared to the previous tracing of the findings are similar. rate pr qrs qt/qtc p qrs t 72 150 76 376/397 62 -53 29 brief hospital course: this is the brief hospital course for a 73 year-old female with non-small cell lung carcinoma metastatic to the brain who presented here for evaluation of nausea, vomitting, and altered mental status. the following medical issues were addressed during this admission: . # brain metastases: she presented with nausea, vomitting, and hypertension. ct scan was suspicious for intralesional brain hemorrhage in the right parietal metastasis and notable for an unchanged degree of vasogenic edema in that same parietal lobe. her nausea and vomitting were thought to be due to her intracranial processes and changes caused by weaning from decadron and the most recent episode of whole brain radiation which the patient underwent. she was started on 6 mg dexamethasone every 6 hours per neurosurgery recommendations, and after discussion with the cardiology service primary medicine team, and her family, her plavix was discontinued as the risks of intracranial bleeding was thought to outweigh the benefits of blood thinning to prevent myocardial ischemia and stent re-stenosis. . # hypertension: she presented with systolic blood pressures in the 220s. this was thought to be due to her intracranial process following weaning from decadron and also cerebral changes post-whole brain radiation. she was started on 6 mg dexamethasone every 6 hours per neurosurgery recommendations, and her systolic blood pressures normalized to 110s to 140s. . # altered mental status: psychiatry was consulted given the patient's history of steroid induced psychosis, and they recommended starting seroquel nightly at 12.5mg and once the patient's qtc was checked for prolongation, she was increased to a dose of 25mg nightly prior to bedtime. . # rheumatoid arthritis: this issue was stable and the patient remains on her methotrexate and steroids for disease control. . # coronary artery disease: this issue was stable and the patient continues on asa 81 mg daily, but has been discontinued from her clopidogrel dose for reasons listed above. . # hyperlipidemia: this issue was stable and the patient continues on simvastatin 40 mg daily. . the patient was discharged home to the facility in where she was prior to admission. she was upset that she was not going home, but cooperated. she will have 2 more radiation treatments for her brain disease, and remains dnr/dni. medications on admission: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain: q5min as needed for chest pain. 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 6. gabapentin 100 mg capsule sig: one (1) capsule po q8h (every 8 hours). 7. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 11. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain or fever. 12. haloperidol 0.5 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for agitation. 13. dexamethasone 2 mg tablet sig: 1.5 tablets po q12h (every 12 hours): initiating taper on of 3mg q12 for 5 more days, 2g x7d, 1g x7d, 1g qd x7d and then stop . disp:*90 tablet(s)* refills:*0* 14. esomeprazole magnesium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 15. methotrexate (anti-rheumatic) 2.5 mg tablets, dose pack sig: six (6) tablets, dose pack po once a week: take weekly on sunday. 16. calcium citrate + d 315-200 mg-unit tablet sig: two (2) tablet po twice a day. 17. cyanocobalamin (vitamin b-12) 1,000 mcg tablet sig: one (1) tablet po once a day. discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. polyethylene glycol 3350 17 gram/dose powder sig: one (1) spoonful po daily (daily). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 7. gabapentin 100 mg capsule sig: one (1) capsule po q8h (every 8 hours). 8. cyanocobalamin (vitamin b-12) 500 mcg tablet sig: two (2) tablet po daily (daily). 9. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 10. quetiapine 25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 11. dexamethasone 2 mg tablet sig: three (3) tablet po q6h (every 6 hours). 12. calcium citrate + d 315-200 mg-unit tablet sig: two (2) tablet po twice a day. 13. methotrexate (anti-rheumatic) 2.5 mg tablets, dose pack sig: six (6) tablets po q sundays. 14. haloperidol 1 mg tablet sig: one (1) tablet po three times a day as needed for acute agitation: please only use if acute agitated. 15. acetaminophen 325 mg tablet sig: two (2) tablet po every six (6) hours as needed for fever or pain. 16. nitroglycerin 0.3 mg tablet, sublingual sig: 1-2 tablets sublingual every 5-10 minutes as needed for chest pain for 3 doses. 17. esomeprazole magnesium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 18. folic acid 1 mg tablet sig: one (1) tablet po once a day. discharge disposition: expired facility: health care center discharge diagnosis: non-small cell lung carcinoma metastases to brain coronary artery disease hypertension steroid psychosis discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: ambulatory- requires assistance or aid (walker/cane). discharge instructions: dear , it was a pleasure to take care of you during your hospital stay. you were admitted to the hospital because your family and neighbors noticed a change in your mental status. tests were run to look inside your brain at the sites where the cancer is. the tests did not show any current areas of bleeding, but this will be a constant concern for you from here on out. for this reason, your doctors have decided, along with your children, that it is in your best interest to no longer take the medication called plavix. this medicine is a blood thinner and can predispose you to brain bleeding. you were originally on the medication because of your heart disease. stopping the medication will place you at a high risk of getting a blockage in one of your heart's artery's again. we discussed this with your children and your other doctors here at the hospital, and everyone agreed that the risks of taking this medication heavily outweighed the benefit. please stop the following medications: -plavix (clopidegrel) please increase the dose of the following medications: -quetiapine (seroquel) now 25mg every night at bedtime followup instructions: you are already scheduled for the remaining two radiation treatments. please have the staff at arrange transportation for you to these appointments and back. the appointments are: . tuesday, @ 2:45pm wednesday, @ 2:45pm . both of the appointments are at in on the in the department of radiation oncology. . you may be contact by your oncologist for additional follow-up. meanwhile, the physicians at the facility will be caring for your immediate, acute medical needs. Procedure: Other radiotherapeutic procedure Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Percutaneous transluminal coronary angioplasty status Nausea with vomiting Other and unspecified hyperlipidemia Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of bronchus and lung, unspecified Cerebral edema Rheumatoid arthritis Do not resuscitate status Other disorders of neurohypophysis

history of present illness: this is a 57-year-old female with history of primary sclerosing cholangitis, inferior myocardial infarction, and sepsis who fell eight feet onto a concrete floor on and broke her right sacrum, right proximal femur, inferior superior rami, left humeral neck and nondisplaced right orbital fracture. she presented to the where ct scan of the c spine was negative and where patient received open reduction internal fixation of the right femur. on , ct scan of the head revealed right intraparenchymal frontal bleeding subarachnoid bleed. the patient was transfused with two packed red blood cells, eight units of platelets while in the icu there. on , the patient was transferred to the floor at . on , the patient had an episode of hematemesis and was transferred to the icu where she received two units of platelets. on , the patient had another episode of hematemesis and was then brought for egd where they sclerosed a 3.5 rent in the lower esophagus. the patient also received one unit ffp and octreotide. on , the patient was then transferred to with the following medications. admission medications: 1. oxycodone. 2. propanolol. 3. percocet. 4. colace. 5. spironolactone. 6. actigall. 7. lactulose. 8. octreotide. 9. levophed. on the air transfer to the , patient's levophed had to be increased from 14 to 20 mcg per hour. she also received 750 cc of iv fluids, 2 mg ativan and 2 units of packed red blood cells during the air transfer. allergies: none. medications at home: 1. actigall 300 mg p.o. q.i.d. 2. zestoretic 10/12.5 one tablet p.o. q.d. 3. aldactone 50 mg p.o. b.i.d. 4. levoxyl 100 mcg p.o. q.d. 5. propanolol 20 mg p.o. b.i.d. 6. prilosec 20 mg p.o. q.d. past medical history: 1. two cesarean sections. 2. inferior myocardial infarction with arrest and cardioversion. 3. hypothyroidism. 4. hernia. 5. cholecystectomy. 6. pneumonia with sepsis in . 7. in primary sclerosing cholangitis by ercp biopsy. 8. in , ascites with klebsiella bacteremia treated with gentamycin and ciprofloxacin. 9. , ascites with liver transplant work up by . physical examination: on admission with a temperature of 97.2 f, pulse 88, blood pressure 104/63 on a ventilator simv 700 times 15 with a peep of 5 and fio2 of 100%. generally this patient is intubated and not arousable to painful stimuli. head, eyes, ears, nose and throat: she had right orbital ecchymosis. pupils are 8 mm, fixed and dilated bilaterally with sluggish reaction to light. tympanic membranes are normal. icteric eyes and bloody oropharynx. neck is supple. cardiovascular: regular rate and rhythm. normal s1, s2. no murmurs or thrills noted. chest: coarse rhonchi heard bilaterally. abdomen is distended with positive fluid wave. extremity: +3 pedal edema bilaterally in the upper and lower extremities. lower extremities are cool to touch. skin: jaundice noted, but no spider angiomas noted. there is no caput medusas seen. laboratory: upon admission labs were a white count of 38.1 with the following differential of 54% neutrophils, 34% bands, 5% lymphocytes and 4% monocytes. hematocrit was 22.4, platelets 198,000. sodium 135, potassium 5.5, chloride 104, bicarbonate 13, bun 40, creatinine 1.0, anion gap 18, glucose 84, calcium 8.1, phosphorus 4.4, magnesium 1.6. pt 20.5, ptt 35.1, inr 2.9. total bilirubin is 11, alt 75, ast 163, amylase 385. albumin 2.0, ldh 651, alkaline phosphatase 164, lipase 56, fibrinogen 145, fibrogen degradation products is 80 to 160. d-dimer is greater than 2,000. abg is 7.42 with pco2 of 21 and po2 of 250 on tidal volume is 700 with respiratory rate of 15, peep of 5 and fio2 of 100. urinalysis is hazy with large blood and positive nitrates, 30 protein and 100 glucose is noted. urine micro shows six to 10 red blood cells with greater than 50 white blood cells and many bacteria. urine blood and acidic cultures are pending. serum osmolality pending. ascites chemistry with a protein of 1.5, glucose 108, creatinine 0.8, ldh 100, amylase 12, total bilirubin 2, albumin 0.6, lactate 13.8. hospital course: 1. gi: hepatology team was consulted and they decided not to perform an egd at this time due to the patient being hemodynamically unstable. instead, an oral gastric tube was placed and we lavaged 1.6 liters of dark blood. a paracentesis was performed and 3.5 liters of acidic fluid was removed. the patient was continued on octreotide and given protonix 40 mg iv b.i.d. for prophylaxis. the patient was typed and crossed, but we were unable to get any blood for transfusion due to difficult type and cross. 2. cardiovascular: hypotension, the levophed was increased to 30 mcg per kilogram per minute, however patient remained hypotensive so vasopressin 0.04 units per minute was added. the patient was also bolused with one liter of normal saline every hour. since no packed red blood cells were available, the patient was infused with 25 grams of albumin. finally, dopamine was added at 10 mcg per kilogram per minute to control the low blood pressure. the patient's blood pressure on these triple pressures and fluid boluses was still settling around a systolic blood pressure of 80. 3. respiratory: the patient was initially put on simv at 700 cc times a respiratory rate of 15 with peep of 5 and fio2 of 100%. since the abg shows quite a low co2 and high po2, the patient was switched over to assist-control at 550 cc times 15 with a peep of 5 and fio2 of 60%. her abg at this time showed a ph of 7.34, co2 21 and po2 of 144. however, patient was overbreathing the respiratory with additional respiratory rate of 30 rather than the set 15. so she was switched over to assist-control 550 cc with a respiratory rate of 30, peep of 5 and fio2 of 60%. it is believed that the patient is overbreathing to compensate for her metabolic acidosis. 4. renal: the patient did have a high bun and a normal creatinine. these values reflect that the patient was having an upper gi bleed. she also had a metabolic acidosis with anion gap. it is believed that this is due to the lactate production due to the ischemia both to her organs. we attempted to maintain a blood pressure above systolics of 80s to profuse her organs, however her metabolic acidosis continued to worsen with a anion gap of 20 and bicarbonate of 11. she was also overbreathing with less co2 compensation. her gasses were showing a ph of 7.18 with a pco2 of only 27. 5. infectious disease: patient was initially given levofloxacin 500 mg times one for prophylaxis for possible egd. since her white count was shown to be 38 with a large bandemia, we started ceftazidine 2 grams iv t.i.d. for treatment of primary spontaneous bacterial peritonitis. we also attempted to pan culture her which showed no results at this time. 6. neurologically: at 2 am, the patient began to have seizures. she was given 200 mg of fosphenytoin, 40 mg of ativan and 20 mg of valium. from 2 am to 10 am, the patient was only able to stop seizing for a couple of minutes for about three to four times throughout the whole period. we were finally able to obtain a ct scan of the head which revealed diffuse cerebral edema and effacement of the sulci. no extraocular hemorrhage was found. there were punctate areas of high attenuation in the right frontal cortex that likely represented a contusion. also, it seems that her cerebral tapholes were heading toward herniation. neurosurgery was consulted, but no treatment could be given at this time. neurology was consulted and en egd was obtained showing electrical activity representing myoclonic actions. this myoclonic activity is likely due to hypoxic injury to brain. neurology informed the team who then informed the family of the poor neurologic prognostic factors. patient continued to receive phenobarbitol and then was put on a propofol drip for her presumed seizure activity at the time. she was also given 25 gram of mannitol to lessen the cerebral edema. disposition: around 12:45 pm on , the patient's family did visit her. after the visit, the family decided that the patient should be comfort measures only. her pressor medications were stopped. then the patient was extubated. at 1:08 pm on , mrs. passed away due to hypovolemic and septic shock. discharge diagnoses: 1. hypovolemic and septic shock. 2. upper gi bleed secondary to esophageal tear. 3. ascites secondary to portal hypotension which is secondary to the primary sclerosing cholangitis. 4. cerebral edema secondary to hepatic failure. 5. ischemic hepatitis. 6. sepsis. 7. lactic metabolic acidosis. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Percutaneous abdominal drainage Diagnoses: Acidosis Unspecified septicemia Portal hypertension Other convulsions Other shock without mention of trauma Esophageal varices in diseases classified elsewhere, with bleeding Cholangitis

allergies: morphine / iodine attending: chief complaint: migraines/stroke major surgical or invasive procedure: - right main coronary artery stent placement (dr. - asd closure via mini right thoractomy with perclose device (dr. history of present illness: this is a 46 year old female who had suffered a cva back in . work up revealed an atrioseptal defect which was not amenable to the standard device closure. she also had right coronary ostium stenoses. the echocardiogram showed that she had a small atrioseptal defect with bidirectional flow. it was, therefore, recommended that she have closure of this asd. the plan was also to schedule her to have a stent of her right main coronary ostium at the same time. past medical history: migraines anemia hodgkins lymphoma s/p chemo and xrt stroke asd pneumonia sternotomy with mediastinal mass partial left lung resection via left thoracomtomy social history: geneticist. lives with husband and 4 children. family history: noncontributory. physical exam: vitals: bp 120/66, hr 93, rr 16 general: well developed female in no acute distress heent: oropharynx benign, poor dental health neck: supple, no jvd heart: regular rate, normal s1s2, soft systolic murmur lungs: clear bilaterally abdomen: soft, nontender, normoactive bowel sounds ext: warm, trace edema, no varicosities pulses: 2+ distally neuro: nonfocal pertinent results: 07:55am blood hct-28.0* 04:35am blood plt ct-207 07:55am blood urean-7 creat-0.6 na-141 k-4.1 cxr small bilateral pleural effusions, left greater than right, which developed between and , is slightly smaller today. aside from severe scarring and radiation-induced bronchiectasis in the left upper lung, lungs are clear. heart is normal size. preoperative leftward tracheal deviation due to this scarring is partially obviated by the left pleural effusion. echo pre device closure of the asd using a perclose device. the left atrium is normal in size. a left-to-right shunt across the interatrial septum is seen at rest. a small secundum atrial septal defect is present. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets(3) appear structurally normal with good leaflet excursion. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. tee guidance was used to help with placement of the wire and catheter across the interatrial septum. dr also present during the procedure to help with the tee and concur with the findings. post device closure of the asd there is no flow demonstrable across the interatrial septum with color flow doppler. lv and rv systolic function appear to be normal. cardiac catheterization 1. single vessel coronary artery disease. 2. normal central blood pressures. 3. successful placement of bare metal stent in ostial rca. 4. successful placement of perclose proglide in left femoral arteriotomy. ospital course: mrs. was admitted to the on for surgical management of her atrial septal defect and her coronary artery disease. she was taken to the operating room where she underwent successful stenting of her right coronary artery and an atrial septal defect closure. please see operative note for details of surgical intervention. postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. plavix was started for her stent. on postoperative day one, mrs. awoke neurologically intact and was extubated. on postoperative day two, she was transferred to the cardiac surgical step down unit for further recovery. she was gently diuresed towards her preoperative weight. beta blockade was initiated and titrated for optimal heart rate and blood pressure control. she remained in normal sinus rhythm with stable hemodynamics. mrs. continued to make steady progress and was discharged home on postoperative day three. she will follow-up with dr. , her cardiologist and her primary care physician as an outpatient. medications on admission: fosamax excedrin imitrex multivitamin discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 10 days. disp:*20 tablet(s)* refills:*0* 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 10 days. disp:*40 capsule, sustained release(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 4. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. hydromorphone 2 mg tablet sig: 1-2 tablets po q3-4h (every 3 to 4 hours) as needed. disp:*50 tablet(s)* refills:*0* 8. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*45 tablet(s)* refills:*2* 9. ferrousul 325 (65) mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 10. ascorbic acid 500 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: asd migraines coma/seizure hodgkin's lymphoma s/p chemo/xrt discharge condition: good discharge instructions: shower, wash incisions with mild soap and water and pat dry. no lotions, creams or powders to incisions. call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. followup instructions: follow up with dr. in four weeks follow up with dr. in weeks follow up with dr. in weeks Procedure: Insertion of non-drug-eluting coronary artery stent(s) Left heart cardiac catheterization Coronary arteriography using a single catheter Angiocardiography of right heart structures Repair of atrial septal defect with prosthesis, open technique Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve insufficiency and aortic valve insufficiency Ostium secundum type atrial septal defect Personal history of other diseases of circulatory system Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites

allergies: penicillins attending: chief complaint: transfer from outside hospital for pvd/left foot ischemia and nstemi major surgical or invasive procedure: -cardiac catheterization, stenting of lad -left common femoral artery - dp bypass history of present illness: 78yo man with 30year history of htn, 15 year history of dm, pmr on steroids, and inferior wall mi in who was admitted to on with an ischemic left foot. angiography showed sfa occluded and occluded popliteal above the knee. pta was done of the mid popliteal with dissection of the politeal below the knee, which was stented. post procedure, he ruled in for nstemi and suffered cardiogenic shock. he was on pressors, natrecor, and intubated. subsequently, the leg worsened, becoming cool and cyanotic. he was then referred to for further management. at , he underwent cardiac catheterization with stenting of the lad. he also had angio/thrombectomy/tpa infusion of left sfa on . he then underwent left cfa to dp bypass on . of note, creatinine was 1.7 on admission, which trended upward to 5.7 on . past medical history: hypertension dm ii cad with inferior wall mi in (no catheterization) pmr on steroids peripheral disease h/o duodenal ulcer cri chf bph dementia social history: lives with wife no etoh or drug use previous history of tobacco use family history: no family history of cad physical exam: physical exam on admission: p 75, bp 160/76, r 24, 100% sat exam significant for - resp: occasional scattered rhonchi - cv: rrr, s1 and s2 - extr: left extremity cool to the touch, motteld and necrotic digit pertinent results: 11:25pm glucose-552* urea n-44* creat-2.0* sodium-137 potassium-3.0* chloride-89* total co2-40* anion gap-11 11:25pm ck(cpk)-297* 11:25pm ck-mb-4 11:25pm calcium-7.2* phosphate-3.4 magnesium-1.6 11:25pm wbc-7.5 rbc-2.83* hgb-9.1* hct-27.1* mcv-96 mch-32.4* mchc-33.8 rdw-13.7 11:25pm plt count-156 11:25pm pt-13.7* ptt-100.2* inr(pt)-1.2 05:25pm inr(pt)-1.6 brief hospital course: 1) cad: suffered nstemi at outside hospital, c/b cardiogenic shock. he underwent cardiac catheterization with placement of stent of lad here. cardiac catheterization revealed the following: -left dominant coronary anatomy -lmca: distal taper of 40% -lad: origin 80% lesion with serial 80% lesion in proximal lad with moderate diffuse disease in the lad -lcx: dominant vesel with moderate diffuse disease -rca: non-dominant vessel with moderate diffuse disease -lsfa: diffuse disease from the fa to the stent; stents are occluded without reconstitution distally; there are mild geniculated collaterals to the infrapopliteal arteries without named vessels below. he was medically managed with asa, plavix, beta blocker, and statin, ace inhibitor. he remained stable. please continue medications on discharge. 2) pump: he was felt to be euvolemic. there were no signs/symptoms of chf despite receiving free water to correct his hyponatremia. he had an echo performed on , which demonstrated the following: -mild dilation of the left atrium -mild symmetric left ventricular hypertrophy with normal lv cavity size -overall lvef preserved = 55% -noted basal inferior hypokinesis -mitral valve leaflets mildly thickened -trivial mitral regurgitation 3) acute/chronic renal insufficiency: acute exacerbation of chronic renal insufficiency; felt to be secondary to contrast nephropathy following multiple procedures. creatinine peaked at 5.7, and trended down to 1.5, which may be his new baseline level. 4)hypernatremia: resolved with free water deficit replaced. encouraging po free h2o. 4) dm2: he was monitored with finger sticks glucose checks and covered with sliding scale insulin. bg levels not well controlled and remained b/w 250-300. he was not on outpt oral medications but started on glipizide 2.5mg on which improved bg control. 5) : he has a significant history of peripheral disease, and is now s/p intervention followed by left cfa-dp bypass for this. as surgery was concerned for infection of hematoma on his left calf,he was started on antibiotic coverage including vanc/levo/flagyl. culture sent and revealed no growth. no microorganisms seen. his antibiotics were changed to keflex and levofloxacin on for empiric coverage. these should be continued for 1 week (last dose on ). ace on calf at all times. he will need toe amputation as an outpatient. he is to follow up with dr. from podiatry on regarding 4th toe amputation and dr. on for r/u after surgery. at that time, he will have staples removed and discuss whether or not to continue antibiotics. : concern for rue edema and infiltration of iv site. plastic surgery was consulted. no compartment syndrome. he has been keeping r arm elevated, as per recs. also continue dressing changes with xeroform over blisters until resolve. much improvement. swelling/ecchymosis cont to decrease. 6) mental status: baseline level of dementia/cognitive impairment, complicated by acute delirium. neurology was involved; head ct was negative for bleed. attempts at lumbar puncture failed. altered mental status was felt to be secondary to sedative medications. as these meds were held, his mental status progressively improved back toward baseline. still has some short-term memory deficits which will likely improve with time, but if they don't will require further neurologic evaluation. medications on admission: prednisone 5mg qd lisinopril 20mg qd plavix 75mg qd lipitor 80mg qd mvi lopressor 50mg protonix 40mg qd discharge medications: 1. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily) for 300 days. 2. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. insulin regular human 100 unit/ml solution sig: please see sliding scale injection asdir (as directed). 4. atorvastatin calcium 40 mg tablet sig: two (2) tablet po daily (daily). 5. multivitamin capsule sig: one (1) cap po daily (daily). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. prednisone 5 mg tablet sig: 0.5 tablet po daily (daily). 8. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). 9. trazodone hcl 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 10. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). 11. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 12. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 13. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 14. hydralazine hcl 10 mg tablet sig: one (1) tablet po q6h (every 6 hours). 15. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 16. glipizide 5 mg tablet sig: 0.5 tablet po bid (2 times a day). 17. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 18. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 19. heparin flush cvl (100 units/ml) 1 ml iv daily:prn 10ml ns followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen qd and prn. inspect site every shift 20. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 1 weeks. 21. keflex 500 mg capsule sig: one (1) capsule po twice a day for 1 weeks. discharge disposition: extended care facility: for the aged - discharge diagnosis: primary diagnosis: nstemi - s/p cardiac catheterization secondary diagnosis: peripheral disease with popliteal artery thrombosis s/p fem-dp bypass diabetes mellitus, type 2 medication induced delerium acute on chronic renal failure secondary to contrast nephropathy. hypertension discharge condition: stable discharge instructions: patient is to be discharged to center. please return to ed if you develop chest pain, shortness of breath, opening of left leg incision, or other worrisome symptom. please follow up with podiatry and surgery as scheduled. followup instructions: you should call dr to schedule a follow-up appointment for 1 week from your discharge for evaluation. also, please follow up with dr from podiatry to evaluate your left toes on at 11:20am. location: . far building. . provider: , surgery where: surgery date/time: 9:45 Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Diagnostic ultrasound of heart Angioplasty of other non-coronary vessel(s) Injection or infusion of thrombolytic agent Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Transfusion of packed cells Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Polymyalgia rheumatica Acute kidney failure with lesion of tubular necrosis Long-term (current) use of steroids Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hematoma complicating a procedure Other complications due to other vascular device, implant, and graft Hyperosmolality and/or hypernatremia Atherosclerosis of native arteries of the extremities with gangrene Drug-induced delirium Unspecified sedatives and hypnotics causing adverse effects in therapeutic use Other and unspecified complications of medical care, not elsewhere classified

history of present illness: the patient is a 61-year-old female with loss of consciousness on at home. she fell in the kitchen sustaining left rib bruising. magnetic resonance imaging showed a cerebral aneurysm. past medical history: 1. the patient reports having had palpitations in the past. 2. hypertension. 3. chronic urinary tract infection. 5. deep venous thrombosis. medications on admission: medications at home included rhinocort, tylenol, hydrochlorothiazide, lipitor, and aspirin. allergies: no known drug allergies. physical examination on presentation: physical examination revealed blood pressure was 148/89. in general, the patient was pleasant and in no acute distress. head, eyes, ears, nose, and throat examination revealed facial structure was symmetric at rest and with smile. pupils were equal, round, and reactive to light. extraocular movements were intact. no nystagmus. mucous membranes were moist and pink. no ulcerations. she has a mass on her hard palate which she said has always been there. soft palate and uvula rose with voice. no ulcerations or nodes that were palpable. the trachea was midline. carotids were palpable. regular pulsations. no bruits were detected. the chest was clear to auscultation bilaterally. cardiovascular examination revealed a regular rate and rhythm. no murmurs. the abdomen was obese with multiple striae. bowel sounds were present in all four quadrants. soft and nontender to palpation. extremity examination revealed palpable pulses in the upper and lower extremities. normal muscle strength. gait was smooth. increased instability with heel-to-toe ambulation, toe walk, and heel walk. swaying with romberg. hospital course: the patient was admitted on and was taken directly to the angiogram suite where an angiogram was performed with coiling of a right internal carotid artery cavernous aneurysm. the patient tolerated the procedure quite well and was sent to the intensive care unit postoperatively where she received a heparin drip. her angiocath was left in during that time. she also received ancef for antibiotic prophylaxis both postoperatively and after the angiocath was removed. the following day, the heparin was stopped, and four hours later the angiocath was removed without complications. the patient was discharged to the regular floor and advanced on a regular diet. the patient ambulated, and in general did quite well. on post angiogram two, the patient developed a rash which was believed to have been caused by the kefzol. the kefzol was immediately stopped, and the patient was given benadryl, and it was expected that the rash would resolve on its own with time after the kefzol had cleared her system. condition at discharge: on , and the patient was discharged in good condition. discharge status: discharge status was to home. medications on discharge: she was to take aspirin 325 mg p.o. q.d. discharge instructions/followup: the patient was to follow up with dr. in two weeks. , m.d. dictated by: medquist36 Procedure: Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Unspecified essential hypertension Cerebral aneurysm, nonruptured

history of present illness: the patient is a 73 year old previously healthy male who, on the day of admission, presented to an outside hospital complaining of substernal chest pain with radiation to the left arm. the patient says that in the weeks prior to admission, he had symptoms consistent with indigestion, which was not being resolved with tums. on the day of admission, he was working on his boat and developed the chest pain. after 20 minutes, during which the pain did not resolve, he called 911. on the scene, there were st elevations noted on the electrocardiogram. the patient was treated with aspirin and nitroglycerin and the nitroglycerin relieved the pain. he continued to have left arm discomfort. he denied any shortness of breath, nausea, vomiting or diaphoresis. he also denied any fevers, chills or sweats. the patient was taken to the outside hospital and underwent a workup for a myocardial infarction. he remained hemodynamically stable. his hematocrit was 40. there, he underwent cardiac catheterization which was significant for a left anterior descending artery with an ostial 60% stenosis followed by serial 90% stenosis. it also showed the left circumflex with 80% stenosis, an obtuse marginal two which was totally occluded, and an obtuse marginal three which was 90% stenotic. the right coronary artery was totally occluded. the patient tolerated the procedure well and was transferred to to dr. service for emergent coronary artery bypass grafting. the patient arrived at in stable condition. past medical history: negative; the patient denies diabetes mellitus, hypertension or hypercholesterolemia. past surgical history: negative. medications on admission: tums p.r.n. indigestion; the patient arrived from the outside hospital on aspirin, plavix, heparin drip and nitroglycerin. allergies: the patient has no known drug allergies. social history: the patient denies any alcohol or tobacco use. physical examination: on physical examination, the patient was an elderly gentleman in no acute distress, currently without angina. lungs: clear to auscultation bilaterally. cardiovascular: regular rate and rhythm, no murmur, rub or gallop. abdomen: soft, nontender, no masses. extremities: warm, no edema. neurologic: intact. laboratory data: admission white blood cell count was 7.5, hematocrit 40.1, platelet count 334,000, sodium 139, potassium 3.9, chloride 98, bicarbonate 32, bun 16, creatinine 0.7, glucose 149, and calcium 9.9. electrocardiogram show normal sinus rhythm at a rate of 69 beats per minute, borderline first degree a-v block, and diffuse st elevations. hospital course: the patient was transferred from an outside hospital in stable condition. he arrived at and, after evaluation by cardiothoracic surgery, the patient was taken to the operating room, where he underwent coronary artery bypass grafting times three. the grafts were left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal one and saphenous vein graft to obtuse marginal two, performed by the team under dr. . the patient tolerated the procedure well. an evh was performed on the right side with hypertechnique of the right graft. postoperatively, the patient was transferred to the cardiothoracic intensive care unit in stable condition. the patient was extubated without any incident. he was slowly weaned off of oxygen. the patient's cardiovascular status remained stable. initially, cardiac output was 1.9. the patient received one unit of packed red blood cells and a bolus of lactated ringer's. output slowly improved to 2.39. he continued to remain hemodynamically stable. the patient remained alert and oriented times three. on postoperative day number one, the patient was transferred to the floor in stable condition. on postoperative day number one at 11:00 p.m., the patient's monitor recorded wide complex ventricular tachycardia. the patient's blood pressure remained in the 110s. the patient was asymptomatic. the longest continuous run included a 12 beat run. otherwise, the patient's rhythm remained alternating between sinus rhythm intermixed with wide qrs complexes, often two to three beats at a time. the patient's blood pressure continued to remain stable. the patient's electrolytes were repleted and the patient spontaneously converted to a normal sinus rhythm. the patient was evaluated by the electrophysiology service and it was determined that the patient likely had reperfusion ventricular tachycardia. the patient has since remained in sinus rhythm and hemodynamically stable. the patient otherwise has remained afebrile. his chest tubes were discontinued on postoperative day number two without incident. pacing wires were discontinued on postoperative day number three without incident. the patient is ambulating at a level 5. early in postoperative day number two, there was a question of patient's mental status. though the patient remained alert and oriented times three, the patient continually requested to be driving home. he was placed on close observation. the patient's mental status has improved and he is at baseline. on postoperative day number three, the patient's hematocrit had moved from 24 to 20.8. the patient was transfused two units of packed red blood cells and his hematocrit remained stable. the patient is now stable and ready for discharge to home. discharge diagnosis: coronary artery disease, status post coronary artery bypass grafting times three. discharge medications: lasix 20 mg p.o.b.i.d. times seven days. potassium chloride 20 meq p.o.b.i.d. times seven days. colace 100 mg p.o.b.i.d. enteric coated aspirin 325 mg p.o.q.d. lopressor 50 mg p.o.b.i.d. niferex 150 mg p.o.q.d. tylenol 650 mg p.o.q.4h.p.r.n. advil 400 mg p.o.q.6h.p.r.n. condition on discharge: stable. follow-up: the patient was instructed to follow up with dr. in six weeks. the patient is to follow up with dr. , his primary care physician, two weeks. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified transient mental disorder in conditions classified elsewhere Paroxysmal ventricular tachycardia

allergies: patient recorded as having no known allergies to drugs attending: addendum: with regard for infection: ms. was afebrile on discharge but had a low-grade fever to 100.4 the evening prior to discharge. blood culture, urine culture, catheter-tip culture, cxr, and abdominal ct have all been unrevealing. with regard to localizing symptoms: she does have oral thrush and has complained of a sensation that something is caught in her throat and a dry cough, although she denies any odynophagia. she does not have any abdominal pain on discharge, or any diarrhea. she actually states she feels "normal" and well. her daughter has had a recent febrile illness, alhtough she has not visited in a week. ms. wbc count on discharge is 16 with a left shift, up from 6 the prior day. however; she was still on neupogen the day of this wbc count, it was discontinued on . her wbc count had been in the 20's earlier in her course, although without bands. she is discharged on a 7-day course of fluconazole and nystatin to treat oropharyngeal thrush. she is instructed to call dr. if she has a fever. she is also instructed to fax cbc with diff to dr. every tuesday and thursday. . with regard to lab results on discharge: n 139, k 3.6, cl 103, bicarb 28, bun 5, cr 0.6, gluc 89 wbc 16 with 66%pmn and 6% bands + toxic gran and dohle bodies hct 29.4, plt 181 . discharge disposition: extended care facility: - md Procedure: Interruption of the vena cava Colonoscopy Transfusion of packed cells Injection or infusion of cancer chemotherapeutic substance Other diagnostic procedures on small intestine Diagnoses: Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute posthemorrhagic anemia Personal history of malignant neoplasm of breast Candidiasis of mouth Other specified cardiac dysrhythmias Bacteremia Hemorrhage of gastrointestinal tract, unspecified Reticulosarcoma, unspecified site, extranodal and solid organ sites Benign neoplasm of colon

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: melena major surgical or invasive procedure: ivc filter placement on history of present illness: 72 yo f with dlbcl s/p small bowel performation with duodenal-jejunal and jejuenal-jejuenal anastomosis, s/p rchop on . her prior hospital course had complications including post-operative pulmonary embolus and gib in the setting of heparin drip/coumadin that stabilized after transfusion of 2u prbc. her course was also complicated by multifocal atrial tachycardia. she was discharged home with lovenox, diltiazem and metoprolol. . she then represented with 1 day melena and shortness of breath with right lower quadrant pain, no nausea or vomiting. she refused ng lavage in emergency department and was found to have a hematocrit of 27.9 (stable from discharge) that fell to 24.4 on repeat. she was transfused 3u prbcs and her hematocrit stabilized. she was then admitted to the icu for observation and colonoscopy. past medical history: 1. rt breast cancer s/p lumpectomy in ; no xrt or chemotherapy. was on tamoxifen prior to dlbcl dx. 2. dlbcl diagnosed when presented with intestinal perforation and repair 3. duodenal-jejunal and jejunal-jejunal anastamosis 4. post-operative pe; treated with heparin and then lovenox 5. gi bleed on heparin 6. multifocal atrial tachycardia vs sinus tach with atrial ectopy diagnosed social history: russian immigrant who lives near to in . her daugter lives in and is involved but unable to take care of ms. daily needs. no tobacco no etoh family history: father died of stomach cancer physical exam: t 98.7, 118/60, hr 73, 96% ra. gen: well appearing russian female, nad. skin pink cv: rrr no m/r/g. good peripheral pulses pulm: cta b abd: soft, non-distended. mild abd pain ruq and epigastrium ext: + pedal edema pertinent results: cxr: impression: 1. right picc likely within the right brachiocephalic vein. 2. no evidence of acute cardiopulmonary process or free intraperitoneal air. . ct abdomen/pelvis: normal appendix. no evidence of obstruction. significant improvement in paraaortic retroperitoneal lymphadenopathy. decrease in size of rim-enhancing fluid collection within the cul-de-sac. no change in hepatic cysts. fibroid uterus. . colonoscopy: small polyp. area of thickened bowl that may be c/w lymphoma. no bleeding seen . : sbft: normal . : pill endoscopy with active bleeding and clot distal to anastomosis site. no avms or diverticuli seen. . : there is interval decrease in size in the previously demonstrated rim enhancing fluid collection, now measuring 33 x 9 mm, previously 34.7 mm on , and measuring 56 x 33 mm on . there is a calcified fibroid uterus. bone windows reveal degenerative changes. grade ii anterolisthesis of l4 and l5 is again demonstrated. brief hospital course: ms is a 72 yo f with diffuse large b cell lymphoma originally presenting in with small bowel perforation, s/p d-j and j-j anastamosis and post-op pulmonary embolus. with history of gi bleed on heparin who represented with gi bleed on lovenox. . gib: ms. was admitted to the medical icu for observation/stabilization and treatment. she received 3 u prbcs in the ed and then 2u prbcs on with stabilization of ther hematocrit. her heparin was intermittently held until hematocrit stabilization. she had a colonoscopy in the micu which did not reveal any cause of her bleeding but did reveal a polyp which was not biopsied. the patient was hemodynamically stable with adequate blood pressure, although she did have tachycardia to the 150's. ms. had had an upper endoscopy in the setting of gib on her last admission which showed normal post-operative changes without bleeding. therefore the patient had a pill endoscopy on wich revealed active bleeding in the area of the distal jejunum, but did not find a specific source. then on ms. had another gib in the setting of a supratherapeutic ptt (approx 100) with 7 point hematocrit drop and 2 episodes of melena. at that point her heparin was discontinued, a large bore iv was placed, and she was transfused 2 u prbcs. q 6hr hematocrits were followed. dr. , ms. gi surgeon, was consulted who felt that surgery was not the best option. she did have a j-j anastamosis but it was difficult to assess if the surgical site was the source of bleeding versus her abdominal lymphoma. interventional radiology was called and an ivc filter was placed on without complications and anticoagulation was not resumed. she has had some episodes of melena, however her hematocrit has now been stable for 4 days. . lymphoma: ms. was s/p cycle 1 rchop on admission. ct abdomen on showed decrease in retroperitoneal lad implying response to the chemotherapy. she received cycle 2 of rituxan-chop as scheduled on with a dose-reduction in cyclophosphamide and daunorubicin. she was treated with allopurinol the day prior to and during her chemotherapy (200mg/day) and will be sent home with this. she has had no signs of tumor lysis syndrome. she tolerated the chemotherapy will with some mild nausea and anorexia as side-effects. daily cbc with diff was followed. she was treated with gcsf injections daily due to her rapid nadir on last admission. she will be due for cycle 3 on . . colon polyp: this was seen on colonoscopy: see omr for full report. biopsy was not taken in the setting of gib and heparinization. this should be followed as an outpatient with repeat colonoscopy and polypectomy. . tachycardia: ms was diagnosed on her last admission with multifocal atrial tachycardia vs sinus tachycardia w/ atrial ectopy on her last admission and was started on metoprolol and diltiazem as per the recommendations of cardiology consult service. this admission ms. has had sinus tachycardia with questionable atrial ectopy up to 150's. it was difficult to decide how to treat her tachycardia becuase of the undesirability of suppressing a reactive sinus tachycardia. after stabilizationin the micu, it was decided eventually to keep her on her diltiazem 30 qid and metoprolol 25 po bid because she maintained adequate bp. she was kept on telemetry. she was tachycardic for a few days in the 100-140 range and then abruptly had a decrease in her hr to 70-100. she remained in sinus rhythm at this rate for 2 days before telemetry was discontinued. her blood pressure has been tolerating metoprolol 25 and diltiazem 30 qid, therefore this regimen will be continued as an outpatient. . kliebsiella bacteremia: ms was finishing a course of levofloxacin for klebsiella bacteremia from her last admission. she finished and was afebrile until when she had a temperature of 100.6. her midline catheter was removed and blood, catheter tip, and urine cultures were obtained that have been no growth to date. cxr showed only some minor atelectasis. abdominal ct only showed decreased size of lymphoma and no abcess. ms. developed oral thrush prior to dispo and is recieving a 1-week course of nystatin + fluconazole. she is feeling well. . pe: ms had a small pulmonary embolus on her last hospitalization in the post operative setting. she clearly demonstrated that she is not an anticoagulation candidate. therefore; and ivc filter was placed without complication on . she has never had an oxygen requirement. . fen: ms. was given ivf with electrolyte replacement as needed. she was npo for much of her hospital course for gi procedures and bleeding. she was advanced to a regular diet prior to discharge which she has tolerated with some mild nausea, but mainly with poor appetite in the post-chemotherapy setting. . ppx: ms. received iv protonix in the setting of gi bleed. . discharge medications: 1. scalp prosthesis scalp prosthesis for alopecia secondary to chemotherapy icd-9 704.0 2. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 4. docusate sodium 100 mg capsule sig: capsules po bid (2 times a day) as needed. 5. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 6. allopurinol 100 mg tablet sig: two (2) tablet po daily (daily). 7. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed. 8. lorazepam 1 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for anxiety. 9. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime). 10. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 11. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed for constipation. 12. outpatient lab work cbc with absolute neutrophil count q tuesday and thursday fax to dr. office 13. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) for 7 days. 14. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 7 days. discharge disposition: extended care facility: - discharge diagnosis: 1. diffuse large b cell lymphoma 2. jejunal bleed 3. pulmonary embolus 4. multifocal atrial tachycardia 5. colon polyp 6. thrush discharge condition: afebrile, hr 73, bp 118/60, 95% on ra, afebrile, hematocrit stable. discharge instructions: please continue taking all medications as prescribed. please have anc and cbc drawn on tuesday and thursday and fax them to dr. /dr. at . please notify dr. or dr. if you continue to have fever over 100.4, if you notice black or tarry stools, if you have severe abdominal pain, or if you become light headed or dizzy. . please schedule an appointment for a colonoscopy for polyp removal. please discuss the timing of this with dr. and dr. . followup instructions: dr. and dr. will contact you with a follow up appointment for cycle 3 rchop on at 10:15 am. Procedure: Interruption of the vena cava Colonoscopy Transfusion of packed cells Injection or infusion of cancer chemotherapeutic substance Other diagnostic procedures on small intestine Diagnoses: Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute posthemorrhagic anemia Personal history of malignant neoplasm of breast Candidiasis of mouth Other specified cardiac dysrhythmias Bacteremia Hemorrhage of gastrointestinal tract, unspecified Reticulosarcoma, unspecified site, extranodal and solid organ sites Benign neoplasm of colon

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: exploratory laparotomy, sbo, repair of enterotomy history of present illness: this is a 73 year old female with a history of having a b-cell lymphoma, comes into the hospital on chemotherapy with a 2-day history of severe abdominal pain and nausea and vomiting. she describes the pain as crampy and colicky. she reports + flatus and + bm today. resuscitated in the ed she was brought to surgery after cat scan revealed an internal hernia with swirling mesenteric suggestive of an ischemic area. past medical history: 1. rt breast cancer s/p lumpectomy in ; no xrt or chemotherapy. was on tamoxifen prior to dlbcl dx. 2. dlbcl diagnosed when presented with intestinal perforation and repair 3. duodenal-jejunal and jejunal-jejunal anastamosis 4. post-operative pe; treated with heparin and then lovenox 5. gi bleed on heparin 6. multifocal atrial tachycardia vs sinus tach with atrial ectopy diagnosed social history: russian immigrant who lives near to in . her daugter lives in and is involved but unable to take care of ms. daily needs. no tobacco no etoh family history: father died of stomach cancer physical exam: vs: 97.3, 88, 165/87, 24, 100% gen: elderly, nad heent: no icterus neck: no increased jvd chest: cta bilat. cv: rrr, no murmur/r/g gi: soft, + distended, + bs, diffuse mild tenderness. guaiac negative. neuro: grossly intact pertinent results: ct abdomen w/contrast 8:07 am ct abdomen w/contrast; ct pelvis w/contrast reason: eval obstruction, diverticulitis, volvulus, other intraabdom medical condition: 72 year old woman with h/o lymphoma, small bowel perf w/p resection w/ abdominal pain, n/v, ? sentinel loop on kub reason for this examination: eval obstruction, diverticulitis, volvulus, other intraabdominal pathology contraindications for iv contrast: none. indication: 72-year-old woman with history of lymphoma, small bowel perforation with resection. now with abdominal pain, nausea, vomiting, question sentinel loop on kub. evaluate for obstruction, diverticulitis, other intra-abdominal pathology. comparison: ct of the abdomen , abdominal x-ray . technique: contrast-enhanced axial ct images of the abdomen and pelvis were obtained with coronally and sagittally reformatted images. 130 cc of iv optiray contrast was used. ct of the abdomen with iv contrast: the lung bases reveal a moderate amount of infiltrate at the lung bases bilaterally. the visualized portions of the heart and pericardium are unremarkable. the liver again demonstrates multiple low attenuation lesions, which are unchanged in size or appearance compared to the previous study. the spleen, pancreas, and adrenal glands are unremarkable. the left kidney again demonstrates a caliceal diverticulum which is unchanged in appearance compared to the previous study. also seen is the previously identified low attenuation lesion at the upper pole of the left kidney which appears unchanged. the right kidney is unremarkable. the infrarenal ivc filter is again visualized. the gallbladder is unremarkable. retroperitoneal lymphadenopathy is again visualized with a conglomerate of lymph nodes in series 2, image 41 measuring 24 x 9 mm. in the previous study in , this conglomerate measured 34 x 15 mm. contrast is seen passing through the first site of small bowel anastomosis, however, the small bowel at this level appears dilated, with a transition point seen distal to the first anastamosis in series 2, image 57. the small bowel distal to this transition point is markedly dilated and fluid filled without contrast seen within the lumen. the small bowel measures up to 3.8 cm in diameter. another transition point is seen distal to this dilated loop of bowel in series 2, images 60 and the small bowel distal to this transition point is fully collapsed. this is very characteristic of a closed loop small- bowel obstruction. the second site of small bowel anastomosis is distal to the second transition point and is collapsed. significant free fluid is seen within the abdomen. the small bowel wall does not appear to be thickened. no free air is identified. ct of the pelvis with iv contrast: the rectum and sigmoid appear collapsed but otherwise unremarkable. fibroids are again seen within the uterus and one of the fibroids appears calcified. free fluid is identified within the pelvis although the rim enhancing fluid collection may appear smaller. no pathologically enlarged lymph nodes are seen within the pelvis. post-surgical changes of the ventral abdominal wall are again identified. osseous structures again reveal degenerative changes and a grade ii anterolisthesis of l4 onto l5. coronal and sagittal reformations support the above findings. impression: 1. closed loop small-bowel obstruction as described above. contrast is seen going through the first small bowel anastomosis. the second small bowel anastomosis is distal to the obstruction. no bowel wall thickening or pneumatosis of the small bowel is seen. significant free fluid is seen within the abdomen. 2. bilateral lower lobe infiltrate suggestive of infectious process. abdomen (supine & erect) 4:42 am abdomen (supine & erect) reason: r/o sbo medical condition: 72 year old woman with abd pain, hx operation reason for this examination: r/o sbo indication: 72-year-old with history of prior operations with severe abdominal pain, rule out small bowel obstruction. comparisons: kub of . ap and supine abdomen: diaphragms are not well shown to fully evaluate for free intraperitoneal air. there are multiple dilated loops of small bowel with air-fluid levels. small amount of distal air within the ascending colon but a paucity more distal to this. ivc filter noted. impression: multiple dilated loops of small bowel with air-fluid levels, suspicious for small bowel obstruction. no definite free intraperitoneal air, however, the regions under the diaphragms are suboptimally evaluated. if there is high suspicion for small bowel obstruction, ct may provide a more accurate assessment. cardiology report ecg study date of 8:56:58 pm sinus tachycardia. normal ecg. compared to the previous tracing the prior abnormalities have resolved. tracing #2 read by: , h. intervals axes rate pr qrs qt/qtc p qrs t 119 142 78 316/ brief hospital course: she was admitted to on due to a closed loop obstruction. she had a wbc of 1.1 on admission. she received neulasta on . pre-operatively she received kefzol and flagyl. oncology: oncology was consulted as she was s/p 4 cycles of chemotherapy and had a low wbc. she was started on cefepime and flagyl post-operatively. if she continues to have fevers, blood cultures should be checked. she will continue to follow-up with her oncologist as an outpatient. pod 1, she was npo, with iv fluids, and a ngt. her pain was well controlled and her urine output was adequate. she was confused at times, but able to be redirected. on pod 3, her ngt was d/c'd. she was started on sips and we awaited return of bowel function. urine and wound cultures were negative for growth and she remained afebrile. she reported + bm on pod #5. she continued to do well and her diet was slowly advanced. she complained of decreased appetite. she was tolerating fluids and small amounts of food. we encouraged po intake. her antibiotics were d/c'd. she was switched to po pain meds. her incisions were clean, dry, and intact without drainage or redness. the staples will be removed at her follow-up appointment. phlebitis: she was noted to have a phlebitic left forearm that responded to abx and hot packs. medications on admission: dilt 30q6, lopressor 25", ativan prn, ambien, ?tamoxifen, oxycodone prn discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* discharge disposition: home with service facility: , discharge diagnosis: small bowel obstruction discharge condition: good discharge instructions: * increasing pain * fever (>101.5 f) * inability to eat or persistent vomiting * inability to pass gas or stool * increasing shortness of breath * chest pain please resume all of your regular medications and take any new medications as ordered. continue to walk several times per day. followup instructions: provider: , m.d. phone: date/time: 8:15 provider: , rn phone: date/time: 9:30 provider: , rn phone: date/time: 9:30 md, Procedure: Suture of laceration of large intestine Other lysis of peritoneal adhesions Other injection into sympathetic nerve or ganglion Other hernia repair Diagnoses: Personal history of malignant neoplasm of breast Accidental puncture or laceration during a procedure, not elsewhere classified Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Phlebitis and thrombophlebitis of superficial veins of upper extremities Hernia of other specified sites, with obstruction Reticulosarcoma, unspecified site, extranodal and solid organ sites Drug induced neutropenia

history of present illness: is the 3.380 kg product of a term gestation. he was born to a 26 year old gravida 1 para 0, now 1 mother readmitted for hyperbilirubinemia on day of life #5. the pregnancy was benign with an edc of . prenatal screens were o+, antibody negative, hepatitis surface antigen negative, rapid plasma reagent nonreactive, rubella immune, group b strep negative. the infant delivered vaginally with apgar scores of 9 at 1 minute and 9 at 5 minutes. blood type is b+, coombs negative. he required phototherapy for an elevated bilirubin of 15.4 at 12 hours of age. he continued phototherapy until day of life #3 when the bilirubin was 14.4 and he was discharged to home. on day of life #4, his bilirubin was 15.7 and on day of life #5, in the primary pediatrician's office, it was 18.8 and he was readmitted for further phototherapy. physical exam on admission: on admission, was well- appearing, though slightly sleepy with jaundice again. he had bilateral breath sounds that were clear and equal. the heart rate was regular without murmur and pulses were 2+ and symmetrical. the abdomen was soft and nontender with no hepatosplenomegaly. his weight was 3.420 kg (greater than birth weight). he had normal male genitalia with bilaterally descended testes. his hips were stable. his tone was normal with normal neonatal reflexes. he as tolerating his feedings fine. summary of hospital course: 1. respiratory: without issues on this admission. breath sounds are clear and equal. 2. cardiovascular: without issues on this admission. he had regular heart rate and rhythm, no murmur and pulses were 2+ and symmetric. 3. fluids, electrolytes and nutrition: birth weight was 3.380 kg (7 lb. 7 oz.). his weight on this admission was 3.420 kg (7 lb. 8 oz.). is currently ad lib breastfeeding and supplementing with expressed breast milk. he is feeding well. his discharge weight is 7 lb. 10 oz. 4. gastrointestinal: bilirubin on was 15.4 at which time double phototherapy was started. his phototherapy was stopped on for a bilirubin of 13.5 with a rebound of 14.4. his bilirubin on was 15.7 and then 18.8 at the primary pediatrician's office on at which time he was readmitted and phototherapy was started. his bilirubin on was 16.9 and on , it was 12.1. phototherapy was discontinued and the rebound bilirubin 8 hours later was 10.7/0.3. 5. hematology: the hematocrit on was 32.8. on , his hematocrit was 40.2 with a retic. of 0.5. his blood type is b+, coombs negative. 6. infectious disease: no issues on this admission. 7. neurological: the infant has been appropriate for gestational age. 8. sensory: auditory hearing screening was performed with automated auditory brainstem responses and the infant passed both ears on his previous admission. hearing screens were repeated on and he passed both ears. 9. psychosocial: family is invested and involved. condition at discharge: stable. discharge disposition: to home. name of primary care pediatrician: scchc, , , , telephone number . care recommendations: 1. continue ad lib feeding. 2. follow up with pediatrician at scchc on . 3. medications - not applicable. 4. car seat position screen - not applicable. 5. state newborn screens were sent on and have not been reported as abnormal. on his previous admission, received hepatitis b vaccine on . 6. immunizations recommended: 1) synagis rsv prophylaxis should be considered from through for infants who meet any of the following 3 criteria - i) born at less than 32 weeks; ii) born between 32 and 35 weeks with 2 of the following - day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or iii) with chronic lung disease. 2) influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contacts and out-of- home caregivers. 7. follow-up appointments recommended for . discharge diagnoses: 1. term average for gestational age male. 2. hyperbilirubinemia likely due to mild abo incompatibility - resolved. , Procedure: Other phototherapy Diagnoses: Hemolytic disease of fetus or newborn due to ABO isoimmunization

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: failure to thrive major surgical or invasive procedure: transfusion 3units prbcs history of present illness: pt is a 85 yo man with metastatic gall bladder cancer presents w/ weakness, disorientation and dehydration. pt was diagnosed with cancer 1 year ago and underwent surgery 5 months ago secondary to increasing ruq abdominal pain. he remained stable until about 1 month ago when he began to feel progressively weaker and have less of an appetite. pt usually slept 18-20 hours per day and when awake would like in a chair in front of the television and only sip broth when forced. for the past 3 days pt has had almost no intake po. this morning grandson describes pt as somnolent and not arousable to voice. he states that pt would stare at him but not respond and was unable to answer his name or where he was. he called pts pcp who advised him to come to the ed. . per pts grandson, during the past month patient has complained of increasing abdominal pain, mid to low back pain, weakness, fatigue and decreased appetite. pt would only take in sips on broth when forced. pts grandson estimates that he has lost about 40lbs in the last month. per pts grandson, he has not complained of nausea, vomiting, fever or chills. he has had minimal urine output. on ros, pt is moderately responsive and denies any pain. past medical history: -gallbladder carcinoma, small cell type. dx , surgical resection with positive margins. pt was not a candidate for systemic chemotherapy. -hypertension -hypercholesterolemia -sick sinus syndrome s/p pacemaker placement -pud -abdominal aortic aneurysm -bph -chronic back pain, bone scan 3wks ago show no evidence of metastatic disease. social history: cimetidine 400mg metoprolol 25mg daily percocet 5-325mg tid prn for pain family history: nc physical exam: vs: tc: 95.6 p: 72 bp: 108/62 rr: 16 o2 sat: 98% weight: 50.4k gen- appears fatigued, responds to commands heent-anicteric, no injections, op clear, mm dry cor- rrr, s1, s2, 2/6 sem lusb lungs- cta b/l abd-palpable epigastric mass, nt, nd, positive bs extrem- no cce pertinent results: cbc: 12:13pm blood wbc-13.6* rbc-2.34* hgb-7.6* hct-23.1* mcv-99* mch-32.7* mchc-33.1 rdw-21.1* plt ct-353 09:00am blood wbc-12.4* rbc-2.85* hgb-9.1* hct-26.7* mcv-94 mch-31.7 mchc-33.9 rdw-21.8* plt ct-245 03:23am blood wbc-14.7* rbc-3.15* hgb-10.3* hct-29.4* mcv-93 mch-32.5* mchc-34.8 rdw-20.7* plt ct-222 05:58am blood wbc-16.5* rbc-2.99* hgb-9.8* hct-27.8* mcv-93 mch-32.8* mchc-35.3* rdw-21.2* plt ct-241 10:36am blood wbc-17.4* rbc-3.03* hgb-9.7* hct-28.9* mcv-96 mch-32.1* mchc-33.6 rdw-21.4* plt ct-223 06:15am blood wbc-16.0* rbc-3.04* hgb-9.9* hct-29.2* mcv-96 mch-32.5* mchc-33.9 rdw-21.6* plt ct-228 06:50am blood wbc-12.1* rbc-2.87* hgb-9.4* hct-27.3* mcv-95 mch-32.7* mchc-34.4 rdw-22.1* plt ct-172 . coags: 12:13pm blood pt-15.2* ptt-25.2 inr(pt)-1.4* 09:00am blood pt-15.6* ptt-25.9 inr(pt)-1.4* 03:23am blood pt-16.5* ptt-27.1 inr(pt)-1.5* 05:58am blood pt-16.6* ptt-27.2 inr(pt)-1.5* 10:36am blood pt-17.1* ptt-30.2 inr(pt)-1.6* . lytes: 12:13pm blood glucose-122* urean-69* creat-1.8* na-143 k-4.6 cl-109* hco3-19* angap-20 09:00am blood glucose-106* urean-55* creat-1.4* na-144 k-3.9 cl-114* hco3-16* angap-18 03:23am blood glucose-78 urean-48* creat-1.4* na-145 k-4.0 cl-119* hco3-14* angap-16 05:58am blood glucose-103 urean-46* creat-1.3* na-147* k-3.8 cl-122* hco3-14* angap-15 10:36am blood glucose-97 urean-40* creat-1.4* na-145 k-3.6 cl-117* hco3-15* angap-17 06:15am blood glucose-92 urean-38* creat-1.3* na-142 k-3.7 cl-116* hco3-15* angap-15 06:50am blood glucose-103 urean-41* creat-1.0 na-141 k-3.3 cl-113* hco3-16* angap-15 . lfts: 12:13pm blood alt-81* ast-171* alkphos-3306* amylase-82 totbili-4.1* 09:00am blood alt-74* ast-170* ld(ldh)-898* alkphos-2799* amylase-57 totbili-5.7* 03:23am blood alt-79* ast-169* ld(ldh)-789* alkphos-2798* totbili-7.4* dirbili-6.0* indbili-1.4 05:58am blood alt-74* ast-146* alkphos-2740* totbili-8.2* 06:15am blood alt-65* ast-129* totbili-13.7* 06:50am blood alt-57* ast-110* alkphos-2444* totbili-14.5* brief hospital course: #) metastatic gall bladder cancer: pt presented with common bile duct obstruction tumor effect from gallbladder mass. there was a palpable abdominal mass on pe and progressively increasing transaminases, bilirubin, alk phos. pt also developed an upper gi bleed with hematemesis at presentation. gi, gi , ercp and ir were consulted re: possible interventions. stenting was not an option given pts anatomy/obstruction during past surgery and pt was not thought to be stable enough for ir intervention for the bleeding. pt was transfused and stabilized in the micu. he has been hemodynamically stable with no continued hematemesis. hct has been stable between 27-29. after discussion with patients family the decision was made for care measure only. pt has been pain controlled with morphine iv and sl. he is very stoic and often denies pain to the medical team but has complained to his family. he has been tolerating clear fluids w/o problem. his family visits him every day. medications on admission: percocet 5-325mg tid prn for pain patient has not been taking: cimetidine 400mg and metoprolol 25mg daily discharge medications: 1. morphine concentrate 20 mg/ml solution sig: po q1-2h () as needed for pain. 2. prochlorperazine 25 mg suppository sig: one (1) suppository rectal q12h (every 12 hours) as needed for nausea, emesis. suppository(s) discharge disposition: extended care facility: of discharge diagnosis: upper gi bleed, common bile duct obstruction secondary to tumor from metastatic gallbladder cancer. discharge condition: stable, poor discharge instructions: you were evaluated for bleeding in your gastrointestinal tract. gastroenterology and interventional radiology were consulted and there was no intervention that would stop the bleeding. you were transfused with blood and have been stable. . it is important that you are comfortable and not in pain. please continue to take all medications for pain as prescribed. please tell your family or other caretakers if you are in pain, uncomfortable, or there is anything else you need. followup instructions: na Procedure: Transfusion of packed cells Diagnoses: Acidosis Other chronic pain Pure hypercholesterolemia Unspecified essential hypertension Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Unspecified protein-calorie malnutrition Secondary malignant neoplasm of other specified sites Cardiac pacemaker in situ Encounter for palliative care Hematemesis Abdominal aneurysm without mention of rupture Dehydration Hyperosmolality and/or hypernatremia Obstruction of bile duct Backache, unspecified Personal history of malignant neoplasm of other gastrointestinal tract

history of present illness: the patient is a 59 year-old male with a past medical history of coronary artery disease status post myocardial infarction, hypercholesterolemia, hypertension who presents with 10 out of 10 substernal chest pain occurring at rest to outside hospital. the chest pain began while lying in bed at around 10:15 p.m. associated with nausea, diaphoresis and radiation to arm and jaw. he went to hospital at 10:30 p.m. at he had an electrocardiogram with st elevations in v2 and v4 of 3 mm and elevations in v4 through v6 with reciprocal st depressions in 2, 3, and avf. it was normal sinus rhythm at 62 beats per minute. the pr prolongation at 155. vital signs were stable at outside hospital. pulse 54, blood pressure 109/80, sating 99% on 4 liters of nasal cannula oxygen. at outside hospital he received a heparin drip, nitro drip, aspirin, beta blocker, integrilin drip and retaplase half dose times two, morphine sulfate times three and ativan. he became chest pain free after the second dose of retaplase and his symptoms and electrocardiogram changes had also been resolved on arrival at emergency room. electrocardiogram in the emergency department showed normal sinus rhythm at 82 beats per minute, pr 106, left axis deviation of .5 to elevations in v2 through v3 with .5 mm elevations in v1, v4 through v5 and resolution of t wave changes in the inferior leads. the patient denies any paroxysmal nocturnal dyspnea, orthopnea or exertional angina at workout, but does report increased fatigue. over the last week the patient has stopped using his statin due to myositis with workouts and stopped his beta blocker on his own over the past few months. past medical history: coronary artery disease status post myocardial infarction with lysis with tissue plasminogen activator in , hypercholesterolemia, hypertension. medications at home: 1. aspirin. 2. folic acid. 3. niacin. allergies: sulfas. social history: he quit tobacco 30 years ago. review of systems: he reports increased fatigue after workouts last month. he works out at the gym four to five times a week with no angina. physical examination: he was afebrile. blood pressure 95/51. heart rate 62. sating 97% on 2 liters of nasal cannula. he was in no acute distress lying in bed. extraocular movements intact. pupils are equal, round and reactive to light. mucous membranes are moist. neck was supple. no jugulovenous distention. heart was regular rate and rhythm. s1 and s2. 1 to 2 out of 6 systolic ejection murmur at the apex. lungs were clear to auscultation bilaterally. abdomen was nontender, soft, nondistended with normoactive bowel sounds. no clubbing, cyanosis or edema of his extremities with 2+ dorsalis pedis pulses. cranial nerves ii through xii were intact. he was alert and oriented times three. there were no bruits in his groin. laboratory data on admission: white blood cell count 9.2, hematocrit 47.7, platelets 194, inr 1.1, ptt 25. chemistries 139, 3.9, 101, 32, 12, and 1.2. his ck was 26, 19, alt and ast 64 and 334. total cholesterol 126, triglycerides 37, hdl 45, ldl 74, tsh 2.1. chest x-ray was negative. the patient was kept on integrilin and heparin drip. his chest pain recurred. he was taken to cardiac catheterization, which showed normal cardiac index, mitral regurgitation, severely abnormal left ventricular ejection fraction, inferobasal akinesis consistent with remote inferior myocardial infarction, anteroapical severe hypokinesis, left ventricular global function depressed, 1+ mitral regurgitation, right dominant coronary angiography. it also showed a large ectatic proximal left anterior descending coronary artery with 85% focal severe hazy stenosis with timi three flow. a stent was placed showing 0% residual post stent. there was diffuse ectasia with mild serial narrowing of the left circumflex on the right coronary artery. in summary, the patient was status post anterior myocardial infarction managed with thrombolysis and then taken to cardiac catheterization for recurrent chest pain during which he had a left anterior descending proximal stent placed. he was continued on integrilin for 18 hours and recommended to continue with plavix for nine months as well as aspirin therapy. the patient remained asymptomatic post catheterization without any arrhythmias. a repeat echocardiogram was done showing ejection fraction of 25% with apical anterior and septal mid septal and basal inferior, inferolateral and apical inferior akinesis. the patient was also evaluated by physical therapy and did well and was deemed safe to go home. he was discharged home to follow up with his cardiologist dr. on a low sodium diet. he was given teaching about a 2 gram sodium diet as well as cardiac rehabilitation. he was discharged with instructions to ambulate 10 to 15 minutes every day, avoid strenuous activity until seen by his cardiologist. discharge diagnoses: 1. myocardial infarction. 2. systolic heart failure. procedures: cardiac catheterization with stent placement. discharge condition: good. discharge medications: 1. aspirin 325 mg po q.d. 2. plavix 75 mg po q.d. 3. lisinopril 2.5 mg po q.h.s. 4. lipitor 10 mg po q.h.s. 5. metoprolol xl 25 mg po q.d. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Acute myocardial infarction of other anterior wall, initial episode of care Personal history of tobacco use Acute systolic heart failure

allergies: penicillins attending: chief complaint: massive intracranial hemmorhage major surgical or invasive procedure: none history of present illness: y/o female admitted to the micu throught the ed with a severe intracranial hemorrhage. pt was found unresponsive at home by her family midmorning. she had been in her normal state of health at 6:30 am. when ems arrived, her respiratory rate was 4. per their notes, she did hava a pulse. she was diaphoretic and having agonal respirations. per notes, her color was greyish. finger stick was 194. the pt was intubated in the field and brought to for further care. at the osh, the pt's vs were 97.9 135 126/68 10 100% on a fio2 of .100. she was noted to be in atrial fib. ct of the head was significant for a very large right frontal-temporal lobar hemorrhage with extensive subarachnoid and ventricular extension and mass effect. pt was given 2 units of ffp for an elevated inr of 3.7. she also received potassium and dilantin. per notes, her pupils were 2 mm and equal. pt was then transferred to for further care. in the ed, the pt's vs were 104 191/126 16 100% on fio2 of .100. she was initially started on a nipride drip with a goal sbp of 130-160 but was later discontinued. the pt also received minitol 50 gm iv x1, ffp, and vitamin k. a neurosurgery consult was obtained to review the ct from the osh and speak with the family. they discussed the pt's very poor prognosis with the family and the decision was made to gather the rest of the family and then most probably discontinue ventilation. the pt will be admitted to the micu until the family can gather at . past medical history: 1. s/p cva 2. past le cellulitis 3. hypertension 4. hypercholesterolemia 5. left shoulder pain 6. atrial fib social history: pt lives at home with her daughter. etoh, tobacco, or drugs. family history: noncontributory. physical exam: pe: 96.4 105 130/88 18 100% on fio2 of .100 gen- unresponsive, intubated lady. does not respond to verbal or physical stimuli. heent- nc at. intubated. pupils fixed. right 3-4 mm. left mm. cardiac- irregularly irregular. no m,r,g. pulm- cta anteriorly and laterally. abdomen- soft. nt. nd. positive bowel sounds. extremities- no c/c/e. neuro- does not respond to voice or touch. appears to withdraw her legs to pain. pupils fixed. right pupil appears blown. negative gag reflex. negative pupilary reflex. upgoing toes bilaterally. pertinent results: 02:50pm blood wbc-13.5*# rbc-4.70 hgb-13.3 hct-39.1 mcv-83 mch-28.2 mchc-33.9 rdw-13.2 plt ct-248 02:50pm blood neuts-80.9* lymphs-15.6* monos-2.9 eos-0.4 baso-0.2 02:50pm blood plt ct-248 02:50pm blood pt-21.6* ptt-26.4 inr(pt)-3.1 02:50pm blood glucose-269* urean-15 creat-1.0 na-139 k-5.0 cl-102 hco3-22 angap-20 02:50pm blood ck(cpk)-126 02:50pm blood ck-mb-8 ctropnt-0.34* 02:50pm blood calcium-9.0 phos-3.2 mg-1.5* 03:03pm blood po2-459* pco2-30* ph-7.42 calhco3-20* base xs--3 brief hospital course: 1. intracranial hemorrhage- pt with a devestating intracranial hemorrhage as described above. seen by neurosurgery in the ed. i spoke to them and per the team she is not a surgical candidate. at this time, she has evidence of brain death. this was discussed with the pt's family and they gathered in the micu for a family meeting. after a long discussion, the family decided that she would not wish to be maintaned on the ventilator with no meaniful hope of any recovery. the pt was extubated and died approximatley 2 hours later. son is . his home phone number is and his cell phone number is . spoke to pt's pcp . so he was aware of the situation throughout the admission. i also called him once the pt died. medications on admission: 1. coumadin 2. atenolol 3. lipitor 4. maxzide 25 mg daily discharge medications: deceased discharge disposition: expired discharge diagnosis: intracranial hemorrhage discharge condition: deceased discharge instructions: deceased Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Transfusion of packed cells Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Intracerebral hemorrhage Long-term (current) use of anticoagulants

allergies: penicillins / sulfa (sulfonamides) attending: chief complaint: recurrent chest pain major surgical or invasive procedure: single vessel coronary artery bypass grafting utilizing vein graft to right coronary artery, mitral valve repair with 26 millimeter ce ring, and aortotomy with partial rca stent removal. cardiac catheterization history of present illness: mrs. is a 73 year old female who has undergone multiple percutaneous interventions and stent placement to her right coronary artery. her most recent was at the . she has been relatively chest pain free since that time. she presented to hospital with recurrent substernal chest pressure and heaviness with left arm/shoulder discomfort. she ruled in for a nstemi. she was stablized on medical therapy and transferred back to the for further medical management. past medical history: congestive heart failure, nstemi, coronary artery disease - s/p multiple rca stents, mitral regurgitation, diabetes mellitus - on insulin therapy, hypercholesterolemia, cerebrovascular disease - s/p cva, known carotid disease, right subclavian stenosis, peripheral vascular disease, history of humeral fracture, gerd, depression, prior bladder surgery social history: lives with her daughter. denies tobacco, etoh and recreational drugs. ambulates with a walker. family history: denies premature coronary disease. physical exam: vitals: t 97.5, bp 165/40, hr 53, rr 18, sat 98% on 2l general: elderly female in no acute distress heent: oropharynx benign neck: supple, no jvd, soft right carotid bruit noted heart: regular rate, normal s1s2, soft systolic ejection murmur at llsb lungs: clear bilaterally abdomen: obese, soft, nontender, normoactive bowel sounds ext: warm, trace edema, no varicosities pulses: decreased distally neuro: alert and oriented, slight left facial droop, mild left sided weakness otherwise nonofocal pertinent results: 05:30am blood wbc-10.2 rbc-3.80* hgb-11.5* hct-32.7* mcv-86 mch-30.3 mchc-35.2* rdw-14.7 plt ct-228 01:58am blood pt-13.8* ptt-23.6 inr(pt)-1.2* 05:30am blood glucose-81 urean-27* creat-0.8 na-140 k-4.4 cl-104 hco3-32 angap-8 radiology final report chest (pa & lat) 9:49 am chest (pa & lat) reason: r/o inf., eff medical condition: 73 year old woman with cad for cabg reason for this examination: r/o inf., eff history: status post cabg, evaluate for infiltrate or effusion. findings: ap chest radiograph compared to . there has been interval extubation and removal of the -gastric tube. there has been interval removal of the swan-ganz catheter (via the right ij) as well. the previously seen retrocardiac density has improved. the pulmonary edema has resolved. the enlarged postoperative mediastinum is unchanged. impression: resolution of pulmonary edema and decreased left basilar atelectasis. the study and the report were reviewed by the staff radiologist. dr. . dr. approved: 2:21 pm brief hospital course: mrs. was admitted and underwent cardiac catheterization. during the procedure, the right coronary artery could not be engaged as there was a significant amount (approximately 7mm) of previously placed stent jutting out into the lumen of the aorta. the right coronary artery appeared to have a severe ostial stenosis despite the presence of the previously placed multiple stents. the lmca, lad and lcx had no angiographic evidence of coronary artery disease. distal aortography was also performed. this demonstrated a large plaque in the aorta just distal to the renal arteries. there was mild-moderate arterial disease in the right and left iliac arteries and mild arterial disease in the right common femoral artery. based on the above results, cardiac surgery was consulted and further evaluation was performed. an echocardiogram on was notable for 2+ mitral regurgitation and depressed left ventricular function with an ejection fraction of 30%. preoperative evaluation was otherwise unremarkable and she was cleared for surgery. on , dr. performed single vessel coronary artery bypass grafting along with a mitral valve repair. he also removed the stent from the right coronary ostium via aortotomy. the operation was otherwise uneventful and she transferred to the csru for invasive monitoring. within 24 hours, she awoke neurologically intact and was extubated. she maintained stable hemodynamics as she weaned from inotropic support. she intermittently required intravenous nitroglycerin for hypertension. given her cerebrovascular and peripheral vascular disease, her sbp was maintained between 120-140 mmhg. she remained mostly in a normal sinus rhythm. very briefs episodes of paroxysmal atrial fibrillation were noted on telemetry, most likely in the setting of hypokalemia. k and mg levles were monitored closely and repleted per protocol. most of her preoperative medications were resumed. she made steady progress and transferred to the sdu on postoperative five. her blood sugars remained well controlled. beta blockade was slowly advanced as tolerated. she remained in a normal sinus rhythm without further episodes of atrial fibrillation. over several days, she continued to make clinical improvements with diuresis and made steady progress with physical therapy. she was cleared for discharge to rehab on postoperative day seven. at discharge, her chest x-ray showed resolution of pulmonary edema with decreased left basilar atelectasis. her bp ranged from the 104-114/50-60's with a heart rate in the 70-80's. her room air saturations were 95%. all surgical wounds were clean, dry and intact without evidence of infection. she had adequate pain control with tramadol and motrin. she was discharged to rehab in stable condition on pod#8. medications on admission: aspirin 325 qd, plavix 75 qd, lasix 40 qd, protonix 40 qd, atenolol 25 qd, lipitor 40 qd, lisinopril 5 qd, imdur 60 qd, humulin insulin 70/30 - 35 units qam and 20 units qpm, advair mdi, atrovent mdi, eye gtts discharge medications: 1. atorvastatin 20 mg tablet sig: two (2) tablet po daily (daily). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 8. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 2 weeks: please decrease to 20 meq qd when lasix drops to qd - titrate accordingly. 9. lasix 40 mg tablet sig: one (1) tablet po twice a day for 2 weeks: then decrease to 40 mg qd - titrate accordingly. 10. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 11. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 12. insulin nph-regular human rec 70-30 unit/ml suspension sig: 15 units units subcutaneous twice a day: increase to home dose of 35 units qam and 20 units qpm as tollerated. 13. insulin regular human 300 unit/3 ml insulin pen sig: per attached sliding scale subcutaneous four times a day. 14. atrovent 18 mcg/actuation aerosol sig: two (2) puffs inhalation twice a day. 15. ibuprofen 400 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. discharge disposition: extended care facility: life care of discharge diagnosis: congestive heart failure, nstemi, coronary artery disease - s/p multiple rca stents, mitral regurgitation, diabetes mellitus, hypercholesterolemia, cerebrovascular disease - s/p cva, known carotid disease, right subclavian stenosis, peripheral vascular disease, brief postoperative atrial fibrillation discharge condition: good discharge instructions: patient may shower, no baths. no creams, lotions or ointments to incisions. no driving for at least one month. no lifting more than 10 lbs for at least 10 weeks from the date of surgery. monitor wounds for signs of infection. please call with any concerns or questions. followup instructions: dr. in weeks. local pcp, . in weeks. local cardiologist, dr. in weeks. Procedure: Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization (Aorto)coronary bypass of one coronary artery Aortography Open heart valvuloplasty of mitral valve without replacement Incision of vessel, aorta Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Atrial fibrillation

allergies: pca, sulfa pt recently admitted to micu 7 with worsening cp with coughing, abd pain with n/v, sob, worsening pedal edema, groin wound infection s/p fem- bypass, pulmonary edema; transferred to floor ; triggered when found unresponsive, sbp 60's, hr 50's, pt bagged and given 1mg atropine and started on dopa, pt awoke during this and projectile vomited (now with probable asp pna); placed on nrb and transferred to micu neuro: pt currently sleeping, prior to this was a+ox3, follows commands, moves all extremities; c/o pain right le and groin, medicated with tylenol po x1, now comfortable; perl 3mm and brisk bilaterally; bilateral foot tremor at rest, per pt daughter, new dev. during past week cv: cont on dopa gtt, able to wean down to 3mg/kg/min, maintaing maps >60, abp 109-136, abp quickly dropped to low 80's when dopa gtt on kvo; hr nsr/sb bbb no ectopy 75-56; 2+ pitting edema le's, diff to palpate pedal pulses; lytes per careview, hct stable; lovenox prophylaxis resp: able to wean o2 down to 5-3 nc; desatted tonight x2 to 88% with turning or when sleeping @ 30 degrees or less; abg this am, pao2 78 paco2 67 acceptable d/t dx probable copd with exacerbation; ls rhonchorous to coarse throughout; and cpt tolerating well, + cough, but not able bring up any secretions; pt with cont pulm edema and now with probable asp pnuemonia; needs sputum sent gi: +bs x4, sm stool x1 tonight; abd soft obese, non-tender, non-distended, no n/v; tolerating thin liqs and applesauce with meds; on bowel regimen gu:foley inplace; pt auto diuresing well, 120-35cc/hr, clear yellow urine skin: reddened buttocks with skin intact, applied skin barrier; right great toe with necrotic area around nailbed, second toe with ? new art wound, reddened base with scab, no drainage; vac dressing in place over right groin wound, dsg intact and draining small amount serous drainage id: tmax 99.8; wbc's from 14.7 to 6.7; cont on vanco and aztreonam; blood cultures pending; previous wound culture + for e/ coli, proteus, and mrsa access: left dl picc and left radial a-line placed by anesthesia wnl : cont cpt/, prn nebs and mdi's; wean dopa as tolrated, maintain maps >60; holding htn meds; holding lasix d/t hypotension, but overloaded/needs diureseis; cont abx, follow cultures; wound ac dsg change q 3days; abd pain n/v ? d/t chronic mesenteric ischemia; chronic anemia, transfuse for <24; ? readdress code status Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Anemia, unspecified Esophageal reflux Other postoperative infection Congestive heart failure, unspecified Unspecified essential hypertension Unspecified protein-calorie malnutrition Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Systolic heart failure, unspecified Paroxysmal ventricular tachycardia Other specified forms of chronic ischemic heart disease Pneumonitis due to inhalation of food or vomitus

allergies: penicillins / sulfa (sulfonamides) attending: chief complaint: shortness of breath, increasing lower extremity edema, cough major surgical or invasive procedure: none history of present illness: hpi: 74 yo f w/ chf ef 20-25%, dm, pvd s/p recent r fem- c/b groin wound infection s/p debridement and vancomycin and aztreonam course, and recent onset c/o sob, increasing pedal edema, nonproductive cough x 1 week. she noted persistent chest pain/pressure triggered by coughing and heavy breathing. at the time, she was experiencing subjective chills. no sick contacts, uri sx, fevers, chronic foley, no back tenderness. the patient also c/o nausea/nonbloody, nonbilious emesis, abdominal pain x 4 days. no hematemesis, hematochezia, melena. . in ed, the patient presented with rales and bnp >. she was diuresed 1l with 40 mg iv lasix, with sbp dropping to 50s-60s transiently and recovering to 100s spontaneously. a central line was placed during the hypotensive episode with cvp measured at 15. she was started on ciprofloxacin for ua. abdominal ct showed no inflammation or abscess as source of infection, improved ascites and bilateral pleural effusions. she was admitted for further management. . past medical history: .congestive heart failure .nstemi .coronary artery disease - s/p multiple rca stents .mitral regurgitation .iddm .hypercholesterolemia .cerebrovascular disease - s/p cva .known carotid disease .right subclavian stenosis, peripheral vascular disease .history of humeral fracture .gerd .depression .prior bladder surgery .fem- bypass complicated by infection social history: lives with her daughter. denies tobacco, etoh and recreational drugs. ambulates with a walker. family history: denies premature coronary disease. physical exam: exam on discharge: vitals: tm: 99.6, tc: 98.2, 150/70 (sbp range 120 to 150), hr 65 (hr range 65-76), o2 sat 100%/2l (baseline) . gen: obese elderly talking without difficulty on nc neck: difficult to assess jvp cv: distant hs, rrr, no mrgs noted chest: + increased e/i ration, poor airmovement, + rales, crackles at bases bilaterally, dull to percussion at bases abd: obese, +bs, tenderness in rlq above area of groin debridement/repair, wound vac in place ext: 2+ pitting edema in le (much improved from admission), vac in place pulses: non palpable dp, pt b/l. neuro: cn iii-xii grossly intact. able to move all 4 ext, nl sensation to lt pertinent results: cbc 6.9 / hct-26.3* mcv-94 / 351 5.4 / hct-31.8* mcv-101 / 320 neuts-75.6* lymphs-17.3* monos-3.2 eos-3.3 baso-0.6 folate 773 b12 18.2 4.4 / 25.9* mcv-101* / 259 retic: 4.2* diff: n64.1 l25.0 m3.6 e6.6* a0.7 guiac negative rbc morphology hypochr anisocy poiklo macrocy microcy polychr . coags pt-13.9* ptt-31.3 inr(pt)-1.2* . chem7 140/4.3/105/32/15/0.6/103 138/ 4.1/ 102/ 33 / 20/ 0.8 /72 . ca 8.0* phos 3.4 mg 1.7 . ua 02:00pm urine color-yellow appear-clear sp -1.021 02:00pm urine blood-sm nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-sm urine rbc-0-2 wbc-* bacteri-few yeast-few epi-0-2 . lfts alt 13 ast 17 ldh 181 alkphos55 tbili0.2 . cardiac enzymes ck(cpk)-24* / blood ck(cpk)-18* /ck(cpk)-22* ctropnt-0.03* /ctropnt-0.03*/ ctropnt-0.01 alt-15 ast-20 alkphos-69 amylase-29 totbili-0.3 lipase-9 probnp-* . 05:10am blood cortsol-28.9* 04:43am blood cortsol-23.7* . reports cxr : mild pulmonary edema and small-to-moderate right pleural effusion have worsened. mild-to-moderate enlargement of the cardiac silhouette is stable. left subclavian and right jugular lines end in the svc. no pneumothorax. . ecg sinus rhythm and occasional atrial ectopy. left atrial abnormality. left bundle-branch block. compared to the previous tracing of the rate has increased ecg : hr 85, nsr, lbbb, lvh, twi in i, avl; q in iii, avf, v1; no acute st changes . ct abd/pelvis: no inflammatory process, anasarca unchanged, pevic ascites and b pleural effusions improved. atelectasis and bil patchy ground glass opacities, likely pneumonitis. . echo: lad, left ventricular hypertrophy. new inferior akinesis, global hypokinesis of the remaining segments (lvef = 25 %). no masses or thrombi in the lv. rv dilated with moderate global free wall hypokinesis. mild to moderate (+) ar. mitral valve annuloplasty ring in place. eccentric moderate (2+) mr. mild pulmonary artery systolic increased interval mild pulmonary artery systolic/diastolic hypertension. . prior echo : lad, dilated lv, lv hypokinesis w/ focalities to the mid and apical infroseptal walls. lvef`35% --> 25% post bypass. nl rv function. echodense mass protruding from r coronary sinus of valsalva c/w consistent with a coronary stent --> absent after bypass. (+) ar. (3+) mr --> not visualized post bypass. cxr right internal jugular catheter has been removed and left picc line remains in standard position. congestive heart failure shows improvement with decreasing pulmonary edema and improving right pleural effusion. left effusion and retrocardiac atelectasis are not substantially changed. . stool analysis : guaiac negative urine cx : yeast, repeat urine cx : no growth isolated blood cx on : coag negative staph ( pending), likely contamination blood cx on : ngtd . chest xray interval worsening of interstitial edema with left basilar opacity representative of collapse/consolidation with probable effusion brief hospital course: 74 yo with chf, pvd, cad, hx of mrsa indwelling foley, s/p recent aorto-fem bypass c/b wound infection admitted with sob likely to chf exacerbation with course c/b self-resolving hypotension following diuresis continued on diuresis on admission. sob decompensated chf given cxr showing worsening effusion and edema. unclear trigger for this event. a new echo performed as an inpatient revealed inferior hypokinesis suggestive of a recent mi of unknown date (ef of 20-25%) but negative troponins and negative ecg on admission. infection was a less likely trigger given the absence of leukocytosis and hx of aztreonam and vancomycin prior to admission. ucx and wound cultures were negative, though the patient presented with thick secretions. pna was an unlikely trigger given a stable cxr with improving pleural effusions, absence of fever/leukocytosis on aztreonam/vancomycin. pe less likely given anticoagulation with lovenox at rehab and absence of supportive hx. no hx of dietary indiscretion or medical noncompliance. . on , while actively being diuresed (on a lasix drip with metolazone), the patient had episode of hypotension and unresponsiveness (a code was called). the patient was subsequently transferred to the micu. this was thought likely to be cause by a combination of hypotension, slight bradycardia and medications administered prior to the code (zofran and morphine). also of note, the systolic blood pressures in her right arm are 30-40 mmhg lower than her left arm (likely subclavian artery stenosis on right). patient had an episode of vomiting and likely aspirated based on the chest x-ray finding of likley aspiration pna. patient had persistent hypotension after the code and the patient was started on dopamine. patient was slowly weaned off, but cause of hypotension is not completely clear though it was thought likely secondary to both hypovolemia and possible measurement of blood pressure from right arm. the patient briefly had an elevated oxygen requirement in the micu, but was kept on aztreonam and vancomycin (as previously started by vascular team with indefinite time course). however, the patient had subsequent fevers and metronidazole was started for concern for aspiration. of note, an art line was placed while in the micu for accurate measurement of bp and abg. subsequently, her lisinopril and carvedilol were resumed. the patient was also noted to have episodes of nsvt, for which an icd may be indicated in the future. the ep team did not recommend amiodarone at the present. will follow up with ep dr. as outpatient. . infectious disease: the patient was treated for >8 weeks on aztreonam and vanc for double coverage given e/o from osh () with wound cultures on positive for e. coli r to tmx-smx, gentamicin, amp, cipro; proteus r to tmx-smx, cipro, levo, cirpo, nitro; and mrsa r to cefazolin, oxacillin, clina, pen, erythro, confirmed with wound cultures from . blood cultures continued to be negative. urine culture positive for yeast only. the patient was therapeutic on vancomycin as an inpatient, with troughs within range. the goal is to continue with the iv aztreonam and vancomycin for indefinite duration. she has follow up appointments with infectious disease specialists at . . fevers: cultures were drawn for occasional spikes in temperature, with no significant growth from blood. initially it was thought to be due to aspiration pna--she was on falgyl and completed 7 day course. also her picc line was taken out on . a new picc was placed on . blood cultures grew coag neg staph from from 1/2 bottles - likely contaminant given that she was already on vanc which was therapeutic. urine cultures grew out yeast initially, with resolution after removal of the foley catheter. her fever curve started trending down and was afebrile for more than 3 days prior to discharge. . abdominal pain: had this during admission though lfts wnl, abdominal ct negative and abdominal exam unimpressive. the patient had a known sma and celiac artery stenosis, though ischemic changes were not evident. . pain control: she continued to have lower extremity pain from her neuropathy and groin wound. gabapentin and tylenol were adequate for pain, with only low doses of morphine as needed, as narcotic effect was causing her somnolence. . anemia: the patient was noted to have a newly macrocytic anemia despite folate and b12 supplementation, most likely anemia of chronic disease. tsh wnl, and lfts wnl. this may also reflect a drug suppressive effect on bone marrow, but the rest of the cbc has been wnl. stool has been guaiac negative, rbc morphology with macrocytosis but no polychromia. the patient was transfused prbc on two occasions in the for hct<24 during this hospitalization. . diabetes: insulin regimen was titrated and upon discharge, it was nph 22u in am, 12u in pm; insulin ss beginning at 4u for fs 151-200mg, with increment of 2u for every +50mg. . pulmonary: she had aspiration pna as mentioned above and completed flagyl course. incentive spirometry as well as chest pt and continued treatement with nebs were encouraged, and the patient's respiratory status improved to an oxygen requirement of 1-2l nc, with cpap as needed at night. . code status: discussed with patient (confirmed by dr. on , patient's status is dnr/dni as of . medications on admission: latanoprost 1 gtt ou qhs tylenol prn metoprolol (12.5 mg or 25 , unclear from records aspirin 81 mg po daily miconazole powder 2% 1 appl tp tid:prn modafinil *nf* 200 mg oral qam simvastatin 10 mg po daily lasix 20mg qdaily . multivitamins 1 cap po daily bisacodyl 10 mg po/pr daily:prn ca/vitd percocets prn omeprazole qdaily cyanocobalamin 1000 mcg po daily sertraline 75 mg po daily thiamine hcl 100 mg po daily folic acid 1 mg po daily zinc sulfate 220 mg po daily senna, colace, dulcolax . aztreonam 1000 mg iv q8h vancomycin 1000 mg iv q 12h lovenox 40sc daily . fluticasone-salmeterol (250/50) 1 inh ih tiotropium bromide 1 cap ih daily insulin 18 nph qam, 10qpm discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 4. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 9. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain/fever. 10. hexavitamin tablet sig: one (1) cap po daily (daily). 11. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 12. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 13. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 14. enoxaparin 40 mg/0.4 ml syringe sig: one (1) subcutaneous daily (daily). 15. sertraline 50 mg tablet sig: 1.5 tablets po daily (daily). 16. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 17. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 18. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 19. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: one (1) inhalation q6h (every 6 hours). 20. acetylcysteine 10 % (100 mg/ml) solution sig: one (1) ml miscellaneous q8h (every 8 hours) as needed. 21. menthol-cetylpyridinium cl 2 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed) as needed for sore throat. 22. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed. 23. gabapentin 300 mg capsule sig: two (2) capsule po q8h (every 8 hours). 24. captopril 12.5 mg tablet sig: one (1) tablet po tid (3 times a day). 25. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed for nausea. 26. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 27. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). 28. aztreonam 1 g recon soln sig: one (1) recon soln injection q8h (every 8 hours). 29. vancomycin 1000 mg iv q 24h 30. insulin nph, humalog sliding scale please see the attached sliding scale discharge disposition: extended care facility: - discharge diagnosis: primary: decompensated systolic congestive heart failure secondary: - cad s/p svg-rca cabg and rca stent - chf ef 20-25% - dm - htn - hyperlipidemia - mv repair with annuloplasty. - cva with residual right sided weakness - bilateral carotid stenosis - right subclavian stenosis - peripheral vascular disease s/p s/p aortic and right external iliac stent; s/p rt fem- bypass w/ goretex c/b groin wound infection and exposed graft s/p 2x debridement and sartorius muscle flap - gerd - depression - prior bladder surgery discharge condition: fair discharge instructions: you were admitted with shortness of breath, dry cough, and low blood pressure. your symptoms were most likely caused by heart failure, which caused fluid to accumulate around your lungs and led to difficulty breathing and leg swelling. an ultrasound of your heart compared to an ultrasound done last year demonstrated that your heart was pumping at less than 25% of its expected level and that a new area at the bottom of your heart was not pumping and injured. . we adjusted the following medications: we increased your insulin nph does to 22u in the morning and 12u at night. you are also on a sliding scale of insulin with meals, starting at 4u at a glucose>151, and increasing by increments of 2u for every 50mg glucose. please see the attached sliding scale. . we added the following new medications: lisinopril, for protection against heart failure, and carvedilol and spironolactone to protect your heart. . we gave you gabapentin and morphine on an as needed basis for your pain. morphine must be used in very low doses as it may make you confused or drowsy. . the wound in your right groin is covered with a vac dressing. this will be changed every three days. . watch for the following signs and symptoms and notify your doctor if these occur: foul-smelling drainage or fluid from the wound; increased redness or swelling of the wound or skin around it; increasing tenderness or pain in or around the wound . if you experience shortness of breath, chest pain, fevers >100.4, copious diarrhea, light headedness/feeling as if you are going to faint, inability to perform your normal activities, or a productive cough, please come to the nearest emergency room or talk to your doctors. followup instructions: you should follow up with your pcp . tuesday at 10:30am. please call phone to reschedule. . you have an appointment for lung function tests , at 1:30pm, . you will go first to do lung function tests at 1:30pm, and then meet with dr. , the pulmonologist to discuss these tests. phone: . you should follow up with your vascular surgeon dr. on at 1pm. please call to reschedule if this is inconvenient to the number or . . you have an appointment with the infectious disease doctor dr. on at 10:30am, on in the medical building. you need to please call to confirm your appointment prior to the appointment. . you have an outpatient appointment with a cardiologist dr. on tuesday at 3:20pm, where you will discuss options for medication called amiodarone, and use of a implanatable cardiac defibrillator vs. biventricular pacemaker to control your heart rhythm. . an interpreter will be present at all these visits. md Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Anemia, unspecified Esophageal reflux Other postoperative infection Congestive heart failure, unspecified Unspecified essential hypertension Unspecified protein-calorie malnutrition Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Systolic heart failure, unspecified Paroxysmal ventricular tachycardia Other specified forms of chronic ischemic heart disease Pneumonitis due to inhalation of food or vomitus

pt. has allergies to both pcn, sulfa pt. was transferred to micu from after code blue called. pt. was found unresponsive, diaphoretic, with a tready pulse. b/p had dropped to 80/50. pt. had received 15mg po morphine 1 hour prior to code being called. no narcan given during this episode. pt. transferred on dopamine gtt at 20mcg/kg/min. pt. remains very lethargic and at times is very difficult to arouse. but pt. will arouse. pt. is noted to mae's with right side weakerr than left, which is her baseline from previous cva. pt. has remained afebrile throughout this shift. with no further neuro deficits noted. pt. has been nsr 60-90's with bbb and no further ectopy noted. b/p continues to be supported with dopamine gtt presently at 5mcg/kg/min. pt. has right subclavian stenosis and b/p with cuff and previous aline exhibits sbp in the 40-60's while aline to left radial exhibits sbp in the 130's. pulses are marked and require doppler. lungs are coarse throughout and at times exhibit exp wheeze. pt. receives neubs with noted effect for approx. 1-2hrs. pt. has been weaned from 100% nrb to high flow neub from 80-50, now back to 80% due to am abg with po2 in the 60's. new abg results pending. pt. has foley catheter in place which continues to drain approx 40-100cc/hr of clear yellow urine. pt. had been on lasix gtt at 15mg/hr iv while on the floor. this remains off at this time. pt. has had two golden semiformed stools, guiac neg. skin ehibits old right fem site is well approximated and healed. pt. has right groin wound which is positive for mrsa with vat dressing on and functioning properly. pt. has left double lumen picc remains in place and functioning well. pt. had multiple attempts fpr aline by house staff. finally line placed after anathesia was called. Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Anemia, unspecified Esophageal reflux Other postoperative infection Congestive heart failure, unspecified Unspecified essential hypertension Unspecified protein-calorie malnutrition Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Systolic heart failure, unspecified Paroxysmal ventricular tachycardia Other specified forms of chronic ischemic heart disease Pneumonitis due to inhalation of food or vomitus

allergies: penicillins / sulfa (sulfonamides) attending: chief complaint: acute coronary syndrome major surgical or invasive procedure: 1. cardiac catheterization with rca stenting history of present illness: 72 y/o w with h/o cva, carotid stenosis, mr, cad s/p mi s/p instent thrombosis x 2 transferred from osh w/ acs s/p cath w/out intervention, who was planned for cabg. she was admitted to the ccu for intensive bp and symptom monitoring and is transferred back to the service after rca stenting which obviated a need for cabg. . pt has a hx of cad s/p stent to rca , returned w/ in-stent thrombosis in w/ rca stent and restenosis in s/p baloon angioplasty. pt presented to osh w/ intermittent left-sided chest pain over the last several days pta which was relieved with sl nitro. the night pta pt had an episode of cp that was unrelieved by sl nitro x 3 and was associated w/ diaphoresis/sob and radiation to the lue. she presented to hospital where she ruled in by enzymes and was transferred to for cath. at peak ck 550, mb 88, mbi 16, trop 0.60. . at cath on admission, she was found to have 90% rca ostial stenosis that was originally not amenable to intervention at the time; the lesion was felt to be calcified instent thrombosis. single-vessel cabg & mvr was planned for . . post cath, the pt had persistent cp which was relieved w/ low dose nitro gtt w/ goal bp 100-160. she was transferred to the ccu for monitoring and optimizaiton of bp to ensure adequate cerebral perfusion in the context of known intracranial stenosis. . she had reported no cp or sob except for progressive exertional dyspnea over the past year intermittently associated w/ cp. she has had no dysuria, cough, or abd pain. she has had occasional constipation relieved with bowel movement. past medical history: pmhx: 1. dm 2. htn 3. hyperlipidemia 4. cad s/p mi stents. presented with 90% ostial lesion of rca c/b in-stent trhombosisx2 ( and ) s/p repeat stent and ptca. 5. humeral fx 6. cva with right sided weakness 7. carotid stenosis social history: no tobacco, etoh, drugs; ambulates with a walker, lives at home alone but her 2 sons and dtr rotate to sleep in her house so she is never alone overnight. she wants to continue in her current living situation. family history: mother w/ , cva; father w/ ? ca; no fhx of scd physical exam: on admission to vs: t af, 97% ra, l 105/43, r = 121/45, rr = 19. gen: pleasant elderly female laying in bed nad heent: mmm, jvp 5 cm above sternal notch cv: nml s1, s2, soft 2/6 sem @ lusb lungs: ctab abd: soft, obese, nt. extremties: faint pulses apprciable with dopplers. no groin bruits or hematomas bilaterally. . on transfer to ccu: af 100.1 bp 92/29 92-122/24-43 80 20 2l nc fs 163 gen: cauc w lying in bed in nad heent: eomi, op clear, l nasolabial fold flattened at baseline neck: jvp @ 16cm h20 heart: sem at apex iii/vi, no radiation; l subclavian sustolic bruit; no r subclavian or carotid bruits; lungs: ctbla, no rales, no wheezing or rhonchi abd: obese, s/nt/nd/no masses ext: trace pitting edema b/l pertinent results: 09:35am glucose-211* urea n-33* creat-1.0 sodium-137 potassium-4.5 chloride-104 total co2-25 anion gap-13 09:35am alt(sgpt)-21 ast(sgot)-61* alk phos-61 amylase-55 dir bili-0.1 09:35am albumin-3.1* 09:35am wbc-7.7 rbc-3.40* hgb-10.8* hct-31.7* mcv-93 mch-31.6 mchc-33.9 rdw-13.5 09:35am pt-14.2* ptt-123.2* inr(pt)-1.3 08:00am glucose-207* urea n-29* creat-1.0 sodium-146* potassium-4.7 chloride-108 total co2-27 anion gap-16 08:00am ck(cpk)-520* 08:00am ck-mb-88* mb indx-16.9* ctropnt-0.23* 08:00am wbc-8.6 rbc-4.18*# hgb-13.2 hct-39.0# mcv-93 mch-31.6 mchc-33.8 rdw-13.5 08:00am neuts-60.9 lymphs-34.1 monos-3.9 eos-0.6 basos-0.5 08:00am plt count-253hct 33 stable creat 1.0 . # 1 ck 520 mb 88 mbi 16.9 trop 0.23 # 2 ck 550 mb 86 mbi 15.6 trop 0.60 # 3 ck 260 mb 30 mbi 11.5 trop 0.62 . u/a lg bld, 74 rbcs . @ ck 114 mb 11 trop i 0.10 bnp 121 . studies: cath : lmca/lad non-obstructed. lcx diffusely diseased large, dominant rca w/ 90% ostial stenosis, couldn't be engaged aorto-ostial nature of the plaque and the prior crushed stent extruding into the aorta; nl flow. . 80% eccentric stenosis of r subclavian involving origin of r vertebral artery w/ gradient 40% eccentric stenosis of l subclavian artery . carotid us (): <70% stenosis bl . ekg: : hr 100bpm, lbbb c/w baseline no significant changes. : hr 72bpm, lbbb c/w baseline no significant changes except mild j-point elevation. . mra : demonstrates several areas of focal narrowing/stenosis in the middle cerebral arteries bilaterally, right greater than the left and also in the a1 segment of the right anterior cerebral artery. irregular areas of narrowing is also noted in the posterior cerebral arteries bilaterally, left greater than the right. the study is minimally limited by motion. if clinically warranted, a mra may be performed when the patient is more stable and cooperative. . tte : 3+ mr, ef 40% (down from 56% in ), nl rv size and wall motion. tte (): ef 56%, 3+ mr; basal portion of inferolat wall hk . cath : rca 90% stenosis, s/p baloon; cath : s/p stent to rca instent restenosis cath : s/p rca stent 80-90% lesion cath : unsuccessful rca stenting. cath : successful rca stenting with cypher des. 1. rca angiography demonstrated a 99% ostial rca in-stent restenosis. 2. successful stenting of the ostial rca was performed with two 3.5 x 23 mm cypher des. brief hospital course: a/p: 72 yo woman with progressive mitral regurgitation and severe right coronary artery disease s/p multiple interventions including successful stenting now in need of optimization of her medical program. . 1. coronary artery disease: ostial rca lesion was successfully intervened upon . the patient had an episode of exertional dyspnea on ambulating to the bathroom earlier today but is currently free of cp and dyspnea and doing well. troponin bump likely due to intervention . - continue asa, metoprolol, atorvastatin - clopidogrel 75 mg daily x9 months - added ace-inhibitor after stenting and renal function stable. titrated up to 10 mg po daily and tolerated by bp. - troponin and ck peaked at 1.04 and 109, have since trended downwards. . 2. stroke: the patient has a known old right-sided stroke and carotid and intracranial stenoses. at baseline, she has bilateral upgoing toes, left facial droop, and general left-sided sensory loss. there are no new neurologic deficits. followed by neurology consultation service as inpatient. continue asa, clopidogrel. . 3. mitral regurgitation: although coronary ischemia was likely playing a role in her dyspnea, her mr is likely contributing as well. mr has been thought to be due to papillary muscle stunning in the setting of myocardial ischemia as opposed to intrinsic valvular defect. - afterload reduced with lisinopril as noted above - no current plans for mvr - goal fluid balance roughly even . 4. dm-ii: continue riss, insulini 70/30 . . 5. htn: control with meds as above. . 6. nsvt: no further events on telemetry. . 7. asthma: continue fluticasone/salmeterol, ipratropium. . 8. depression: continue sertraline. . 9. neuropathic pain: continue gabapentin. . 10. f/e/n: cardiac diet/, check lytes daily. . 11. proph: heparin sq, bowel regimen, ppi. . 12. code: full code, but patient has stated, "i don't want to be on machines for a long time." hcp are pt's children. . 13. disposition: pt stable and improved. pt recommending rehabilitation, from which patient will benefit. medications on admission: allergies: pcn, sulfa . medications at home: atenolol asprin lipitor plavix colace lisinopril isosorbide mononitrate fluticasone-salmeterol . medications on transfer to ccu: acetaminophen aspirin ec 325 mg po q24h atenolol 25mg po q24h atorvastatin 80mg po q24h clopidogrel bisulfate 75mg po q24h docusate sodium fluticasone-salmeterol (100/50) furosemide 40mg po q24h heparin gtt insulin ss ipratropium bromide neb isosorbide mononitrate (extended release) 60mg po q24h lisinopril 5mg po q24h magnesium sulfate morphine sulfate nitroglycerin sl nitroglycerin gtt now d/c'ed pantoprazole sertraline hcl senna travatan ou discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. atorvastatin calcium 80 mg tablet sig: one (1) tablet po daily (daily). 4. travoprost 0.004 % drops sig: one (1) drop ophthalmic at bedtime. 5. sertraline hcl 50 mg tablet sig: one (1) tablet po daily (daily). 6. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puffs inhalation every six (6) hours. 7. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 8. gabapentin 100 mg capsule sig: one (1) capsule po q12h (every 12 hours). 9. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily) for 10 months. 10. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 11. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 12. insulin 70/30 70-30 unit/ml suspension sig: thirty five (35) units subcutaneous qam. 13. insulin 70/30 70-30 unit/ml suspension sig: twenty (20) units subcutaneous qpm. discharge disposition: extended care facility: life care center of discharge diagnosis: 1. coronary artery disease 2. systolic heart failure 3. mitral regurgitation 4. bilateral carotid artery stenosis discharge condition: chest pain free with mild exertional dyspnea likely due to deconditioning. stable for discharge to rehab. discharge instructions: take all medications as prescribed. followup instructions: call dr. () when you get home to arrange for a follow-up appointment at his discretion. Procedure: Coronary arteriography using two catheters Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Systolic heart failure, unspecified Long-term (current) use of insulin Other complications due to other cardiac device, implant, and graft Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Unspecified late effects of cerebrovascular disease Stricture of artery

allergies: penicillins / sulfa (sulfonamides) attending: chief complaint: foot pain, fevers, sepsis, cardiogenic shock major surgical or invasive procedure: none history of present illness: chief complaint: transferred from for management of acute on chronic congestive heart failure. . history of present illness: mrs. is a 76 year-old portuguese-speaking woman with insulin dependent diabetes, hyperlipidemia, cerebrovascular disease (with stroke), copd, depression, gerd, heart failure (lvef 20%) and chronic renal failure presenting to hospital with generalized weakness, possible abdominal pain, and leg and right foot pain. today she is transferred to for management of fluid overload. . the discharge summary from mentions that she was suffering from gout with treatment begun in the nursing home, abdominal ct to assess ?abdominal pain, and generalized weakness. she had also presented with a creatinine of 2.2 and it appears that fluid resuscitation was commenced that has now reduced her creatinine but worsened her heart failure. in her summary, lower extremity pain was attributed to vascular disease and possibly in need of vascular studies and intervention. she is also to be worked-up for acute causes of heart failure. ct scan of the right kidney is suggestive of pyelonephritis that has so far been treated with levaquin (renal dosing). while in-house at . one blood culture bottle was positive for staphlococcus but this was atributed to contamination. another set from was negative at the time of transfer. cxr was suspicious for infiltration of the lower lobes. . per the patient: there was no joint tap to diagnose gout. osh records state that she was given allopurinol two weeks ago in the nursing home for suspected gout along with colchicine (unclear if renally dosed). she is mostly concerned for the pain in her right foot which is the reason she gave for her admission to . she says that it had become painful in the nursing home and that she could no longer stand on it. she has trouble walking due to her left hemiparesis, and now with foot and bilateral leg pain. past medical history: .chronic congestive heart failure (lvef ~ 20%) .nstemi .coronary artery disease - s/p multiple rca stents .mitral regurgitation .iddm .hypercholesterolemia .cerebrovascular disease - s/p cva (left hemiparesis) .known carotid disease .right subclavian stenosis, peripheral vascular disease .history of humeral fracture .gerd .depression .prior bladder surgery .fem- bypass complicated by infection .cardiac risk factors: diabetes, dyslipidemia, hypertension social history: lives in nursing home and is retired. denies tobacco, etoh and recreational drugs. ambulates with a walker at baseline. lives with her daughter. denies tobacco, etoh and recreational drugs. family history: denies premature coronary disease. physical exam: vs - t 99.2 bp 117/54 hr 91 rr 22 sato2 100% 2l glucose 310 pain 0/10 gen: resting awake and comfortably. very pleasant and grateful. some poverty of spontaneous speech and movement. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp to the angle of the mandible at 60 degrees. cv: rrr with occasional ectopy, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: no chest wall deformities. resp were unlabored, no accessory muscle use. crackles worse on the right base. no wheezes or rhonchi. patient could not sit so listened to posterolateral lung. patient had some difficulty following instructions for breathing during examination. abd: soft, ntnd. no hsm or tenderness. ext: + edema of the extremities. no clubbing. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: edema was severe limiting examination. neurological: left hemiparesis of leg, arm, face, with an upper motor neuron pattern of weakness. speech was not dysarthric, slightly slowed, little spontaneous expression or speech. possibly some limitation of comprehension but english is second to portuguese. sensation intact at extremities, forearm and lower legs. some degree of pain asymbolia possible - said touching feet very painful but seemed blase. reflexes not tested. unable to walk. pertinent results: imaging: . cxr: impression: minimal pulmonary edema in the presence of mild cardiomegaly. no new consolidation. . echo: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is severe global left ventricular hypokinesis (lvef = 15-20 %). the right ventricular cavity is dilated with depressed free wall contractility. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. moderate (2+) aortic regurgitation is seen. the aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. the mitral valve leaflets are mildly thickened. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. there is moderate thickening of the mitral valve chordae. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. no masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . impression: no evidence of vegetation or abscess. severe global lv hypokinesis. the lateral wall has relatively better function. the ventricle appears dyssynchronous. moderate mitral, aortic and tricuspid regurgitation (all may be underestimated due to acoustic shadowing from widespread calcification). moderate pulmonary artery systolic hypertension. . compared with the prior study (images reviewed) of , overall ejection fraction is probably slightly less. degree of aortic regurgitation has increased, degrees of mitral and tricuspid regurgitation probably similar. estimated pulmonary artery systolic pressures are higher. . ct chest/abdomen/pelvis: chest: trace pleural fluid is present bilaterally with minimal dependent bibasilar atelectasis. images are somewhat degraded due to respiratory motion artifact; however, there is no consolidation. small amount of fluid is present in the dependent portion of the central trachea. cardiomegaly and heavy coronary arterial calcifications and atherosclerotic calcification of the thoracic aorta is unchanged. there is no mediastinal or axillary lymphadenopathy. median sternotomy wires are in place. . abdomen: the liver, spleen, adrenals, and kidneys are within normal limits. numerous surgical clips in the gallbladder fossa and at the posterior aspect of the right hepatic lobe from previous cholecystectomy are again seen. there is no biliary ductal dilatation. the pancreas is within normal limits. there is diffuse atherosclerotic calcification of the abdominal aorta, aortic branches, and intrarenal vascular calcifications are noted. right femoropopliteal arterial graft is again noted. there are no peritoneal fluid collections. there is a large amount of stool in the rectum, descending colon, and distal transverse colon. there is no small- bowel obstruction. a normal appendix is noted. there is no bowel wall thickening or pneumatosis. . pelvis: the urinary bladder is collapsed about a foley catheter balloon. focus of air in the nondependent portion of the bladder is likely related to foley catheter placement. again seen is a calcified uterine fibroid. there are no adnexal masses. there are no pelvic fluid collections. . abdominal wall: numerous areas of infiltration of the subcutaneous fat in the anterior abdominal wall, few foci of subcutaneous air are likely related to injection sites. . bones: multilevel degenerative changes of the thoracic and lumbar spine are unchanged. compression deformity of the superior endplate of l1 is unchanged. right glenohumeral joint degenerative change and mild bilateral hip osteoarthritis is noted. . impression: 1. no pneumonia, as questioned. 2. no abdominal or pelvic collections. no findings suggestive of ischemic colitis. . ct head: findings: there is no intracranial hemorrhage, mass effect, shift of normally midline structures, or edema. the ventricles and cerebral sulci remain prominent, compatible with age-related involutional change. periventricular regions of hypodensity are unchanged, consistent with small vessel ischemic change. bilateral basal ganglia calcifications are again noted. the -white matter differentiation remains normal. chronic left basal ganglia, thalamic and left frontal infarcts are unchanged. mastoid air cells are hypoplastic. the paranasal sinuses are otherwise well aerated. . impression: no intracranial hemorrhage. . cta lower extremities impression: 1. occluded left superficial femoral artery with reconstitution at the popliteal. complete occlusion of the left posterior tibial artery with severely diseased, but patent anterior tibial and peroneal arteries. 2. patent fem- bypass graft on the right with stable severe narrowing at the insertion of the bypass graft into the popliteal artery. occluded native superficial femoral artery on the right. evaluation for the runoff to the lower right leg is limited as the entire lower leg is not visualized on this study. however, it does appear that the posterior tibial artery is occluded on this side. . micro: . , c. diff: neg blood cx: , , x2: ngtd blood cx: , , x2: negative urine cx: : yeast, : negative . labs on admission: 08:10pm blood wbc-14.9*# rbc-4.01*# hgb-12.7# hct-40.0# mcv-100* mch-31.7 mchc-31.7 rdw-15.7* plt ct-146*# 08:10pm blood neuts-89* bands-0 lymphs-10* monos-0 eos-1 baso-0 atyps-0 metas-0 myelos-0 08:10pm blood pt-19.3* ptt-29.2 inr(pt)-1.8* 08:10pm blood glucose-303* urean-63* creat-1.6* na-131* k-4.6 cl-96 hco3-26 angap-14 08:10pm blood alt-378* ast-177* ck(cpk)-41 alkphos-76 totbili-0.6 08:10pm blood ck-mb-notdone ctropnt-1.67* 08:10pm blood albumin-2.9* calcium-8.4 phos-2.3* mg-2.8* 05:28pm blood lactate-1.4 . labs on discharge: 05:50am blood wbc-23.4*# rbc-3.96* hgb-12.6 hct-40.9 mcv-103* mch-31.8 mchc-30.9* rdw-17.5* plt ct-232 05:50am blood neuts-90.9* lymphs-6.8* monos-1.9* eos-0.2 baso-0.2 10:00am blood pt-23.8* ptt-34.5 inr(pt)-2.3* 10:00am blood glucose-307* urean-129* creat-2.3* na-143 k-5.7* cl-108 hco3-17* angap-24* 04:24am blood alt-80* ast-96* ld(ldh)-303* alkphos-40 totbili-1.3 10:42am blood type- po2-63* pco2-35 ph-7.29* caltco2-18* base xs--8 10:42am blood lactate-6.3* brief hospital course: 76 yo f with mmp including chf and pad, initially admitted for foot pain, transferred to and felt to be in acute on chronic chf (ef 20%), s/p aggressive diuresis, now presenting with intermittent fevers without source, progressive altered mental status, noted to be in oliguric acute renal failure, and in early sepsis. . brief hospital course: in brief, 76 yo f with mmp, admitted to hospital for foot pain. she was empirically started on colchicine and allopurinol, despite lack of gout hx or joint tap. she was noted to be in arf (cr 2.2, baseline 1.2 in ). some concern for pyelo, despite normal u/a. transferred to for heart failure. admitted to service, where she was aggressively diuresed total of 10l over next several days. cr started to rise and 1.6-1.8. pt spiked on and wbc 11. left leg appeared red. neg leni's. started on vanco and cipro for cellulitis. switched to vanc and ceftriaxone given hx of cipro resistant e.coli at the site of her fem- bypass in the past. on , underwent cta with contrast, seen by vascular, and planned for angio procedure, given concern for ischemia in leg. on , triggered for ?encephalopathy and ams. on , ct head negative for hemorrhage. ngt placed for concern for inability to take in po. on , triggered again, this time unresponsive and tachycardic. concern for sirs/sepsis given bp 90/50, hr 130, and transferred to micu. given fluid boluses, started on vanco/cefepime/flagyl. ct chest/abd/pelvis without consolidation or fluid collections. echo neg for vegetations. pancultured without source. on , given fluid boluses for low uop. on , had neg tte study again, given concern for intermittent temp spikes. after discussion with icu team, patient dnr/dni. on , spiked again and wbc to 23, with lactate rising (now 4.5). discussion with family re: goals of care, and family wished to pursue comfort measures. . detailed hospital course: . course: # acute on chronic heart failure/fluid overload: felt to be significantly fluid overloaded from aggressive hydration in osh and perhaps earlier, given her poor systolic heart function. physical exam significant for basilar crackles, raised jvp, significant edema throughout. cxr imaging noting pulmonary edema, without signs of infection. other acute causes of pump dysfunction were considered including myocardial ischemia/infarction, medication error, colchicine, thyroid disease, anemia, atrial fibrillation. patient initially started on sodium restriction, fluid restriction, lasix drip 15 mg/hr, metolazone (5 mg po bid). ekg, cardiac enzymes, and tsh were non-revealing. echo was performed showing, "severe global left ventricular hypokinesis with relative preservation of the basal anterior septum and inferolateral walls. the remaining segments are severely hypokinetic (lvef = 25 %). mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. an eccentric, anteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension." patient diuresed approximately 10l. . ## lower and right foot pain: possible etiologies felt to include arterial insufficency, dvt, severe edema secondary to acute on chronic renal and heart failure as well as hypoalbuminemia, possibly with neuropathic contribution. gout is possible, but the appearance of the feet and distribution of pain are not consistent with monoarticular or oligoarticular gout, particularly not the great toe. dvt is possible but seen as less likely given bilateral symmetry and given the the degree of edema is somewhat in keeping with that of her hand and other signs such as crackles, raised jvp. arterial insufficiency is also possible as is diabetic neuropathy. initial workup consisted of leni's (negative for dvt), and treatment for cellultis (started on vanco and cipro, switched to vanc and ceftriaxone given hx of cipro resistant e.coli at the site of her fem- bypass in the past). cta lower extremities performed showing occluded left superficial femoral artery with reconstitution at the popliteal. complete occlusion of the left posterior tibial artery with severely diseased, but patent anterior tibial and peroneal arteries. patent fem- bypass graft on the right with stable severe narrowing at the insertion of the bypass graft into the popliteal artery. occluded native superficial femoral artery on the right. evaluation for the runoff to the lower right leg is limited as the entire lower leg is not visualized on this study. however, it does appear that the posterior tibial artery is occluded on this side. it was felt that patient's leg pain was largely from pad/pvd/lower extremity ischemia, and vascular was consulted. however, angiogram was not performed, given co-morbidities and remainder of hospital course. . ## renal failure: multifactorial, and likely from medications, impaired forward flow from heart failure, being physiologically pre-renal despite fluid overload, contrast nephropathy and possibly atn. . ## confusion/altered mental status: unclear but felt to be toxic metabolic in setting of elevated bun. head ct negative for cva/ich. diuresis was held at this point. . micu course: ms. is a 76 yo female w/ multiple medical problems, transferred to micu for further management of presumed sepsis. . # sepsis: patient re-developed fevers on on a regimen of vancomycin / ceftriaxone. patient had no previous positive cultures since . initial concern for infectious etiologies included the following: *** intra-abdominal: given pain on palpation, and fevers while on broad spectrum gram positive coverage with somewhat limited gram negative/anaerobic coverage. initial differential included c. diff colitis, mesenteric ischemia (given multiple vasculopathies, elevated lactate), abscess. however, ct torso was negative and pain resolved with disimpaction and bowel regimen. patient was intermittently started on flagyl which was discontinued after the negative imaging. *** urine: there was initial concern for renal abscess given prior history of pyelonephritis; however, ct was negative. *** graft site infection of right fem- graft site: given right foot pain and history of resistant e. coli/ mrsa at the wound site. in icu, antibiotics were initially broadened for gram negative coverage to cefepime to cover pseudomonas. infectious disease was consulted who. drug induced fever was considered. . # volume status/chronic systolic hf: as evidenced by her abgs and electrolyte profile, she may have been over-diuresed at time of admission to micu. diuresis was held and the patient was provided fluids. her ace was also held given hypotension. . # peripheral arterial disease: will follow up vascular surgery recs re: need for angio once hemodynamically stable. . # insulin dependent diabetes: continued iss with fingersticks # hypertension: held antihypertensives while managing sepsis . # peripheral arterial disease: s/p recent right fem- bypass graft c/b wound infections with mrsa/e. coli requiring prolonged courses of vanc/cefazolin/aztreonam-->linezolid/cephpodoxime (for cipro resistant e. coli). then minocycline for mrsa suppression lifelong. . general wards: # altered mental status: after discussion with family and extensive chart review, markedly off baseline. at baseline, patient alert, oriented, and conversant. now has had progressive decline in mental status to the point that she is no longer verbal. has had trigger for same event for unresponsiveness. ddx includes toxic metabolic (uremia) vs. infectious (though culture negative to date) vs. cva/ich (ct negative). most likely etiology felt to be toxic metabolic. nephrology was consulted, but given other co-morbidities, goals of care were discussed in parallel with potential dialysis. . # oliguric acute renal failure: likely multifactorial in the setting of sepsis, cardiorenal syndrome (at baseline with poor ef), contrast/dye load (given ), overdiuresis (), and then decreased po intake (). baseline cr 1.2, then has been progressively increasing. now holding diuresis. currently bun 118, cr 2.1. renal consulted, and goals of care discussed. . # sirs/early sepsis: patient with intermittent fevers without source throughout hospital stay. on morning of , lactate 4.4, patient tachycardic and tachypnic, and low grade fevers. repeat lactate > 6. with regard to source, suspect overt infection as opposed to occult infection, given jump in wbc from 13.5 to 23.4. suspect cdiff or bacteremia despite previous negative blood cultures/negative micro. started on po flagyl (in addition to previous iv vanco and cefepime). goals of care discussed with family and hcp. family and hcp elected to make patient . palliative care and pastoral care services offered. family at bedside when patient passed. medications on admission: medications on transfer: ssi phytonadione 2 mg po daily duration: 3 days acetaminophen 325-650 mg po q6h:prn fever >100 lactulose 30 ml po tid senna 1 tab po bid docusate sodium 100 mg po bid heparin 5000 unit sc tid cefepime 1 g iv q24h vancomycin 1000 mg iv q48h day discharge medications: n/a discharge disposition: expired discharge diagnosis: primary: septic shock cardiogenic shock discharge condition: expired discharge instructions: n/a followup instructions: n/a Procedure: Enteral infusion of concentrated nutritional substances Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Cellulitis and abscess of leg, except foot Cardiogenic shock Septic shock Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Metabolic encephalopathy Acute on chronic systolic heart failure Other and unspecified coagulation defects Atherosclerosis of native arteries of the extremities, unspecified

allergies: nickel attending: chief complaint: headaches. major surgical or invasive procedure: right craniotomy for evacuation of subdural hematoma. history of present illness: 60yo woman with pmh signficant for cad s/p mi in , san fever s/p rul lung resection, presents as an osh transfer with two weeks r sided headache. she reports her symptoms began approximately two weeks ago, when she had "flu-like symptoms" - body aches, headache. she was concerned this was the san , as the body aches were similar (but were accompanied by fever and unclear if accompanied by headache, this time they were without fever and with headache). she treated these symptoms with tylenol, alleve, and other cold medications but the headache did not go away. it continued to worsen, and was waking her up from sleep. she describes it as a shooting pain behind her right ear (never on the left side), constant and gnawing, with occasional "jolts" that cause her to lose her balance, become nauseous, and once vomit. it feels "like someone's driving a stake through your head." she went to the hospital when she could no longer stand the pain or the lack of sleep. she found no aggravating or alleviating factors (?if ice may have helped), no change with position. she had no preceding trauma, loss of consciousness, numbness, tingling, weakness, change in speech, difficulty thinking, bowel or bladder dysfunction, hearing problems, or diplopia. she feels it is more difficult to see becuase her eyes are "running" more and it hurts to focus, as if she has sandpaper over her eyes. she denies fevers or chills. she presented to an osh, where she had a hct and was found to have a right sided subdural hematoma. she was transferred to the ed, where she had a repeat hct and received first morphine, then dilaudid for her headache. further history became somewhat limited as she became more somnolent immmediately after receiving the dilaudid. past medical history: -san fever s/p rul resection -cad s/p mi in social history: smokes 1/2ppd x 40yrs, no etoh or drug use family history: noncontributory physical exam: afebrile, 113/61,71,17,98% ra . gen: wd/wn, uncomfortable heent: ncat, neg raccoon's, neg battles, neck: supple. lungs: decreased breath sounds to rul rml regions / otherwise clear. cardiac: rrr. s1/s2. no obvious murmur abd: soft, nt, bs+ no obvious masses extrem: warm and well-perfused. no c/c/e. . neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and year/month - thought today was the 27th (24th) language: speech fluent with good comprehension and repetition. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3to2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. no diplopia v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to finger rub bilaterally. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. . motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. left upper extremity drifts upward on testing sensation: intact to light touch, proprioception, pinprick and vibration bilaterally. pertinent results: 08:30am blood wbc-5.7 rbc-3.95* hgb-11.8* hct-34.6* mcv-87 mch-29.9 mchc-34.3 rdw-13.2 plt ct-371 06:40am blood wbc-9.0 rbc-3.87* hgb-11.4* hct-33.7* mcv-87 mch-29.5 mchc-33.9 rdw-13.0 plt ct-281 03:04am blood wbc-10.5 rbc-3.89* hgb-11.7* hct-33.9* mcv-87 mch-30.2 mchc-34.7 rdw-13.3 plt ct-238 01:47pm blood wbc-7.8 rbc-3.81* hgb-11.6* hct-33.5* mcv-88 mch-30.4 mchc-34.6 rdw-13.3 plt ct-290 04:50pm blood neuts-71.0* lymphs-24.8 monos-3.1 eos-0.8 baso-0.4 08:30am blood plt ct-371 06:40am blood plt ct-281 06:40am blood pt-13.6* ptt-28.6 inr(pt)-1.2* 08:30am blood glucose-93 urean-10 creat-0.6 na-145 k-3.5 cl-107 hco3-30 angap-12 06:40am blood glucose-89 urean-10 creat-0.5 na-140 k-3.7 cl-104 hco3-23 angap-17 05:05am blood glucose-109* urean-9 creat-0.6 na-141 k-3.9 cl-104 hco3-27 angap-14 06:40am blood calcium-8.0* phos-2.5* mg-1.9 05:05am blood calcium-8.2* phos-3.3 mg-1.8 03:04am blood phenyto-7.9* 07:40pm urine blood-lg nitrite-pos protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-tr . . 7:40 pm urine site: catheter **final report ** urine culture (final ): escherichia coli. >100,000 organisms/ml.. trimethoprim/sulfa sensitivity testing confirmed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s imipenem-------------- <=1 s levofloxacin----------<=0.25 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . . 2:29 pm mrsa screen site: rectal source: rectal swab. **final report ** mrsa screen (final ): no staphylococcus aureus isolated. . . 2:29 pm mrsa screen site: naris (nare) nasal swab. **final report ** . . ct head w/o contrast impression: acute on chronic right subdural hemorrhage measuring 9 mm with 11 mm of rightward midline shift. no evidence for acute ischemia, hydrocephalus or herniation. given the foci of acute hemorrhage within this chronic subdural collection, close short-term followup is recommended. note added at attending review: there is subfalcial and uncal herniation. this revised interpretation will be conveyed to the physicians caring for the patient. . . ct head w/o contrast 11:07 am impression: acute on chronic right subdural hemorrhage accompanied by rightward midline shift, subfalcial and uncal herniation, unchanged from prior exam. . . ct head w/o contrast 7:30 am impression: status post right frontal craniotomy and evacuation of extra-axial hematoma, with small residual collection, and improvement in ventricular effacement, shift of the midline structures and uncal herniation. . . ct head w/o contrast impression: 1. essentially unchanged appearance of the right frontal craniotomy site with small residual collection. unchanged degree of midline shift and mass effect on the right cerebral hemisphere from 9/27/06.2. hypodensity within the right temporal lobe probably represents contusion secondary to the recent craniotomy. this contusion contains a linear hyperdensity which may represent a thrombosed vessel or hemorrhage. mrsa screen (final ): no staphylococcus aureus isolated. . . brief hospital course: this patient was admitted on . she had a urinary tract infection for which she was treated; she was then prepared and consented for surgery as per standard. intraoperatively, there were no major complications which occured. the patient recovered well and was transfered to the neuro stepdown unit. she had some complaints of bilateral eye swelling but no changes in her vision. she was seen by anesthesia for this. the patient was then transfered to the floor, where she was able to tolerate a regular diet, ambulate and was discharged in a good condition. she is to return to the clinic for staple removal 10 days post-surgery; she is also to arrange a follow-up appointment in the clinic in weeks. medications on admission: asa discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*40 tablet(s)* refills:*1* 3. outpatient occupational therapy outpatient ot per reccomendation of ot department. 4. fosamax 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. celebrex 100 mg capsule sig: one (1) capsule po twice a day: please begin after . disp:*30 capsule(s)* refills:*2* 6. soma 350 mg tablet sig: one (1) tablet po three times a day as needed for muscle pain. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: acute on chronic right subdural hematoma. discharge condition: good. discharge instructions: please call your doctor or return to the er for any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomitting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomitting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your skin, or the whites of your eyes become yellow * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * you have shaking chills, or a fever greater than 100.4 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. followup instructions: please arrange a follow-up appointment with , by calling . this appointment is to be arranged in weeks time from now. you must also call the above number for your staples to be removed on . md Procedure: Other incision of brain Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Compression of brain Old myocardial infarction Subdural hemorrhage Swelling or mass of eye

allergies: penicillins attending: chief complaint: arf major surgical or invasive procedure: renal artery stent chest tube history of present illness: the patient is an elderly female who had undergone a left nephrectomy at an outside institution. she had diminished urine output over approximately 48 hours and was diagnosed on mra with a high-grade right renal artery stenosis. she was urgently transferred to our institution. she was received directly in the cardiac catheterization holding area and brought urgently into the procedure room. she was prepped with chloraprep and draped in the usual fashion. past medical history: pmh: htn, tcc, ras, l. maxillary sinus tumor, tah/bso social history: pos smoker pos drinker family history: non contributary physical exam: pe: afvss neuro: perrl / eomi mae equally answers simple commands neg pronator drift sensation intact to st 2 plus dtr neg babinski heent: ncat neg lesions nares, oral pharnyx, auditory supple / farom neg lyphandopathy, supra clavicular nodes lungs: cta b/l cardiac: rrr without murmers abdomen: soft, nttp, nd, pos bs, neg cva tenderness ext: rle - palp fem, , pt, dp lle - palp fem, , pt, dp pertinent results: 04:50am blood wbc-12.6* rbc-3.16* hgb-9.6* hct-28.4* mcv-90 mch-30.4 mchc-33.8 rdw-18.9* plt ct-178 03:44am blood pt-12.7 ptt-26.0 inr(pt)-1.1 04:50am blood plt ct-178 10:13am blood glucose-109* urean-56* creat-5.3* na-137 k-3.7 cl-101 hco3-26 angap-14 03:48am blood ld(ldh)-465* totbili-0.7 dirbili-0.3 indbili-0.4 10:13am blood calcium-8.1* phos-5.7* mg-2.0 urine color-yellow appear-cloudy sp -1.010 urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-mod urine rbc-0-2 wbc->50 bacteri-many yeast-none epi-0 renalep-<1 10:05 pm sputum site: expectorated gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). respiratory culture (final ): moderate growth oropharyngeal flora. gram negative rod(s). rare growth. 4:16 pm chest (pa & lat) reason: please reassess pneumonia comparison is made with the prior chest x-ray of . patchy infiltrates are still present in the right upper lobe, mildly improved since the prior chest x-ray. bilateral effusions are again seen, probably indicating the presence of some underlying failure as well. the position of the two lines remains unaltered. impression: marginal improvement in right upper lobe pneumonia, some failure persists. cardiology report echo study date of interpretation: findings: left atrium: dilated la. right atrium/interatrial septum: dilated ra. dilated ivc (>2.5 cm), with minimal respiratory variation c/w elevated ra pressure of >20 mmhg. left ventricle: normal lv wall thickness, cavity size, and systolic function (lvef>55%). right ventricle: rv hypertrophy. dilated rv cavity. aortic valve: mildly thickened aortic valve leaflets (3). no as. mitral valve: mildly thickened mitral valve leaflets. no mvp. moderate mitral annular calcification. mild thickening of mitral valve chordae. calcified tips of papillary muscles. no ms. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets. mild tr. severe pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. normal main pa. no doppler evidence for pda pericardium: no pericardial effusion. conclusions: the left atrium is dilated. the right atrium is dilated. left ventricular wall thickness, cavity size, and systolic function are normal (lvef 60-70%). the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. 11:16:48 pm ekg sinus rhythm and occasional ventricular ectopy. otherwise, compared to the previous tracing of no diagnostic interim change. intervals axes rate pr qrs qt/qtc p qrs t 72 158 96 428/451.85 9 -24 45 2:29 pm ct chest w/o contrast reason: elevated wbc with persistent right infiltrate, ? pulmonary a diffuse bilateral pulmonary abnormalities are present, including smoothly thickened septal lines, areas of reticulation, and multifocal ground-glass opacities. these findings involve multiple lobes of both lungs but are asymmetrically distributed. in the left lung, they are most severe in the lingula and in the right lung, most severe in the right upper lobe. additionally, there are multiple areas of patchy consolidation, most pronounced in the right upper lobe. within the left lower lobe, there is a focal area of confluent opacity with associated volume loss, favoring atelectasis over consolidation. similarly, a confluent area of opacity in the right lower lobe, immediately adjacent to pleural fluid is probably due to focal atelectasis. asymmetric soft tissue density in right supraclavicular region could be due to asymmetrical musculature but is difficult to distinguish from lymphadenopathy in the absence of intravenous contrast. numerous mediastinal lymph nodes are present, measuring up to 2 cm in diameter in greatest short axis dimension in the precarinal region. subcarinal nodes measure up to 1.3 cm in short axis dimension. pulmonary hila are difficult to assess in the setting of enlarged pulmonary arteries and absence of intravenous contrast, but there is likely at least mild hilar lymphadenopathy present. the main pulmonary artery is enlarged at 3.7 cm. the heart is upper limits of normal in size. coronary artery calcifications are present. small bilateral dependent pleural effusions are present, right slightly greater than left. within the imaged portion of the upper abdomen, there is diffuse nonspecific soft tissue stranding within the mesentery. right renal artery stent is present. no suspicious abnormalities are identified within the liver on this unenhanced study. there is a rounded low attenuation lesion within the spleen measuring about 1.8 cm in diameter, and a second smaller central lesion measuring about 8 mm in diameter. these are also difficult to assess in the absence of contrast. superficial surgical clips are present in the left posterior upper abdominal wall, and there is nonspecific soft tissue stranding near the clips. comparison ct abdomen demonstrates a similar appearance in this region. the pleural effusions have slightly increased in size bilaterally since the prior abdominal ct, and the left basilar opacity has worsened. right lower lobe is slightly better aerated posteriorly compared to the prior abdominal ct. with regard to the splenic lesions, the two lesions appear unchanged from the recent abdominal ct. impression: 1. multifocal ground glass opacities and septal thickening, most likely due to hydrostatic pulmonary edema. 2. asymmetrical consolidation predominantly involving the right upper lobe is concerning for infectious pneumonia given the history of elevated white blood cell count. asymmetrical edema is within the differential diagnosis. 3. small bilateral pleural effusions, right greater than left, slightly increased from recent abdominal ct. 4. bulky mediastinal lymphadenopathy and questionable right supraclavicular nodes. if nephrectomy was performed for renal cell carcinoma, followup ct with intravenous contrast would be recommended to exclude the possibility of metastatic lymphadenopathy. differential diagnosis includes reactive/hyperplastic lymph nodes. 5. status post left nephrectomy and right renal artery stenting. 6. splenic lesions without change from recent abdominal ct 3:00 pm ct head w/o contrast findings: there is no intracranial mass effect, hydrocephalus, shift of normally midline structures, or major vascular territorial infarction. the -white differentiation is preserved. a small rounded area of low attenuation is seen in the head of the caudate nucleus on the right side, representing an old lacunar infarct. a similar area of low attenuation is visualized in the right medial temporal lobe, also representing lacunar infarct, chronic in age. the surrounding soft tissue and osseous structures are unremarkable. there is evidence of a probable left maxillary medial wall antrostomy- please confirm and correlate with prior history. impression: no mass effect or hemorrhage radiology final report 11:18 am mr head w/o contrast technique: multiplanar t1- and t2-weighted imaging of the brain was performed. however, this study could not be completed as the patient's sats dropped and patient did not want to continue the study. findings: the few sequences (sagittal and axial t1, axial t2, and axial flair) are limited due to motion artifacts. the cerebral sulci appear hyperintense on the pre-contrast t1-weighted images. this appearance could be due to the retained ct contrast given intravenously, due to the associated renal failure. the ventricles are unremarkable. no mass effect, shift of normally midline structures noted. the osseous and the soft tissues structures are unremarkable, including the paranasal sinuses and the orbits. impression: 1. incomplete study as the patient's sats dropped and did not want to continue the study. 2. limited images reveal hyperintense cerebral sulci, which could be due to be retained ct contrast given intravenously, considering the patient's renal failure brief hospital course: the patient is an elderly female who had undergone a left nephrectomy at an outside institution. she had diminished urine output over approximately 48 hours and was diagnosed on mra with a high-grade right renal artery stenosis. she was urgently transferred to our institution. she was received directly in the cardiac catheterization holding area and brought urgently into the procedure room. renal stent placed / plavix started / sheath removed without complications. nephrology consulted. k normal, anuric x 24 hours. swam placed / pt with pnx / chest tube placed without incident pt needs dialysis, persistently anuric evaluated for replacement of right ij with hd catheter team to decide currently also with left swan ganz. no hd needed, not volume overloaded. tte w/lvef, no thrombus acute r hemiplegia and dysarthria. suspect d/t htn, vs ? hit. still oliguric, k 5.8, 7.33/45/97. kayexelate. hd after head ct. goal sbp 150-160, uf 1.5 kg, qb 150-200, x 2 h. overall volume up, tachypneic but better with suctioning so a lot is upper respiratory. bcx x2 neg spcx w/4+gnr, heavy pseudomonas, klebsiella pan sensitive likely tia, neuro consulted, ct head neg, eeg neg, cvl changed, moved to sicu ucx w/pseudomonas>100k spcx w/2+gpc, 2+gpr, cx w/oropharyngeal flora duplex carotids w/bilat<40% stenosis ct abd w/o bleed, has bilat effusions tte w/elevated pa pressures right ij perma-cath placement. no complications. pt seen by hematology for decreased plts / dic vs ttp stable tolerated hd today with 2 u prbc some problems with hypotension throughout, chilled dialysate, modeled na seemed to help blood helped most doing much better evaluate for hd in am if creatinine continues to increase dialyze but no more than 1kg off, to allow good pressures not expand atn if cr stable of decreased would hold hd. she is fine. the bp running slightly high but no evidence of uremic s/s and volume overload is noted. will get hd on . got hd. dropped her bp. had sob. got nebs and 1 unit of prbc. she is feeling fine. no hd. she feels fine. u/o is going up. no need for hd today. lue picc placed, cxr w/persistent lll consolid, bilat infiltrates she feels fine. u/o ok. will possibly get hd on . she is getting better. no volume overload or uremic symptoms. the creatinine is going up but slower every day. no hd done over the weekend. evaluate daily. nephrology clears for home pt / oob / pt did well / cleared for home final recommendations for home with pt, given by nephrology. pt to follow-up in . appointments made for one week. pt to get lab draws at home. medications on admission: lisinopril, hctz discharge medications: 1. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for 10 days: prn. disp:*2 ipratropium bromide (inhalation) 0.02 % solution* refills:*0* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. disp:*2 albuterol sulfate (inhalation) 0.083 % solution* refills:*0* 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. ciprofloxacin 500 mg tablet sig: one (1) tablet po once a day for 9 days. disp:*9 tablet(s)* refills:*0* 7. labs please draw a chem 10 / fax the results to / this should be done discharge disposition: home with service facility: homecare discharge diagnosis: arf s/p left nephrectomy ptx requiring chest tube pna uti chf hd m/w/f discharge condition: stable discharge instructions: what is it? there are two general categories of kidney failure: acute and chronic. in acute kidney failure, the kidneys suddenly lose much of their ability to filter blood, often because of an injury, serious damage to the kidneys or other organs, or exposure to a toxin (poison). some of the illnesses that can lead to acute kidney failure include a severe blood loss, severe dehydration, severe drops in blood pressure, heatstroke, severe muscle damage and heart or liver failure. in addition, anything that blocks the organs' blood supply or the outflow of urine -- including tumors or an enlarged prostate -- can lead to kidney shutdown. the toxins that can trigger acute kidney failure include such medications such as antibiotics, nonsteroidal anti-inflammatory drugs (nsaids), and certain anesthetics. occasionally, procedures done in a hospital can also lead to acute kidney failure. whatever the cause, acute kidney failure can be deadly. without the normal waste removal system, the blood often becomes loaded with potassium -- an imbalance called hyperkalemia, which can lead to heart rhythm disturbances. the blood also becomes highly acidic and dangerously low in sodium. if a patient isn't producing enough urine, fluids build up rapidly and swamp other tissues. the death rate from acute renal failure can be high, depending on the cause of the kidney failure and other complications that the patient may have. on the bright side, the kidneys have an amazing capacity to heal themselves. this means most patients who survive acute kidney failure can enjoy a complete recovery within one to two months. some patients, however, need a year or so before their kidneys are fully functional again. others, whose kidneys have been severely damaged, may go on to chronic kidney failure. while acute kidney failure can happen in days, chronic kidney failure is a slow decline that often spans several years and often leads to irreversible damage. diabetes and high blood pressure can slowly damage the kidneys and trigger a long-term decline in function. other conditions associated with chronic kidney failure include polycystic kidney disease and use of the drug lithium. kidneys in chronic failure will never recover their normal function. when kidneys go into chronic failure, much of the body suffers. the buildup of fluids and waste products can set off a cascade of complications, including weakened bones, hypertension, stomach ulcers, anemia, miscarriages, changes in skin color, congestive heart failure, and lapses in concentration and memory. (not all kidney failure patients -- acute or chronic -- have a decrease in urine. in some patients, the kidneys continue to excrete urine that's mainly water without removing most of the body's waste products. while these people don't suffer from fluid buildup, imbalances from excess waste products remain a problem.) when the symptoms of advanced renal failure are present, a person is said to have end-stage renal disease, often called esrd. at this point, the patient will need treatment -- either dialysis or a kidney transplant -- to stay alive. followup instructions: call dr office, he can be reched at . your daughter has scheduled an appoinment with nephrology in for you to continue dialysis. it is very important that you keep this appointment. the point of contact is , phone number . Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Hemodialysis Angioplasty of other non-coronary vessel(s) Venous catheterization for renal dialysis Pulmonary artery wedge monitoring Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Transfusion of packed cells Arteriography of renal arteries Transposition of cranial and peripheral nerves Insertion of two vascular stents Procedure on single vessel Diagnoses: Hyperpotassemia Thrombocytopenia, unspecified End stage renal disease Tobacco use disorder Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Hematoma complicating a procedure Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Pneumonia due to Pseudomonas Atherosclerosis of renal artery Iatrogenic pneumothorax Disorders of phosphorus metabolism Dermatitis due to drugs and medicines taken internally Personal history of urinary calculi Unspecified transient cerebral ischemia Personal history of malignant neoplasm of kidney Other specified antibiotics causing adverse effects in therapeutic use

allergies: nkda psh: none ros: neuro- alert, opens eyes to speech, nods approp, fc, moving legs slightly in bed, min movement l arm, moves r arm spont and purposefully. perrla 3-4mm. no seizure activity noted, dph level 18.9 propofol at 20mcgs/kg/min to maintain sync w/ vent. mental status waxes-n-wanes when alert rr 18-33 when asleep rr 6-9. weak cough. resp- sux for sm amts thick white secretions, lots of thick oral secretions. bs clear in upper fields and coarse at bases. sao2 100% rested on imv over night. gd abg. cvs- occ episode of hypotention responded well to fluid boluses. hct 25 ho aware. hr 98-116 st no ectopy. maps 70's-80's. tm 102.4 responded to tylenol. gi- abd soft and distended, oozing sm amts of stool all night, brown soft guiac (-). ogt to lis, draining very little. gu- gd uo, clear yellow. foley patent. skin- intact, r hand edematous from old infiltrate. soc: living with mom, deceased recently due to ca. a+p: monitor per routine, follow dph levels, possib wean and extubate today. monitor closely for seizure activity. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Non-invasive mechanical ventilation Other permanent tracheostomy Percutaneous [endoscopic] gastrostomy [PEG] Diagnoses: Pneumonia, organism unspecified Acidosis Other convulsions Acute respiratory failure Paralytic ileus Poisoning by hydantoin derivatives Other conditions due to chromosome anomalies Accidental poisoning by anticonvulsant and anti-parkinsonism drugs Cerebral artery occlusion, unspecified with cerebral infarction

discharge medications: 1. dilantin 300 mg per gastrostomy tube h.s. 2. ativan 0.5 mg per gastrostomy tube t.i.d. 3. diastat 10 to 15 mg p.r. p.r.n. for seizures every two hours. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Non-invasive mechanical ventilation Other permanent tracheostomy Percutaneous [endoscopic] gastrostomy [PEG] Diagnoses: Pneumonia, organism unspecified Acidosis Other convulsions Acute respiratory failure Paralytic ileus Poisoning by hydantoin derivatives Other conditions due to chromosome anomalies Accidental poisoning by anticonvulsant and anti-parkinsonism drugs Cerebral artery occlusion, unspecified with cerebral infarction

service: curlin history of present illness: is a 29 year-old woman with melas (mitochondrial encephalo-myopathy with lactic acidosis and stroke like symptoms) who was brought into the emergency room by her mother for a gradual decline in mental status over the past week that led to a fall the had been increasingly agitated and emotional for the past few days. family members report that she took her anti-seizure medication of the next 3-4 days all at once and became "confused". the patient remembers falling, but cannot relay the immediate events prior to and after the fall. until recently was driving, working as a greeter at an mother reports that she has been less able to care for herself and has had to move back into her mother's house in the past few weeks. states that she feels like she is "going to die" and that her "mother is going to leave," but expresses no intention to harm herself. past medical history: melas diagnosed at age 18 after presenting with poor weight gain, headaches, repeated seizures. prior to these events was enrolled in college. mother reports three strokes at age 20, 24 and 29 namely one month ago. her mother reports no residual effects of any of the strokes. medications on admission: 1. dilantin 100 t.i.d. 2. verapamil 240 q.d. 3. vitamin c 500 b.i.d. 4. vitamin e 400 iu q.d. 5. co-enzyme q 150 q.d. 6. riboflavin/calcium 100/40 q.d. 7. mebaral 50 q.d. 8. klonopin 0.5 t.i.d. allergies: no known drug allergies. social history: no alcohol, drugs or tobacco use. her parents are divorced. she is currently cared for by her mother and a . physical examination: she was afebrile. she had a blood pressure of 127/73. heart rate of 70 and was sating 100% on room air. she was lying in the stretcher and was easily distracted. she had an ecchymosis over her left eye and some perioral dermatitis. her abdomen was soft, nontender and nondistended. her fundi were clear. she was alert and did not follow commands well. she knew her name, date and place. she was able to spell her name forward and backward. her immediate recall was 4 out of 4 with her memory being 0 out of 4 after 30 seconds. she was able to repeat sentences, read name tags and follow two step commands. she was able to clap her hands. she had normal facial sensation. her face was symmetric. her hearing was intact and her tongue was midline. her muscle bulk was decreased without hypotonia. she is moving her extremities spontaneously and on command and lifted her legs well. she had no tremor. her sensation was intact to light touch throughout her upper and lower extremities. her toes were down going. her lungs were clear and her heart rate was regular in rhythm and rate with no murmurs. laboratory: her hcg was negative. her electrolytes were normal. her dilantin level was 35. head ct showed no acute process. hospital course: ms. was admitted for observation given her high dilantin levels and her mental status changes. over the next few days, ms. developed severe metabolic acidosis with high lactate levels and an aspiration pneumonia that required intubation and icu admission. she was given levaquin with clearing of her pneumonia. her lactic acidosis was succesfully corrected with hyperventilation and fluids in the next day. however, she failed extubation twice and on the required placement of a tracheostomy tube. she also had a peg tube placed at that point. she then developed seizures that were eventually controlled with dilantin, keppra, and ativan. at this point she developed a second right lower lobe pneumonia. she was initially treated with clindamycin and cipro. due to her decreased responsiveness with quadriplegia, a head mri was obtained on the that showed wide spread bilateral cortical hyperintensitis on flair, dwi and t2wi consistent with stroke- like lesions and remarkable subcortical atrophy with a normal mra. emg was also obtained that showed diffused severe myopathy possibly consistent with critical care myopathy. an abdominal ct obtained around that time showed a right colon impaction believed to be secondary to dysmotility from melas syndrome. a general surgical consult believed that she was not a good surgical candidate and had recommended that she become npo with ngd compression and tpn for nutrition. dr from the neuro-muscular service was also consulted who reccomended a 5 day-course of high dose iv prednisone. at the end of the 5 days due to her lack of significant improvement, a family consult was obtained that agreed on making the patient dnr/dni, comfort measures only and the antibiotics were stopped on the . at this point she began to show clinical improvement and so was reinstated to full code status on the . tpn was restarted and aggressive bowel regimen was begun to try to clear her partial large bowel obstruction. on the she became febrile and was found to have coag negative staph bacteremia. the right subclavian line she had in was stopped at that point and she was started on vancomycin and ceftriaxone. a chest x-ray on the showed increasing infiltrates in the right middle lobe and the left lung, so her ceftriaxone was changed to zosyn. as she was seizure free from the she was transferred to the medicine service to manage her pneumonia and her partial large bowel obstruction. after her transfer she remained afebrile and repeat blood cultures were negative. an infectious disease consult was obtained that recommended five days of vanco for her line sepsis and fourteen days of zosyn for her pneumonia. she did well on both of these treatments. a gi consult was obtained with regard to her partial large bowel obstruction and an aggressive bowel regimen including reglan, suppositories, enemas, colace and golytely was recommended, which helped to clean out most of her bowel. by the time of this dictation her abdomen is soft and only a single mass of stool is palpable in the suprapubic region. she was on tpn for nutrition for most of until the when her family decided they wished to withdraw treatment and at that point her tpn was stopped. from a neurological standpoint her dilantin level was 26 on the and so it was held and will be restarted after her level drops to the low 15. she will continue on iv ativan for seizure prophylaxis. on the her neurological status has progressed to the point where she is not responsive to voice except for occasionally. she has been afebrile for over a week and has improved clinically in terms of her pneumonia with decreased secretions on the zosyn. she will have three more days of zosyn and then be done with antibiotics. her ng tube and peg tube are clamped and she is receiving no more drugs for her bowel regimen. she continues to receive trach care and suctioning with stable amount of secretions. her antiepileptic drugs include ativan and dilantin. the dilantin is being held and his being restarted after the levels are less then 15. she is in the midst of a solu-medrol taper. the only other medications that she is receiving are heparin and protonix for prophylactic purposes. discharge diagnoses: 1. end-stage melas with diffused multiple bilateral cortical stroke-like lesions, a severe generalized myopathy and gi dysmotility resulting in a partial large bowel obstruction. 2. resolving pneumonia. discharge medications: 1. ativan 0.5 mg iv t.i.d. 2. dilantin 300 mg iv q.h.s. 3. zosyn 4.5 mg q 8 hours times three days. her zosyn will end on the . solu-medrol 10 mg iv q 8 hours being tapered. 5. heparin 5000 units subcutaneously b.i.d. 6. protonix 40 mg iv q.d. 7. tylenol prn. 8. ativan 0.25 to 0.5 mg q 6 hours prn for facial twitching and arm trembling. , m.d. dictated by: medquist36 d: 10:17 t: 10:54 job#: Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Non-invasive mechanical ventilation Other permanent tracheostomy Percutaneous [endoscopic] gastrostomy [PEG] Diagnoses: Pneumonia, organism unspecified Acidosis Other convulsions Acute respiratory failure Paralytic ileus Poisoning by hydantoin derivatives Other conditions due to chromosome anomalies Accidental poisoning by anticonvulsant and anti-parkinsonism drugs Cerebral artery occlusion, unspecified with cerebral infarction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache major surgical or invasive procedure: suboccipital decompressive craniotomy, c1 laminectomy, duraplasty history of present illness: the patient is a 42-year-old patient who is well known to the neurosurgical service. he has been seen in dr. office multiple times on an outpatient basis. he has been diagnosed with a chiari ii malformation in the setting of a previously operated spinal meningeal viral series. the patient has classic signs of headaches that are positional and aggravated by coughing. the patient has been worked up with an mri scan that shows the tight posterior fossa with inferior displacement of parts of the cerebellum to the level of c1. he was counseled. he wished to proceed with elective decompression today. the patient was consented in the office. he was taken to the operating room on the evening of . past medical history: past medical history: 1. anxiety/depression. 2. chiari ii malformation with hydrocephalus. family history: not obtained physical exam: general: mildly anxious man but well appearing. neurologic exam: mental status: patient is alert, awake, mildly anxious affect with some tangential speech. good attention, tells a coherent story. language is fluent with good comprehension, repetition, able to read. he naming intact. no dysarthria. no neglect or left/right mismatch. cranial nerves:i-xii-intact. sensory: normal touch, vibration, proprioception, pinprick sensation. motor: slightly increased tone in the legs. no pronator drift. mild postural tremor, fine, low amplitude with arms outstretched. full strength. reflexes: brisk throughout 3+ with crossed adductors and bilaterally upgoing toes. + bilaterally. coordination: finger-to-nose slowwer on l, but normal heel to shin, rapid alternating movements. gait:gait appears normal but unable to tandem. brief hospital course: pt was admitted and brought to the or electively on for decompressive suboccipital craniotomy and c1 laminectomy and duraplasty under general anesthesia. post op he was transferred to sicu for close neurological monitoring. he remained neurologically intact. he was intermittently bradycardic. post op head ct showed good appearance. he was transferred to the floor. his diet and activity were advanced. his dressing was clean and dry. medications on admission: lithium bicarbonate (generic) 300/150/300, cymbalta 60mg daily. discharge disposition: home discharge diagnosis: chiari malformation discharge condition: neurologically stable discharge instructions: keep incision dry. call for fever or any signs of infection -redness, swelling or drainage from wound. followup instructions: follow up with dr. for suture removal in 10 days - call - for appt. Procedure: Other repair of cerebral meninges Other craniotomy Diagnoses: Hyposmolality and/or hyponatremia Dysthymic disorder Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Spina bifida with hydrocephalus, cervical region Superficial injury of cornea Other symptoms referable to back

discharge medications: 1. lithium carbonate 300 mg twice a day. 2. duloxetine 60 mg daily. 3. docusate sodium 100 mg twice a day. 4. percocet 1-2 tablets q.4 hours as needed for pain. 5. erythromycin ophthalmic ointment to be applied to the right eye 4 times a day for 5 days. discharge diagnoses: 1. chiari ii malformation. 2. major depression. 3. generalized anxiety disorder. 4. corneal abrasion. 5. sinus bradycardia. 6. hyponatremia. , md Procedure: Other repair of cerebral meninges Other craniotomy Diagnoses: Hyposmolality and/or hyponatremia Dysthymic disorder Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Spina bifida with hydrocephalus, cervical region Superficial injury of cornea Other symptoms referable to back

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: subdural hematoma s/p fall major surgical or invasive procedure: four vessel angiography history of present illness: 78 yo f s/p fall found down, pt denies loc . on xray has a c7 cervical fracture, head ct with small l sdh. neurologically intact, no focal weakness, numbness, parasthesias past medical history: glaucoma, hydrocephalus, r total knee replacement social history: unknown family history: unknown physical exam: 99 127/52 91 18 100% on nasal canula a/o x 3 perrl rrr cta b/l abd soft, nt/nd ext warm, no edema neuro intact pertinent results: four vessel angio with right mca acute occlusion brief hospital course: pt admitted with c7 fracture and l sdh after 4 vessel angio found to have r mca occlusion and will need intervention. medications on admission: toprol mvi aricept discharge medications: protonix metoprolol hydralazine discharge disposition: extended care facility: & rehab center - discharge diagnosis: acute right mca occlusion/stroke l sub dural hematoma c7 fracture glaucoma ?hydrocephalus r total knee replacement hypertension dementia discharge condition: critical discharge instructions: bedrest venodyes pul toilet npo ivf c collar on neuro checks followup instructions: f/u with interventional neuroradiology Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries Arterial catheterization Diagnoses: Unspecified essential hypertension Unspecified fall Other persistent mental disorders due to conditions classified elsewhere Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Cerebral artery occlusion, unspecified with cerebral infarction Closed fracture of seventh cervical vertebra Knee joint replacement

history of present illness: acute right middle cerebral artery occlusion, stroke, following four vessel angiogram, left subdural hematoma, c7 fracture, glaucoma, question of hydrocephalus and a right total knee replacement. hospital course: the patient was a 78 year old woman with a history of hypertension, glaucoma and dementia who was found unconscious by her bed by her brother and wife. she was taken to an outside hospital and found to have a c6-7 fracture and sent to . hemodynamically stable in the hospital but on route she had an episode of confusion and in the hospital with garbled speech. neurologic examination was intact at the time. she had no complaints of pain on arrival. neurosurgery was consulted for the subdural hematoma and on , she underwent a four vessel angiogram. after , four vessel angiogram, the patient was noted to have signs and symptoms consistent with a right cerebrovascular accident. the four vessel angiogram was to rule out vertebral artery dissection. per dr. , throughout the procedure, she was conversant, though slightly agitated, but she was given 0.5 mg of midazolam times two. she remained conversant until just after the right carotid was imaged at which time she manifested garbled speech. on examination, she had garbled speech and was uncooperative with motor examination although she was moving all extremities but decreased on the left. head ct showed no focal lesions, however, magnetic resonance imaging showed silent embolus of middle cerebral artery and accordingly dr. of neurology-stroke was consulted. trauma surgery considered transfer of patient to for neurosurgery intervention, however, this was not possible due to procedure space availability. already had another intervention team to complete another emergent procedure until 10:00 p.m. when the window for intervention would have been ended. therefore, the plan was for supportive care. no aspirin or heparin was provided per neurosurgery because of her left subdural hematoma. the patient's course in the intensive care unit continued to improve at which point on , she was transferred to the floor. the patient then required a percutaneous endoscopic gastrostomy tube for feeding which was placed on , without incident. she was started on tube feeds and tolerated that well. she is currently no full strength tube feeds at 60 cc/hour. the patient continued to improve throughout the hospital course. condition on discharge: fair. medications on discharge: 1. bisacodyl 10 mg p.o. or pr as needed. 2. metoprolol 12.5 mg twice a day. 3. aspirin 81 mg once daily. 4. colace in liquid form 100 mg twice a day. 5. lasoprazole 30 mg p.o. once daily. follow up: the patient is to follow-up with interventional neuroradiology department , dictated by: medquist36 d: 11:57:52 t: 13:09:44 job#: Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries Arterial catheterization Diagnoses: Unspecified essential hypertension Unspecified fall Other persistent mental disorders due to conditions classified elsewhere Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Cerebral artery occlusion, unspecified with cerebral infarction Closed fracture of seventh cervical vertebra Knee joint replacement

history of present illness: this 72-year-old white male is status post cabg in and recently presented to his physician with pnd and wheezing. he has had these symptoms for 2 weeks. this has been associated with increasing fatigue and dyspnea on exertion. he also has had worsening pedal edema which he says is chronic. he was seen by his physician and then evaluated in the emergency room for chf and treated with lasix. he ruled out for a myocardial infarction but had bnp of 810. he had an echocardiogram which revealed an ef of 35%, moderate mr , and mild ai, with distal septal dyskinesis, and moderate hypokinesis in the inferior lateral region. he is transferred for cardiac catheterization. past medical history: significant for a history of hypertension, coronary artery disease, status post cabg in (with a saphenous vein graft to the rca), and a history of chronic lower extremity edema. allergies: he has no known allergies. medications on admission: propranolol 20 mg p.o. b.i.d., adalat 30 mg p.o. daily, aspirin 81 mg p.o. daily, and combivent inhaler. family history: significant for coronary artery disease. social history: he is married and lives with his wife. drinks 3 beers a day and quit smoking 20 years ago. review of systems: unremarkable. physical examination on admission: he is an elderly white male in no apparent distress. vital signs were stable, afebrile. heent exam revealed normocephalic and atraumatic. extraocular movements were intact. the oropharynx was benign. neurologic exam was nonfocal. the neck was supple with full range of motion. no lymphadenopathy or thyromegaly. the carotids were 2+ and equal bilaterally without bruits. the lungs had bibasilar rales. cardiac exam was regular in rate and rhythm with a 3/6 systolic murmur and a positive s4. the pulses were 1+ bilaterally throughout. hospital course: he was admitted and underwent cardiac catheterization which revealed an occluded rca, 90% stenosis of saphenous vein graft, a complex lad lesion at the bifurcation of 90%, and a 70% left circumflex lesion, with an ef of 35%. dr. was consulted. he had carotid studies which revealed a less than 40% bilateral stenosis. he was diuresed. on he underwent a redo cabg x 1 with a mosaic mvr. he had a lima to the diagonal, and he had a 29-mm mosaic mvr. his vessels were intramyocardial, and his other vessels were unable to be bypassed. he was transferred the csicu on levophed, epinephrine, and propofol. on his postoperative night he had some hypotension but then was more stable by the morning. he was transfused a unit of blood. he remained intubated the first day to stabilize his blood pressure. his epinephrine was discontinued on postoperative day #2. his levophed was gradually weaned off. he was extubated on postoperative day #2. he required aggressive diuresis and pulmonary therapy. he continued to slowly progress. discharge status: he was transferred to the floor on postoperative day #5. he had his wires discontinued on postoperative day #6. he continued diuresis and physical therapy. he was discharged to home in stable condition with visiting nurse services and home physical therapy on postoperative day #9. laboratory data on discharge: his laboratories on discharge were white count of 10,400, a hematocrit of 27.3, platelets of 409,000, 138, 5.1, 104, 26, 27, 1.0, and 133. medications on discharge: 1. lopressor 50 mg p.o. b.i.d. 2. lasix 80 mg p.o. b.i.d. for 1 week and then 80 mg p.o. daily for another week. 3. plavix 75 mg p.o. daily. 4. multivitamin 1 p.o. daily. 5 lipitor 10 mg p.o. daily. 1. percocet 1 to 2 p.o. q.4-6h. as needed (for pain). 2. aspirin 81 mg p.o. daily. 3. protonix 40 mg p.o. daily. discharge diagnoses: 1. hypertension. 2. hyperlipidemia. 3. coronary artery disease. discharge followup: he will follow up with dr. in 4 weeks and with dr. in 1 to 2 weeks. , Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Open and other replacement of mitral valve with tissue graft Transfusion of packed cells Transfusion of other serum Continuous intra-arterial blood gas monitoring Diagnoses: Other iatrogenic hypotension Anemia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Aortocoronary bypass status Alcohol abuse, continuous

history of present illness: is the former 3.49 kg product of a 38-2/7 weeks gestation pregnancy born to a 26-year-old g5, p2, now 3 woman. prenatal screens were blood type o positive, antibody negative, rubella immune, rpr nonreactive, hepatitis b surface antigen negative, group beta strep status unknown. the pregnancy was uncomplicated. the mother presented for repeat elective cesarean section. previous ob history was notable for 2 cesarean sections. the infant was born at 1540 hours on . he was noted to have retractions after birth and was transferred to the neonatal intensive care unit for observation and monitoring. he required blow-by oxygen. apgars were 8 at 1 minute and 8 at 5 minutes. physical examination: upon admission to the neonatal intensive care unit, weight was 3.49 kg, length 51 cm, head circumference 35 cm, all 75th to 90th percentile for gestational age. general: the infant appears consistent with a gestational age of 38 weeks, pink and nasal cannula o2, well-perfused, responsive. head, ears, eyes, nose and throat: normocephalic, anterior fontanelle soft and flat. ears are normal. palate is intact. neck: normal. chest: clavicles normal, breath sounds equal bilaterally with grunting, intercostal retractions. cardiovascular: normal heart sounds, no murmur. peripheral pulses are normal. abdomen: soft, nondistended, nontender, no masses, no hepatosplenomegaly. gu: normal male, anus patent. spine: normal. extremities: normal. skin: normal without lesions. neuro: mildly decreased tone with intact reflexes. hospital course by systems including pertinent laboratory data: respiratory: was initially on nasal cannula o2 due to his increased work of breathing. he was changed to continuous positive airway pressure. he remained on the continuous positive airway pressure until 8 p.m. on when he transitioned to room air. he remained stable in room air with oxygen saturations greater than 95% with minimal work of breathing. chest x-ray was consistent with retained fetal lung fluid on day of life #1. repeat chest x- ray on day of life #2 showed improvement. there was no concern for pneumonia and the antibiotic course was discontinued at 48 hours. cardiovascular: has maintained normal heart rates and blood pressures. no murmurs have been noted. fluids, electrolytes and nutrition: was initially npo on intravenous fluids. after the discontinuation of the continuous positive airway pressure, enteral feeds were started. he has been breastfeeding ad lib and maintaining normal glucoses. the mother's choice is to exclusively breastfeed with no formula. weight on the day of transfer is 3.44 kg. serum electrolytes at 24 hours of life were within normal limits. infectious disease: due to the unknown etiology and severity of the respiratory distress, was evaluated for sepsis upon admission to the neonatal intensive care unit. a complete blood count had a white count of 25,100 with a differential of 39% neutrophils, 20% band neutrophils and normal platelets. intravenous ampicillin and gentamicin were started. a repeat complete blood count on day of life #2 had a white blood cell count of 29,400 with a differential of 77% polymorphic neutrophils and 7% band neutrophils. blood culture obtained prior to starting antibiotics was no growth and the antibiotics were discontinued at 48 hours as the respiratory symptoms had resolved. gastrointestinal: serum bilirubin on day of life #1 was a total of 5.7 mg/dl. a recheck bilirubin is to be drawn along with the state screen on the morning of . hematological: hematocrit was birth was 47.8%. neurological: neurological exam improved with his improvement in respiratory status. he has maintained a normal neurological exam and there are no neurological concerns at the time of discharge. sensory: audiology hearing screening has not yet been performed. condition at discharge: good. discharge disposition: transferred to the newborn nursery under the care of the newborn service. primary pediatrician: dr. , center, phone number . care and recommendations at the time of discharge: 1. ad lib breastfeeding. 2. no medications. 3. car seat position screening not recommended. 4. state newborn screen to be drawn on . 5. no immunizations administered to date. discharge diagnoses: 1. near term infant. 2. respiratory distress secondary to retained fetal lung fluid. 3. suspicion for sepsis ruled out. , Procedure: Non-invasive mechanical ventilation Prophylactic administration of vaccine against other diseases Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Transitory tachypnea of newborn

history of present illness: the patient is a 34 year-old male with hypertrophic obstructive cardiomyopathy diagnosed four years ago status post new ethanol ablation on this admission. he was active until about last experiencing increased dyspnea on exertion even with short walks and short climbs of stairs. also often accompanied by mild chest discomfort, which the patient has described as aching/burning. note this patient had a holter monitoring in , which was normal. the patient denies any claudication, orthopnea, paroxysmal nocturnal dyspnea, but positive lightheadedness since starting his medications. his last echocardiogram in showed a dilated left atria, also a posteriorly directed narrow jet flow of mr hugging the wall of the la with an asymmetric septal hypertrophy with of the mitral valve and outflow track gradient of 102 mmhg. posterior wall thickening was 1.2 with fractional shortening of at least 54%. denies any fevers or chills, nausea or vomiting. the patient was admitted to coronary care unit post planned ethanol septal ablation for observation with temporary rv pacemaker in place per protocol for risk of acute heart block accompanying the ablation. past medical history: 1. depression. 2. hocm diagnosed four years ago. 3. left ankle surgery in . 4. partial parathyroidectomy for hypercalcemia in . 5. tonsillectomy in . allergies: general anesthesia gives him a violent reaction when awakening up from it. home medications: 1. atenolol 50 q day. 2. verapamil 120 sr q.d. 3. aspirin 81 mg po q day. social history: single, divorced male, has a supportive girlfriend. occasional ethanol use. no tobacco. no drugs. manages a construction company. family history: strong family history of hocm. mother and maternal grandmother and aunts all with hocm. no family history of sudden death. mother has had a history of ventricular tachycardia and has required a defibrillator placed and duel chamber pacemaker two years ago. physical examination on admission (from cath lab following ablation): temperature 98.3. blood pressure 134/69. pulse 96. respirations 18. o2 sat 95% on room air. examination generally no acute distress, alert and oriented times three. heent pupils are equal, round, and reactive to light and accommodation. extraocular movements intact. mucous membranes are moist. neck supple. the patient has a right ventricular temporary pacemaker placed through a right ij sheath. dry and intact and functional. cardiovascular regular rate and rhythm. trace systolic murmur best heard at the apex, blowing in nature. no gallops or rales. respirations clear to auscultation bilaterally. abdomen soft, nontender, nondistended. bowel sounds present. no rebound or guarding. no costovertebral angle tenderness. extremities no clubbing, cyanosis or edema. groin sites were dry and intact. no hematoma. bilateral pulses present, 2+. no bruit appreciated. no hematoma appreciated on both groin sites, the entry sites for the catheterization. laboratories on admission: white blood cell count 11.7, hematocrit 39.9, platelets 208, sodium 132, potassium 4.3, chloride 104, bicarb 23, bun 17, creatinine 1.5, glucose 155, magnesium 1.7. his arterial blood gas was 7.36, 41, co2 150 02 on room air, 24 bicarb, ck 1292, ckmb 174, troponin t was 3.39. hospital course: the patient was admitted for his cardiac procedure. the patient was status post ethanol ablation, which is a deliberate controlled myocardial infarction hich was done without complication. for coronary artery protection he was placed on aspirin. his home dose of aspirin was increased to 325 mg po q day. he tolerated well without any complications. he had no chest pain until the day before discharge at which point he complained of some chest pressure. no electrocardiogram changes noted. no radiation and positionally changed more comfortable in sitting forward position then laying backward, but resolved with ibuprofen since. no electrocardiogram changes. his pre cath echocardiogram showed a hocm with valve and severe resting lvot gradient, moderate eccentric mitral regurgitation, biatrial enlargement, peak resting, lvot gradient of 60, pasp of 25 and his left ventricular ef was greater then 75% and inducible gradient was 80-160 mmhg. at conclusion following intervention, peak lvot gradient in presence dobutamine reduced to 20 mmhg. in terms of his rate the patient was placed on a temporary pacemaker in the cath lab. the temporary pacemaker was initially set at a rate of 70 with a threshold, which was about 1.5 to 2, which upon the transfer to coronary care unit the lead had moved up from the right ventricle to the right atrium and the patient was a pacing. at which point the cardiology service was consulted and he had a bedside fluoroscopy, readjustment of his pacemaker leads done and was replaced back into the right ventricle without any difficulty. follow up chest x-ray showed patient's lead again correctly placed in rv. the patient had two episodes of occasional v pacing two days prior to discharge when his heart rate dropped into the 50s. since then his heart rate parameter was decreased to 35 and the problem was alleviated since then and the patient since has not required any v pacing since he was in the coronary care unit. in terms of his history of parathyroidectomy, his calcium was checked on admission and his calcium levels had been within normal limits and monitored closely without any difficulties. in terms of his fluids, electrolytes and nutrition he tolerated his diet well after the first day and no nausea or vomiting and he was advanced to a regular diet cardiac since. prophylactically, he was on protonix, pneumoboots and a bowel regimen and did well while he was here. because of his age, strong family history of hocm, and high physical stress occupation, the ep service was consulted re consideration of future placement of aicd to lower risk of sudden death. after talking to dr. and the other cardiologists on service he is now thinking about getting an icd placed in a couple of weeks. he has dr. number and will follow up with. he is also to follow up with his cardiology physician who is dr. in in the next week. the patient is being discharged to home in stable and good condition. the patient is to call or follow up if any new chest pain or shortness of breath, lightheadedness, difficulty breathing, palpitations develop, seek medical attention as soon as possible. final diagnosis: familial hocm, nyha class iii on multidrug therapy. status post ethanol septal ablation this admission. recommended follow up: the patient is to follow up with dr. on at 1:00 p.m., at the building. he is also to follow up with dr. in two weeks, call for an appointment. also follow up with his physician . within one week. per usual protocol for ablation, repeat echo should be performed in 3 months (lv will undergo continued remodeling of outflow track in this interval). if outflow gradient at rest and with provocation is minimal, tapering of atenolol and/or verapamil may be considered at that time. major surgical and invasive procedures done while in service: status post ethanol septal ablation, status post cardiac catheterization. discharge condition: good, stable. discharge medications: 1. atenolol 50 mg po q day. 2. verapamil 120 mg sr q 24 hours. 3. aspirin 81 mg po q day. , m.d. dictated by: medquist36 d: 02:21 t: 08:03 job#: Procedure: Excision or destruction of other lesion or tissue of heart, endovascular approach Insertion of temporary transvenous pacemaker system Diagnoses: Pure hypercholesterolemia Mitral valve disorders Depressive disorder, not elsewhere classified Unspecified disease of pericardium Mechanical complication due to cardiac pacemaker (electrode)

history of present illness: this 62-year-old gentleman presented with two week history of epigastric discomfort ruled in for myocardial infarction and had an episode of v-fib that responded to cardioversion. he was transferred into for cardiac catheterization, which showed 80% left anterior descending artery lesion, 40% diagonal lesion, 60% circumflex lesion, om-2 30% lesion, om-3 30% lesion, a 50% right coronary artery lesion with a 30% pda lesion, and an ejection fraction of 27%. on cath lab an intra-aortic balloon pump was placed for his ventricular dysfunction and severe three-vessel disease. he is referred to cardiothoracic surgery service for evaluation of cabg. preoperative laboratory work was white count of 9.3, hematocrit 42.5. sodium 137, k 4.4, chloride 102, co2 27, bun 18, creatinine 1.1 with a blood sugar of 219. past medical history includes hypertension and hypercholesterolemia as well as bilateral kidney stone removal and appendectomy. patient also reported a two small purulent nodal areas in his abdomen and his left thigh, non-insulin dependent-diabetes mellitus. he had no known allergies. medications on admission were zocor, cozaar, glyburide, glucophage, and was now on iv integrilin when seen by cardiac surgery. on examination, his blood pressure was 107/64 with a heart rate of 71. he had no carotid bruits. heart was regular, rate, and rhythm. his lungs were clear bilaterally. his abdominal examination was benign. he had no varicose veins and had distal pulses present in his feet. his electrocardiogram showed q waves in v1 through v3 as well as st depressions in v4, v5, and 6, and avl. he will referred to dr. . on , he underwent coronary artery bypass grafting x4 with a lima to the left anterior descending artery, a vein graft to the pda, a vein graft to diagonal-1 and vein graft to om-2, who was transferred to cardiothoracic intensive care unit in stable condition. on postoperative day one, he continued on his perioperative vancomycin and was on the following drips: neo-synephrine at 1 mcg/kg/min, nitroglycerin at 0.25 mcg/kg/min, milrinone at 0.25 mcg/kg/min, and insulin drip for glucose coverage. he was extubated the night of operation and the following morning was in sinus rhythm in the 90s with a blood pressure of 95/43. cardiac index of 2.6 with an intra-aortic balloon pump at 1:1. he remained on a face mask with postoperative laboratories of a hematocrit of 27.5, k of 4.8, and bun of 18, and creatinine of 0.8. his heart was regular, rate, and rhythm. his respiratory sounds were slightly coarse. he had dopplerable pulses in his feet with no signs of ischemia in his legs. the plain was to discontinue his milrinone first and try to wean his balloon later. he remained in the intensive care unit. diuresis was not started pending his hemodynamic status following drips and balloon removal. on postoperative day two, his balloon was removed. his chest tubes were removed. he remained only on a neo-synephrine drip at 0.75 mcg/kg/min. he was saturating well on nasal cannula with a good blood pressure and was slightly tachycardic at 106, but his lopressor was held until he was off his neo-synephrine and he started his oral medications. he was transferred 2 units of blood for his hematocrit of 20.8. he was seen by physical therapy for evaluation and case management. on postoperative day three, his hematocrit rose to 25 after transfusion. he was restarted on his oral sugar medications. he remained tachycardic in sinus rhythm at 105 with a good blood pressure. he was started on lopressor 12.5 . his diet was advanced. his foley was removed. he began his lasix diuresis and was transferred to the floor. on postoperative day four, he continued with his lopressor and diuresis. remained now in sinus rhythm at 82 with a good blood pressure. hematocrit holding at 24.1 with a bun of 14 and creatinine of 0.6. he was alert and oriented. he was on po pain medications. he continues diuresis. on postoperative day five, he continued to do well and to improve. he was ambulating. his pacing wires were removed. his incisions were clean, dry, and intact. his lungs were clear bilaterally. he was sating 92% on room air. he was receiving percocet for po pain. on , postoperative day six, he was discharged to home in stable condition with instructions to followup with dr. , his primary care physician weeks, and follow up with dr. , his surgeon in four weeks at the office. discharge medications: aspirin 325 mg po q day, docusate 100 mg po bid, glyburide 5 mg po q day, metformin 500 mg po bid, lopressor 50 mg po bid, zocor 40 mg po q day, ibuprofen 600 mg po prn q8h, percocet 1-2 tablets po prn q4-6h for pain. discharge diagnoses: 1. status post coronary artery bypass grafting times four. 2. non-insulin dependent-diabetes mellitus. 3. hypertension. 4. hypercholesterolemia. 5. status post bilateral kidney stone removal. 6. status post appendectomy. again, he was transferred home in stable condition on . , m.d. dictated by: medquist36 Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Implant of pulsation balloon Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Ventricular fibrillation

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bloody diarrhea major surgical or invasive procedure: transfused 2 units packed red blood cells. colonscopy egd history of present illness: this is a 47to f h/o fibroids with brspr and diarhhea of 3 days duration. on thursday afternoon (), ms. was at work (employed as unit coordinator at the ) when she began to feel dizzy and short of breath, without any associated chest pain. she went home, where she had her first episode of bloody diarrhea at 5 pm. the observed blood was described as dark and sufficiently voluminous to fill the toilet bowel (estimated volume = 1 cup). she went to bed, and the next morning, she had two more episodes of bloody diarrhea, with progressively worsening light-headedness with shortness of breath on walking short distances (ie., to bathroom). she came to the ed on because she was concerned by her bloody diarrhea and shortness of breath. . on arrival to the ed vital signs were t 98.6 hr 110, bp 134/59 rr 24 o2 sats 100 on ra. she was found to have a hct of 17, mcv of 57, hgb 4.4 (calc hct 13). gross blood was found in the vault, but ng lavage was negative. she received 2 units of prbc in the ed and remained stable throughout her admission to the micu, with slight tachychardia to the 120's. past medical history: sx: elbow fx with surgical intervention fibroids removed 13 years ago . ob/gyn: regular periods 26x5 days. reported as heavy first two days. . social history: the patient works as a unit coordinator at . she lives by herself in . she occasionally uses alcohol, and smokes about 10 cigarettes per week. previous 10 pack-year history. family history: family history: father--mi at age 55. mother--lung cancer. sister--uterine fibroids. . physical exam: gen: nad, supine on bed. heent: nc/at, perla, no lad heart: distinct s1, s2, systolic murmer at ursb and ulsb. no t/r abd: s/nt. distended. + bowel sounds ext: warm, well-perfused. neuro: aox3, no focal defecits. pertinent results: 09:11pm hct-22.5* 04:06pm hct-19.4* 10:53am hgb-4.4* calchct-13 09:40am urine hours-random 09:40am urine gr hold-hold 09:40am urine color-straw appear-clear sp -1.011 09:40am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 08:45am glucose-130* urea n-17 creat-0.9 sodium-138 potassium-4.4 chloride-109* total co2-20* anion gap-13 08:45am ld(ldh)-152 08:45am iron-7* 08:45am caltibc-420 haptoglob-76 ferritin-2.2* trf-323 08:45am pt-13.2* ptt-22.9 inr(pt)-1.1 08:30am wbc-12.1* rbc-3.09* hgb-4.7* hct-17.5* mcv-57* mch-15.1* mchc-26.7* rdw-19.4* 08:30am plt count-405 08:30am ret man-3.3* brief hospital course: on arrival to the ed (), vital signs were t 98.6 hr 110, bp 134/59 rr 24 o2 sats 100 on ra. the patient was found to have a hct of 17, mcv of 57, hgb 4.4 (calc hct 13). gross blood was found in the vault, and ng lavage was negative. the patient received 2 units of prbc in the ed and remained stable throughout her admission to the micu, with slight tachychardia to the 120's. . in the micu, the patient was started on iron and scoped from above and below. upper endoscopy was unremarkable except for grade i esophagitis in the ge junction and lower third of the esophagus. colonoscopy showed clotted blood as well as diverticuli in the distal transverse colon, splenic flexture, descending colon and sigmoid colon. a single non-bleeding polyp was located in the mid-sigmoid region. the polyp was not removed but recommendation was made for removal at a later date. . the patient remained hemodynamically stable and was transferred to the internal medicine service on saturday night (). hematocrit was in the 27's on saturday night and sunday morning. she had one episode of dark bloody stool on sunday afternoon, likely residual and not indicative of new bleeding. her heamtocrits trended upwards from sunday to monday afternoon (27.3-->29.0-->30.1) with no bloody stool. the patient was discharged on iron and ascorbic acid with follow-up with her pcp. was made to dr. ( for removal of polyp. . medications on admission: advil zantac discharge medications: 1. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* 2. ascorbic acid 250 mg tablet sig: one (1) tablet po three times a day: please take one tablet each time you take your ferrous sulfate for better absorbtion. disp:*90 tablet(s)* refills:*2* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* discharge disposition: home discharge diagnosis: 1. diverticulitis 2. acute on chronic anemia discharge condition: good. discharge instructions: 1. please follow-up with your doctors below. 2. please return to the ed for new shortness of breath, difficulty breathing, bloody diarrhea, or severe abdominal pain. 3. please take your iron pills (ferrous sulfate) and ascorbic acid as directed. you will take these pills until your pcp determines that your hemoglobin level normalizes. followup instructions: 1. please go to ( ) at 9:30 on this , for repeat colonoscopy with removal of your polyp. instructions for your bowel prep. will arrive at your home in the mail this week. 2. please follow-up with your pcp (dr. ) on at 11:30. please ask your pcp to evaluate your systolic murmur best heard at the right upper sternal border, as well as your history of heavy menses. Procedure: Other endoscopy of small intestine Colonoscopy Transfusion of packed cells Diagnoses: Acute posthemorrhagic anemia Benign neoplasm of colon Diverticulosis of colon with hemorrhage

history of present illness: 65-year-old gentleman with past medical history significant for neck cancer, admitted to - for cardiac catheterization following arrest. the patient originally was admitted to following an unwitnessed arrest. the patient's wife reports that patient got up to go to the bathroom. he did not return and his wife subsequently found him down unresponsive and approximately five minutes later ems found patient to be in asystole. he was resuscitated following epinephrine, atropine and lidocaine. he also got an aspirin and heparin. the rhythm strip showed him to be in the rhythm of atrial fibrillation with a blood pressure initially of 25/palp and then 60/palp. the patient was then taken to . upon arrival at an ekg showed inferolateral st depression. he was then transferred to - for cardiac catheterization. past medical history: neck cancer, status post dissection in and status post chemotherapy and radiation. medications: no home medications. medications on transfer: heparin, lidocaine. allergies: unknown social history: married. tobacco use 1?????? packs per day. physical examination: temperature 92.4??????, heart rate 95, blood pressure 131/86, respirations - intubated, on ventilator. general: intubated and sedated, on vent. heent: pupils dilated and non-reactive to light. cardiovascular: regular rate, no murmurs, rubs or gallops. lungs: clear to auscultation anteriorly, right breath sounds slightly decreased as compared to the left. abdomen: decreased bowel sounds. extremities: pulses intact in extremities times four. neurological: pupils fixed and dilated, no corneal reflexes, no gag reflexes. no response to pain or stimuli. areflexic. does not withdraw extremities to pain. laboratory data: on admission, white count 7.8, hematocrit 35.7. sodium 138, potassium 4.3, chloride 105, bicarbonate 14, bun 7, creatinine 1.2, glucose 152. electrocardiogram - sinus tachycardia with inferior st depression at approximately 2 mm. normal axis. abg 6.97, 64, 52 on 100% fio2. hospital course: 1. cardiovascular. patient admitted following asystolic arrest with prolonged down time. there is significant concern for patient's neurologic status given his neurologic exam and his ph of 6.97 at admission. initially cardiac catheterization was held until a further determination of his prognosis and likelihood of recovery could be determined. his arrest was thought to be likely ischemic with his lateral st depressions versus primary arrhythmia. the patient was monitored. he had an echo which showed an ejection fraction of 50% and significant valvular disease. the patient was monitored supportively and further cardiac intervention was not undertaken given his neurologic status. 2. neurology. patient admitted unresponsive with no brain stem functions. however, he did not meet the criteria for brain death. patient continued to decline neurologically and began to develop wide temperature fluctuations and autonomic dysfunction. patient was thought to have hypothalamic dysfunction due to his severe anoxic brain injury. neurology was consulted and patient was thought to have a very poor prognosis, supportively, until he suffered the cardiorespiratory arrest. 3. severe acidosis. patient admitted with an ph of 6.97. this was thought to represent severe lactic acidosis in the setting of prolonged hypoxia and asystolic arrest. he was maintained supportively. disposition: patient transferred to the idmc following the asystolic arrest with prolonged down time in the field. patient was severely acidotic and had minimal intact neurologic function. his status rapidly declined following admission to the ccu and he developed severe autonomic dysfunction thought to be due to his anoxic brain injury. patient then suffered a cardiopulmonary arrest. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Paroxysmal ventricular tachycardia Acute myocardial infarction of inferolateral wall, initial episode of care

past medical history: pertinent for hypertension; obesity; status post pacemaker for sick sinus syndrome in ; cva x 2, first in , a second in , affecting the left side with minimal permanent deficits; osteoarthritis; gerd, status post intestinal bypass; as well as appendectomy; and cholecystectomy, as well as a hernia repair; depression; fibromyalgia; diabetes mellitus, baseline. allergies: sulfa with which she gets a rash. outpatient meds: include atenolol 50 mg qd, perphenazine 37.5 mg po bid, and tagamet, aspirin. initial exam: the patient was not alert and oriented, was not answering questions, or following commands. vitals - 97.6, heart rate 92-117, bp 156/70, respiratory rate 16, satting 96% on room air. in general, she was in no apparent distress. oropharynx was clear. pupils equally round and reactive to light. mucous membranes were dry. no bruits on neck. chest - anterior chest with coarse breath sounds. cardiology - irregularly, irregular, borderline tachycardic. abdomen was mildly distended, good bowel sounds, nontender. extremities - good distal pulses. neuro exam - again, not alert and oriented, 1+ reflexes diffusely, good muscle tone, unable to answer questions. laboratory data: the patient's hematocrit was 28.4, repeat 25.5, white blood cell count not elevated. chem-7 141, sodium 4.7, potassium 110, chloride 22, bicarb 26, creatinine 1.4. all three sets of cardiac enzymes were negative. inr 1.3, pt 14, ptt 27.6. abg 7.34, carbon dioxide 40, and oxygen 115. ua was noted to have white blood cells, with occasional bacteria. urine culture showed no growth. hip culture on showed no growth to date. chest x-ray had ventricular enlargement and possible early chf. ekg had atrial fibrillation. issues - 1) mental status changes: most likely secondary to narcotic overuse. the patient was given 3 tabs po percocet, as well as 2 mg of iv dilaudid. there was a question of stroke versus subdural versus infection. ct scan of the head was negative. the patient remained afebrile. urine culture was negative. blood culture pending. again, the patient responded very well during the hospital course in terms of mental status changes resolved. the patient, upon dispo, is clear mentally, back to baseline. 2) atrial fibrillation: blood pressure has been stable, but because of a rapid ventricular response was given lopressor pushes, and then finally po atenolol to keep her heart rate within normal limits. the patient was on telemetry. the patient was started on anticoagulation of iv heparin, will be d/c on lovenox and then coumadin 4 mg until she is therapeutic. 3) low hematocrit: likely secondary to blood loss, given the 900 blood loss. stool guaiac negative. post-transfusion, her crit has been stable for 24 hours. 4) hip fracture: she will continue lovenox anticoagulation, as well as continue physical therapy, going to rehab. she has a right subclavian in terms of access which will be d/c. she was full code, and we were in communications with the daughter. discharge medication: included lovenox 40 mg subcu qd, atenolol 50 mg po qd, perphenazine 37.5 mg po bid, tylenol 650 mg po q 4-6 h. , m.d. dictated by: medquist36 Procedure: Open reduction of fracture with internal fixation, femur Removal of implanted devices from bone, femur Bone graft, femur Diagnoses: Esophageal reflux Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Cardiac pacemaker in situ Drug-induced delirium Nonunion of fracture

discharge medications: 1. coumadin 5 mg po q hs to be adjusted for an inr of 2 to 3 2. vitamin b12 1000 mcg intramuscular or subcutaneous q week x3 weeks and then q month 3. heparin intravenous until coumadin is therapeutic 4. protonix 40 mg po qd 5. lopressor 100 mg po tid 6. msir 15 mg po q6h prn pain. the msir should be adjusted according to her mental status and pain control. , m.d. dictated by: medquist36 d: 14:08 t: 14:30 job#: Procedure: Left heart cardiac catheterization Coronary arteriography using a single catheter Open reduction of fracture with internal fixation, femur Diagnoses: Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Atrial fibrillation Unspecified fall Other B-complex deficiencies Hyperosmolality and/or hypernatremia Chest pain, unspecified Closed fracture of subtrochanteric section of neck of femur

history of present illness: the patient is a 75-year-old woman with a history described in the past medical history, who was admitted to hospital on with left-sided chest pain and ruled out for myocardial infarction. she was found to be in new onset atrial fibrillation. persantine thallium revealed a reversible defect, prompting transfer to for catheterization. however, prior to catheterization, she had chest pain and fell, a mechanical fall resulting in a left intertrochanteric fracture. she had a negative head ct and cervical spine, and then was transferred to . past medical history: 1. hypertension 2. obesity 3. history of sick sinus syndrome status post pacemaker in 4. depression 5. cerebrovascular accident x 2 in and affecting the left side 6. osteoarthritis 7. gastroesophageal reflux disease 8. intestinal bypass, cholecystectomy, appendectomy and hernia repair 9. fibromyalgia medications on transfer: her medications as an outpatient are atenolol, zoloft, aspirin and tagamet. allergies: sulfa drugs, which cause a rash. social history: she has no tobacco or alcohol use. she lives in . physical examination: at the time of admission, notable for a blood pressure of 112/72, pulse 78, respirations 24, 91% on room air, 97% on 3 liters. in general, she is sleepy, falling asleep during the examination, complained of pain, but in no acute distress. heart was irregularly irregular, no murmurs, no jugular venous distention, no carotid bruits. the lungs are clear to auscultation anteriorly and laterally. the abdomen is soft, obese, with active bowel sounds, nontender. the extremities showed no edema, cool, 2+ pedal pulses bilaterally. neurological examination is alert and oriented x 3. cranial nerves intact. upper extremities 4/4 strength bilaterally. laboratory data: on admission, notable for creatinine of 1.3, normal liver function tests. troponin less than .02 x 3. urinalysis was negative. all of this was at the outside hospital. upon admission to , her ck was 1058 with an mb of 19, presumed secondary to the fall, and her bun and creatinine had increased to 36 and 2.6 respectively. phos was 7.0. hip x-ray revealed a left hip intertrochanteric fracture with varus deformity, superior displacement of the distal fragment, no evidence of dislocation. persantine thallium revealed an ejection fraction of 48% with an ischemic inferoapical wall and anteroapical fixed abnormality, hypokinesis of the apex and lateral wall and inferoapical wall. chest x-ray revealed moderate cardiomegaly, no pneumonia or congestive heart failure. hospital course by system: 1. neurology: the patient had mental status changes after extubation, was able to only answer a few questions, however, this improved as her sodium decreased back down to a normal range. it may also have been related to benzodiazepines or medications that she had at the time of intubation, which were washed out of her system. at the time of discharge, she is alert and oriented x 3. the patient also had two head ct studies which did not show any evidence of acute focal processes. 2. heart: she was in atrial fibrillation rhythm. it is unclear when that originally occurred. she remained on telemetry for her hospital course, and she was not taking oral medications. she was taking metoprolol intravenously to keep her pulse and blood pressure stable. she became hypertensive and tachycardic in the 130s to 140s at times. once she was able to pass her swallowing evaluation, she was restarted on lopressor and then switched to atenolol at discharge. possible cardioversion was discussed, possibly as an outpatient. the cardiac catheterization was done and revealed minimal coronary artery disease. therefore, the chest pain was believed not to be secondary to cardiac ischemia. 3. pulmonary: the patient was intubated at the time of surgery for the left hip repair, and was weaned in the surgical intensive care unit after surgery. 4. gastrointestinal: the patient was kept nothing by mouth until her mental status had cleared. she had failed two swallowing studies because of lack of cooperation, however, she was finally able to pass a swallowing study on the , and was restarted on oral intake and oral medications. she received zantac throughout her hospital course intravenously. 5. endocrine: her sugars were well controlled for the most part on regular insulin sliding scale. 6. renal: creatinine and bun improved during the hospital course. discharge plan: to transfer the patient on the following medications: coumadin 5 mg by mouth daily at bedtime to be adjusted for an inr of 2 to 3, vitamin b12 1000 mcg intramuscularly or subcutaneously weekly for three weeks then monthly, heparin intravenously until the coumadin is therapeutic, protonix 40 mg by mouth once daily, atenolol 100 mg by mouth once daily. she will have physical therapy and be on a cardiac diet. discharge diagnosis: 1. left hip fracture 2. hypernatremia 3. atrial fibrillation 4. diabetes mellitus , m.d. dictated by: medquist36 Procedure: Left heart cardiac catheterization Coronary arteriography using a single catheter Open reduction of fracture with internal fixation, femur Diagnoses: Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Atrial fibrillation Unspecified fall Other B-complex deficiencies Hyperosmolality and/or hypernatremia Chest pain, unspecified Closed fracture of subtrochanteric section of neck of femur

pmhx: htn, obesity, sss s/p pacer , cva x 2 & with lt sided residual weakness, depression, gerd, oa, intestinal bypass, appy, hernia repair, fibromyalgia, & stress echo negative. preadm meds: zoloft, asa, pepcid and atenolol allergies: sulfa->rx rash soc-> lives in center. supportive daughter per notes who is the spokesman. or course-> pt acidosic and hemodyn unstable initially in or. pt intubated and tx with bicarb and ivf as noted. pt 3.8l lr and 2uprbc intraop while on a neosynephrine gtt. pt admitted to icu at 11:30pm. placed pap in icu upon admission d/t cardiac and renal status. see careview for opening numbers. Procedure: Left heart cardiac catheterization Coronary arteriography using a single catheter Open reduction of fracture with internal fixation, femur Diagnoses: Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Atrial fibrillation Unspecified fall Other B-complex deficiencies Hyperosmolality and/or hypernatremia Chest pain, unspecified Closed fracture of subtrochanteric section of neck of femur

allergies: levaquin / penicillins / flagyl attending: chief complaint: dyspnea on exertion/syncope major surgical or invasive procedure: aortic valve replacement (21mm ce pericardial tissue valve) history of present illness: 83 y/o female with dyspnea on exertion and syncope who was found to have severe aortic stenosis with of 0.6 cm2. referred for elective cardiac surgery. past medical history: hypertension, hypercholesterolemia, asthma, hypothyroidism, gastroesophageal reflux disease, patent foramen ovale, h/o c. diff colitis, heart block s/p pacemaker insertion , s/p ercp w/ bile duct stent, s/p cholecystectomy, s/p hernia repair social history: lives alone, independent in all adl/iadls; 8 children involved in her care no tob, etoh family history: father died of mi in 60's physical exam: vs: 74 16 136/76 140/82 5'3" 150 general: wd/wn female in nad skin: erythema inferior to breasts heent: eomi, perrl, edentulous neck: supple, from, -jvd, -carotid bruits chest: ctab -w/r/r heart: rrr +s1s2, murmur abd: soft, nt/nd +bs, ext: warm, well-perfused, trace edema, few varicosities neuro: grossly intact, a&o x 3, mae, non-focal pertinent results: echo : prebypass: there is a bidirectional shunt across the interatrial septum at rest. a small secundum atrial septal defect is present. there is mild symmetric left ventricular hypertrophy. resting regional wall motion abnormalities include mild hypokinesia of the mid and apical portions of the inferior wall. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. post bypass: biventricular systolic function is unchanged. bioprosthetic valve seen in the aortic position. valve is well seated and the leaflets move well. no aortic insufficiency present. peak gradient across the aortic valve post replacement is 17 mm hg. the mitral regurgitation is more on the mild side post aortic valve replacement. small secundum asd present- not repaired by surgeons. 02:47pm blood wbc-6.9 rbc-3.35* hgb-9.7* hct-28.3* mcv-85 mch-29.0 mchc-34.4 rdw-14.0 plt ct-107* 02:47pm blood pt-15.1* ptt-39.8* inr(pt)-1.4* 04:03pm blood urean-15 creat-0.7 cl-111* hco3-23 clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia: negative. 07:50am blood wbc-10.5 rbc-3.87* hgb-11.4* hct-33.3* mcv-86 mch-29.5 mchc-34.3 rdw-14.5 plt ct-324# 02:00am blood pt-12.8 ptt-28.3 inr(pt)-1.1 07:50am blood glucose-95 urean-13 creat-1.0 na-140 k-4.3 cl-100 hco3-31 angap-13 07:55am blood calcium-8.2* phos-2.0* mg-1.8 brief hospital course: ms. was electively admitted after pre-operative work-up was done as an outpatient. she was brought directly to the operating room where she underwent an aortic valve replacement (tissue). please see operative report for surgical details. she tolerated the procedure well and was transferred to the csru for invasive monitoring in stable condition. she remained intubated until post-op day one secondary to decline in spo2. she was extubated following awaking neurologically intact. chest tubes were removed on post-op day two. beta blockers and diuretics were started and she was gently diuresed towards her pre-op weight. ep interrogated pacemaker before and after surgery. later on post-op day two she was transferred to the cardiac surgery step down floor. epicardial pacing wires were removed on post-op day three. physical therapy worked with patient during entire post-op course for strength and mobility. c. diff assay was negative all 3 times. over the next several days she continued to make good progress and was discharged to rehab on post-op day eight with the appropriate follow-up appointments. medications on admission: lipitor 20mg qd, levoxyl 75mcg qd, omeprazole 20mg qd, atenolol 25mg qd, celexa 10mg qd, aspirin 325mg qd, mvi, vancomycin 250mg discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 4. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 6. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. vancomycin 250 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 9. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 10. potassium chloride 20 meq packet sig: one (1) packet po q12h (every 12 hours) for 7 days. disp:*14 packet(s)* refills:*0* 11. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: tcu discharge diagnosis: aortic stenosis s/p aortic valve replacement pmh: hypertension, hypercholesterolemia, asthma, hypothyroidism, gastroesophageal reflux disease, patent foramen ovale, h/o c. diff colitis, s/p pacemaker insertion , s/p ercp w/ bile duct stent, s/p cholecystectomy, s/p hernia repair discharge condition: good discharge instructions: take shower. gently pat incision dry. do not take bath. do not apply lotions, creams, ointment or powders to incision. do not drive for 1 month. do not lift greater than 10 pounds for 10 weeks. if you develop a fever or notice redness or drainage from incision, please contact office immediately. please call to make all follow-up appointments. p instructions: dr. in 4 weeks dr. weeks dr. in weeks Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Open and other replacement of aortic valve with tissue graft Artificial pacemaker rate check Artificial pacemaker rate check Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Aortic valve disorders Other and unspecified hyperlipidemia Ostium secundum type atrial septal defect Fitting and adjustment of cardiac pacemaker

history of present illness: the patient is a 53 year old man with a history of coronary artery disease, insulin dependent diabetes mellitus for 40 years and a renal transplant in who presented who presented with an increased dyspnea on exertion and shortness of breath at rest, increased over a chronic baseline level. the patient noted symptoms acutely worsened one day prior to admission prompting an emergency room visit. in the emergency room the patient denied chest pain, palpitations, nausea, vomiting or diaphoresis as well as fever and chills. the patient did note that his usual dose of lasix was not working. in the emergency room he was found to be sating high 90s on 2 liters after 80 mg of lasix. he was admitted to the floor he was found to have a low saturation. he was put on 100% nonrebreather, sating in the mid 90s. respiratory rate was 30s to 40s. the patient was given 40 plus 40 of intravenous lasix without any increased urine output. on the nitroglycerin drip and morphine the patient was able to diurese 200 cc. the patient's respiratory rate decreased to the 20s. the patient's examination had improved. the patient was taken to the catheterization laboratory where he was found to be 80% on 100% nonrebreather. the patient was also found to have lateral electrocardiogram changes. he was diaphoretic and not complaining of chest pain but noting paroxysmal nocturnal dyspnea and orthopnea. past medical history: 1. insulin dependent diabetes mellitus for 40 years with triopathy; 2. status post renal transplant ; 3. status post bilateral below the knee amputation; 4. coronary artery disease, with three vessel disease with poor touchdowns, not a surgical candidate with recent in-stent stenosis of the left anterior descending stent treated with brachytherapy; 5. recent admit for right knee ulcer to . allergies: no known drug allergies. medications on admission: pravachol 20 mg p.o. q.d.; aspirin 325 mg p.o. q. day; lasix 60 mg p.o. q. day; enalapril 20 mg p.o. b.i.d.; lasix 75 mg p.o. q. day; isordil 20 mg p.o. t.i.d.; prednisone 10 mg p.o. q.o.d.; sandimmune 100 mg p.o. q. am and 50 mg p.o. q. pm; imuran 50 mg p.o. q. day; ativan 2 to 4 mg p.o. q. 4 to 6 hours prn; nph 20 units subcutaneously in the morning and 14 units subcutaneously in the pm; regular insulin sliding scale; toprol xl 12.5 mg p.o. q. day. social history: the patient is full code. he lives alone. his wife had died recently. the patient quit smoking tobacco 20 years ago. he denied any alcohol use. family history: significant for gastrointestinal and breast cancer. physical examination: the patient's pulse was 95, blood pressure was 125/38 with map 67, respiratory rate 22 and oxygen saturation 97% on 100% nonrebreather. on general examination the patient was a very chronically ill appearing man in no apparent distress who was bolt upright in bed. on head, eyes, ears, nose and throat examination the patient had pupils which were nonreactive. neck examination revealed no lymphadenopathy and a central venous pressure of approximately 10 cm of water. cardiac examination revealed a regular rate and rhythm, normal s1 and s2 with no murmurs, rubs or gallops. there was presence of an s3. pulmonary examination revealed rales up to of the lung fields with bilateral pleural effusions. on abdominal examination the patient's belly was soft, nontender, nondistended with normal bowel sounds. extremity examination reveals bilateral below the knee amputations, 2+ edema. there was a left stage 3 decubitus ulcer of the patella region. laboratory data: pertinent laboratory findings revealed a white blood cell count of 9.4, hematocrit 40, platelets 291. the patient had a bun of 31, creatinine 1.4. the patient's ck was trending downwards. electrocardiogram revealed normal sinus rhythm at 75 with normal axis, left atrial abnormality, st elevations v1 through v4, 1 to 3 mm. there were also small q waves in 3 and f. chest x-ray showed congestive heart failure with bilateral pleural effusions. , stress mibi, the patient with reversible moderate inferior and anterior and septal wall defect. echocardiogram performed , revealed sinus tachycardia with no anxiety, abdominal aortic aneurysm, st increased v2 to v4, the patient also had biphasic t in v6. cardiac catheterization, the patient had ejection fraction of 20 to 30% with 100% proximal right coronary artery lesion, 95% recurrent in-stent mid left anterior descending lesion. this focal lesion was dilated successfully. hospital course: the patient is a 53 year old man with a history of coronary artery disease, myocardial infarction and renal transplant as well as insulin dependent diabetes mellitus and congestive heart failure. 1. cardiovascular - from the cardiovascular standpoint the patient presented in acute decompensated heart failure in the setting of ischemic heart disease. from a coronary artery disease standpoint the patient has severe three vessel disease. multiple interventions including recent percutaneous transluminal coronary angioplasty and brachiotherapy to the left anterior descending now presented with recurrent in-stent left anterior descending stenosis, status post percutaneous transluminal coronary angioplasty. the patient was ruled out for myocardial infarction. he was evaluated by cardiac surgery who felt that the patient was not a coronary artery bypass candidate. he was continued on aspirin, plavix and beta blockers as well as pravachol. from a myocardial standpoint the patient had an ejection fraction of 20% with severe hypokinesis, left ventricular hypertrophy, and diastolic dysfunction. he presented with decompensated heart failure. he ruled out for myocardial infarction, however, his congestive heart failure was felt to be secondary to ischemic heart disease. the patient was diuresed with lasix and eventually a combination of diuril and lasix. the patient was started on natrecor which initially caused some hypotension but then the patient reported improvement in his shortness of breath. he had augmented diuresis while on the natrecor. the patient was considered for aldactone although with his history of hyperkalemia this was deferred. plan was to use bipap if the patient were to have further acute pulmonary edema. post cardiac catheterization the patient had an episode of acute pulmonary edema which was responsive to morphine and lasix. the patient was continued on his outpatient heart failure regimen which included enalapril, isordil, and toprol. from a conduction standpoint the patient remained in sinus rhythm and was continued on his beta blocker. from an endocrine standpoint the patient presented with a history of insulin dependent diabetes mellitus and was maintained on a regimen of nph and regular insulin sliding scale as per his outpatient regimen. from a renal standpoint the patient is status post renal transplant on an immunosuppressant regimen. he presented at his baseline creatinine. however, with fingerstick diuresis the patient's creatinine climbed from 1.4 to approximately 1.8. his cyclosporin level of 113 was within normal limits. the renal transplant team followed the patient. his creatinine gradually began to trend down at the end of the hospital course. infectious disease - the patient presented with a left knee ulcer near the site of the left below the knee amputation. vascular surgery was consulted and felt the patient should be on levofloxacin and flagyl. they debrided the ulcer. the patient was continued on levofloxacin and flagyl for approximately a course of 14 days. the patient had a swab that grew enterobacter as well as stenotrophomonas. infectious disease was contact regarding the treatment of his stenotrophomonas. given the marked clinical improvement in the ulcer, the feeling was that the stenotrophomonas was a colonizer and that there was no need to add additional coverage. vascular surgery recommended the patient follow up with his vascular surgeon at . condition on discharge: good. discharge status: the patient was discharged to follow up with dr. in heart failure clinic in approximately one to two weeks. the patient will also follow up with his vascular surgeon at in approximately one week. due to high likelihood of repeat lad in-stent stenosis, elective relook angiography with standby for ptca will be considered in 4 months. discharge medications: 1. tylenol 650 mg p.o. q. 4-6 hours prn 2. pravachol 20 mg p.o. q. day 3. plavix 75 mg p.o. q. day 4. cyclosporin 100 mg p.o. q. am and 50 mg p.o. q. pm 5. azathioprine 50 mg p.o. q. day 6. metoprolol xl 2.5 mg p.o. q. day 7. colace 100 mg p.o. b.i.d. 8. aspirin, enteric coated 325 mg p.o. q.d. 9. ativan 0.5 to 1 mg p.o. q. 4-6 hours prn anxiety 10. flagyl 500 mg p.o. t.i.d. for nine days 11. levofloxacin 500 mg p.o. q. day for nine days 12. prednisone 10 mg p.o. q.o.d. 13. enalapril 20 mg p.o. b.i.d. 14. lasix 80 mg p.o. q. day 15. isordil 20 mg p.o. t.i.d. prn 16. regular insulin sliding scale, nph 20 units subcutaneously q. am and 14 units subcutaneously q. pm discharge instructions: the patient is to have dry sterile dressings b.i.d. to his left lower extremity ulcer. he will also need daily weights at home with a sitdown scale. case management was contact to obtain a sitdown scale for the patient. services will aid the patient in the dressing changes. discharge diagnosis: 1. congestive heart failure 2. coronary artery disease with three vessel disease status post percutaneous transluminal coronary angioplasty 3. insulin dependent diabetes mellitus 4. sepsis, recent 5. status post bilateral below the knee amputations 6. left knee ulcer 7. renal transplant with chronic immunosuppression. , m.d. dictated by: medquist36 d: 13:33 t: 15:41 job#: Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Implant of pulsation balloon Nonexcisional debridement of wound, infection or burn Nonoperative removal of heart assist system Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Other complications due to other cardiac device, implant, and graft Below knee amputation status Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Legal blindness, as defined in U.S.A. Kidney replaced by transplant Infection (chronic) of amputation stump

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: nausea major surgical or invasive procedure: intubation central line placement echocardiography history of present illness: 58 year old with pmh of ischemic cm (ef 20%), cad, severe 3vd (not a cabg candidate), type 1 dm presents with nausea and hypotension. recently seen in advanced heart failure clinic on , bp noted to be over 200, and his hyral was increased from 25 qid to 50 tid. lasix increased from 60 qam to 60 am/40 qpm. also got mri of his kidneys which showed severe renal artery narrowing. pt reports that since the next day after the mri, he has increasing nasuea; no f / c / n s / c p/sob/pnd/orthopnea/vomiting/diarrhea/hematochezia/melena/recent nsaid use/decreased uop. in ed, initial vs sbp in 60s, af, pulse in 60s. given insulin/d50, kayexalate, ca for k of 6.1. blood and urine sent. started on dopa, central line placed. given vanc/levo/flagyl/hydrocort, 1 am nabicarb. past medical history: 1. ischemic cm with ef 20% 2. cad with severe 3vd, not cabg candidate 3. pvd s/p b aka 4. type 1 dm 5. blindness 6. complete occlusion of r ica 7. cri s/p renal xplant ; b/l cr 1.2-1.4 social history: lives alone, no smoking or alcohol use family history: non-contributory physical exam: pe 97.8 90 94/47 20 91%2l cvp 5 pertinents mmm supple, jvp 8 cm rales way up rrr, grade ii/vi sem, ?diastolic murmur no tenderness around iliac fossa pertinent results: data ct 1. no evidence of intraabdominal abscess. 2. patchy consolidation at the right lung base. could represent pneumonia or atelectasis. clinical correlation is recommended. bilateral pleural effusions, right greater than left. 3. distended stomach likely representing gastroparesis. 4. extensive vascular calcification. 5. transplant kidney is seen in the right lower quadrant brief hospital course: this is a 56 year old gentleman with dm type i and a history of 3 vessel coronary disease (seen in cath.), ischemic cardiomyopathy (ef of 25 % on echo this admission), aortic stenosis ( 0.9 cm), pvd s/p b/l aka, s/p renal transplant (baseline cr 1.2 to 1.4) who was admitted for hypotension and nausea. pta he had been in heart failure clinic on where sbp noted to be in 200's; his hydralazine dose was doubled and his lasix dose increased. on presentation to ed sbp noted to be 60's pulse in 60s. also given insulin/d50, kayexalate, ca for k of 6.1. started on dopa, central line placed. given vanc/levo/flagyl/hydrocort, 1 am nabicarb. pt admitted to micu, intubated. started on 2 pressors for blood pressure support with gentle ivf. per cardiology service recommendations, a swan-ganz catheter was placed to help determine etiology of hypotension. initial swan numbers revealed elevated pcwp of 23, pap of 63/23, cvp 9, and svr of 1300 consistent with cardiogenic shock and l ventricular overload. echo peformed on revealed no significant changes from prior with ef of 25%, degree of av stenosis was essentially unchanged. pt weaned off pressors and began lasix diuretic therapy for chf exacerbation. his estimated pcwp has trended down since then with creatinine today 1.8 down from 2.2. serial chest x-rays revealed resolving pulmonary edema. pt also being followed by renal service for elevated creatinine and for his status post renal transplant in . the patients creatinine was elevated on admission but slowly trended back to normal range by discharge. he was maintained on his immunosuppressive therapy of azathioprine, prednisone, and cyclosporine. per his nephrologist dr. , his cyclosporine levels were adequate. there was some concern for rejection on a renal ultrasound but the patient's creatinine had returned to his baseline pt was extubated . pt is now off pressors with stable blood pressure, breathing normally on room air. swan ganz catheter d/c'd . last readings were pap of 54/21 cvp of 7. he was transferred to the floor. his stay was relatively uneventful. his blood pressure was generally stable (sbps in 100-110 range). his blood sugars were noted to trend downward and was found to be 31 in morning of . this resolved with amp of d50 (to 131); his insulin sliding scale was converted from regular to humalog; his nph dosing was adjusted to 10 units in the morning and 5 units at bedtime. pt was also noted to have a hematocrit that had trended down from 28 to 25 over the prior week. per renal service, this was felt to be secondary to his renal disease and his epogen was therefore doubled in dosing; in addition, the patient received one unit of blood before his discharge; blood was given with lasix. in summary, this is a 56 year-old type i diabetic male with 3 vessel cad, ischemic cardiomyopathy with ef 25%, aortic stenosis, s/p b/l aka, admitted for hypotension after increases in blood pressure medication and admitted to micu for hypotension, intubated for respiratory distress. found to be in cardiogenic shock necessitating pressor support and in chf. now off pressors, blood pressure w.n.l. breathing on room air with no sign of volume overload on physical exam. infectious workup has been unrevealing. . issues and pal 1) cardiovascular . perfusion: three vessel disease not amenable to pci, not candidate for cabg -continue aspirin and plavix -continue lipitor (40) -started smaller dose of beta blocker (metoprolol 12.5) . pump: ef 25%, aortic stenosis ( 0.9), chf seems to be class ii. status post cardiogenic shock--now resolved, appears secondary to increase in his blood pressure medications. -continue lasix at 40 mg po bid -continue digoxin at 0.0625 mg every other day, check digoxin levels regularly -avoid lisinopril given renal disease -continue hydralazine at 25 mg po tid -please restart isordil and uptitrate as his pressure tolerates. -will follow up with of outpatient heart failure service. rhythm: nsr occasional pvcs -low ef, pt may benefit from icd placement; per attending dr. , patient has declined this option understanding that he remains at increased risk of scd. . pvd: s/p b/l amputations -continue aspirin and plavix -will need physical therapy from extended hospital stay . 2) renal disease, s/p transplant, creatinine now at baseline -continue azathioprine, cyclosporine, please have nephrologist follow this patient. dr. is his primary nephrologist. -csa levels to be checked regularly -if creatinine levels rise, please check renal ultrasound -renally dose all medications . 3) anemia. status post 1 prbc transfusion prior to discharge -have increased epogen from 4000 to 8000 qmwf -monitor hct -if pt needs further transfusion, please give lasix (40 mg iv) before and after transfusion to prevent volume overload. . 4) diabetes, (type i) -in setting of renal insufficiency and renal transplant will need to be on humalog sliding scale. also should continue nph 10 units qam, 5 units qpm. . 5) fen: diabetic/cardiac healthy; please continue sodium and fluid restriction. . 6)prophylaxis should include hep sc, ppi . 7) code: full . 8) disposition: was seen by physical therapy who recommended rehabilitation. patient is being discharged to hospital. medications on admission: prednisone 10 qod lipitor 40 hydral 50 tid plavix asa enalapril 10 lasix 60/40 toprol xl 50 imuran 50 qd isordil 20 tid cyclosporin 100/50 ativan insulin discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. azathioprine 50 mg tablet sig: one (1) tablet po daily (daily). 4. cyclosporine modified 100 mg/ml solution sig: 0.25 ml po q pm (). 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 6. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 7. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 8. prednisone 10 mg tablet sig: one (1) tablet po qod (). 9. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed. 10. cyclosporine modified 25 mg capsule sig: one (1) capsule po q am (). 11. epoetin alfa 4,000 unit/ml solution sig: one (1) injection injection qmowefr (monday -wednesday-friday). 12. miconazole nitrate 2 % powder sig: one (1) appl topical prn (as needed) as needed for rash. 13. lorazepam 1 mg tablet sig: four (4) tablet po hs (at bedtime) as needed for insomnia. 14. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 15. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 16. insulin nph human recomb subcutaneous 17. insulin for insulin, please give 10 units in the morning and 5 units at bedtime. please use humalog sliding scale per attached flow sheet. 18. digoxin 50 mcg capsule sig: 1.5 capsules po every other day (every other day). 19. metoclopramide 5 mg/ml solution sig: one (1) ml injection q6h (every 6 hours). 20. dolasetron 12.5 mg/0.625 ml solution sig: one (1) injection intravenous q8h (every 8 hours) as needed for nausea. 21. hydralazine 25 mg tablet sig: one (1) tablet po tid (3 times a day). discharge disposition: extended care facility: & rehab center - discharge diagnosis: cardiogenic shock. congestive heart failure exacerbation/ischemic cardiomyopathy. aortic stenosis. coronary artery disease (three vessel disease) diabetes type i. peripheral status post kidney transplant. discharge condition: good. now breathing normally on room air. blood pressure stable. no symptoms of dizziness or nausea. no chest pain. able to work with physical therapy for rehabilitation exercises. discharge instructions: please return to hospital if you experience chest pain, shortness of breath or palpitations. please return to hospital if you start becoming light-headed, dizzy, and/or you feel like passing out. please return to hospital if pt becomes hypotensive. followup instructions: patient is going to rehabilitation facility. please follow up with the nephrology service. please coordinate care with his pcp and nephrologist dr. . pt also to be followed up by of outpatient heart failure service. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Pulmonary artery wedge monitoring Monitoring of cardiac output by other technique Transfusion of packed cells Infusion of vasopressor agent Diagnoses: Hyperpotassemia Anemia in chronic kidney disease Coronary atherosclerosis of native coronary artery Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Aortic valve disorders Other specified forms of chronic ischemic heart disease Acute respiratory failure Atherosclerosis of renal artery Cardiogenic shock Unspecified disorder of kidney and ureter Complications of transplanted kidney Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Above knee amputation status Unqualified visual loss, both eyes Gastroparesis

code status:full code allergies:nkda 58 yo blind male with pvd s/p bilat aka and a pmh of ischemic cm (ef 20%), cad, complete occlusion of r ica, severe 3vd (not a cabg candidate),cri s/p right kidney transplant and type 1 diabetes admitted with symptoms of nausea and hypotension,evidence of extensive vascular calcification, bilat. effusions (right greater than left)and question of gastroparesis. mri of kidney showed severe renal artery narrowing. neuro:a&ox3, pt is blind,pupils are equal and non reactive to light, pleasant demeanor,ue strong grip bilat.,obeys commands and responds appropriately to questions. cv:hr:82-90 nsr rare pvc's,nbp: 98/26, asbp:87-121, cvp:, pap:s 30-61/d 17-26,pcwp: 15-16, co therm. dilution:3.39/3.19, fick: 2.9,ci:2.40/2.26,sv:40/37, tmax 97.5,hct 27.6 with a plan for 1 unit prbc's today. pt recieved on 3.0 mcg/kg/min of levophed, titrated then suspended @ 10am, bp progressively declined to sbp 80's, restarted @ 1300 to 0.050 mcg/kg/min. access lines patent with sharp waves forms. resp:pt received on simple mask of 70% and titrated to 2l nc with an spo2 of high 90's,abg 7.49/84/38 hco3 29,ls cta. gi/gu: npo, speech and swallow consult tomorrow, poor gag reflex, weak cough. no stool, foley u/o 80-160, yellow sedimentary urine, fluid goal is even for 24 hours. abd. soft, non tender non distended, hypoactive bowel sounds. endo:fsbs q1hr insulin drip. pt received on 3u/hr suspended gtt at 0800 protocol. restarted 1100 at 1.5 u/hr. integ: coccyx reddened, barrier cream applied. social: family visited today and updated by this nurse. plan for team to discuss code status with family tomorrow. plan:speech and swallow consult tomorrow. fluid goal even. continue to wean levo as tolerated by patient. continue to wean o2 as tolerated by patient. plan to discuss code status with family tomorrow. continue to monitor bg protocol. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Pulmonary artery wedge monitoring Monitoring of cardiac output by other technique Transfusion of packed cells Infusion of vasopressor agent Diagnoses: Hyperpotassemia Anemia in chronic kidney disease Coronary atherosclerosis of native coronary artery Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Aortic valve disorders Other specified forms of chronic ischemic heart disease Acute respiratory failure Atherosclerosis of renal artery Cardiogenic shock Unspecified disorder of kidney and ureter Complications of transplanted kidney Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Above knee amputation status Unqualified visual loss, both eyes Gastroparesis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: lethargy and hypotension major surgical or invasive procedure: none. history of present illness: 58 year old with history of ischemic cardiomyopathy (ef 20%), severe 3 vessel coronary artery disease, type 1 diabetes, chronic renal disease status post renal transplant in who presents with lethargy and fever to 102.6. he had had decreased ability to care for himself over the last few days with a progressive nonproductive cough. he notes a dry nonproductive cough. he denies chest pain, shortness of breath, nausea, vomiting, diarrhea, or hematochezia. past medical history: 1. ischemic cardiomyopathy with ef 20% 2. coronary artery disease with severe 3 vessel disease and not a cabg candidate 3. peripheral vascular disease status post bilateral above knee amputation 4. type 1 diabetes 5. blindness 6. complete occlusion of right ica 7. chronic renal insufficiecy renal xplant ; baseline creatinine 1.2-1.4 social history: he lives alone and independent of adl's. his sister is extremely involved in his care and stays with him 4 times a week. she sets up his medications, checks his glucose fingersticks and draws up his insulin. he has a vna nurse times per week when his sister is not there. family history: non-contributory physical exam: vitals: temperature:102.6 pulse:67 respiratory rate:25 blood pressure:90/50 oxygen saturation:100% on non-rebreather gen: frail, diaphoretic, chronically ill-appearing male in nad heent: right eye enucleated neck: supple, jvp at ear, left carotid bruit pulm: anteriorly with crackles throughout, no wheezes cardiac: rr, nl. s1, s2, ii/vi systolic murmur heard best usb abd: scaphoid, soft, nt/nd, normoactive bowel sounds ext: bilateral above knee amputations skin: warm, diaphorectic neuro: sleeping but alert . pertinent results: hematology: wbc-7.9 hgb-10.1 hct-30.8 plt ct-346 neuts-87.8 lymphs-5.8 monos-5.5 eos-0.8 baso-0.2 . chemistries: glucose-117* urean-69* creat-1.3* na-138 k-4.4 cl-102 hco3-24 calcium-8.9 phos-2.2* mg-1.9 . lfts: alt-40 ast-81 ld(ldh)-251 alkphos-116 amylase-22 totbili-0.7 . cardiac: ck(cpk)-178 ck-mb-5 ctropnt-0.38 probnp- imaging: chest x-ray: new moderate-to-severe pulmonary edema. brief hospital course: this is 56 year-old male with severe ischemic cardiomyopathy (ef 20%) and type 1 diabetes who presented with hypotension, pulmonary edema, and fever to 102.6. . 1. hypotension/fever: etiology of his presentation was unclear. his hypotension responded to fluid ressucitation and pressors. he was intially treated with stress dose steroids, which were stopped once he had a normal cortisol stimulation test. infectious work-up was negative with the exception of a possible infiltrate on chest x-ray. urinary legionella was negative. he was treated with levofloxacin for presumed community acquired pneumonia. he was discharged to complete a 14 day course of levofloxacin. . 2. ischemic cardiomyopathy: he had no evidence of acute ischemia. he had 3 sets of cardiac enzymes that were negative. he was maintained on his outpatient aspirin, plavix, statin, and digoxin. his metoprolol was initially held given hypotension, but was restarted prior to discahrge. once he was no longer hypotensive, he was restarted on his outpatient diuretics to decrease his pulmonary edema. he diuresed well. . 3. chronic kidney disease: he is status post renal transplant. his creatinine was initially slightly above his baseline and that improved with fluid ressucitation. he was maintained on cyclosporin (level therapeutic), azathioprine, and prednisone for immunosuppression. . 4. diabetes: while in the intensive care unit, he required an insulin drip for good glycemic control. once on the floor, he was restarted on his outpatient glargine at 26 units at night. at the time, he was not eating regularly and he had problems with hypoglycemia. his glargine was decreased to 6 units with improvement in hypoglycemia. his glargine will need to be increased back to 26 once he is eating regularly. . 5. anemia: he has anemia secondary to renal disease. he receives epoeitin as an outpatient and did not received any while an inpatient. he did receive 1 unit of red cells during this admission. . 6. fen: cardiac, low salt, diabetic diet. he had speech and swallow evaluation that recommended a soft diet. . 7. code: full code . 8. dispo: he was discharged to an acute rehab medications on admission: medications at home: - metoprolol 12.5 mg b.i.d. - hydralazine 25 mg t.i.d. - digoxin 150 mg every other day (last ) - lipitor 40 mg once daily, - azathioprine 50 mg qam - prednisone 10 mg every other day (last dose ) - cyclosporin 100 qam, 50 qpm - lasix 40 mg b.i.d. - metoclopramide 5 mg q.i.d. - ativan 2 mg qam, 4 mg qhs - lantus insulin 26 units qhs - humalog insulin sliding scale - procrit 35,000 units,last given (monday ) discharge disposition: extended care facility: & rehab center - discharge diagnosis: pneumonia. diabetes. renal disease status post-transplant. discharge condition: stable. discharge instructions: please take all medications as prescribed and keep all follow-up appointments. . seek medical attention if you have fevers, chills, nausea, vomiting, shortness of breath, chest pain, or anything else that you find worrisome. weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: followup instructions: provider: . phone: date/time: 9:00 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Anemia in chronic kidney disease Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Peripheral vascular disease, unspecified Other specified forms of chronic ischemic heart disease Kidney replaced by transplant Diabetes with unspecified complication, type I [juvenile type], uncontrolled Profound impairment, both eyes, impairment level not further specified

history of present illness: the patient is a 52-year-old man with diabetes type 1, for 40 years, complicated by retinopathy with blindness, status post living donor kidney transplant in , status post bilateral bkas with recent stump revision on , with prior known .............. from catheterization in , who presented with chest pain on , from admitted for unstable angina, as well as right stump cellulitis. the patient was treated with ancef and cipro per infectious disease recommendations for the cellulitis. he was kept on intravenous heparin, aspirin, nitroglycerin drip, beta-blocker over the weekend for unstable angina without further chest pain or shortness of breath, awaiting prior catheterization data which had reportedly shown unintervenable ........... per the patient. his primary cardiologist is dr. . laboratory showed a troponin on admission of 0.8 which increased to 16.8 with negative cks but positive mb fraction. on the morning of , the patient had sudden shortness of breath, diaphoresis, nausea and vomiting. he was found to be hypoxic with an oxygen saturation in the 60s, on 100% non-rebreather, systolic blood pressure 150-160, heart rate 80-90s. his electrocardiogram showed hyperacute t-wave anteriorly, st depressions in v2-v4, and chest x-ray was consistent with failure. the patient was given lasix 40 iv x 1, with 500 cc urine output. he was given 1 amp of calcium gluconate and was started on intravenous nitroglycerin with improvement in his electrocardiogram changes. abg was done which showed ph of 7.18, pco2 73, po2 46. the patient was intubated on the floor emergently. the decision was made to take him to cardiac catheterization for acute coronary event. bedside echocardiogram revealed an ejection fraction of less than 20-25%, inferior akinesis, and anterolateral hypokinesis. in the catheterization lab, his coronaries were diffusely diseased. the patient had been previously turned down for a coronary artery bypass grafting, but ct surgery was reconsulted and again did not feel that he would be a good operative candidate. .................. requested a second ct surgery opinion which was prior to recathaterization to attempt lad intervention. this was obtained, and again several ct surgeons did not feel that he would be a good operative candidate secondary to high risk, lack of good touchdown, and lack of vein grafts secondary to his previous surgeries. otherwise in the ccu, the patient was diuresed and extubated on , without complication. his creatinine was slightly increased with this event. his captopril was temporarily discontinued, and diuresis was continued. he was on continued antibiotics for stump cellulitis. laboratory data: his initial lab data at the time of transfer back to the service on , showed a white count which was 19.1, hematocrit 30.0, platelet count 466,000; inr 1.1, ptt 58.0; sodium 128, potassium 4.3, chloride 93, bicarb 23, bun 78, creatinine 1.8, glucose 255, ck 45, calcium 8.5, magnesium 2.2, phosphorus 4.2; cyclosporin level was normal at 151. cardiac catheterization showed ra pressure of 9, rv was 40/10, ra 40/21, wedge pressure 21, ser 1390, cardiac index of 3.0. he had 100% proximal rca lesion, normal pda, left main was normal, mid lad had a tubular 90% lesion, distal lad 40% lesion, d1 70%, d2 99%, om1 70%. echocardiogram showed a ................. asd with left-to-right shunt seen, left ventricular size and thickness normal. there were multiple areas of akinesis and hypokinesis. there was a hypertrophied right ventricular free wall with normal right ventricular function. there was a small amount of mitral regurgitation, small to moderate pericardial effusion, and a right pleural effusion noted. medications on transfer: cyclosporin 100 mg b.i.d., neurontin 100 mg t.i.d., lipitor 20 mg q.d., fentanyl patch 25 q.72, sliding scale insulin, cefazolin iv, cipro 500 q.d., mucomyst 600 b.i.d., colace 100 b.i.d., lasix 80 p.o. b.i.d., lopressor 75 mg p.o. b.i.d., prednisone taper, zantac, enteric coated aspirin q.d., nph 4 u subcue at 6:30 a.m. and 4:30 p.m. allergies: no known drug allergies. past medical history: as above. he is also with hypertension, hyperlipidemia, diabetes, peripheral vascular disease, status post bilaterally bkas, chronic angina, legally blind since . social history: the patient is married. his wife is also blind. he has two daughters. was recently in the nursing home. hospital course: 1. cardiovascular issues: he was turned down for coronary artery bypass grafting. he was taken for re-catheterization on , and he had ptca stent placement to lad. in addition to his other cardiac medications, heparin was discontinued, and he was started on plavix x 1 month. he was continued on aspirin, beta-blocker, lipitor, lasix, and his ace inhibitor was restarted prior to discharge given his normal renal function. 2. pulmonary: he was able to be weaned off his oxygen with good room air saturations and was continued on ............... 6 b.i.d. without p.r.n. doses needed. 3. renal insufficiency: the patient had resolving bun and creatinine with a creatinine of 1.1 on discharge. he did well continuing on his cyclosporin for status post renal transplant. 4. from a vascular and infectious disease standpoint concerning his most pressing issue currently, he is continued on antibiotics for stump cellulitis. an infectious disease consult was requested, as the area of cellulitis spread with dry gangrene setting in. they did not feel that he was septic or toxic and that this most likely represented stump failure. vascular was consulted, and they too agreed that this was most likely not primarily an infectious process but represented a failure of the stump revision. this was discussed at length with the patient who wished to pursue further surgery at where he had been with the same surgeon for 20 years. we discussed this with the covering surgeon who agreed to accept him for evaluation. his need for surgery will have to be balanced against his recent cardiac catheterization, as he would be at very, very high risk for reclosure of his lad stent if his aspirin or plavix were to be discontinued at all, and cardiology recommended strongly that the aspirin nor plavix should be held for even a day or two given his high risk and the very narrow caliber of the lad stent. discharge medications: ................ t.i.d., captopril 12.5 t.i.d., hydralazine 10 mg p.o. q.i.d., tylenol 650 mg p.o. q.4 hours p.r.n., aspirin 325 p.o. q.d., plavix 75 mg p.o. q.d. x 30 days, insulin nph 14 u q.a.m. and 10 u q.p.m., cyclosporin 100 mg p.o. b.i.d., neurontin 100 mg p.o. t.i.d., lipitor 20 mg p.o. q.d., fentanyl patch 25 mg q.72 hours, sliding scale insulin, cefazolin 1 g q.12 iv, lopressor 75 mg p.o. b.i.d., lasix 80 mg p.o. q.d., prednisone taper which is now down to 10 mg p.o. q.d. which is his baseline dose status post kidney transplant, colace 100 mg p.o. b.i.d., zantac 150 mg p.o. b.i.d., cipro 500 mg p.o. b.i.d. follow-up: the patient should follow-up with his primary cardiologist dr. in one month. he will be evaluated at the hospital for possible aka. cardiology recommended that the surgery be done emergently as our vascular surgeons feel that it should be postponed for two weeks to one month until the plavix can be discontinued, as it is imperative that the aspirin and plavix not be stopped even for an operation, as he at high risk for stent reclosure. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Left heart cardiac catheterization Coronary arteriography using a single catheter Insertion of endotracheal tube Arterial catheterization Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified protein-calorie malnutrition Acute respiratory failure Gangrene Kidney replaced by transplant Infection (chronic) of amputation stump Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled