Datasets:

adalbertojunior

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like 1

Admission Date: [**2187-5-25**] Discharge Date: [**2187-6-5**] Date of Birth: [**2131-8-27**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache with naseau and vomitting Major Surgical or Invasive Procedure: Craniotomy History of Present Illness: 55F visiting from [**Location (un) **] who reportedly has a [**2-20**] day history of headache and associated vomiting that was thought to be secondary to a flu or flu-like etiology. She was taken to an OSH for increasing symptoms and lethargy. She was sent to the CT scanner which revealed a large right sided temporal bleed, and subsequently transferred to [**Hospital1 18**] for definitive treatment. Prior to transfer, she was sedated and intubated to protect airway. Of note, patient also had documented INR of 6.3, and received Vitamin K, and Platelets to reverse coagulopathy. Past Medical History: 1. CVA 2. Depression 3. MVR 4. Pacemaker Social History: Married lives in the UK. Here visiting for a graduation. Works as an education consultant Family History: Non contributory Physical Exam: VS: Tc 100.8 Tm 100.8 BP 121-138/62-79 P 60(paced) R 18-20 02 100%) Gen: well-developed, well-nourished Heent: supple neck, no carotid bruits, no lymphadenopathy Chest: pacemaker in left chest, lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi Heart: regular rate and rhythm, no murmurs, Abd: soft, non-distended, non-tender, no mass, positive bowel sounds Ext: no cyanosis, clubbing, or edema Skin: no erythema Neuro: MS: alert and oriented x2 (thinks that she is still at [**Hospital3 **], fluent, follows unilateral commands intermittently, intact naming (window), intact repetition, knows that [**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 174**] is prime minister of [**Location (un) **], CN: possible left homonymous hemianopsia, congenital ptosis, pupils equal, round, and sluggishly reactive, extraocular movements intact, intact light touch, intact facial strength and symmetry, intact tongue/uvula/palate, [**4-23**] SCM and trapezius Motor: normal tone and bulk of all four extremities, no tremor no pronator drift D B T grasp Left 4 4 4 4 Right 4+ 4+ 4+ 4+ IP Q H DF PF Left 4 4+ 4 4 4 Right 4+ 5- 4+ 4+ 4+ Sensory: intact light touch of all four extremites made mistakes with double simultaneous stimulation on both sides Reflex: T BR B K A toes Left 2 2 2 2 2 up Right 2 2 2 2 2 down Pertinent Results: [**2187-5-30**] 06:25AM BLOOD WBC-5.0 RBC-3.57* Hgb-10.2* Hct-30.7* MCV-86 MCH-28.5 MCHC-33.1 RDW-14.7 Plt Ct-210 [**2187-5-25**] 06:45PM BLOOD Neuts-85.3* Lymphs-8.9* Monos-5.3 Eos-0.3 Baso-0.3 [**2187-5-30**] 06:25AM BLOOD Plt Ct-210 [**2187-5-30**] 06:25AM BLOOD Glucose-86 UreaN-18 Creat-0.7 Na-137 K-5.4* Cl-108 HCO3-20* AnGap-14 [**2187-5-25**] 09:50PM BLOOD Fibrino-383 [**2187-5-30**] 06:25AM BLOOD Albumin-3.4 Calcium-8.5 Phos-2.0* Mg-1.8 [**2187-5-30**] 06:25AM BLOOD Phenyto-8.5* [**2187-5-26**] 09:41AM BLOOD Type-ART pO2-136* pCO2-34* pH-7.47* calTCO2-25 Base XS-2 [**2187-5-26**] 09:41AM BLOOD Glucose-158* K-4.7 [**Known lastname 78290**],[**Known firstname **] [**Medical Record Number 78291**] F 55 [**2131-8-27**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2187-6-4**] 9:59 AM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG FA11 [**2187-6-4**] SCHED CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 78292**] Reason: eval for post op bleeding - pt starting coumadin Final Report HISTORY: 55-year-old female status post craniectomy for intraparenchymal hemorrhage, on Coumadin. Evaluate for postoperative hemorrhage, patient starting Coumadin. COMPARISON: Multiple prior head CTs ([**2187-5-25**] and [**2187-5-26**]). TECHNIQUE: Contiguous axial imaging was performed from the cranial vertex to the foramen magnum without IV contrast. HEAD CT WITHOUT IV CONTRAST: A previously large left temporal hemorrhage has undergone extensive resorption, with a small amount of residual edema. There is no new hemorrhage. There is slight decrease in degree of subdural hemorrhage posteriorly along with falx and tentorium. Subcutaneous gas and new expected post-surgical pneumocephalus have resolved. IMPRESSION: 1. No evidence of new hemorrhage. 2. Marked interval resorption of right temporal hemorrhage, with minimal residual edema. 3. Decrease in degree of subdural hematoma posteriorly along falx and tentorium. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 3900**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: MON [**2187-6-4**] 4:10 PM Imaging Lab [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 78290**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78293**]Portable TTE (Complete) Done [**2187-5-29**] at 2:24:34 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] J. [**Hospital1 18**] - Division of Neurosurger [**Hospital Unit Name 18400**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2131-8-27**] Age (years): 55 F Hgt (in): 67 BP (mm Hg): 134/75 Wgt (lb): HR (bpm): 61 BSA (m2): Indication: Prosthetic valve function. Craniotomy ICD-9 Codes: 435.9, 423.9, V43.3, 424.3, 424.2 Test Information Date/Time: [**2187-5-29**] at 14:24 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 8154**] Bzymek, RDCS Doppler: Full Doppler and color Doppler Test Location: West Inpatient Floor Contrast: None Tech Quality: Adequate Tape #: 2008W031-0:42 Machine: Vivid i-3 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *7.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.8 cm <= 5.2 cm Right Atrium - Four Chamber Length: *8.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.6 cm Left Ventricle - Fractional Shortening: 0.32 >= 0.29 Left Ventricle - Ejection Fraction: 50% >= 55% Aorta - Sinus Level: 2.0 cm <= 3.6 cm Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.2 m/sec Mitral Valve - E Wave deceleration time: 240 ms 140-250 ms TR Gradient (+ RA = PASP): 15 to 21 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Increased IVC diameter (>2.1cm) with <35% decrease during respiration (estimated RAP (10-20mmHg). LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF. No resting LVOT gradient. Paramembranous VSD. RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function depressed. Prominent moderator band/trabeculations are noted in the RV apex. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). MVR well seated, with normal leaflet/disc motion and transvalvular gradients. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic tricuspid valve supporting structures. No TS. Moderate to severe [3+] TR. PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No PS. Physiologic (normal) PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). There is a paramembranous ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate to severe [3+] tricuspid regurgitation is seen. The pulmonic valve leaflets are thickened. There is no pericardial effusion. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2187-5-29**] 14:54 [**Known lastname 78290**],[**Known firstname **] [**Medical Record Number 78291**] F 55 [**2131-8-27**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-5-26**] 6:28 AM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2187-5-26**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 78294**] Reason: check ETT positioning, NGT position Final Report HISTORY: 55-year-old female with brain hemorrhage. Chest radiographs to check the position of the nasogastric and the endotracheal tubes. COMPARISON: With examination of [**2187-5-25**]. FINDINGS: The endotracheal tube terminates approximately 3 cm from the carina. The nasogastric tube has its distal tip within the stomach. A left pacemaker is seen with a single intact lead in the standard position. There is massive cardiac enlargement, which could represent underlying cardiomyopathy or a pericardial effusion. The lungs are grossly clear. There is no pneumothorax. CONCLUSION: Tip of the ET tube is 3 cm from the carina. Cardiac enlargement, which could represent cardiomyopathy or underlying pericardial effusion. Lungs are clear. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 28783**] [**Name (STitle) 28784**] DR. [**First Name (STitle) **] [**Doctor Last Name **] Approved: SAT [**2187-5-26**] 3:38 PM [**Known lastname 78290**],[**Known firstname **] [**Medical Record Number 78291**] F 55 [**2131-8-27**] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2187-5-25**] 6:43 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2187-5-25**] SCHED CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # [**Clip Number (Radiology) 78295**] Reason: eval for bleed Contrast: OPTIRAY WET READ: Acute parenchymal hemorrhage inthe right temporal lobe 6.9 x 4.8 cm with ventricular component. Mass effect on homolateral ventricle and 4 mm leftward shift, mild subfalcine herniation. Right infratentorial acute subdural blood. Parenchymal hemorrhage surrounded by vasogenic edema and contains air-fluid levels, differential includes mass and hemorrhagic infarction. Emergent neurosurgery evaluation recommended Final Report EXAM: CT of the head. CLINICAL INFORMATION: Patient with intracerebral hemorrhage, for further evaluation. TECHNIQUE: Axial images of the head were obtained without contrast. Following this using departmental protocol CT angiography of the head was acquired. FINDINGS: HEAD CT: There is a large intracerebral hematoma identified in the right temporal lobe measuring 7 x 5 cm. The hematoma contains an intrinsic area of fluid-fluid level. CT ANGIOGRAPHY OF THE HEAD: CT angiography demonstrates elevation of the right middle cerebral artery secondary to mass effect from the hematoma. No abnormal vascular structures or aneurysm identified. There is no vascular occlusion seen. There is no evidence of dural sinus thrombosis seen. CT ANGIOGRAPHY OF THE NECK: CT angiography of the neck demonstrates normal appearances of the carotid and vertebral arteries without stenosis or occlusion. Both carotid arteries measure approximately 5 to 6 mm in the proximal and 4 mm in the distal cervical region. The patient is seen to have endotracheal intubation. Sternotomy sutures are seen in the partially visualized thorax. IMPRESSION: 1. Large right temporal intraparenchymal hematoma with mild surrounding edema and mass effect on the right lateral ventricle. 2. No evidence of abnormal vascular structures or aneurysm on the CTA of the head. Displacement of the right middle cerebral artery is seen secondary to mass effect. 3. No evidence of occlusion or stenosis in the arteries of the neck. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Approved: FRI [**2187-6-1**] 9:30 AM [**Hospital1 69**] [**Location (un) 86**], [**Telephone/Fax (1) 15701**] Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 78296**],[**Known firstname **] [**2131-8-27**] 55 Female [**-7/2173**] [**Numeric Identifier **] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 395**]/mtd SPECIMEN SUBMITTED: Temporal Lobe tissue. Procedure date Tissue received Report Date Diagnosed by [**2187-5-25**] [**2187-5-26**] [**2187-6-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mb???????????? DIAGNOSIS: Brain, "temporal lobe tissue", resection: -Cortical [**Doctor Last Name 352**] and white matter with acute and subacute hemorrhage and reactive change. -No evidence of neoplasm, infection, or amyloid angiopathy is detected. Clinical: Subdural hematoma right. Specimen submitted: temporal lobe tissue. Gross: Multiple fragments of soft white brain tissue and blood clot measuring 7 x 5.5 x 2.5 cm in aggregate. The majority of the brain tissue and representative sections of blood clot are submitted in cassettes A-B. Brief Hospital Course: 55F with large temporal lobe hemorrhage with associated edema, and 4mm MLS, mild subfalcine herniation. She was brought emergently to the OR a right sided craniotomy for evacuation of hematom. She was loaded with Dilantin and her BP was kept less than 140. Her coagulopathy was reversed prior to the OR. On POD#1 she was extubated and follow commands and was moving everything symmetrically. A neurology consult was completed to identify reason for bleed,they recommended a CTA head and neck showed No evidence of abnormal vascular structures or aneurysm on the CTA of the head. Displacement of the right middle cerebral artery is seen secondary to mass effect. No evidence of occlusion or stenosis in the arteries of the neck. As the patient became more alert she complained of blurry vision. A opthamology consult was obtained and she was found to have exposure heratopathy with abrasion in both eyes secondary to lagaophlamous. She was started on Bacitracin and patching at sleep.Within two days the eye had significant improvement. Continue to tegaderm eyes closed at hs. Medicine was consulted due to her porcine MVR past anticoagulation and developed oliguria on [**5-29**]. She was trialed on lasix given mild dyspnea, 400 cc urine made, dark. An echo was done that showed echo reveals EF 50%, 3+ TR. She was restarted on a standing dose of a diuretic. Neurologically she continued to progress, she was orientated X3, slight left IP weakness she was full assist with ambulation. She was tolerating a regular diet. Her wound was clean and dry. Neurology was consulted for INR therapeutic dosing - She restarted her coumadin on post op day #10 (monday [**6-5**]) with a dose of 5mg. Her INR is pending at this pt and in speaking to the receiving physiatrist at [**Hospital1 **] - the pts INR will be called to 2 South where the pt will be admitted and they will dose her for this evening. The INR recommended by the neurology team is 2.5-3.5. Her INR yesterday was 1.3 prior to her first dose of coumadin. The pts family was requesting a hematology consult for explanation of why this pts INR suddenly "shot up". The pt is refusing this consultation stating that she feels her family wants to blame her for the bleeding on the brain. Medications on Admission: Warfarin ASA 75mg daily Zocor 20mg qhs Dalteparin 7500mg [**Hospital1 **] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-20**] Drops Ophthalmic Q1H (every hour). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 12. Amiloride 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 14. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)): continue until [**6-8**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: intracerebral hemorrhage TIA CVA Mitral valve replacement Hematuria Permanent pacemaker Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**First Name (STitle) **] TO BE SEEN IN 4 WEEKS with head CT or follow up with a neurosurgeon in the UK Completed by:[**2187-6-5**]

Admission Date: [**2108-4-2**] Discharge Date: [**2108-4-12**] Date of Birth: [**2073-12-11**] Sex: M Service: NEUROLOGY Allergies: Depakote / Bactroban Attending:[**First Name3 (LF) 11344**] Chief Complaint: Seizures Major Surgical or Invasive Procedure: none History of Present Illness: 34 y/o M w hx of MR, [**First Name3 (LF) 862**] disorder who presents today with a cluster of seizures. Was doing well at his group home when he was noted to have about 5 two-minute petite mal seizures that resolved on their own. Was taken to OSH where he again had 2 more siezures, this time more tonic clonic. Was treated with 2 mg ativan IV x1 and then valium 5 mg IV x1, and tegretol for continued seizing. He was found to have PNA on CXR and treated with zosyn. He was transferred here because he gets his neurology care at [**Hospital1 18**]. . In the ED, initial vs were 98.4, 96/62, 72, 14, 98% NRB. Patient was given vanco and levofloxacin here. He also got 1L NS. He was unable to be weaned from the non-rebreather, so admitted to the ICU. Between signout and transfer to the floor, he had another [**Hospital1 862**] and was given 2 mg IV of ativan which resolved the [**Hospital1 862**]. . Per report, a friend from his group home was with him in the emergency room and said that he often has groups of seizures like this when he gets infected. . On the floor, he is sedated, arousable to pain, non-verbal. His friend or relative was no longer with him, so a history was difficult to obtain. Past Medical History: Congenital encephalopathy Spastic quadraparesis Mental retardation Hamstring release surgery G-tube placement (carer will check on what date it was placed, and what date it was replaced at the group home) G-tube MRSA colonization Pneumonia [**11-5**] Social History: Lives in [**Location (un) 82321**], [**Location (un) 15739**], MA group home. Mother: [**Name (NI) 6744**] 1-[**Telephone/Fax (1) 82322**]. Family History: Non-contributory Physical Exam: T97.3 (Tmax97.7) HR 67-73 BP 105/70 RR 13-16 SpO2 on a non-rebreather 100% General: scoliotic, head is tilted to the right, eyes closed, severe contracture of the right arm. CVS: RRR, S1+2, no added sounds Resp: decreased air entry at both bases GI: soft, scaphoid, with hypoactive bowel sounds. G-tube site has pus skin: acneform skin rash over his torso Neurological Exam Mental status: non communicative at baseline Cranial nerves II, III, IV, VI - pupils 2.5-->2 mm b/l, fundoscopy normal V, VII - corneals and nasal tickle in tact His mouth is clenched shut, and is difficult to open, could not check gag Motor Spastic quadriparesis, whole body habitus looks wasted. He has very poor muscle bulk in his arms and legs. His reflexes are present, and his plantars are upgoing. He does not withdraw to noxious stimuli. Pertinent Results: Admission Labs: 138 | 103 | 7 --------------< 83 3.6 | 23 | 0.5 Ca: 8.4 Mg: 1.6 PO4: 2.6 14.4 11.0 >------< 216 42.7 Dilantin: 17.9 Carbamazepine: 5.3 Imaging: CXR ([**4-2**]): FINDINGS: Single portable upright chest radiograph is reviewed in comparison to [**2107-7-13**]. Retrocardiac opcity is likely accounted for by hiatus hernia and atelectasis, less likely pneumonia. There is no other focal consolidation to suggest pneumonia. There is no effusion or pneumothorax. The hilar and cardiomediastinal contours are unchanged, with redemonstration of mild cardiomegaly. The visualized bones demonstrate no acute abnormality. Numerous air-filled bowel loops are identified in the upper abdomen. IMPRESSION: Retrocardiac opacity likely accounted for by atelectasis and hiatus hernia. No definite pneumonia. Discharge Labs: Brief Hospital Course: 34 y/o M with hx of MR [**First Name (Titles) **] [**Last Name (Titles) 862**] disorder who presents with new cluster of seizures in conjunction with a new pneunomia. Hospital Course: . # Seizures: Increased frequency was thought likely due to pneumonia; per notes and reports from his group home, he tends to have clusters of seizures when he is infected. However as seen below there was not sufficient evidence for an pneumonia and it may have been a viral infection. His phenytoin and carbemazepine levels were at goal. While in the MICU on [**2108-4-2**], he had a [**Date Range 862**] lasting 13 minutes characterized by right eye and face twitching and associated with tachycardia to 140s and hypoxia to O2sat 70s. He received ativan 1mg x 2. He was then started on standing Ativan, initially 1mg Q6hr, and transferred to the Neurology service. His Zonegran was increased to 500mg QHS, and his Dilantin was returned to his prior dose of 150mg/200mg. He remained [**Date Range 862**] free on [**4-3**], and the Ativan was tapered further from 1mg q8hr to 0.5mg Q6hr. He was doing well until [**4-6**] his tube feeds stopped flowing and he was noted to have an ileus. His medications were switched to IV form. He has a few seizures while on IV formulation and his ativan was bumped back to 1mg q6h. His ileus resolved and he was placed back on his oral medications and his Zonegran was increased to 500mg. The ativan was tapered off and he was [**Month/Day (4) 862**] free at discharge. . # Pneumonia: Found to have a new possible LLL pneumonia on CXR. As patient does have a h/o MRSA infection and comes from a group home setting, he was started on vancomycin, zosyn, and azithromycin for HCAP and CAP coverage. He initially was on a non-rebreather, but throughout the course of the day on [**4-2**] he was titrated off all oxygen, and was back on room air by [**4-3**]. Repeat CXR still showed no sign of pneumonia, the patient was afebrile, and WBC count had improved so antibiotics were stopped on [**4-3**]. It was thought that the inciting factor this time was possible a viral upper respiratory tract infection, as there had been concern about increased congestion and cough during the week prior to admission . # FEN: Tube feeds: patient was unable to tolerate tube feeds for several days as high residuals were noted. There was concern for mild ileus with a KUB showing Multiple air-filled dilated loops of small and large bowel. He was kept NPO for several days and then tube feeds were resumed without any difficulty. He tolerated Fibersource HN Full strength at 45 ml/hr with minimal residuals. He abdominal exam remained soft and non-distended and he had regular bowel movements. # Communication: Patient, mother [**Name (NI) 6744**] [**Telephone/Fax (1) 82323**] # [**Name2 (NI) 7092**]: DNR/DNI Medications on Admission: Lorazepam 1 mg [**Hospital1 **]? Levetiracetam 1500 mg TID Topiramate 50 mg [**Hospital1 **] Dilantin 150 mg [**Hospital1 **] Carbamazepine 400 mg PO qAM, 600 mg PO qPM Baclofen 10 mg TID Omeprazole 20 mg [**Hospital1 **] Flonase PRN Discharge Medications: 1. Acetaminophen 650 mg Suppository Sig: [**12-31**] Suppositorys Rectal Q6H (every 6 hours) as needed for pain. 2. Zonisamide 100 mg Capsule Sig: Five (5) Capsule PO HS (at bedtime). Disp:*150 Capsule(s)* Refills:*2* 3. Carbamazepine 100 mg/5 mL Suspension Sig: Twenty (20) ml PO Q10AM (): 400mg in AM. 4. Carbamazepine 100 mg/5 mL Suspension Sig: Thirty (30) ml PO Q10PM (): 600mg in PM. 5. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO twice a day. Disp:*240 Tablet, Chewable(s)* Refills:*2* 6. ProCel Powder Sig: One (1) scoop PO twice a day. 7. Keppra 500 mg Tablet Sig: Three (3) Tablet PO twice a day. 8. Potassium Chloride 10 % Liquid Sig: One (1) PO once a day: 20meq at 3pm daily. 9. Baclofen 10 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Lactobacillus Acidophilus Capsule Sig: One (1) Capsule PO twice a day. 11. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day. 12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal once a day. 13. Cromolyn 4 % Drops Sig: One (1) drop Ophthalmic once a day: in each eye. 14. Nystatin 100,000 unit/g Powder Sig: One (1) sprinkle Topical twice a day. 15. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. 16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Discharge Disposition: Home With Service Facility: Group Home Discharge Diagnosis: Primary: Epilepsy Secondary: Upper respiratory tract infection and ileus Discharge Condition: MS: non-verbal at baseline, opens eyes, does not reliably track or blink to threat Motor: spastic quadraparesis, does not withdraw, left arm with increased tone, right decreased secondary to tendon release Discharge Instructions: You were admitted with increased [**Month/Day (2) 862**] frequency. This was thought to be due to a viral illness. Your Zonegran was increased, and you were also started on standing Ativan while you were in the hospital. While you were here your tube feeds were not able to be adavance and you stopped having bowel movements. It was noted that you had an ileus (a temporary halt of forward motion in the bowel). You were placed on bowel rest and all your anti-[**Month/Day (2) 862**] medications were turned to Iv equivalents. After 2-3 days your bowels stared to move again and you were able to restart tube feeds. You medications were restarted and you have been doing well since that time. You also are having consistent bowel movements. Your seizures have been well controlled over the last few days, and the ativan was tapered off. Medication changes: -Increased Zonegran to 500mg/day Your other AEDs are as follows: Carbamazepine 400mg/600mg am/pm Phenytoin Infatab 200mg/200mg am/pm Keppra 1500mg [**Hospital1 **] You are also requested to have your Dilantin and Carbamazepine level drawn in one week (and weekly for 3 weeks after that) and the results faxed to attn:[**First Name8 (NamePattern2) 10733**] [**Last Name (NamePattern1) 12536**] at [**Telephone/Fax (1) 7020**] If you notice any of the concerning symptoms listed below, please call your doctor or return to the emergency department for further evaluation. Followup Instructions: Neurology: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] & DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2108-4-26**] 11:00

Admission Date: [**2123-1-1**] Discharge Date: [**2123-1-8**] Date of Birth: [**2089-6-9**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3190**] Chief Complaint: 33M s/p 15' fall, unwitnessed, c ?SDH, small scattered bifrontal SAH, T8-T9 fx Major Surgical or Invasive Procedure: Open reduction of T8-9 dislocation, instrumented spinal fusion for T8 fracture. History of Present Illness: Pt sp unwitnessed [**2089**]5' from deck. GCS on arrival to [**Hospital **] Hospital 13-14. Intubated [**2-6**] pt unable to follow commands. Report of no LE movement but intact UE movement. Past Medical History: denies Social History: ETOH Tobacco Marijuana Family History: non contributory Physical Exam: pt arrived from outside hospital medically sedated and intubated chest clear heart regular neck supple, no deformity abdomen soft spine: palpable stepoff mid thoracic area neuro: sedated and intubated vascular intact Pertinent Results: [**2123-1-1**] 08:12PM GLUCOSE-133* UREA N-8 CREAT-0.9 SODIUM-136 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14 [**2123-1-1**] 08:12PM WBC-10.5 RBC-3.11* HGB-9.6* HCT-28.2* MCV-91 MCH-31.0 MCHC-34.2 RDW-13.2 [**2123-1-1**] 08:12PM PT-12.1 PTT-25.9 INR(PT)-1.0 [**2123-1-1**] 06:24PM TYPE-ART PO2-112* PCO2-44 PH-7.35 TOTAL CO2-25 BASE XS--1 INTUBATED-INTUBATED [**2123-1-5**] 07:30AM BLOOD WBC-6.5 RBC-3.01* Hgb-9.1* Hct-26.6* MCV-88 MCH-30.2 MCHC-34.3 RDW-12.9 Plt Ct-308 [**2123-1-5**] 07:30AM BLOOD PT-11.6 PTT-22.0 INR(PT)-1.0 [**2123-1-5**] 07:30AM BLOOD Glucose-125* UreaN-12 Creat-0.8 Na-134 K-4.0 Cl-97 HCO3-28 AnGap-13 [**2123-1-5**] 07:30AM BLOOD Calcium-8.8 Phos-2.0* Mg-2.3 Brief Hospital Course: [**2123-1-1**] CT HEAD: 1. Small SAH and a 6-mm IPH/SAH within the left parietal lobe. No mass effect or midline shift. The findings are roughly stable compared to outside hospital CT taken one hour prior. . CT TORSO: T8 3 colulmn injury with inevitable ligamentous injury. T8 fx include: anterior superior corner, through vertbral body, through left posterior costo-vertebral joint, with perched facets (T8 on T9) bilaterally, anterolisthesis of T8 on T9, T8 spinous process fx. Bony fragments abut left side of thecal sac at T8, with likely small epidural hematoma and no obvious cord compression- to be evaluated by MRI. T9 fractures include anterior superior corner --> through vertebral body --> Left T9 transverse process. Pt to OR with Ortho Spine for open redution and instrumented fusion with no complication. He tolerated the procedure well and returned to the ICU. On POD 2, he was transferred to the spine service and the regular hospital floor. A TLSO brace was obtained for use with ambulation. He remained medically stable with no complications of the hospital stay. A ambulated safely and was cleared by physical and occupational therapy. He was discharged to home in stable condition. Medications on Admission: none 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. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. Disp:*10 Suppository(s)* Refills:*0* 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 4. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: HomeHealth VNA Discharge Diagnosis: Thoracic spine fracture T8 Discharge Condition: Good Discharge Instructions: Keep the incision dry. You may shower as long as you cover the incisions with Band-aids. Do not take a bath or submerge the incision under water. You need to wear the brace whenever you are out of bed. You do not need the brace when you are in bed. Do not lift anything heavier than a gallon of milk. do not bend or twist from the lower back. Do not smoke. call the office if you have a fever over 101F or if you have an increase in pain or discharge from the incisions. Physical Therapy: Activity: Out of bed to chair [**Hospital1 **] Thoracic lumbar spine: when ambulating pt may be OOB to chair without brace. Treatment Frequency: Please continue to change the dressings daily with dry sterile gauze. Followup Instructions: Dr. [**Last Name (STitle) 363**] in 2 weeks, call the office for an appointment: [**Telephone/Fax (1) 18552**]

Admission Date: [**2146-11-3**] Discharge Date: [**2146-11-10**] Date of Birth: [**2079-1-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Patient is a 67 year old female with a history of Type II DM, HTN, stage III CKD, and 2 vessel CAD admitted on [**2146-11-3**] with hyperglycemia. The patient was hospitalized two months ago with dysphagia and provided history suggestive of CHF. Subsequent evaluation showed severely depressed LVEF, 20-25%, with elevated right- and left-sided filling pressures. A diagnostic left- and right-heart cath was performed, and attempted PCI to mid-LAD was unsuccessful. The patient was evaluated by CT surgery, and was determined to be a poor surgical candidate. The patient was discharged with a plan to optimize medical management of presumed ischemic heart disease (there had been a question of possible tachycardia-induced cardiomyopathy, alcoholic cardiomyopathy). Iron studies did not show evidence of hemachromatosis. The patient had scheduled Cardiology follow up on [**2146-11-2**] which she unfortunately did not keep. The following day, the patient was found to be hyperglycemic, with home FSBGs in the 500s. Since admission, management of hypervolemia from CHF has been limited by hypotension. We are asked to provide recommendation for management of patient's CHF. On further history, patient notes progressive DOE over the past summer. She denies any inciting event. Her exercise capacity and level of activity have been limited over the past few months due to progressive DOE. On cardiac review of symptoms, patient denies any current or prior chest pain/pressure/angina. Denies palpitations, presyncope, and syncope. Patient does have [**1-19**] pillow orthopnea with occasional PND. Lower leg swelling has not changed over prior two months. Currently, the patient notes fatigue and mild shortness of breath at rest during the interview. She denies chest pain/pressure, lightheadedness, and is otherwise asymptomatic. Past Medical History: DM A1c 7.9% [**2146-9-27**] 2VD s/p unsuccessful PCI mid-LAD [**2146-9-13**] Ischemic CMP EF 20-25% by TTE [**2146-9-11**] CKD stage III b/l Cr ~1.4 HTN Hyperlipidemia s/p bilat cataract surgeries Cardiac Risk Factors include diabetes, dyslipidemia, hypertension, and family history of CAD Social History: Patient is retired since [**2139**] from Met Life. She has been divorced for many years. Currently not sexually active. Admits to drinking alcohol rarely and has a 10 pack-year smoking history (she quit 25 years ago). Denies illicit drug use. Says she enjoys walking but has been limited by DOE more recently. One son, 43yo, in good health, with 6 children, lives in [**Location (un) 5426**]. Family History: Mother passed away from MI at age 85. Siblings with asthma and diabetes. ? CAD in brother. 1 sister with breast cancer. Physical Exam: Vitals: T: 97.9 BP: 98-100/68-74 P: 101-110 R: 20-24 O2: 100 on RA-2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated to jawline, no LAD Lungs: decreased breath sounds at bases, crackles bilat L > R CV: Tachy rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes, lesions Pertinent Results: [**2146-11-3**] 10:00AM URINE OSMOLAL-347 [**2146-11-3**] 10:00AM URINE HOURS-RANDOM UREA N-376 CREAT-45 SODIUM-26 [**2146-11-3**] 12:00PM PLT SMR-NORMAL PLT COUNT-285 [**2146-11-3**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2146-11-3**] 12:00PM NEUTS-78.4* BANDS-0 LYMPHS-14.1* MONOS-6.3 EOS-0.8 BASOS-0.4 [**2146-11-3**] 12:00PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.3 [**2146-11-3**] 12:00PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.3 [**2146-11-3**] 12:00PM GLUCOSE-479* UREA N-39* CREAT-1.8* SODIUM-121* POTASSIUM-7.2* CHLORIDE-85* TOTAL CO2-23 ANION GAP-20 [**2146-11-3**] 12:00PM GLUCOSE-479* UREA N-39* CREAT-1.8* SODIUM-121* POTASSIUM-7.2* CHLORIDE-85* TOTAL CO2-23 ANION GAP-20 CXR: [**2146-11-3**] A moderate right pleural effusion is largely unchanged. Linear opacity adjacent to the effusion is most consistent with atelectasis. There is improved aeration of the left lung base. Upper lung zones are well aerated without new consolidation. There is no pneumothorax. Pulmonary vascularity is normal. There is no hilar enlargement. The cardiomediastinal silhouette is grossly stable. IMPRESSION: Persistent moderate-to-large right pleural effusion and small left pleural effusion, with atelectasis. No edema ECHO: [**2146-11-7**] The left atrium is elongated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 20 %). No masses or thrombi are seen in the left ventricle (fibrotic apical trabeculations are seen). The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**11-19**]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2146-9-11**], the right ventricular cavity is slightly larger with more severe free wall hypokinesis. The other findings are similar. Brief Hospital Course: 67 F with DM, 2 vessel CAD, CKD, and ischemic cardiomyopathy (EF (20-25%) initially admitted with hyperglycemia after missing insulin for several days. With administration of home doses of insulin, hyperglycemia corrected. There was no evidence for an infection. Hospital course was then complicated by the development of hypotension from decompensated CHF. Although patient ruled out for an acute ischemic event, echo showed progression of cardiac dysfunction with an EF of 20%, 3+ tricuspid regurgitation and severe RV dysfunction with free wall hypokinesis. Transferred to the CCU for further management and started on lasix and milironone drip to optimize cardiac output. CCU course complicated by the development of PEA requiring cardiac resuscitation with intubation and 4 pressor support. Given the patient's end stage heart failure and prognosis, the family decided to withdraw care. A morphine drip was initiated and pressors and mechanical ventilation was discontinued. Time of death was 4:30am on [**2146-11-10**]. Her son (next of [**Doctor First Name **]) and niece [**Name (NI) 382**], declined an autopsy. Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Insulin Glargine Insulin 4 units each morning (up titrate as needed) Humalog sliding scale. QACHS. At FS 150 start at 2 units and increase by 2 unit for every additional 50 point rise in blood glucose. If > 400 contact supervising physician. [**Name10 (NameIs) **] evening dosing do not start additional insulin unless > 200. . Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: end stage systolic congestive heart failure hyperglycemia Discharge Condition: deceased Discharge Instructions: N/A Followup Instructions: N/A

Admission Date: [**2121-12-17**] Discharge Date: [**2122-1-10**] Date of Birth: [**2089-2-18**] Sex: M Service: MEDICINE Allergies: Amiodarone Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: SOB and nasal congestion Major Surgical or Invasive Procedure: Multiple cardiac catheterizations (both right and left-sided) History of Present Illness: This history was taken with the help of a Portuguese interpreter. Patient is a 32 yo male with a history Dilated Cardiomyopathy (TTE [**8-2**]: EF 20%), CHF, h/o ventricular tachycardia, atrial fibrillation on Coumadin, h/o L PCA CVA, and hyperthyroidism secondary to Amiodarone who presents with a history of SOB and nasal congestion. He reports that over the past few days, he has felt increasingly short of breath at rest, and has noticed nasal congestion. He denies cough, fever, or sick contacts, but he does reports a history of chills. On the morning of admission, he felt a very brief pinching feeling in his chest. He reports decreased exercise tolerance and increased fatigue. He can currently walk 10 minutes without getting short of breath (but he says he can usually walk longer than that). He reports medication-compliance, but has eaten more salty food than usual over the past few days. He denies orthopnea and PND, but has had increased ankle edema. He has occasional palpitations. Denies dizziness, lightheadedness, syncope, or the feeling of shocks from his ICD. He was at a routine outpatient visit with Dr. [**First Name (STitle) 437**], who admitted him for a Lasix gtt. . On admission, the patient was slightly SOB, but denies chest pain or lightheadedness. His initial blood pressure was 85/49 -> 93/47 -> 80/50. Dr. [**First Name (STitle) 437**] was notified, and the decision was made to send him to the CCU for Dobutamine IV and Swan in the AM. . On admission to the CCU the patient reports mild SOB, otherwise ROS as above. Past Medical History: -Dilated Cardiomyopathy, TTE [**8-2**]: EF 20%, diagnosed after presenting with Class III CHF symptoms in [**9-27**], thought to be viral etiology, s/p AICD -CHF, dry weight 100 kg -Ventricular Tachycardia, first noted in [**9-27**], s/p syncope from VT in [**9-1**], ICD in place -Atrial Fibrillation, on Coumadin, diagnosed in the setting of hyperthyroidism -CVA (L PCA, thought to be cardioembolic) -Hyperthyroidism, secondary to Amiodarone (d/ced [**3-1**]), s/p prednisone and methimazole-->hypothyroidism -SDH s/p fall [**12-27**] syncope in [**9-1**] (Coumadin held [**Date range (1) 9358**]) -Fe deficiency Anemia -Obesity -Depression -Osteoporosis -s/p R knee surgery Social History: Portuguese speaker, moved from [**Country 4194**] in [**2113**]. Lives with wife and two young children. Pt does NOT work. Used to have job as dishwasher but was only employed one day per week and the restaurant closed so currently unemployed. Wife works at [**Company 44769**] and this is the only income source for the family. Pt is primary child caretaker. Denies tobacco, occ EtOH. Family History: Father with "[**Last Name **] problem" at age 52; mother with "[**Last Name **] problem" at age 25, also with a thyroid condition. Physical Exam: ADMISSION PHYSICAL EXAM: VS - T 97.2 HR 64, irreg, 100/57, R 20, 98% RA Gen: WDWN middle aged obese male in NAD. Oriented x3. Mood, affect appropriate. Portugese speaking. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: supple. +JVD to ear when sitting upright CV: PMI located in 5th intercostal space, midclavicular line. irregular irregular, I/VI HSM LLSB, Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND, obese. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: 2+ LE edema b/l Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2121-12-17**] 09:01PM WBC-9.7 RBC-4.58* HGB-12.9* HCT-38.7* MCV-84 MCH-28.1 MCHC-33.3 RDW-16.1* [**2121-12-17**] 09:01PM PLT COUNT-184 [**2121-12-17**] 09:01PM PT-27.7* PTT-37.6* INR(PT)-2.8* [**2121-12-17**] 09:01PM GLUCOSE-100 UREA N-22* CREAT-1.3* SODIUM-139 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17 [**2121-12-17**] 09:01PM CALCIUM-9.3 PHOSPHATE-4.1 MAGNESIUM-2.3. EKG demonstrated afib at 64, diffuse low voltage with no significant change compared with prior. [**2121-12-18**] Head CT FINDINGS: There is a chronic infarct in the left occipital and temporal regions. There is adjacent ex vacuo dilation of the temporal [**Doctor Last Name 534**] of the left lateral ventricle. There has been resolution of the previously noted right- sided subdural hematoma. Encephalomalacia from the prior right frontal contusion is noted as well as white matter hypodensities in the subcortical region of the high right frontal lobe suggestive of prior diffuse axonal injury ([**Doctor First Name **]) in this region. These findings are unchanged from the most recent study. The visualized paranasal sinuses and mastoid air cells are clear. The soft tissues appear unremarkable. IMPRESSION: 1. Resolution of the previously noted right-sided subdural hematoma. 2. Sequela of prior infarct, contusion, and probable [**Doctor First Name **], as above. [**2121-12-23**] Head CT No change compared to the prior study. Stable encephalomalacic changes in the right frontal and left parieto-occipital regions. No evidence for subdural hematoma or mass effect. [**2121-12-26**] TTE The left atrium is moderately dilated. The right atrium is markedly dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20%). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderately dilated left ventricle with severe global systolic dysfunction. Elevated filling pressures. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2121-8-8**], the findings are similar. [**2122-1-1**] Cardiac Catheterization 1. Selective coronary angiography of this left dominant system revealed no angiographically apparent coronary artery disease. The LMCA, LAD, LCX and RCA had no angiographically apparent flow-limiting stenoses. 2. Resting hemodynamics revealed mildly elevated right and left sided filling pressures with RVEDP of 12 mm Hg and PCWP mean of 19 mm Hg at baseline. There was moderate pulmonary arterial hypertension of 45/21 mm Hg. Systemic arterial blood pressure was normal at 103/65 mm Hg. Cardiac index was depressed at a baseline value of 1.7 l/min/m2. After milrinone bolus of 0.5 mcg/kg IV over 10 minutes, left sided filling pressure were unchanged with a PCWP mean of 19 mm Hg. Pulmonary arterial pressure decreased to 40/18 mm Hg. Pulmonary vascular resistance also decreased. Cardiac index improved to 2.2 l/min/m2. There was no change in systemic arterial blood pressure. 3. Left ventriculography was not performed. Brief Hospital Course: (1) DILATED CARDIOMYOPATHY AND CHF Mr. [**Known lastname **] has a dilated cardiomyopathy that was diagnosed after presenting with Class III CHF symptoms in [**9-27**]; it is thought to be of viral etiology. TTE from [**8-2**] showed an EF of 20%. He is s/p AICD placement in [**2117**] after VT was diagnosed on Holter monitor. During this admission, he had evidence of worsening heart failure on CXR ultimately requiring intubation for pulmonary edema that was refractory to diuresis. After six days on a lasix drip, he was weaned off the ventillator. He was also on milrinone for inotropic support. On [**2122-1-1**], he was taken for a milrinone study in the cath [**Date Range **], which showed improvement in CI from 1.7 l/min/m2 off milrinone to 2.2 l/min/m2 after a milrinone bolus. He was continued briefly on milrinone after the study. However, he was ultimately discharged to home off milrinone. He was sent home on metoprolol 150 mg PO TID, lisinopril 2.5 mg PO BID and digoxin 0.125 mg PO QD. (2)ATRIAL FIBRILLATION with RAPID VENTRICULAR RATE He has pre-existing AFib with RVR with heart rates as high as 160's. His rate was controlled to the 90 - 110 range with metoprolol, and he was discharged on metoprolol 150 mg PO TID. He was on a heparin drip throughout the hospitalization for anticoagulation and sent home on coumadin with [**Hospital 6669**] [**Hospital3 **] follow-up. (3) C. DIFF COLITIS Mr. [**Known lastname **] had a fever and diarrhea and was found to be C. diff toxin positive. He was treated initially with PO flagyl; however, PO vancomycin was later added when his leukocytosis, fever and symptoms did not improve and there was for concern for a flagyl-resistant strain. He completed a 14 day course of PO flagyl and PO vancomycin after his broad spectrum antibiotics were discontinued (see below). (4) PERSISTENT FEVERS AND LEUKOCYTOSIS Although most likely secondary to C. diff infection, his fever and leukocytosis persisted even after treatment for C. diff colitis was initiated. Blood and urine cultures were negative. There was a question of RUL infiltrate on CXR, and he was treated empirically for five days with IV vancomycin and cefepime for a possible hospital acquired pneumonia. (5) ACUTE RENAL FAILURE His baseline creatinine is ~0.8 - 1.0. On admission Cr was noted to be 1.3, likely from decreased renal perfusion from his cardiac disease. Later in the admission, he again developed ARF likely secondary to contrast exposures, intravascular volume depletion and poor cardiac output. He was discharged with Cr above baseline but trending down, with out-patient follow-up. Medications on Admission: -ASPIRIN 325 mg daily -DILT-XR 240 mg daily -LANOXIN 125 mcg daily -LASIX 120 mg PO bid -LEVOXYL 75 mcg daily -LISINOPRIL 10 mg daily -Toprol XL 200 mg tid -PROTONIX 40 mg--1 tablet(s) by mouth daily while taking prednisone -SPIRONOLACTONE 25 mg daily -WARFARIN 5mg Mondays and 7.5mg six days/week -Docusate 100 mg [**Hospital1 **] prn constipation -Senna 8.6 mg daily prn constipation Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*30 Tablet, Chewable(s)* Refills:*2* 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 4 days. Disp:*16 Capsule(s)* Refills:*0* 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 7. Torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 10. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:*120 Tablet(s)* Refills:*2* 11. Outpatient [**Hospital1 **] Work Please draw STAT PT/INR; fax results to [**Company 191**] [**Hospital 3052**] at ([**Telephone/Fax (1) 3053**] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Dilated cardiomyopathy acute on chronic Congestive heart failure, systolic . Secondary Diagnoses: C. diff colitis Acute renal failure Discharge Condition: Stable-- satting in the upper 90's on room air, breathing comfortably; no lower extremity edema and lung clear to ascultation. Discharge Instructions: Weigh yourself every morning, call your doctor if your weight increases more than three pounds. They may need to adjust your torsemide dosage. . Please carefully follow the list of medications that the nurse gives you when you leave the hospital. Some of your old medications were stopped or the dosages changed, and some new medications were started. The changes are as follows: - You will need to continue to take antibiotics vancomycin and flagyl for the next 4 days - Your lasix has been changed to torsemide. You should no longer be taking lasix - Your lisinopril dose was decreased and you will now be taking it twice a day - Your warfarin dose was changed. You will need to have your INR checked on Tuesday [**2122-1-13**] to have your dose titrated. - Your Spironolactone has been stopped. . You should call your doctor or return to the Emergency Room if you experience chest pain, worsening shortness of breath or leg swelling. Followup Instructions: Please call Dr.[**Name (NI) 3536**] office at ([**Telephone/Fax (1) 2037**] to schedule a follow up appointment in the heart failure clinic in the next 1-2 weeks. You have the following appointments: (1) Provider: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2122-1-14**] 11:00 . (2) Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2122-1-30**] 11:00 . (3) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2122-1-30**] 12:00 . (4) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-1-30**] 3:15 pm . In addition, you need to be seen in the [**Hospital3 **] next week so that they can check your blood levels. They will call you to set up a time for you to come into the clinic.

Admission Date: [**2192-12-2**] Discharge Date: [**2192-12-10**] Date of Birth: [**2120-3-13**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 832**] Chief Complaint: Fevers, chills, cough and weakness Major Surgical or Invasive Procedure: None History of Present Illness: 72-year-old male with AChR +ve myasthenia [**Last Name (un) 2902**], Duodenal angiomas, asthma, diastolic CHF and AF who presented following a 4 day hx of fever, chills, and generalized weakness. Patient felt hot with chills past 2 nights for which he did not take his temperature but took acetamionophen for this. He noticed increasing wheeze past 2 days and did feel more SOB yesterday with no cough, sputum or hemoptysis. Since last night noted palpitations with an associated "funny feeling" in the chest. THis was a mild chest pressure which lasted 2 minutes and subsided. He had further sweating, fever, palpitations and chest discomfort (again which was self-limiting lasting 2 minutes per pt) and called an ambulance. Upon EMS arrival the patient was in a rapid AF with a heart rate about 130, O2 sat was approximately 95% on 4 L. Patient denies any chest pain, but noted mild difficulty breathing and mild nausea. Of note, he had missed his diltiazem this am. He denied emesis or abdominal pain. No recent hospital admissions. . In the ED, patient was noted to have a low grade temp 100 and was in fast AF with rate 130's and 94% 3L NC. CXR showed multifocal pneumonia. Labs demonstrated WBC 13 pt received, acetaminophen, IV levoflox/vancomycin and 2L NS and his SBP was 110's. No rate control was given. ECG showed fast AF with no ischemic changes. Vitals on transfer were 120 139/93 27-30 97% 3L NC. . Regarding myasthenic sx pt noted increased generalised weakness past 4 days with no diplopia or blurred vision and no swallowing problems. [**Name (NI) **] did not take any of his myasthenia meds until in the [**Hospital Unit Name **] which may account for his significant dysarthria although patient denies diplopia. . On arrival to the [**Hospital Unit Name 153**] vitals were T 99.6 123/91 HR 143 RR 19 sO2 97% 2.5L O2. Patient was complaining of soem SOB and mild wheeze and otherwise not disturbed by tacycardia. . ROS: The patient denies any weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: ACh R Ab +ve Myasthenia [**Last Name (un) **] on azathioprine and pyridostigmine has had for 3 years and had trouble with left ptosis 2 years. Diplopia resolved 2 years ago. Has never required ICU treatment for his MG. Colonic Polyps Duodenal angiomas (s/p thermal therapy) GI bleeding - capsule endoscopy [**10/2192**] (for guaiac +ve stools) showed mild, focal gastritis and no active bleeding sites were found. Gastritis HTN Asthma Constrictive pericarditis Chronic renal insufficiency Congestive heart failure diastolic Diverticular disease of the colon with a redundant colon Atrial fibrillation on diltiazem exudative pleural effusion . P Surgical Hx: s/p R total hip replacement S/p appendectomy . Social History: retired cab driver, ? h/o mild developmental delay, lives in [**Location (un) 453**] apt alone in [**Location (un) **] Smoking - Ex-smoker quit 16 years ago prev 2 cigars/day no ETOH, no illicits or IVDU. [**Name (NI) 1094**] brother is a retired internal med MD . Family History: Brother with DM, Mother d. 73, Father d. 73 CAD Physical Exam: On Admission: Vitals: T: 99.6 BP: 123/76 HR: 121 RR: 28 O2Sat: 95% 2.5L GEN: Tachypneic, c/o SOB. Left intermittently complete ptosis HEENT: sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2. JVP not elevated PULM: Markedly decreased BS L>R with crackles in left base and mild occasional wheeze. Generally poor air entry bilaterally. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords. Calves SNT. NEURO: alert, oriented to person, place, and time. CN II normal, complex ophthalmoplegia with significant limitation with some adduction and very limited abduction and R eye good abduction and 75% adduction with significantly limited elevation and depression of both eyes although patient cooperation was not ideal. Left complete ptosis although intermittent and weakness in eye closure bilaterally L>R but otherwise facial muscle power good. V, VIII, normal. Significant dysarthria. Good palatal movement. Somewhat impared sniff and good cough. Good tongue movement. Tone normal UL and LL. Power 4+/5 in shoulder abduction bilaterally and otherwise mild weakness in proximal muscles (Elbow F/E) bilaterally with good distal power. In LL Hip 4+/5 bilaterally with 5-/5 in hip extension and otherwise [**4-4**] in LL. Proximal weakness was fatiguable. Reflexes present and symmetrical in UL and Difficult to ellicit in the lower limb due to poor patient compliance. Plantar reflex flexor bilaterally. Coordination normal in UL. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . On Discharge: Pertinent Results: Admission labs: [**2192-12-2**] 12:20PM BLOOD WBC-13.0*# RBC-4.03* Hgb-12.3* Hct-35.2* MCV-87 MCH-30.5 MCHC-34.9 RDW-15.6* Plt Ct-270 [**2192-12-2**] 12:20PM BLOOD Neuts-90.1* Lymphs-3.6* Monos-6.2 Eos-0.1 Baso-0.1 [**2192-12-2**] 12:20PM BLOOD PT-14.4* PTT-23.7 INR(PT)-1.2* [**2192-12-2**] 12:20PM BLOOD Glucose-172* UreaN-29* Creat-1.4* Na-137 K-3.2* Cl-94* HCO3-31 AnGap-15 [**2192-12-2**] 12:20PM BLOOD cTropnT-0.01 [**2192-12-2**] 12:20PM BLOOD Calcium-9.1 Phos-2.4* Mg-2.0 [**2192-12-2**] 12:27PM BLOOD Glucose-153* Lactate-1.5 K-3.2* [**2192-12-2**] 12:27PM BLOOD Hgb-12.5* calcHCT-38 . Other labs: [**2192-12-2**] 08:04PM BLOOD Type-ART Temp-36.5 pO2-95 pCO2-43 pH-7.47* calTCO2-32* Base XS-6 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**] [**2192-12-2**] 12:27PM BLOOD Glucose-153* Lactate-1.5 K-3.2* [**2192-12-2**] 08:04PM BLOOD Lactate-1.3 [**2192-12-2**] 12:27PM BLOOD Hgb-12.5* calcHCT-38 . . Urine [**2192-12-2**] 07:33PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2192-12-2**] 07:33PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG [**2192-12-2**] 07:33PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [**2192-12-2**] 07:33PM URINE Mucous-RARE . Microbiology: BC [**12-2**] no growth to date UCx [**12-2**] negative [**2192-12-2**] Legionella Urinary Ag -ve . [**2192-12-3**] 2:49 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2192-12-3**]** GRAM STAIN (Final [**2192-12-3**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2192-12-3**]): TEST CANCELLED, PATIENT CREDITED. . . Radiology . XR CHEST (PORTABLE AP) Study Date of [**2192-12-2**] 12:25 PM FINDINGS: There is a rounded opacity in the right upper lobe. There is left basilar atelectasis. Lung volumes are slightly low. The cardiac silhouette, hilar and mediastinal contours appear within normal limits. There is no pneumothorax or pleural effusion. IMPRESSION: Right upper lobe consolidative opacity worrisome for pneumonia. Recommend repeat chest radiograph after appropriate treatment to assess for resolution. Left basilar atelectasis. . XR CHEST (PORTABLE AP) Study Date of [**2192-12-3**] 5:07 AM Portable AP chest radiograph was reviewed in comparison to [**2192-12-2**]. The right upper lobe rounded opacity appears to be slightly bigger than on the prior study and might be consistent with gradual progression of infectious process. Left retrocardiac consolidation is unchanged. Right basal atelectasis is unchanged. Cardiomediastinal silhouette is stable. Followup of the right upper lobe consolidation to complete resolution is mandatory. . [**2192-12-6**]: MRI BRAIN WITHOUT IV CONTRAST: The study is very limited, with incomplete diffusion imaging. Within the limitations of obtaining only the directional sequence of the diffusion study, there is no evidence of acute infarction. Non-contrast sagittal T1-weighted images show no mass effect or hematoma. IMPRESSIONS: Very limited study due to early termination shows no evidence of acute infarction, mass effect, or hematoma. Brief Hospital Course: 72-year-old male with AChR +ve myasthenia [**Last Name (un) 2902**], Duodenal angiomas, asthma, diastolic CHF and AF presents with fevers, chills and SOB and was found to be in fast AF with evidence of multifocal pneumonia on CXR. Considerable myasthenic sx (not affecting respiratory muscles but had mild proximal fatiguable weakness) on admission but now improving with persistent eye signs. . # Multi-lobar Pneumonia with acute respiratory failure: Evidence of predominantly RUL consolidation but also left base changes in context of fevers, chills and worsening SOB. Patient started on Levofloxacin and Ceftriaxone for CAP and given potential for worsening MG with levofloxacin this was changed to azithromycin. BCs, Sputum cultures, Urine legionella Ag was negative. WBC downtrending on hospital day 2 but CXR ppeared slightly worse with evidence of left base consolidation. He was treated with PRN nebs. He symptomaticlly improved, and was discharged to complete a total of 14 days of treatment on cefpodoxime (already completed 1 week of azithromycin). He will need a repeat CXR in [**3-6**] weeks to monitor for resolution. . # Rapid Atrial Fibrillation: On home maintained on diltiazem 240mg [**Hospital1 **]. Noted to have rate 130 at EMS and rate in ICU 100s-140s however had not received daily nodal agents. On evening of admission received 120mg of diltiazem. On morning of hospital day 2 resumed full home dose diltiazem 240mg [**Hospital1 **]. He was changed to short acting diltiazem 90mg Q6 on [**12-3**] as rate was still high. Regarding anticoagulation, patient not anticoagulated as an outpatient. Started on ASA 325mg which was discontinued in the setting of GI bleeding. He was discharged from the ICU on [**12-3**] and his HR was 90s-100s. On diltiazem 240 mg po bid he had HR in the 80's on the day of discharge. . # AChR +ve Myasthenia: Sees O/P neurologist. Usually on regular pyridostigmine and azathioprine. Current significant symptoms with complex ophthalmoplegia, ptosis and fatiguable proximal weakness with dysarthria. Generally poor chest wall movement. Baseline ABG obtained which was reassuring for intact respiratory status and showed respiratory alkalosis. Patient was unable to cooperate with FVC. Patient continued on azathioprine 150mg and pyridostigmine 90mg qid and glycopyrrolate. By Day 2 he had improved - no longer had proximal weakness but had persistent ocular symptosm with partial ptosis on left and very limited eye movement on the left especially in adduction and upgaze bilaterally. Neurology were consulted and followed. He eventually stabilized on his home doses of pyridostigmine and azathioprine, as well as glycopyrollate. . # Gait ataxia. He exhibited gait ataxian on hospital day 3. This improved slowly with increased ambulation. A partial MRI was completed, which showed no acute infarcts. He will be discharged with home PT and a walker. . # HTN: On admission relatively hypotensive systolic pressures improved in [**Hospital Unit Name 153**]. Held furosemide in setting of presenting hypotension thoguh this was restarted prior to discharge. . # Hx dCHF: furosemide was held during admission, with no signs of volume overload. Furosemide 80 mg po daily was restarted at discharge. . # Asthma: No further significant wheeze. He was given PRN Xopenex nebs . # Gastrointestinal bleeding, with history of angiomas. He was started on heparin SC and aspirin 325, then 81. On hospital day 4, he developed guaic positive stool. Prilosec was increased to 40 mg po bid, and heparin and aspirin were discontinued. He had a slow drift down in his hematocrit. He will follow up with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1940**], his primary gastroenterologist for an enteroscopy in the next 4-6 weeks. . # Diarrhea. The patient developed diarrhea occurring 3 times daily at the time of discharge. C Diff testing was negative. It is most likely that this represents a mediation side effect potentially from glycopyrollate. He will follow-up as an outpatient for further management of this issue. . Key follow up: Repeat CXR 4-6 weeks Medications on Admission: Calcitriol 0.25 mcg PO DAILY Xopenex Neb *NF* 1.25 mg/3 mL Inhalation q4 SOB Simvastatin 20 mg PO/NG DAILY Vitamin D 1000 UNIT PO/NG DAILY Ferrous Sulfate 325 mg PO/NG DAILY Citalopram 10 mg PO/NG DAILY Omeprazole 20 mg PO BID Diltiazem Extended-Release 240 mg PO Q12H Glycopyrrolate 1 mg PO/NG QHS Azathioprine 50 mg am 100mg pm Pyridostigmine Bromide 90 mg PO/NG Q6H Furosemide 80mg am 40mg pm Potassium chloride 20mEq [**Hospital1 **] FeSO4 325mg qd Discharge Medications: 1. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* 2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. azathioprine 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. glycopyrrolate 1 mg Tablet Sig: One (1) Tablet PO four times a day: with pyridostigmine. 5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation q6 prn () as needed for SOB. 13. diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 14. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: ## Gastrointestinal bleeding ## Multifocal community acquired pneumonia with acute respiratory failure ## Myasthenia [**Last Name (un) 2902**] with chronic ptosis of left eye, and weakness in setting of illness. ## Gait ataxia, ## Chronic diastolic CHF without acute exacerbation ## Atrial fibrillation with RVR, ## Stage II CKD, at baseline ## Chronic asthma without acute exacerbation. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with pneumonia and an exacerbation of your myasthenia. You were initially admitted to the ICU and then transferred to the floor. The neurology team saw you, and you did not have any respiratory failure due to your myasthenia [**Last Name (un) 2902**]. You improved with antibiotics. You also developed gastrointestinal bleeding likely due to your angiomas, while on heparin shots and aspirin. These were stopped and your prilosec was increased. With these changes, your bleeding stopped. . Medication changes: Complete 6 more days of CEFPODOXIME 200 mg po twice daily Increase PRILOSEC to 40 mg po twice daily Followup Instructions: Name:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA Specialty: Primary Care Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3530**] When: [**Last Name (LF) 2974**], [**12-14**] at 11:30am . Please also call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office to schedule a follow-up appointment in the next 1-2 weeks.

Admission Date: [**2118-4-8**] Discharge Date: [**2118-4-14**] Date of Birth: [**2052-8-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: jaundice/abdominal swelling Major Surgical or Invasive Procedure: hemodialysis line placement History of Present Illness: HPI: 65 yo M with h/o HTN p/w increasing abdominal girth and jaundice found to have liver failure and erythrocytosis. Pt was in his USOH until approximately 4 weeks ago when he developed increasing abdominal swelling, yellowed skin and worsening fatigue. He gained approximately 10 pounds over 2 weeks before seeing his PCP who noted some abnormal labs. Pt recalls that he had an elevated creatinine and bilirubin. He was referred by his PCP to [**Name Initial (PRE) **] gastroenterologist. Pt had an EGD performed which demonstrated no varices per the pt, though it did demonstrated "small ulcers." Pt also had a CT torso [**2118-3-25**] at [**Hospital1 **] showing an enlarged and heterogeneous liver, indicating either cirrhosis with regenerating nodules or dysplastic nodules. The pt was started on diuretics and lost approximately 12 pounds. The patient's gastroenterologist recommended the pt be electively admitted to [**Hospital1 18**] for further evaluation. . In the ED, vitals: t95, bp 110/64, hr 56, rr 16, sat 97% ra. Labs notable for hct initially 70->66, plt 146. BUN 75, cr 3.5. AG 23. INR 3.5. AST 184, ALT 48. T bili 55, d bili 30, AP 238. S/U tox negative. U/A with 3-5 wbcs, mod bacteria. CXR neg for an acute process. Abd u/s with portal vein thrombosis and cirrhotic liver. ekg: nsr@61 bpm, rbbb. Heme saw pt for erythrocytosis and phlebotomized one unit from pt. Pt transferred to the MICU for further management. . ROS: As above, otherwise denies CP/SOB/fever. Past Medical History: hypertension Social History: sh: lives with wife, [**Name (NI) **] 1 ppd x 50 yrs, etoh: 4 drinks/wk, no illicits, mechanical engineer Family History: fh: Father with polycythemia or hemachromatosis,treated with periodic phlebotomy until death at 74yrs. Mother with DM2, HTN. Daughter with MS. Physical Exam: Temp 97.1 BP 94/55 Pulse 62 Resp 20 O2 sat 96% ra Gen - comfortable, no acute distress HEENT - PERRL, sclera icteric, mucous membranes dry Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs appreciated Abd - palpable liver extending 8 cm below costal border and across midline, mildly tender to palp, distended, normoactive bowel sounds Extr - trace edema in LEs. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, no asterixis Skin - + jaundice, +palmar erythema rectal: in ED, black stool, guaiac positive Pertinent Results: ekg: nsr@61 bpm, rbbb . abd u/s: IMPRESSION: 1. Left portal vein thrombosis. This finding appears to have been present on prior ultrasound and CT examinations. . 2. Biliary sludge and stones but no secondary findings to suggest acute cholecystitis. Trace amount of pericholecystic fluid and hepatic dome ascites. . 3. Diffusely heterogeneous and coarsened liver echotexture with nodular external contour, likely related to underlying cirrhosis. No focal underlying intrahepatic masses were identified. A biopsy may be of benefit for pathologic evaluation. . cxr: IMPRESSION: No acute intrathoracic pathology including no pneumonia . [**2118-4-8**] 10:35PM HAPTOGLOB-LESS THAN [**2118-4-8**] 09:30PM URINE HOURS-RANDOM [**2118-4-8**] 09:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2118-4-8**] 09:30PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 [**2118-4-8**] 09:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-1 PH-7.0 LEUK-TR [**2118-4-8**] 09:30PM URINE RBC-[**6-28**]* WBC-[**3-23**] BACTERIA-MOD YEAST-NONE EPI-[**6-28**] TRANS EPI-[**3-23**] RENAL EPI-[**3-23**] [**2118-4-8**] 09:30PM URINE BILICRYST-MOD [**2118-4-8**] 06:50PM WBC-6.8 RBC-6.67* HGB-21.5* HCT-66.7* MCV-100* MCH-32.2* MCHC-32.1 RDW-22.9* [**2118-4-8**] 06:50PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-1+ POLYCHROM-2+ STIPPLED-1+ HOW-JOL-1+ PAPPENHEI-1+ [**2118-4-8**] 06:50PM PLT SMR-LOW PLT COUNT-146* [**2118-4-8**] 05:50PM estGFR-Using this [**2118-4-8**] 05:50PM LIPASE-38 [**2118-4-8**] 05:50PM ALBUMIN-3.7 IRON-85 [**2118-4-8**] 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2118-4-8**] 05:50PM WBC-7.37 RBC-7.08* HGB-22.3* HCT-70.6* MCV-100* MCH-31.5 MCHC-31.6 RDW-21.1* [**2118-4-8**] 05:50PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-1+ POLYCHROM-2+ STIPPLED-1+ PAPPENHEI-1+ [**2118-4-8**] 05:50PM PLT SMR-LOW PLT COUNT-147* [**2118-4-8**] 05:50PM PT-33.8* PTT-58.8* INR(PT)-3.5* Brief Hospital Course: 65 year old man with history of hypertension p/w increasing abdominal girth and jaundice found to have liver failure, renal failure and erythrocytosis . Liver failure: On admission, the ultrasound demonstrated that the patient's liver was diffusely heterogeneous with no discreet mass. Imaging was consistent with cirrhosis, though biopsy would be needed to confirm diagnosis. The differential diagnosis was broad, including infectious disease, autoimmune disease, and inherited disorders, such as hemosiderosis, which was strongly considered given the positive family history. The liver service was consulted and a full work-up was initiated. Hepatitis serologies were unremarkable. An AFP> 1 million was concerning for HCC. Iron studies were suggestive of hemochromatosis and hemochromatosis gene analysis was positive for a homozygous C282Y mutation. An abdominal MRI demonstrated background hemosiderosis, a large left lobe liver mass compatible with hepatoma invading left portal vein with left portal vein thrombosis, and additional multifocal areas of signal abnormality scattered throughout both lobes of liver compatible with multifocal hepatoma. It was felt that the patient had developed cirrhosis secondary to hemochromatosis and in turn developed malignant transformation. The liver oncology service was consulted and felt that given the multifocal involvement, locoregional therapies or transplantation were not indicated. Sorafenib was felt to be of limited benefit. The patient declined further aggressive chemotherapy and elected to be comfort measures only. He was discharged home with hospice. . erythrocytosis: The differential diagnosis included polycythemia [**Doctor First Name **] vs. epo producing neoplasm such as hepatocellular carcinoma. The patient had an elevated epo level and evidence of HCC as above. The patient was treated with serial phlebotomy per the hematology service. . renal failure: The renal service was consulted. The patient was felt to have hepatorenal syndrome. Dialysis was initiated in-house and was discontinued on discharge given the change toward hospice care. . portal vein thrombus: Felt to likely be associated with HCC. Anti-coagulation was initially held given the patient's occult blood positive stool. Further therapy was held given the patient's change in goals of care toward palliation. . hypertension: The patient's home medications were held given his borderline blood pressures throughout the admission. . FEN: The patient was placed on a renal diet. He was given dextrose IV as needed for hypoglycemia. . ppx: The patient was placed on heparin sc throughout the admission. . Communication: Multiple family meetings were held with the patient, his wife and children involved. Medications on Admission: Toprol XL another antihypertensive - name not known 2 new diuretics, name unknown Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Comfort medications per discharge planning sheet. Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: liver failure, suspected hepatocellular carcinoma hepatorenal syndrome erythrocytosis Discharge Condition: The patient is comfortable. Discharge Instructions: The patient is being discharged home with hospice.

Admission Date: [**2145-9-4**] Discharge Date: [**2145-9-7**] Date of Birth: [**2110-8-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: Abdominal pain, vomiting, coffee ground emesis Major Surgical or Invasive Procedure: RIJ central venous line placed Esophagoduodenoscopy hemodialysis History of Present Illness: 35 yo M with h/o DM, ESRD on HD, with history of gastroparesis, recent hospitalizations for emesis [**2-24**] gastroparesis. He presents now with coffee ground emesis for one day. Initially he woke up Friday morning with nausea and vomiting which was non-bloody, non-bilious and persisted throughout the day. During the night prior to presentation he had an episode of vomiting which was coffee ground appearing but not frankly bloody. He had multiple episodes of coffee ground emesis and so decided to go to ED. N/V is associated with [**2144-7-30**] epigastric pain that is sharp, non-radiating, not assoicated with PO intake, though he has not been tolerating POs during this presentation. In the ED he was given IVF 1L NS, protonix 80 mg IV, Reglan 10 mg, Compazine 10 mg, Zofran 8 mg, morphine 8 mg. Type and screen sent and his lactate was found to be 5.7. EJ was placed for access as he has poor peripheral veins, labs had to be drawn from femoral sticks because of poor peripheral access. In ED he also vomited 300 cc of coffee ground vomitous, was guaiac positive and had guaiac positive brown stool from below. He was sent to MICU for GI bleed, hematemesis and elevated lactate. Past Medical History: IDDM2 CKD stage IV on HD Diabetic gastroparesis Hypertension Hyperlipidemia Anxiety/Depression Mild esophagitis on EGD [**1-/2145**] Social History: He denies tobacco, alcohol, or drug use except for smoking marijuana which he smokes daily. He is currently on disability. . He lives with his wife, son, and daughter in [**Name (NI) **]; his wife recently had a daughter on [**2145-3-31**] Family History: DM2, HTN; Siblings: DM2 (he has 4 brothers and 3 sisters) Physical Exam: ADMISSION: VS: T106.6 HR 109 BP 172/110 RR: 17 O2 99% GEN: Lethargic appearing, laying in bed with epigastric abdominal pain but otherwise does not appear to be in any acute distress. HEENT: dry mucous membranes CV: Tachycardic S1 S2 clear and of good quality, no murmurs appreciated. EJ appears elevated to mastoid process with a pulsatile wave. PULM: Clear to auscultation bilaterally ABD: Obese, soft, tender to palpation over mid epigastrium but otherwise NT, ND, diminished bowel sounds. Tympanic to percussion EXT: Poor peripheral pulses in UE and LE bilaterally. Chronic venous stasis changes to LLE. Bilateral LE edema NEURO: Lethargic though alert, interactive, appropriate and oriented x3 He was gastrolavaged with 2L saline through NGT. He cleared somewhat but some coffee grounds did persist after 2 L were completed. DISCHARGE: VS: T:96.8, BP:100-129/70-100 P:96-108 R:18 O2:98RA GENERAL: Well-appearing man in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, holosystolic murmur to axilla, nl S1-S2. LUNGS: CTA bilat, good air movement. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-27**] throughout, sensation grossly intact throughout, Pertinent Results: [**2145-9-4**] 10:41PM WBC-10.0 RBC-4.97 HGB-12.6* HCT-42.6 MCV-86 MCH-25.4* MCHC-29.6* RDW-20.1* [**2145-9-4**] 10:41PM PLT COUNT-219 [**2145-9-4**] 05:50PM GLUCOSE-220* UREA N-63* CREAT-6.2* SODIUM-134 POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-24 ANION GAP-23* [**2145-9-4**] 05:50PM CALCIUM-8.7 PHOSPHATE-11.5*# MAGNESIUM-2.3 [**2145-9-4**] 05:50PM WBC-10.0 RBC-5.00 HGB-12.8* HCT-43.0 MCV-86 MCH-25.6* MCHC-29.7* RDW-20.4* [**2145-9-4**] 05:50PM PLT COUNT-206 [**2145-9-4**] 05:50PM PT-15.8* PTT-24.6 INR(PT)-1.4* [**2145-9-4**] 02:59PM TYPE-ART PO2-89 PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 [**2145-9-4**] 02:59PM LACTATE-3.1* NA+-134* K+-4.7 CL--90* [**2145-9-4**] 06:45AM LIPASE-34 [**2145-9-4**] 09:15AM DIR BILI-1.0* [**2145-9-4**] 09:28AM freeCa-0.95* . Abdominal ultrasound 1. No evidence of intra- or extra-hepatic biliary ductal dilatation or evidence of retained biliary stone. 2. Small amount of ascites noted in the right and left lower quadrant as well as left upper quadrant. 3. Mildly echogenic liver might be secondary to steatosis. Other forms of hepatic disease cannot be excluded. . CXR [**9-4**]: The patient has received a right internal jugular vein catheter. The tip of the catheter projects over the superior IVC. No evidence of complications, notably no pneumothorax. Moderate cardiomegaly without evidence of pulmonary edema. No pleural effusions. No focal parenchymal opacities suggesting pneumonia. Known small sclerotic lesion in the right clavicle, likely reflecting a bone island. . CXR [**9-5**]: As compared to the previous radiograph, there is no relevant change. Moderate cardiomegaly without overt pulmonary edema. No pleural effusions. No focal parenchymal opacity suggesting pneumonia. Unchanged course and position of the right central venous access line. Brief Hospital Course: 35 yo M with IDDM, ESRD on HD, chronic gastroparesis requiring hospital admissions for emesis who presents now with hematemesis. . #Hematemsis/Abdominal Pain: Given chronic history of emesis and acute history of vomiting all day before hematemesis started the most likely cause of bleeding is from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear. Other possiblities in differential included peptic ulcer disease although the patient is on protonix at home, gastritis or esophagitis. The patient's nausea was controlled to prevent vomiting induced GI bleed with Reglan, Zofran and then reinitiation of Erythromycin. The patient was kept on IV pantoprazole 40mg twice daily. He had cleared with 2 liters NG tube lavage and therefore, his NGT was removed - also per the patient's strong request. His hematocrits were rechecked every 8 hours and his hemodynamics monitored closely in the MICU - which all remained stable. The patient was typed and crossed for four units of blood and kept NPO per below. He received Dilaudid IV PRN and his home aspirin was held. When EGD was performed, there was evidence of erosive esophagitis and Barretts could not be excluded. He was recommended high dose [**Hospital1 **] PPI and follow up EGD in [**3-26**] months. Follow up with GI was arranged. . #Anion Gap Metabolic Acidosis. His AG was 20 on presentation to the MICU. His ABG demonstrated normal pH so he likely has a component of metabolic alkalosis as well. Likely lactic acidosis and a metabolic alkalosis from vomiting. He also has ESRD and so he has electrolyte/pH imbalance chronically from renal failure. On recheck prior to transfer out of the MICU, he still had an anion gap ~16 but it appears he has had gaps in the past. The patient was given gentle fluids to improve his metabolic status, antiemetics to reduce acid loss from vomiting and his ESRD was managed with hemodialysis, nephrocaps, aluminum hydroxide and increased sevelamer (predominantly for hyperphosphatemia). . # Gastroparesis. He was continued on home erythromycin and was able to tolerate home diet at the time of his discharge. . #DM: Chronic issue, poorly controlled. The patient was continued on home insulin regimen. . #HTN: Chronic, poorly controlled. He has been hemodynamically stable and actually hypertensive in the setting of hematemesis. The patient was restarted on his home medications for hypertension and in general, he was closely monitored for hemodynamic instability in the setting of his hematemesis. He remained stable on Amlodipine 5mg daily, lisinopril 5mg daily. . #ESRD: Chronic, on Hemodialysis Monday, Wednesday, Friday. The patient was very gently volume resuscitated given his risk of volume overload. Renal was aware of the patient for his usual dialysis schedule. He was continued on Nephrocaps and Sevelemer was increased in the setting of hyperphosphatemia to >11. The patient was also started on aluminimum hydroxide. Nephrotoxins were avoided. . #Nutrition: The patient was kept NPO for the first evening and first full day of admission secondary to ongoing nausea and dry heaving/gags. NGT initially placed but patient requested its removal. The patient was then kept NPO although improving feelings of nausea as the patient was to be kept NPO after midnight for possible EGD in the morning anyway. Post EGD, he was tolerating a full diet and he was discharged . #Access: RIJ was placed given poor access . #Communication: Patient, Wife . #Code status: Full Medications on Admission: 1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol) as needed for cellulitis: Pt will recieve two more [**Date Range 4319**] of Vanc at HD on Monday [**8-9**] and Wednesday [**8-11**]. 2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. insulin lispro 100 unit/mL Solution Sig: ASDIR Subcutaneous four times a day: As directed by sliding scale. 13. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. . Allergies: No Known Allergies Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*80 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Tablet, Chewable(s) 6. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO three times a day: Take medication with meals. 7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 9. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Capsule(s) 11. insulin lispro 100 unit/mL Solution Sig: -- Subcutaneous As directed by sliding scale. 12. insulin glargine 100 unit/mL Solution Sig: One (1) 15 units Subcutaneous at bedtime: 15 units Subcutaneous at bedtime. 13. Zofran 4 mg Tablet Sig: One (1) Tablet PO Q6H:PRN for 3 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Esophagitis Secondary: End Stage Renal Disease Diabetes Gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 8182**], It has been a pleasure caring for you during your hospitilization. Your were admitted due to your abdominal pain and vomiting. The endoscopy showed that you had severe inflamation of your esophagus. A follow up appointment has been made with the gastroenterologists to make sure adequate healing has taken place. A large IV was placed in the neck for access while you were hospitalized as you don't have good veins elsewhere. Please kept he area clean and dry. Contact your doctor if you develop any redness or oozing at the site of the catheter. Please take all your medications with the following changes: 1. Add Prilosec 40 MG Twice a Day (dose change) 2. Add Zofran 4 MG if you have nausea Please attend all follow up appointments. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED When: FRIDAY [**2145-9-10**] at 9:50 AM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2145-9-28**] at 1 PM With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED When: THURSDAY [**2145-9-30**] at 11:00 AM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[**2145-9-8**]

Admission Date: [**2135-3-4**] Discharge Date: [**2135-3-15**] Date of Birth: [**2060-11-2**] Sex: M Service: MEDICINE Allergies: Ampicillin / Dilantin / Haldol / Ceftazidime Attending:[**First Name3 (LF) 689**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 23203**] is a 74 yo male with recent history of CVA ([**12/2134**]) on coumadin who presented with rhinorrhea (3 days), productive cough (2 days) and mental status change (over the 16 hours PTA). The night PTA, he had restless sleep, woke at 3:30am and showered to get ready for the day. His wife got up at 6:30 and prepared breakfast. Prior to breakfast he was sitting [**Location (un) 1131**] the newspaper and his wife noted that he was "shaking" badly. He commented that he was "cold". She took his temp, which was 97F. They sat down to eat breakfast and he began to act odd. He sat very far away from the table. With prompting, he scooted to the table. He then was unable to properly use his fork to eat his eggs. His wife then called her PCP who recommended that they go to the ED. She called 911. Per the ED report (but no documentation in the chart), the pt was hypoglycemic in field to 27 and received dextrose. In the ED, he had a head CT that was negative for bleed or infarct. Glucose was 108. He had a temperature of 104. Initially his VS were BP 133/78, H 84 and evolved to 90-100s systolic and HR of 100-120s. He was given dilt 5mg x 2 for RVR. CXR was initially read as right middle lobe infiltrate and he was given ceftriaxone 1 g and azithromycin 500mg. There was some discussion about meningitis, but he was not given meningitis doses of medications. His neurologist felt that this was less likely meningitis and recommended against LP in the setting of therapeutic INR. When he arrived to the MICU, his SBPs were in the 70s. An arterial line was placed. He was bolused 4 more liters with improvement to 90-100s. ROS: +cough, +rhinorrhea, -diarrhea, -chest pain, -urinary problems Past Medical History: Traumatic Subdural/Subarachnoid hemorrhage- ([**2124**]) relating to fall in setting of ? alcohol use. No apparent residual symptoms. Hypertension Hypercholesterolemia Bipolar disorder- well controlled on depakote Depression- on effexor ? BPH- tried flomax and developed orthostatic syncope/hypotension. ? Delirium with prior hospital admission for SDH/SAH. ? Atrial fibrillation Social History: lives at home with his wife, retired schoolteacher and coach for baseball, football and other sports, 3 grown children live in the [**Location (un) 86**] area, ? history of alcoholism, currently rarely drinks, had 2 drinks last night for new year's celebration, no h/o illicit drug use. Family History: Mother- had DM, had strokes in her 50's [**Name (NI) 12238**] CAD [**Name (NI) 8765**] died from DM complications Physical Exam: MICU Admission Exam: T: 103.0 rectal BP: 84/52 NIBP, 97/52 Art line P: 106 afib RR: 17 O2 sats: 96% 4LNC Gen: lethargic HEENT: icteric injected, PEERL 3-2mm, OP with dry mucous membranes Neck: JVP flat CV: tachy, slightly irregular, distant Resp: clear anteriorly Abd: +BS, slightly distended, non-tender Ext: bruise on right arm, No edema/warm 2+ pulses Neuro: lethargic, oriented x 3, short-term memory difficulty, 5/5 strength, Pertinent Results: ADMISSION LABS: [**2135-3-4**] 10:50AM BLOOD WBC-11.1* RBC-5.33 Hgb-16.0 Hct-46.6 MCV-88 MCH-30.1 MCHC-34.4 RDW-13.4 Plt Ct-217 [**2135-3-4**] 10:50AM BLOOD Neuts-77* Bands-15* Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2135-3-4**] 10:50AM BLOOD PT-25.4* PTT-30.0 INR(PT)-2.5* [**2135-3-4**] 10:50AM BLOOD Glucose-113* UreaN-17 Creat-0.8 Na-137 K-4.2 Cl-99 HCO3-27 AnGap-15 [**2135-3-4**] 10:50AM BLOOD ALT-38 AST-24 AlkPhos-60 TotBili-0.8 [**2135-3-5**] 04:03AM BLOOD Albumin-3.2* Calcium-7.3* Phos-2.3* Mg-1.5* [**2135-3-4**] 03:07PM BLOOD Type-ART pO2-213* pCO2-29* pH-7.50* calTCO2-23 Base XS-0 [**2135-3-4**] 11:06AM BLOOD Lactate-2.6* [**2135-3-4**] 10:50AM BLOOD Valproa-41* [**2135-3-4**] 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2135-3-10**] 07:10AM BLOOD VitB12-1148* [**2135-3-9**] 07:10AM BLOOD calTIBC-229* Ferritn-762* TRF-176* [**2135-3-10**] 07:10AM BLOOD TSH-1.3 [**2135-3-10**] 07:10AM BLOOD Free T4-1.1 IMAGING: [**2135-3-4**] CT HEAD W/O CONTRAST: 1. No acute intracranial hemorrhage or major vascular territorial infarct. If there is continued concern for ischemia, MRI with DWI is more sensitive. 2. Extensive bifrontal encephalomalacia. [**2135-3-4**] CXR: Likely right middle lobe pheumonia; follow up in 6 weeks recommended MICROBIOLOGY: [**2135-3-5**] INFLUENZA DFA: Positive for Influenza A viral antigen. [**2135-3-11**] RIGHT CHIN DFA of VESICULAR RASH: Positive for Herpes Simplex Virus Type 1 by direct antigen staining [**3-4**], [**2135-3-5**] Blood cultures: no growth [**2135-3-5**] Urine cultures: no growth [**2135-3-5**] Sputum: OP flora [**2135-3-7**] ECHOCARDIOGRAM: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Mild mitral regurgitation. Trace aortic regurgitation. Dilated ascending aorta. Brief Hospital Course: RESPIRATORY SYMPTOMS: Mr. [**Known lastname 23203**] is a 74 yo male who presented with a three-day history of progressive respiratory symptoms (rhinorrhea, productive cough, fevers) and mental status change. He was found to have a RML pneumonia radiographically and was positive for influenza A. On presentation, he initially required aggressive fluid resuscitation, but thereafter remained hemodynamically stable. He required admission to the MICU for hypotension and concern for sepsis. He was started empirically on vancomycin and ceftrazidime, as well as tamiflu for influenza. Sputum cultures were negative. He competed a five day course of levofloxacin and tamiflu. CHANGE IN MENTAL STATUS: The patient's course was complicated by delirium, in particular sun-downing in the evenings. This was felt to be due to his underlying flu, pneumonia and the ICU environment. He became significantly agitated at night, requiring chemical and mechanical restraints. He also required a 1:1 sitter for safety. The decision was made to start the patient on a low dose of seroquel early in the evening, although this was discontinued by the time of discharge. His mental status dramatically improved with treatment of his underlying lung processes, and he was doing crossword puzzles and had no evidence of delirium upon discharge. ATRIAL FIBRILLATION WITH RVR: While in the ICU, the patient was noted to have AFib with RVR with heart rates as high as 150 during periods of intense agitation. He was started on a diltiazem drip. He later became hypotensive and was temporarily on digoxin until blood pressure stabilized, at which point he was restarted on home lopressor. An ECHO was also obtained which showed normal cardiac function. He was maintained on coumadin for anticoagulation, though his INR was labile while on antibiotics. HSV-1 OUTBREAK: The patient was noted to have multiple vesicular lesions on the upper and lower lips in the mid-line, as well as a small area of vesicles on the right chin and right neck. DFA was positive for HSV-1. He was started on a short course of acyclovir PO. **** PENDING ISSUES FOR FOLLOW-UP: (1) He needs an INR check with necessary Coumadin dosage adjustment on Friday, [**3-18**]. This is to be done by the PCP [**Name Initial (PRE) 3726**]. Medications on Admission: Venlafaxine SR 225 mg QHS Divalproex 500 mg Tablet Sustained Release QHS Warfarin 3 mg QHS Metoprolol Tartrate 50 mg [**Hospital1 **] Discharge Medications: 1. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. 4. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnoses: Influenza Secondary Diagnoses: Hypertension Hypercholesterolemia BPH Discharge Condition: Stable-- feeling well; breathing comfortably and satting in the upper 90's on room air at rest and on ambulation. Uses a cane for ambulation, as before. Discharge Instructions: You were admitted to the hospital with influenza. Please call your doctor if you develop new symptoms such as shortness of breath or fever. Please return to the emergency department if you cannot reach your doctor. Followup Instructions: Please see your primary care doctor, Dr. [**First Name8 (NamePattern2) 951**] [**Last Name (NamePattern1) **], on Friday, [**3-18**], at 9 am. His office number is [**Telephone/Fax (1) 6163**]. You also need to have your coumadin levels checked at this appointment.

Admission Date: [**2105-6-10**] Discharge Date: [**2105-6-23**] Date of Birth: [**2038-10-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath, referred from OSH Major Surgical or Invasive Procedure: s/p CABGx4(LIMA->LAD, SVG->PDA, OM, Ramus)/AVR(23mm CE Perimount bioprosthesis) [**2105-6-19**] History of Present Illness: This 66-year-old man with COPD, PVD who was admitted to OSH on [**6-6**] in respiratory failure. He was intubated and admitted to the ICU. His initial blood gas was 7.06/94/134/26 (on 100% O2). Chest xray showed pulmonary edema. Initial EKG (not included in transfer records) was read as sinus tachycardia at 120, LVH with repolarization. Initial TnI 0.11 and peaked at 0.21. BNP was 874. He was treated with nebs, diuretics, antibiotics and was extubated on [**2105-6-7**]. He was transferred to telemetry where he has been pain free. He was stressed yesterday and found to have an EF of 20-25% with a fixed defect. Patient has been on RA w/ sats >95%. He was OOB with no complaints prior to transfer. Upon arrival to [**Hospital1 18**] he states that his shortness of breath started approximately 4-5 days prior to his presentation. He states that the shortness of breath was sudden onset ~1am and progressively got worse. He states that he started taking Avandia 4 days prior to his symptom onset. He denies chest pain, jaw pain, or arm pain. He had a cough during this time but denies any sputum production. Also, he has had no fevers, chills, or sweats. The shortness of breath was no positional. He has had intermittent leg swelling over the past few weeks but not progressively so. He does have chronic pain in his calves when walking <1 block; the pain is relieved with rest. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: COPD PVD s/p peripheral revascularization in [**2095**] ?fem-fem ([**Hospital1 2025**]) NIDDM HTN "Hepatitis" >20 yrs ago + tob abuse + ETOH abuse (without DT's) Social History: Social history is significant for the presence of current tobacco use. There is history of alcohol abuse. Lives alone. Has one daughter ([**Name (NI) **] [**First Name8 (NamePattern2) **] [**Name (NI) 46**]). retired Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - T 97.3 BP (right) 137/58 (left) 89/69; HR 80; RR 18; 98%RA. FS: 254 Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. multiple missing teeth. Neck: Supple with JVP of 5 cm. CV: PMI barely palpable in midclavicular line. RR, normal S1, S2. II/VII syst murmur at RUSB w/o radiation. No thrills, lifts. No S3 or S4. Chest: Barrel chested. No scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. well healed lower abd scar Ext: No c/c/e. No femoral bruits. Skin: does have mild varicose veins. No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 1+ Popliteal faint DP doppler PT doppler Left: Carotid 2+ Femoral 1+ Popliteal faint DP doppler PT doppler Neuro: alert and oriented x3, CN II-XII intact, moving all four extremities symmetrically Pertinent Results: [**2105-6-23**] 07:00AM BLOOD WBC-9.6 RBC-3.53* Hgb-11.3* Hct-33.1* MCV-94 MCH-31.9 MCHC-34.0 RDW-13.1 Plt Ct-160 [**2105-6-23**] 07:00AM BLOOD PT-13.6* INR(PT)-1.2* [**2105-6-23**] 07:00AM BLOOD Glucose-182* UreaN-11 Creat-0.6 Na-134 K-4.0 Cl-97 HCO3-26 AnGap-15 [**2105-6-15**] 06:35AM BLOOD ALT-17 AST-14 LD(LDH)-166 AlkPhos-78 TotBili-0.4 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2105-6-20**] 5:28 PM CHEST (PORTABLE AP) Reason: Pneumothorax, After removal of chest tubes. [**Hospital 93**] MEDICAL CONDITION: 66 year old man with s/p AVR/CABG REASON FOR THIS EXAMINATION: Pneumothorax, After removal of chest tubes. HISTORY: Status post AVR, CABG, assess for pneumothorax, status post removal of chest tubes. chest, 1 vw Compared with [**2105-6-19**], the ET tube, NG tube, left chest tube and question mediastinal drains have been removed. Swan-Ganz catheter remains present, tip overlying theright pulmonary artery. No pneumothorax or gross effusion is identified. No CHF is seen. There is patchy increased retrocardiac density, increased compared with [**2105-6-19**], consistent with development of left lower lobe collapse and/or consolidation. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**] Cardiology Report ECHO Study Date of [**2105-6-19**] PATIENT/TEST INFORMATION: Indication: cabg/avr Status: Inpatient Date/Time: [**2105-6-19**] at 10:45 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *6.0 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 15% to 20% (nl >=55%) Aorta - Ascending: *3.8 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: *2.7 cm (nl <= 2.5 cm) Aortic Valve - LVOT VTI: 21 Aortic Valve - Valve Area: *0.7 cm2 (nl >= 3.0 cm2) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Moderately dilated LV cavity. Severe regional LV systolic dysfunction. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated ascending aorta. Simple atheroma in ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate to severe (3+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. Conclusions: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with moderated HK of basal segments and severe HK of mid and distal segments.. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2) by continuity, but mild AS by planimetry. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: An aortic valve prosthesis is in place. No leak, no AI. Good RV systolic fxn. Improved LV systolic fxn, with EF 35-40%, on Epi and Milrinone infusions. Aorta intact. No MR. [**First Name (Titles) **] [**Last Name (Titles) 31845**] as pre-bypass. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2105-6-19**] 12:02. Brief Hospital Course: Mr. [**Known lastname **] is a 66 year old man with PVD, multiple cardiac risk factors presented with signs and symptoms of new CHF. He ruled-out for acute MI then subsequently underwent cardiac catheterization to identify the cause of the new onset heart failure. The coronary angiography revealed 3 vessel disease and he was referred to cardiac surgery for CABG. A subsequent echocardiogram revealed moderate to sever aortic regurgitation. On [**2105-6-19**] he was taken to the operating room and underwent a coronary artery bypass graft times four (LIMA to LAD, SVG to PDA, SVG to OM and SVG to Ramus) and an AVR (23mm CE Perimount Bioprothesis). This procedure was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. He tolerated the procedure well and was able to be transferred in critical but stable condition to the surgical intensive care unit. In the surgical intensive care unit he progressed well. He was extubated and his chest tubes were removed by post-operative day one. He was weaned from his pressors. On the following day his epicardial wires and swan were removed. He was placed on amiodarone for atrial fibrillation. On post-operative day three he was transferred to the surgical step down floor. On the floor he was seen in consultation by the physical therapy service. The [**Last Name (un) **] diabetes clinic saw him in consultation. By post-operative day four he was ready for discharge in stable condition to home. Medications on Admission: Isordil 50 mg daily verapamil 240 mg [**Hospital1 **] lipitor 20 mg daily Actos 15 mg daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 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:*2* 4. 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* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days: Decrease dose to 400 mg PO daily for 7 days after twice a day dose completed, then decrease the dose to 200 mg PO daily after that. Disp:*60 Tablet(s)* Refills:*0* 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 11. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: CAD COPD IDDM PVD-s/p aorto bifem bypass HTN PUD Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Do not use creams, lotions, or powders on wounds. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for sternal drainage, temp>101.5. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 32668**] in 1 week [**Telephone/Fax (1) 12551**] Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks [**Telephone/Fax (1) 170**] Wound check appointment [**Wardname **] [**Telephone/Fax (1) 170**] [**7-3**] at 1200 Completed by:[**2105-6-25**]

Admission Date: [**2158-9-12**] Discharge Date: [**2158-9-20**] Date of Birth: [**2106-2-18**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Intubated Central Line History of Present Illness: The patient is a 52 yo F with h/o ETOH and cocaine abuse who presented to an OSH from home after a drinking binge and ingestion of cocaine with symptoms of withdrawal, black diarrhea and abdominal pain. She states that she usually binge drinks around [**9-17**] which is her mother's birthday. She has had little po but ETOH for the past two days and reports a single ingestion of cocaine with her girlfreinds several days ago. She reports history of DTs but no history of seizures. Vitals on scene were BP 165/124, HR 1008, o2 97. Her glucose was 47. She was brought to [**Hospital1 **] [**Location (un) 620**] ED and her ABG there was 7.45/45/18. Her lactate was 10 and Hct 57. sodium and K 130, 2.5. Her CIWA WAS 36 and she was given ativan (total 1.5 mg iv). A central line was placed and she was given 7L IVF. She remained hypotensive to the 70s and norepinephrine was stared. She also received zofran 4mg iv x1, zosyn and k and mag repletion. Before transfer to ED here, ABG was 7.31/37/78 and lactate 2.7. On arrival to ED here, BP 128/57 HR 81 O2 96 on 2L NC. Her antibiotics were broadened to vancomycin/zosyn given her hypotension and given her OB positive stool and abdominal pain with elevated lactate, a CT was obtained which showed non-specific enteritis. Surgery was consulted and recommended admission to medicine with GI consult and CTA id persisetent concern for ischemic colitis. During her ED course she received valium 10 IV x 2, protonix 80mg IV x 1 and additional K repletion. He levophed was weaned and has been off since 0510 this am. . On arrival to ICU, she is complaining of abdominal pain. She states taht she has had nothing but etoh for 3 days. Her binge began 3 weeks ago. She drinks at least a gallon of dark rum per day. Other than when binging, she does not drink every day and can go "for weeks". She used cocaine only once and prior use before then was about a year. She reports that she began vomiting and having diarrhea on sunday. She did not have any ETOH to drink on Monday. On tuesday, she felt withdrawal symptoms and had six "nips" (airplane bottle size). Her sister called EMS that evening. She reports seeing maroon blood in her diarrhea, mioxed in. She has seen this before and has assumed that it is from her hemorhoids which falre whn she drinks. She denies seeing any blood or coffee grounds in her emesis. . Review of systems: see metavision. negative for cp. positive for exertional dyspnea. Past Medical History: hypothyroidism ETOH abuse depression with h/o suicide attempt by overdose in [**6-17**] fibromyalgia h/o ortho surgeries to right arm, left leg (MVA, fall) hypertension Social History: - Tobacco: 1ppd - Alcohol: daily - Illicits: cocaine Family History: Non Contributory to ischemic colitis Physical Exam: Exam on Transfer out of MICU to floor. General Appearance: No acute distress, Anxious Eyes / Conjunctiva: PERRL, Pupils dilated Head, Ears, Nose, Throat: Normocephalic, NG tube Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , Crackles : anterior) Abdominal: Soft, Bowel sounds present, Tender: diffuse but mostly in RUQ an LLQ Extremities: Right lower extremity edema: Absent, Left lower extremity edema: bsent, No(t) Cyanosis, No(t) Clubbing Skin: Not assessed, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed . Discharge Exam: AVSS Neck with site of CVL, no significant redness, site or prior sutures intact. Card: S1 S2 No MRG Lungs: Clear Abd: Soft Non-Tender BS+ Extr: No Edema Pertinent Results: Admission Labs: [**2158-9-12**] 01:29AM BLOOD WBC-11.0 RBC-3.49* Hgb-11.7* Hct-31.8* MCV-91 MCH-33.5* MCHC-36.7* RDW-15.4 Plt Ct-134* [**2158-9-12**] 01:29AM BLOOD Neuts-36* Bands-35* Lymphs-12* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-10* Myelos-0 [**2158-9-12**] 01:29AM BLOOD Glucose-100 UreaN-56* Creat-1.5* Na-137 K-2.9* Cl-100 HCO3-19* AnGap-21* [**2158-9-12**] 10:44AM BLOOD ALT-29 AST-62* LD(LDH)-301* CK(CPK)-295* AlkPhos-70 TotBili-0.5 [**2158-9-12**] 01:29AM BLOOD ALT-32 AST-72* AlkPhos-65 Amylase-52 TotBili-0.5 [**2158-9-12**] 10:44AM BLOOD Albumin-3.1* Calcium-6.4* Phos-3.7 Mg-2.6 Iron-PND [**2158-9-12**] 01:29AM BLOOD Calcium-6.1* Phos-3.6 Mg-2.4 [**2158-9-12**] 04:34AM BLOOD Lactate-2.0 [**2158-9-17**] 02:57AM BLOOD WBC-4.9 RBC-3.12* Hgb-10.3* Hct-30.3* MCV-97 MCH-32.9* MCHC-33.9 RDW-14.9 Plt Ct-84* [**2158-9-14**] 05:02AM BLOOD Neuts-79.1* Lymphs-15.9* Monos-4.5 Eos-0.4 Baso-0.1 [**2158-9-13**] 03:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-1+ [**2158-9-17**] 02:57AM BLOOD Plt Ct-84* [**2158-9-17**] 02:57AM BLOOD PT-13.3 PTT-25.5 INR(PT)-1.1 [**2158-9-17**] 02:57AM BLOOD Glucose-128* UreaN-8 Creat-0.7 Na-143 K-3.6 Cl-103 HCO3-33* AnGap-11 [**2158-9-13**] 03:20AM BLOOD ALT-24 AST-39 LD(LDH)-224 AlkPhos-68 TotBili-0.6 [**2158-9-12**] 10:44AM BLOOD ALT-29 AST-62* LD(LDH)-301* CK(CPK)-295* AlkPhos-70 TotBili-0.5 [**2158-9-17**] 02:57AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.7 Mg-1.7 [**2158-9-16**] 06:00PM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0\ TTE: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild hypokinesis of the basal to mid left ventricle. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2158-9-13**], the function of the basal to mid segments has improved and is nearly normal. The degree of mitral regurgitation has decreased. CXR: FINDINGS: As compared to the previous radiograph, the patient has been extubated and the nasogastric tube has been removed. The bilateral parenchymal opacities are unchanged in extent. A minimal right-sided pleural effusion might have newly occurred. Unchanged size of the cardiac silhouette. No pneumothorax. Discharge Labs: [**2158-9-19**] 05:45AM BLOOD WBC-5.0 RBC-3.21* Hgb-10.6* Hct-31.6* MCV-98 MCH-33.1* MCHC-33.7 RDW-15.1 Plt Ct-161 Brief Hospital Course: Please see below: Ms. [**Known lastname 90842**] Hospital course was divded into an ICU (described by daily events below), and subsequently the general medical floor (divided by problem). . 52F with h/o ETOH and cocaine abuse, suicide attempt in [**Month (only) 596**] [**2158**] who presented to an OSH and transferred to the [**Hospital1 18**] ICU after a drinking binge and ingestion of cocaine with symptoms of withdrawal, black diarrhea and abdominal pain. . [**9-12**]: -per PCP [**Name Initial (PRE) 3726**]: HCT 41.8 in [**3-/2158**], 39.9 in [**10/2157**] -CT read: 1. Abnormal small bowel, with segmental areas of wall thickening and mild peripheral stranding which may be contiguous (or separated by a small amount of normal small bowel) from inflamed terminal ileum. This picture is compatible with enteritis, which could be inflammatory, infectious, or, less likely, ischemic 2. Probable colonic wall thickening and fatty infiltration consistent with chronic inflammatory changes in the proximal colon. 3. Fatty liver. 4. Right basal aspiration or atypical pulmonary infection. - [**Location (un) 620**] blood cultures still pending. need to f/u. - brother gave her methadone for her fibromyalgia. - GI consult: get KUB tonight (no free air), CT abdomen tomorrrow, consider TTE - HCT 31.8-> 28.3. . [**9-13**]: - opacicity right lung base ?aspiration -Liberal with valium/haldol, added physical restraints -CT abd held off for tomorrow; no new GI recs -[**Location (un) **] micro: NGTD - TTE read - LVEF 40% Moderate MR [**First Name (Titles) 151**] [**Last Name (Titles) 20691**] normal valve morphology. Normal left ventricular cavity size with mild global hypokinesis in a pattern suggesting a non-ischemic cardiomyopathy. - EKG QTc 432 earlier in evening, 480 @ 2:30am - she got some rest over night which is important - total valium > [**9-13**] ~240mg, [**9-14**] ~50mg - total haldol > [**9-13**] ~12.5mg, [**9-14**] ~10mg - gave 5mg olanzapine as well - RR ~50's > O2 Sat 92, CXR pending, ABG pH 7.52 pCO2 31 pO2 60 HCO3 26 , A-a gradient ~50. - called CVS in [**Location (un) **] to confirm meds [**Telephone/Fax (1) 90843**] ---cymbalta 120mg qhs - sack - 58-[**Telephone/Fax (1) 90844**] ---amitryptaline 150mg qhs ---hctz 25 daily ---clonazepam 2mg once [**Doctor Last Name **] ---cymbalta 30 mg daily twice daily gowda ---meloxicam ---acyclovir 400mg daily ---baclofen 20mg daily ---vicodin es 7.5/500 120/month, q 6 hour ---levoxyl 75mcg daily ---meloxicam 15 mg 1 qam .5 qpm ---prilosec 40 [**Hospital1 **] . [**9-14**]: -intubated for hypoxic respiratory failure. Now on PSV. Getting PRN fentanyl. -CXR shows satisfactory position of ET tube (4.5cm), NGT advanced, ? aspiration PNA -vancomycin added to zosyn to cover for HCAP -family ([**Doctor Last Name **]) updated -GI: no new recs -nutrition consult -> TF started -increased IV metoprolol to 5mg q6h . [**9-15**]: -during weaning of peep, PS she has become tachypnic up to 40s with tidal volumes of only ~200-250, RR improves to 16-18 after bolus of fentanyl, she past RSBI -tube feeds stopped: above EG junction, high residuals. -advanced NG tube. -dry - slightly hypernatremic; increased free water flushes to 250Q4 . [**9-16**]: -extubated -GI: cont supportive care -Got 1L D5W for hypernatremia. PM Na: 144 -restarted amitryptyline 50mg restarted hctz 50 (home dose) for am -d/c iv metoprolol (standing), can use prn - converted levothyroxine from IV to PO . [**9-17**]: - plan to continue abx for full 8 day course (2 more days starting tomorrow.) - social work consulted - GI signing off - called out to HMED, bed pending . MEDICAL FLOOR: ([**Date range (1) 9846**]) . # E.Coli Pneumonia: CXR evidence of evolving RLL pna. The patient continued to be treated HCAP PNA, potentially from aspiration PNA. The pt was treated initially with Vancomycin and Zosyn in the ICU, this was changed to Ceftriaxone on the floor. The patient received treatment through her date of discharge, at which time she had received 9 days of antibiotics. The patient was breathing comfortably on room air at discharge. . # ETOH withdrawal: h/o dts but no seizures. Pt was on CIWA while in ICU (see above), on floor, no valium was require. Outpatient follow-up recommended. . # Bloody diarrhea, Bowel wall thickening: Pt presented with symptoms. Per radiology intervening section of small bowel may be normal but does not contain oral contrast for it is difficult to evaluate. a skip lesion would change differential making inflammatory and infectious more likely than ischemic. area of bowel thickening is also large for watershed ischemia. the patient has been taking total of 20mg of meloxicam daily and reports compliance with this med even over past week. The CT findings could be NSAID induced enteritis. Concern also for ischemic enteritis secondary to cocaine induced vasospasm. KUB with no free air. Serial abdominal examinations unchanged. Infectious diarrhea was negative. . # Cardiomyopathy: Initial CV function depressed per echo. Some diastolic +/- systolic dysfunction. QTc prolongation may be due to ingestion of methadone; trending EKG esp given use of haldol / Cardiomyopathy. Intial TTE ([**9-13**]) showed LVEF 40% Moderate MR with [**Month/Day (4) 20691**] normal valve morphology. Normal left ventricular cavity size with mild global hypokinesis in a pattern suggesting a non-ischemic cardiomyopathy. A repeat TTE ([**9-17**]) was later performed that revealed EF 55% with mild hypokinesis of the basal to mid left ventricle. *Cardiology recommends outpatient follow-up and potential pMIBI, this has not yet been ordered* . #: Hypertension: Restarted on home meds on discharge. . # Depression, fibromyalgia: Restarted on home meds on discharge. Held while in house. . # Hypothyroid: Continued levothyroxine . # Chronic pain: Pt on vicodin as outpatient. No narcotics were provided to the patient on d/c. Medications on Admission: called CVS in [**Location (un) **] to confirm meds [**Telephone/Fax (1) 90843**] ---cymbalta 120mg qhs - sack - 58-[**Telephone/Fax (1) 90844**] ---amitryptaline 150mg qhs ---hctz 25 daily ---clonazepam 2mg once [**Doctor Last Name **] ---cymbalta 30 mg daily twice daily gowda ---meloxicam ---acyclovir 400mg daily ---baclofen 20mg daily ---vicodin es 7.5/500 120/month, q 6 hour ---levoxyl 75mcg daily ---meloxicam 15 mg 1 qam .5 qpm ---prilosec 40 [**Hospital1 **] Discharge Medications: 1. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day: Do not drive or operate heavy machinery while taking this medication. 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. amitriptyline 150 mg Tablet Sig: Two (2) Tablet PO at bedtime. 9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every 4-6 hours. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Alcohol Withdrawl - Aspiration Pneumonia - Stress inducted cardiomyopathy . Secondary Diagnosis - Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for alcohol withdrawl and subsequently developed a pneumonia. You were evaluated by cardiology that would like to evaluate you as an outpaient. Followup Instructions: Name: GOWDA,SAVITHA Location: [**Hospital **] MEDICAL ASSOCIATES, P.C. Address: [**Street Address(2) 75807**], STES 3A, B, [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 54268**] Appt: [**9-29**] at 2pm Department: CARDIAC SERVICES When: FRIDAY [**2158-10-6**] at 10:20 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Unit No: [**Numeric Identifier 62035**] Admission Date: [**2119-7-11**] Discharge Date: [**2119-7-11**] Date of Birth: [**2119-7-11**] Sex: M Service: NB HISTORY AND PHYSICAL: The infant is a 35-5/7 weeks 2195 gram male newborn who was admitted to the NICU for congenital heart disease. The infant was born to a 35 year old G1 P0 mother. Prenatal screens were O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. This pregnancy was complicated by a placenta subchorionic hematoma noted at 8 weeks, chronic hypertension maintained on Aldomet, and known congenital heart disease. Question of heart disease was raised on the first initial fetal survey. A fetal echocardiogram at 30 weeks done at [**Hospital3 1810**] revealed a probable tetralogy of Fallot, possible pulmonary atresia, good sized branched pulmonary arteries, overriding aorta, co-ventricular VSD, and good biventricular function. Maternal medications included Nexium, Zoloft, Aldomet and prenatal vitamins. Mother had been routinely followed at the [**Hospital1 69**] antepartum testing unit for fetal decelerations. Today the infant failed an oxytocin challenge test, prompting decision to deliver today by cesarean section. Referring hospital was [**Hospital3 **], and pediatric provider is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3501**] of [**Hospital 1465**] Pediatrics. At delivery, the infant was vigorous, with good tone and spontaneous cry. Routine neonatal resuscitation was given, including blow-by O2 for poor color. Apgars were 8 and 8. The infant was shown to the parents, then transported to the NICU. On exam, vital signs were heart rate 144, respiratory rate 40- 60s, actively crying, blood pressure 72/65 with a mean of 67, temperature 99. Growth parameters - weight of 2195 grams (25th percentile), length 45 cm (25-50th percentile), head circumference 30 cm (just greater than the 10th percentile). The infant was vigorous, in no acute distress, although cyanotic in room air, with room air oxygen saturations 82- 85%. He appeared slightly dysmorphic, with low set ears and a broad nasal bridge. Anterior fontanel was soft and flat. The lungs and chest revealed mild intermittent grunting, though he was clear to auscultation bilaterally and equal. Cardiac exam was regular rate and rhythm. He did have a murmur which was loudest at the left mid sternal border to the upper sternal border, with some radiation across to the right upper sternal border. There were no clicks or extra heart sounds. 2+ femoral pulses and [**2-12**] second perfusion. Abdomen was soft, with good bowel sounds and no hepatosplenomegaly. Genitourinary was a normal male, patent anus, no sacral anomalies. Hips were stable and he moved all his extremities well. Impression/Plan: This is a preterm male newborn with known cyanotic congenital heart disease. Two peripheral intravenous lines were started, and a prostaglandin infusion was begun at 0.01 mcg/kg/minute. Early management was discussed with the cardiology service, and the infant was transferred to the cardiology service at [**Hospital3 1810**] for continued care and management. The infant was placed NPO and was receiving maintenance intravenous fluids. Although he was preterm, there was no sign of respiratory distress syndrome, though with his intermittent mild grunting, he possibly has some mild TTN, and respiratory support will need to be continued to be monitored. There are no sepsis risk factors, though he was premature and mother had an unknown GBS status. A CBC with differential and blood culture was obtained, and antibiotics were not begun at this time. The plan for stabilization and transfer had been discussed with the family at the time of the prenatal consult. CONDITION ON DISCHARGE: Guarded. DISPOSITION: [**Hospital3 1810**] cardiac unit, P6. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3501**], [**Hospital 1465**] Pediatrics. CARE RECOMMENDATIONS: 1. NPO. 2. MEDICATIONS: Prostaglandin drip at 0.01 mcg/kg/minute. 3. A car seat position screening test was not done prior to transfer, and will need to be done per AAP recommendations prior to discharge to home. 4. State newborn screening status - An initial state newborn screen was obtained at less than 24 hours prior to discharge from the [**Hospital1 69**] NICU. 5. No immunizations have been received. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks. 2. Born between 32-35 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. With chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach six 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. DISCHARGE DIAGNOSES: 1. Preterm male. 2. Appropriate for gestational age. 3. Congenital heart disease, tetralogy of Fallot. 4. Question of mild dysmorphic features. Rule out DiGeorge syndrome. 5. Rule out sepsis, with no antibiotics at this time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Last Name (NamePattern4) 56994**] MEDQUIST36 D: [**2119-7-11**] 20:20:40 T: [**2119-7-11**] 21:03:46 Job#: [**Job Number 62036**]

Admission Date: [**2128-7-2**] Discharge Date: [**2128-7-17**] Date of Birth: [**2062-12-18**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: SOB and productive cough. Inability to wean from ventilator at [**Hospital 55664**] Hospital. Major Surgical or Invasive Procedure: Post-pyloric nasogastric tube. Extubation. Removal of chest tube #1. Right Internal Jugular Central Line Placement. History of Present Illness: Pt is a 65 yo Vietnamese male w/ a PMH sig for Non-small cell endobronchial lung CA s/p RMSB stent ([**5-21**]), COPD, and CRI recently admitted to OSH on [**6-27**] w/ increased SOB and O2 sat in the 70??????s. He denied CP/N/V/HA/change in UO/recent travel/sick contacts/pedal edema at that time. He was found to have a MSSA pna and COPD exacerbation. He was started on steroids, Nebs, BiPAP, and gatafloxacin. On [**6-28**] he was intubated secondary to resp failure, w/ resultant PTX. 2 Chest tubes were placed at that time. Pt was not able to be weaned off the vent and he was transferred to [**Hospital1 18**] MICUA on [**7-2**]. Pt was extubated on [**7-7**] and one of his CT??????s was removed on [**7-8**]. Pt was initially noted to be confused and agitated, which has subsequently improved once he left the MICU. A post-pyloric NGT was successfully placed and pt was at goal tube feeds of 40 cc/hr. He noted a non-radiating pain in his L chest over the CT and pain at his peripheral IV site. He continued to have a cough. He denies substernal CP/SOB/Abd pain/N/V/D/HA. Current Hx obtained via translator. Past Medical History: 1. Non-Small Cell Lung CA s/p RMSB stent [**5-21**] 2. HTN 3. COPD 4. TB 10 yrs ago tx??????ed in [**Country 3992**] 5. ? h/o DVT 6. CRI (baseline Cr 1.7) 7. Chronic b/l LE pain and paraesthesia 8. hyperlipidemia 9. asymmetric pupils 10. Asthma FEV1 0.7 L 11. EF 64%, Mild MR, mild diastolic dysfxn 12. h/o MSSA pna in[**5-21**] Social History: Pt denies tob or EtOH use. Family History: GM w/ Lung CA. Physical Exam: O: Tm: 100.4 Tc:99.2 BP: 130 /53 (119-130/43-60) HR: 70 (63-81) RR: 15 (15-20) O2Sat.: 98-100% 2.5 LNC I/Os: 2770/1310 Gen: Cantonese speaking gentlemen, appears comfortable, sitting up in bed. HEENT: NC/AT. asymmetric pupils, PERRL. Anicteric. MMM. No pallor, pos Ecchymosis on post pharynx. Neck: Supple. No masses or LAD. No JVD. Subcutaneous crepitus over entire neck to ears Lungs: Pos rhonchi and expiratory wheezes, decreased BS over R base to mid lung fields. Cardiac: distant heart sounds, RRR. S1/S2. No M/R/G. Abd: pos subcutaneous crypitus, Soft, NT, ND, +NABS. No rebound or guarding. Extrem: No C/C/E. Pertinent Results: [**2128-7-2**] 09:42PM TYPE-ART TEMP-37.3 RATES-20/ TIDAL VOL-400 O2-60 PO2-191* PCO2-65* PH-7.29* TOTAL CO2-33* BASE XS-3 -ASSIST/CON [**2128-7-2**] 09:42PM LACTATE-2.3* [**2128-7-2**] 09:42PM freeCa-1.14 [**2128-7-2**] 08:05PM GLUCOSE-153* UREA N-45* CREAT-1.9* SODIUM-142 POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15 [**2128-7-2**] 08:05PM ALT(SGPT)-19 AST(SGOT)-27 ALK PHOS-47 TOT BILI-0.2 [**2128-7-2**] 08:05PM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-2.9 MAGNESIUM-2.3 IRON-61 [**2128-7-2**] 08:05PM calTIBC-187* VIT B12-537 FOLATE-14.1 FERRITIN-443* TRF-144* [**2128-7-2**] 08:05PM WBC-22.2*# RBC-3.18* HGB-9.0* HCT-28.8* MCV-91 MCH-28.4 MCHC-31.4 RDW-14.2 [**2128-7-2**] 08:05PM NEUTS-81* BANDS-6* LYMPHS-1* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-5* MYELOS-4* [**2128-7-2**] 08:05PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2128-7-2**] 08:05PM PLT SMR-NORMAL PLT COUNT-410 [**2128-7-2**] 08:05PM PT-12.3 PTT-26.6 INR(PT)-1.0 Brief Hospital Course: Pt is a 65 yo Vietnamese male with a PMH sig for Non-small cell endobronchial lung CA s/p RMSB stent ([**5-21**]), COPD, and CRI admitted to [**Hospital1 18**] MICU on [**2128-7-2**] for inability to wean from a ventilator. Pt was inititally admitted to an OSH with resp failure secondary to pneumonia, which required intubation. He susequently developed a Left PTX and received 2 Left sided chest tubes. Pt was extubated on [**7-7**] and one of his CT??????s was removed on [**7-8**]. Pt was initially noted to be confused and agitated, which has subsequently improved once he left the MICU. A post-pyloric NGT was successfully placed and pt was at goal tube feeds of 40 cc/hr. Throughout his stay he noted a non-radiating pain in his L chest over the CT. He continued to have a cough. Pt also received a post-pyloric nasogastric tube after he failed a swallow evaluation post extubation. He was maintained at goal tube feeds of 40 cc/hr until he pulled out the tube. A repeat swallow evaluation was normal and the patient's diet was advanced as tolerated. 1. Respiratory Failure. Etiology thought to be multifactorial. Pt was successfully extubated on [**2128-7-7**] and transferred out of the intensive care unit on [**2128-7-10**]. His O2 sats were initially maintained on 2.5 L NC and on RA prior to discharge. Oncology was consulted while the pt was in the intensive care unit for his NSCLC. It was determined that he was not a surgical candidate and radiation oncology was consulted to talk to the pt about radiation therapy for palliation. A CT w/ contast was done to evaluate his tumor burden. He was given IVF and mucomyst for his CRI. Pt will follow-up with radiation oncology and oncology as an out-patient. 2. COPD. Likely contributing to his respitory symptoms. He was started on prednisone in the unit, which was subsequently tapered prior to his discharge. He was continued on nebulizer and inhaler treatments. He was also given Guaifenesin q 6 hrs for cough. 3. PTX, thought to be secondary to barotrauma. One chest tube was removed in the unit. Subcutaneous emphysema developed. It sebsequently improved and the chest tube was changed from wall suction to water seal and then to air. It continued to drain pus and was left in place at the time of discharge as per thoracic surgery's recommendation. The patient and his daugher were instructed on how to care for the tube and a follow-up appointment was made with thoracic surgery. They plan to remove the tube 2 inches per week. 4. HTN. Well controlled throughout his hospital stay on ACEI and B-B. 5. Hyponatremia. Etiology thought to be secondary to large amounts of free water boluses added to his tube feeds. Hyponatremia resolved once the fluid boluses were decreased. 6. CRI. Baseline Cr reported as 1.7. Cr decreased to 1.2, however bumped to 1.5 post contrast. He was aggressively hydrated and his Cr improved to 1.3 on day of discharge. 7. ID. staph bacteremia- initially started on iv oxacillin which was then changed to dicloxacillin. Pt continued to spike temps during his stay. Bld, Sputum, Pleural fluid, and Urine cultures were obtained. Blood and pleural fluid with MSSA. Urine grew GPC in pairs and clusters. Pt started on IV Vanco while on the floor. 8. GI. Pt had 1 episode of melena. Etiology thought to be gastritis or small ulcer. pt has 2 PIV's. he was consented and crossmatched, however remained hemodynamically stable. He was on po protonix. No EGD performed given clinical stability & comorbities. 9. Agitation. Noted while pt was in the unit, however appeared to resolve once the patient was on the floor. He was initially controlled on Haldol prn with a sitter. 10. Social. SW consulted to help pt and family cope w/ new dx of CA. Medications on Admission: 1. Neurontin 100 tid 2. Atrovent 3. Alb IH 4. Lipitor 20 qd 5. Nifedipin 60 qd 6. Atenolol 75 qd 7. Colace 8. Tylenol 9. Senna Discharge Medications: 1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q1-2H () as needed. Disp:*1 * Refills:*0* 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q1-2H () as needed. Disp:*1 * Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO every six (6) hours as needed for cough. Disp:*90 ML(s)* Refills:*0* 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 8 days. Disp:*32 Capsule(s)* Refills:*0* 8. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Non-small Cell Lung Cancer status-post Right Main Stem Bronchus Stent. MSSA pneumonia Probable Gastritis. Discharge Condition: Stable. Ambulating with walker, tolerating regular diet, breathing comfortably on RA. Discharge Instructions: Please call return to the hospital if you have difficulty breathing or any other problems arise. Followup Instructions: 1. Provider: [**Name10 (NameIs) **],[**Doctor Last Name **] THORACIC LMOB 2A Where: THORACIC LMOB 2A Date/Time:[**2128-7-20**] 10:30 2. Radiation Oncology. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 442**]. [**2128-7-20**] at 2:00 PM.[**Telephone/Fax (1) 55665**]. 3. Pt is to follow up at [**Hospital3 55666**], located at [**State **]. [**Location (un) 86**], [**Numeric Identifier 4809**]. The phone number is ([**Telephone/Fax (1) 26420**]. He has an appointment for Thursday, [**7-22**] at 1000. The patient must bring his medication list, discharge worksheet, and identification. He should have his renal function checked at this appointment. 4. Please call [**Hospital **] clinic to set up appointment with Dr. [**Last Name (STitle) **]. [**0-0-**] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Admission Date: [**2107-9-14**] Discharge Date: [**2107-10-3**] Date of Birth: [**2032-5-11**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Erythromycin Base Attending:[**First Name3 (LF) 1406**] Chief Complaint: "dizziness" and shortness of breath Major Surgical or Invasive Procedure: [**2107-9-20**] Cardiac Catheterization [**2107-9-26**] Redo sternotomy/Aortic valve replacement(21 mm [**Doctor Last Name **] pericardial) History of Present Illness: Patient is a 75 year old male with PMH significant for CAD s/p CABG in [**2089**] (LIMA to LAD, SVG to D1 and SVG to RCA), DM2 and critical AS s/p balloon valvuloplasty [**8-22**] with valve area improvement from 0.6 to 0.74. He was recently discharged from the hospital on [**8-24**]. He reports feeling well and gaining strength the first week after discharge but for the past week has been getting dizzy and shortness of breath with minimal activity. Visting nurse has noted approximately 14 lbs weight gain since discharge three weeks ago. He got dizzy while tying his shoes today which finally prompted him to come to ER at OSH where he was noted to have pulmonary edema on exam, CE -ve x 1. He was tranferred to [**Hospital1 18**] for further management of his decompensated heart failure secondary to his severe aortic stenosis. Past Medical History: Aortic stenosis s/p balloon valvuloplasty [**8-22**] Congestive heart failure Coronary Artery Disease s/p coronary artery bypass graft [**2089**] Hypertension Dyslipidemia Benign Prostatic Hypertrophy Diabetes Mellitus type 2 Retinopathy Bipolar disorder (in remission) Right eye blindness (retinal vein rupture [**2090**]) s/p repair trigger finger L 4th finger Social History: Retired particle physicist. Widower, lives alone at home in [**Location (un) 1157**], MA. denies T/E/D. Family History: No family history of coronary artery disease Physical Exam: Admission Physical Exam 65" 158# Gen: Male in no acute distress Tc: 96.3 BP:125/73 P:57 RR:18 O2sat:98%RA HEENT: supple neck without lymphadenopathy Chest: Decrease breath sound at LLL. Crackles upto mid bases. Heart: 4/6 SEM best heard at RUSB and radiating to carotids. [**4-16**] holosytolic murmur best heard at apex. Abd: Soft, NT and ND. NABS External: 2+ pitting edema upto midleg. No rashes Neuro: Alert and oriented x 3. 5/5 strength in UE and LE. Sensation intact. Pertinent Results: Cardiac Cath ([**2107-9-20**]): 1. Resting hemodynamics revealed moderately elevated right and left sided filling pressures with an RVEDP of 13mmHg and LVEDP of 21mmHg. There was moderate-to-severe pulmonary arterial systolic hypertension with a PASP of 68mmHg. The cardiac index was mildly reduced at 2.11L/min/m2. FINAL DIAGNOSIS: 1. Mildly elevated right and left sided filling pressures. 2. Pulmonary hypertension and moderately elevated PVR LE US ([**2107-9-25**]): No evidence of DVT in the left lower extremity. Probable hematoma extending from the anterior upper to mid calf. Clinical correlation advised. Echo ([**2107-9-26**]) PREBYPASS: The left atrium is markedly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). There is hypokinesis of the inferior and septal walls. Right ventricular systolic function is normal with normal free wall contractility. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with some restriction of both the anterior and posterior leaflets. Moderate to severe (3+) mitral regurgitation is seen. 3D imaging reveals failure of coaptation between the A3 and P3 leaflets. There is mild tricuspid regurgitation. There is no pericardial effusion. There is a left pleural effusion. POSTBYPASS: The patient is A-paced on epinephrine and phenylephrine infusions. Left ventricular systolic function is improved with the inotrope (LVEF 50-55%). Hypokinesis of the inferior and septal walls persists. Right ventricular systolic function is now mildly depressed. Mild tricuspid regurgitation persists. There is a new aortic bioprosthetic valve which is well seated with good leaflet excursion. Peak/mean gradients are 15/7 mmHg. The aortic valve area was calculated to be 1.5 cm2. There is trace aortic regurgitation which is central. There are no perivalvular leaks. Mitral regurgitation is now moderate (2+). Aortic contours are normal. Dr. [**Last Name (STitle) **] was informed of the results at the time of the study. [**2107-9-15**] 03:45AM BLOOD WBC-6.3 RBC-3.61* Hgb-10.7* Hct-32.4* MCV-90 MCH-29.5 MCHC-32.9 RDW-15.9* Plt Ct-266 [**2107-9-22**] 06:05AM BLOOD WBC-6.7 RBC-3.94* Hgb-11.4* Hct-35.7* MCV-91 MCH-28.9 MCHC-31.9 RDW-15.7* Plt Ct-342 [**2107-10-3**] 05:17AM BLOOD WBC-8.4 RBC-3.45* Hgb-10.2* Hct-30.2* MCV-88 MCH-29.4 MCHC-33.6 RDW-15.8* Plt Ct-302 [**2107-9-15**] 03:45AM BLOOD PT-24.7* INR(PT)-2.4* [**2107-9-22**] 06:05AM BLOOD PT-14.5* PTT-76.0* INR(PT)-1.3* [**2107-9-26**] 02:00PM BLOOD PT-14.3* PTT-43.3* INR(PT)-1.2* [**2107-9-15**] 03:45AM BLOOD Glucose-186* UreaN-27* Creat-1.0 Na-138 K-3.7 Cl-101 HCO3-33* AnGap-8 [**2107-9-22**] 06:05AM BLOOD Glucose-128* UreaN-24* Creat-1.0 Na-139 K-4.4 Cl-96 HCO3-36* AnGap-11 [**2107-10-3**] 05:17AM BLOOD Glucose-168* UreaN-36* Creat-0.7 Na-137 K-3.9 Cl-100 HCO3-31 AnGap-10 [**2107-9-22**] 06:05AM BLOOD ALT-25 AST-26 LD(LDH)-252* AlkPhos-86 TotBili-0.5 [**2107-9-15**] 03:45AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0 [**2107-9-30**] 04:31AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.4 [**2107-9-22**] 06:05AM BLOOD %HbA1c-8.5* eAG-197* Brief Hospital Course: 75 year old male with past medical history significant for coronary artery disease s/p coronary artery bypass graft in [**2089**] (LIMA to LAD, SVG to D1 and SVG to RCA), diabetes mellitus and critical Aortic Stenosis s/p balloon valvuloplasty on [**8-22**] with valve area improvement from 0.6 to 0.74. He was admitted with decompensated heart failure (acute on chronic) secondary to his severe aortic stenosis. Upon admission he was medically managed for his heart failure and aggressively diuresed. with vast improvement in peripheral and pulmonary edema prior to surgery. He was also treated for his previous history of Atrial fibrillation. He received Amiodarone and beta-blockers daily and was transition from Coumadin to Heparin for anticoagulation. Diabetes management was also closely monitored and [**Last Name (un) **] was consulted for management due to his insulin resistant state and variable diet. On [**9-20**] he underwent a right heart cath to evaluate volume status and PA hypertension prior to aortic valve replacement. Cath revealed mildly elevated right and left sided filling pressures. Along with pulmonary hypertension and moderately elevated PVR. On [**9-21**] he underwent a TEE to further assess his mitral valve. Echo revealed moderate to severe (3+) mitral regurgitation. On this day cardiac surgery was consulted and he required a few additional lab studies prior to surgery. Mr. [**Known lastname 25307**] developed a right thigh hematoma post-cath with difficulty with leg flexibility. Ultrasound revealed a thigh hematoma. Orthopaedics was consulted to evaluate for compartment syndrome. Orthopaedics evaluation was negative for compartment syndrome and patient received pain management. IV Heparin was discontinued before surgery due to this hematoma and he was cleared for surgery on [**9-26**]. On this day he underwent a redo-sternotomy, aortic valve replacement with Dr. [**Last Name (STitle) **]. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable but critical condition (titrated on propofol, epinephrine,and phenylephrine drips). Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Immediately post-op pulmonary was consulted for improved management of his pulmonary hypertension (Nitric Oxide and Sildenafil was started). On post-op day one he was started on beta-blockers and aggressively diuresed. By post-op day two pressors were titrated off. Chest tubes and pacing wires were removed per protocol. He remained in the CVICU until post-op day four receiving additional care for his pulmonary status as described above. On this day he was transferred to the telemetry floor for further care. Physical therapy and [**Last Name (un) **] followed Mr. [**Known lastname 25307**] during his entire post-op course. His diet was slowly transitioned back to a regular consistency diabetic diet. He continued to receive pulmonary toilet, medical management and repletion of his electrolytes over the next several days. On post-op day seven he appeared to be doing well enough to be discharged to rehab ([**Hospital **] center in [**Location (un) 1157**]). Appropriate medications and follow-up appointments were made. Medications on Admission: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). Disp:*900 ML(s)* Refills:*2* Disp:*36 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: start on [**2107-9-11**]. Disp:*30 Tablet(s)* Refills:*2* 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 10. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 12. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous every am. 13. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous in the evening. 14. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day. 12. Outpatient Lab Work BUN, Creat, Potassium twice weekly 13. Lantus 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous bfast and dinner. 14. humalog per sliding scale fingerstick 15. Viagra 25 mg Tablet Sig: Twenty (20) mg PO BID (2 times a day) for 4 days: then decrease to 20mg po daily for 7 days then d/c. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Location (un) 1157**] Discharge Diagnosis: Aortic stenosis s/p redo sternotomy, Aortic Valve Replacement Acute on chronic systolic heart failure Past medical history: Aortic valve balloon valvuloplasty [**8-22**] Mitral regurgitation Coronary Artery Disease s/p coronary artery bypass graft [**2089**] Atrial fibrillation Hypertension Dyslipidemia Benign Prostatic Hypertrophy Diabetes Mellitus type 2 Retinopathy Bipolar disorder (in remission) Right eye blindness (retinal vein rupture [**2090**]) s/p repair trigger finger L 4th finger Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema: 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] Wed [**10-26**] @ 1:45pm Please call to schedule appointments with your : Primary Care Dr.[**Last Name (STitle) 25301**] in [**2-12**] weeks Cardiologist Dr.[**Last Name (STitle) **] in [**2-12**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2107-10-3**]

Admission Date: [**2148-10-3**] Discharge Date: [**2148-10-5**] Service: CCU CHIEF COMPLAINT: Chest pain and shortness of breath status post left anterior descending stenting HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old woman, a nursing home resident, with known coronary artery disease status post percutaneous transluminal coronary angioplasty of the left anterior descending x 2 in [**2137**], non-Q myocardial infarction in [**2145**], who complained of chest pain associated with shortness of breath starting the night prior to admission. She was given sublingual nitroglycerin at the nursing home. She was then brought to the Emergency Room at 2 P.M. on the day of admission. In the Emergency Room, her temperature was 97.6, blood pressure 91/43, pulse 75, respirations 21, and oxygen saturation 98% on 2 liters. Her examinations were notable for bilateral pedal edema, bilateral crackles, and guaiac positive stools. Her electrocardiogram revealed atrial fibrillation with slow ventricular rate, incomplete left bundle branch block, ST elevations in V1 to V2, ST depression in I, II, AVL, V5 to V6, with T wave inversions in I, II, AVL and V3 through V6. She remained stable in the Emergency Room, and her initial CK was 91, troponin was less than .3, hematocrit was 33.4, and INR was 2.9. Because of the concern for acute myocardial infarction, she was started on a nitro drip and was brought to the catheterization laboratory directly. Catheterization revealed three vessel disease with left anterior descending proximal 80%, left circumflex proximal 70%, obtuse marginal I 80%, obtuse marginal II 80%, and right coronary artery proximal 60%, and mid 70% stenosis. The proximal left anterior descending was successfully stented. The right heart catheterization showed PA 63% with a calculated cardiac index of 2.34, RA pressure mean of 14, RV pressure 49/11, with an end diastolic pressure of 16, PA pressure 56/26, with a mean of 39, wedge of 25. Because of her initial INR of 2.9, she had excessive bleeding at the right femoral site, with Angioseal post-catheterization. The bleeding was controlled with pressure for two hours. Due to excessive bleeding, no Integrilin was given post-catheterization, and two units of fresh frozen plasma were ordered. She was transferred to the Coronary Care Unit for overnight observation. PAST MEDICAL HISTORY: Coronary artery disease status post acute anterior myocardial infarction in [**2137**], status post percutaneous transluminal coronary angioplasty of left anterior descending x 2, status post non-Q myocardial infarction in [**2145**], congestive heart failure, last echocardiogram in [**2147-1-19**] with an ejection fraction of 20 to 25%, new onset atrial fibrillation, started on Coumadin [**2148-8-20**], diabetes Type 2 diagnosed in [**2146**], chronic renal insufficiency, status post acute renal failure in [**2146**], baseline creatinine 1.7 to 2.0, hypertension, ascending aortic aneurysm size 4 x 4 cm, right upper lobe mass with mediastinal lymphadenopathy, dementia, osteoarthritis, glaucoma, status post right hip fracture in [**2136**]. MEDICATIONS AT NURSING HOME: Aspirin 81 mg once daily, Coreg 12.5 mg twice a day, Digoxin .125 mg every other day, enalapril 10 mg twice a day, lasix 20 mg once daily, Glipizide 10 mg twice a day, insulin 70/30 32 units in the morning, Imdur 20 mg once daily, sublingual nitroglycerin as needed, Axid 150 mg twice a day, Warfarin 3 and 3.5 mg every other day, Zocor 40 mg once daily, vitamin B12 1 mg once daily, folic acid 1 mg once daily, Prozac 40 mg once daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: [**Hospital3 **] resident, no alcohol, no tobacco. REVIEW OF SYSTEMS: Worsening of dyspnea on exertion for several months, persistent chest pain associated with shortness of breath for about 12 hours prior to admission. PHYSICAL EXAMINATION: Afebrile, blood pressure 100 to 110/30s to 40s, heart rate 60s to 70s, oxygen saturation 100% on 4 liters nasal cannula. General: Awake, alert and oriented times three, lying flat in bed, in no acute distress. Cardiovascular: Irregular rate and rhythm, normal S1 and S2. Lungs: Clear to auscultation bilaterally anteriorly. Abdomen: Soft, nontender, nondistended. Extremities: Right groin site with pressure dressing, large ecchymosis around the site, small hematoma, not extending beyond the marks, slight tenderness, bilateral distal pulses. LABORATORY DATA: White count 8.8, hematocrit 33.4 down to 22.9 post-catheterization, platelets 177 down to 161. PT 20.4, PTT 26.8, INR 2.9. After two units of transfusion, PT 16.4, PTT 42.8, INR 1.2. Chem 7: Sodium 139, potassium 4.9, chloride 107, bicarbonate 19, BUN 67, creatinine 1.9, glucose 215. First CK 91, troponin less than .3. HOSPITAL COURSE: She was ruled out for myocardial infarction with serial negative cardiac enzymes. Follow-up electrocardiograms were unremarkable. She received two units of fresh frozen plasma and one unit of packed red blood cells. Her hematocrit remained stable in the 30s after the transfusion. She was gently diuresed with low doses of intravenous lasix (20 mg), with good responses. Her oxygen saturations remained in the high 90s after being weaned off oxygen. While in-house, she had no more complaints of chest pain or shortness of breath. She reported feeling at her baseline. Given the multiple comorbidities, the decision was made to maximize her medical management. She was restarted on her regular outpatient regimen on hospital day two except with increased dose of lasix and a post-stenting Plavix. She was observed in-house for one more day, and discharged home on hospital day three in stable condition. Her most recent laboratories prior to discharge show a hematocrit of 30.2, platelets 150. Potassium 4.4, BUN 61, creatinine 1.8, glucose 124. CK 91 on admission, down to 83, down to 76. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: [**Hospital3 **]. DISCHARGE DIAGNOSIS: 1. Congestive heart failure exacerbation 2. Coronary artery disease status post proximal left anterior descending stent DISCHARGE MEDICATIONS: 1. Aspirin 81 mg once daily 2. Coreg 12.5 mg twice a day 3. Digoxin .125 mg every other day 4. Enalapril 10 mg twice a day 5. Lasix 40 mg once daily 6. Zocor 40 mg once daily 7. Warfarin 3 mg daily at bedtime 8. Sublingual nitroglycerin as needed 9. Glipizide 10 mg twice a day 10. Insulin 70/30 32 units every morning 11. Imdur 20 mg once daily 12. Folic acid 1 mg once daily 13. Vitamin B12 1 mg once daily 14. Prozac 40 mg once daily 15. Axid 150 mg twice a day 16. Plavix 75 mg once daily for 30 days [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 44831**] MEDQUIST36 D: [**2148-10-4**] 22:39 T: [**2148-10-5**] 02:20 JOB#: [**Job Number **]

Admission Date: [**2148-1-30**] Discharge Date: [**2148-2-10**] Service: HISTORY OF THE PRESENT ILLNESS: The patient is an 82-year-old male with known mitral valve disease and has been experiencing increased shortness of breath for several months and initially it was attributed to COPD; however, on repeat echocardiogram which showed worsening MR and LV dilatation, scheduled for cardiac catheterization and it showed LAD 80% occluded, left circumflex 99% occluded, 3+ MR, and elevated PA pressures. The patient was initially admitted to the Medicine Service for stabilization. PAST MEDICAL HISTORY: 1. COPD. 2. Mitral valve disease. 3. Hypertension. 4. Pulmonary hypertension. 5. Coronary artery disease. 6. Status post MI in [**2120**]. 7. GERD. 8. Cataract. 9. Bladder cyst. HOSPITAL COURSE: The patient was initially admitted to the Medicine Service and stabilized on the Medicine Service. The patient was taken by Dr. [**Last Name (STitle) **] to the Operating Room on [**2148-2-2**] and underwent a CABG times three, mitral valve repair, and annuloplasty. On postoperative day number one, the patient was admitted to the DIC CRSU on an intra-aortic balloon pump and paralyzed and sedated on Milrinone, Levophed, epinephrine, and Pitressin. The patient required multiple units of packed red blood cells and FFP to maintain his cardiac index. On postoperative day number one, the patient was started on CVVH given his renal impairment and also given his fluid overload. The patient was transferred to the unit. Postoperatively, the chest was left open because difficulty ventilating the patient because of COPD intraoperatively and at the time of operation it was decided to leave the chest open. The patient was transferred to the CRSU with the chest open. The chest tube was clotted off postoperatively on postoperative day number one and stopped draining. The patient was becoming increasingly difficult to ventilate. The decision was made to re-explore and evacuate a hematoma at the bedside on postoperative day number one for which the procedure was carried out and the patient stabilized. He was continued on CVVH by the Renal service. The patient was continued on the .................... stable state for the next several days without any event. He was on CVVH on milrinone, epinephrine, Levophed, and was being paralyzed and sedated for the next several days. TPN was started on postoperative day number three. On postoperative day number five, we began to try some trophic feeds; however, the patient did not tolerate trophic feeds. On [**2148-2-9**], the patient's cardiac index appeared to be deteriorating and the decision was made to re-explore the chest again at the bedside. The procedure was carried out; 1/2 liters of fluid was evacuated from the right pleural space and some clots were evacuated from the chest tube. However, since that day on the patient's condition began to deteriorate rapidly and overnight the patient began to require several amps of bicarbonate still having a pH of 7.21 on ABG. Throughout the night of [**2148-2-9**], the patient continued to require bicarb. He went into A fib and was cardioverted and went back into A fib again. Eventually, on the morning of [**2148-2-10**], at approximately 6:30 a.m., the patient went into asystole. Cardioversion was carried out and several amps of bicarbonate and several amps of calcium were given. The epinephrine drip was turned up. Milrinone was turned up to maximum. Pitressin was turned up to maximum, however, to no avail. The patient expired on the morning of [**2148-2-10**] at approximately 6:30 a.m. DISCHARGE PROCEDURE: Status post coronary artery bypass graft, MVR and revision. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease. 2. Mitral valve disease. 3. Hypertension. 4. Pulmonary hypertension. 5. Coronary artery disease. 6. Status post myocardial infarction. 7. Gastroesophageal reflux disease. 8. Cataract. 9. Bladder cyst. Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2148-2-10**] 09:16 T: [**2148-2-10**] 10:44 JOB#: [**Job Number 49401**]

Admission Date: [**2190-2-3**] Discharge Date: [**2190-2-10**] Date of Birth: [**2140-10-11**] Sex: M Service: Medical Intensive Care Unit, [**Location (un) **] Team CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 49 year old male initially admitted to the Medicine Service on [**2-3**] with shortness of breath and spontaneous pneumothorax after several cycles of Bleomycin for testicular seminoma who was transferred to the Medical Intensive Care Unit on [**2190-2-5**] for hypoxia. Briefly, the patient was initially diagnosed with seminoma in [**2189-7-20**], status post orchiectomy for testicular mass. Patchular vascular invasion with preoperative Beta HCG 9 that remained elevated postoperatively. Computerized tomography scan showed metastatic evidence to chest, neck and abdomen with both the retroperitoneal and subclavicular lymphadenopathy. The patient was treated with Bleomycin 180 units, Etoposide and Cisplatin in [**2189-10-19**] to [**2189-12-20**]. This was complicated by pneumonia on [**11-22**] and no normalization of LDH, acid fast bacillus and Beta GG was admitted to [**Location (un) **] outside hospital on [**1-10**] to [**1-15**] with shortness of breath. Chest computerized tomography scan showed no pulmonary embolism but did show bronchiectasis and interstitial fibrosis. Pulmonary function tests showed decrease in his DLCO per the chart. It was thought that he had drug toxicity. Amiodarone was stopped and Prednisone 60 mg p.o. q. day was started. The patient was readmitted to the outside hospital on [**1-27**] through [**1-29**] with spontaneous pneumothorax and managed expectantly. He was seen on [**2-1**], felt okay and could walk [**11-22**] mile. On [**2-2**], after increasing shortness of breath after coughing he went to the outside hospital. He had shaking chills, nasal congestion, increased clear sputum and central chest congestion with occasional wheezing. He had a son at home with similar symptoms. No orthopnea, paroxysmal nocturnal dyspnea, or edema. The patient had a 74% room air saturation and increased subcutaneous emphysema. So, a left chest tube was placed with hemi valve. The patient was transferred to [**Hospital6 2018**] on [**2-3**] where he had a respiratory rate of 27, saturations 83% on 3 liters to 91%, on 6 liters with an arterial blood gases of 754, 32 and 68, and was admitted to the Medicine Service. The patient was started initially on intravenous Bactrim empirically for primary care physician given he was on Prednisone 60 as an outpatient and Prednisone was increased to 80 mg p.o. q. day. Cultures including viral cultures were sent that were negative to date. Chest computerized tomography scan showed pulmonary fibrosis and moderate left pneumothorax with pneumomediastinum emphysema, soft tissue enlarged pulmonary artery. Cardiothoracic Surgery was consulted and recommended an existing chest tube placement of 20 cm of water suction. Echocardiogram was performed and broad-spectrum antibiotics with Bactrim, Azithromycin and Ceftriaxone were started empirically. The patient was with deteriorating oxygen saturation, so the patient was transferred to the Intensive Care Unit. PAST MEDICAL HISTORY: 1. Cardiomyopathy in [**2182**], viral, also per chart from outside hospital in [**2189-10-19**] had an ejection fraction of 55%. No mitral regurgitation, trace tricuspid regurgitation. PA pressure is 25 to 30. 2. Testicular cancer in [**2189-7-20**], radical orchiectomy, pure seminoma with vascular invasion. 3. Atrial fibrillation treated on Amiodarone discontinued [**2189-12-20**], secondary to question of pulmonary fibrosis. 4. Depression. 5. History of mild renal insufficiency, baseline creatinine of 2.5. ALLERGIES: Codeine. MEDICATIONS AT HOME: Atenolol 25 mg p.o. q. day, Lipitor 20 mg p.o. q. day, Humibid LA one tablet p.o. q.h.s., Lasix 40 mg p.o. q. day, Magnesium oxide 400 mg p.o. t.i.d., Calcium carbonate 500 mg p.o. t.i.d., Guaifenesin and Codeine 5 to 10 cc p.o. prn cough, Protonix 40 mg p.o. q. day, Haldol 2 mg t.i.d. prn agitation, Bactrim 450 mg intravenously q. 8, Prednisone 80 mg p.o. q. day, Tessalon pearls 100 mg p.o. t.i.d., Morphine 5 to 10 mg q. 6 hours prn sublingual, subcutaneous heparin 5000 mg p.o. q. 8 hours, Ceftriaxone 1 gm q. 24, Azithromycin 500 mg intravenously q. 24. SOCIAL HISTORY: Married with three children, works in roadside construction. Denies tobacco history. FAMILY HISTORY: Non-contributory. PHYSICAL EXAMINATION: Temperature 97.4, blood pressure 120/80, heart rate 75, respiratory rate 27, sating 80% on 6 liters. In general, this gentleman is in moderate respiratory distress, was able to speak. Head, eyes, ears, nose and throat, mucous membranes moist. Neck, no lymphadenopathy. Cardiovascular, regular rate and rhythm, no murmurs, rubs or gallops. Lungs, positive rales and wheezes, right greater than left. Abdomen, positive bowel sounds, soft, nontender, nondistended, no masses. Extremities, warm bilaterally. LABORATORY DATA: Pertinent laboratory data revealed white blood cell count 20.9, hematocrit 41.3, platelets 192, white cell count differential is 97% polys, 2% lymphs, 2% monos. INR 1.1, PTT 19.6, creatinine 1.5, potassium 4.3, LDH 362. Nasal swab viral cultures, pending. Chest x-ray [**2-5**], increasing left apical pneumothorax with 20% volume loss, left lower lobe atelectasis, left pigtail catheter in place, bilateral diffuse interstitial opacities, blunting of the right costophrenic angle. Chest computerized tomography scan [**2-4**], small left pneumothorax, pneumomediastinum and subcutaneous emphysema and intramuscular emphysema, extensive pulmonary fibrosis, left greater than right, right predominantly lower lobe. Pulmonary artery prominence with no consolidations. [**2190-2-5**], echocardiogram, ejection fraction greater than 55%, no patent foramen ovale, by Bubble study, mild right atrial enlargement. Electrocardiogram, sinus rhythm with a rate of 112, axis -36, T wave inversions in 3 and 6, biphasic Ts and AVF. HOSPITAL COURSE: 1. Hypoxia - The patient presented with diffuse infiltrates concerning for pulmonary fibrosis and Bleomycin lung toxicity. The patient had been on Amiodarone which has also contributed and the patient also had a spontaneous pneumothorax on chest x-ray which was managed with chest tube placement as per Cardiothoracic Surgery. The patient was maintained on antibiotic treatments for his pneumonia, given his sick contacts, also atypical presentation, given his previous immunosuppression and therefore the patient was continued on Prednisone. So, the patient was titrated oxygen. Subsequently, however, the patient had worsening hypoxia and on [**2-6**], after extensive discussion with the patient and his wife, the patient was subsequently intubated given his worsening respiratory status. The patient continued to be intubated with worsening hypoxemia throughout the hospital course and on [**2-10**], an extensive discussion was made with the family and given the patient's inability to wean off of his FIO2 and with worsening hypoxia it was agreed upon that the patient should have comfort care as an ultimate goal for his hospitalization, and on [**2-10**], the patient was subsequently placed on Comfort-Measures-Only. The patient's family was informed. Subsequently the patient also had some hypotension which was covered with pressors and on [**2190-2-10**], at 10:26 PM, the patient had worsening hypoxia and after withdrawal of care, the patient was found to be unresponsive to deep sternal rub, no heartsounds were palpable. The patient was warm. The pupils were fixed and dilated, and subsequently the patient was declared dead on [**2190-2-10**] at 10:26 PM. Autopsy was declined per family. 2. History of atrial fibrillation - The patient was maintained on Amiodarone and Atenolol for rate control. 3. Cardiomyopathy - The patient was maintained on Lasix. 4. Seminoma - The patient was status post three cycles of Bleomycin, Etoposide and Cisplatin. There were no acute issues to be followed up with Oncology. 5. Renal - The patient's creatinine continued to rise, likely due to hypotension. The patient's medications were renally dosed. [**Known firstname **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 5227**] MEDQUIST36 D: [**2190-2-24**] 12:16 T: [**2190-2-24**] 12:58 JOB#: [**Job Number 54403**]

Admission Date: [**2162-5-16**] Discharge Date: [**2162-6-3**] Date of Birth: [**2094-7-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Respiratory distress Pulmonary emboli Major Surgical or Invasive Procedure: Endotrachial intubation and mechanical ventilation Central venous line placement Arterial line placement IVC filter placement PICC line placement History of Present Illness: This is a 67 year old man with hx Non-Small Cell Lung CA, DVT, recent GIB who is transfered from [**Hospital1 **] [**Location (un) 620**] with dx of PE. [**First Name8 (NamePattern2) **] [**Location (un) 620**] notes, he was found to be hypoxic with SaO2 50%. CTA showed multifocal PE's with RV strain on CT. Heparin gtt started. Bp 96/73 and HR 135. Given recent GIB, decided not to TPA but transfer to [**Hospital1 18**]. In the ED: The patient arrived tachpnic, "dusky", BP 118/80. ABG showed alkalosis and hypoxia: 7.56/28/56. The patient was intubated and required high amounts of versed for sedation. Cardiothoracic surgery saw the patient and did not think embolectomy would be indicated. An echo was performed by cardiology, with RV strain and dilation but no collapse or HD compromise. Vitals on arrival: 96.1 133 118/80 34 abg 87 nrb Vitals at transfer: Hr 106 BP 90/60 (87/67 - since sedation) Past Medical History: 1. Non-small cell Lung CA s/p resection in [**2157**] 2. History GIB in [**2162-4-17**] 3. DVT [**2152**], on coumadin for years, dc'ed one month ago 4. Hypertension 5. Low back pain 6. Alcohol abuse 7. History of alcoholic hepatitis Social History: He worked as a painting contractor. He is married, with two grown children. His wife works part-time at the [**Name (NI) 4068**]. He smoked at least a pack per day for about 45 years but was able to stop smoking albeit with some difficulty and help of a patch since his diagnosis. He drinks two to three alcoholic drinks per night. Family History: His father also heavy smoker died at age 53 of lung or head/neck ca. His mother had a stroke. His one-half sibling died of a ruptured aneurysm, one died of motor vehicle accident. He thinks his grandmother may have had ovarian cancer. Physical Exam: General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy. Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: ADMISSION LABS: [**2162-5-16**] 06:22PM WBC-4.4 RBC-2.95* HGB-10.0* HCT-31.2* MCV-106* MCH-34.0* MCHC-32.2 RDW-13.7 [**2162-5-16**] 06:22PM PLT COUNT-147* [**2162-5-16**] 06:22PM PT-14.3* INR(PT)-1.2* [**2162-5-16**] 06:22PM GLUCOSE-87 UREA N-12 CREAT-1.0 SODIUM-145 POTASSIUM-3.2* CHLORIDE-117* TOTAL CO2-20* ANION GAP-11 DISCHARGE LABS: White Blood Cells 8.5 Red Blood Cells 2.29 Hemoglobin 7.3 Hematocrit 23.8 MCV 104 MCH 32.1 MCHC 30.9 RDW 14.3 Platelet Count 838 ANEMIA LABS: Iron: 19 TIBC: 166 Ferritin: 232 Reticulocyte count: 3.0 Haptoglobin: 253 LDH: 236 Tbili: 0.4 Folate: 14.7 Vitamin B12: 534 ECHO ([**2162-5-16**]): The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. ECHO ([**2162-5-18**]): The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is dilated with depressed free wall contractility. The interatrial septum is markedly thickened around the fossa ovale secondary to lipomatous hypertrophy. Compared with the findings of the prior study (images reviewed) of [**2162-5-17**], the interatrial septum and right atrium are better visualized, and the mass in the right atrium is now seen clearly to be secondary to lipomatous hypertrophy of the interatrial septum. LENI ([**2162-5-16**]): 1. Right popliteal DVT extending to the calf veins. 2. Partially occlusive DVT in the left popliteal [**Last Name (LF) 5703**], [**First Name3 (LF) **] be subacute, with extension to the calf veins. CT HEAD WITHOUT CONTRAST ([**2162-5-22**]): No evidence for acute hemorrhage or acute transcortical infarction. ABDOMINAL ULTRASOUND ([**2162-5-27**]): 1. Diffusely fatty liver markedly limits evaluation for focal liver lesion although no large liver lesion is identified. 2. Mild splenomegaly to 12.3 cm. No evidence of ascites. LOWER EXTREMITY ULTRASOUND ([**2162-5-31**]): Partially occlusive DVT in the left popliteal [**Month/Day/Year 5703**], which has not significantly changed from [**2162-5-16**]. PLAIN FILMS LEFT HIP AND FEMUR ([**2162-6-1**]): There is severe degenerative change of the lower lumbar spine. There are mild degenerative changes of the hip joints. No fracture is identified. Incidental note is made of a sclerotic lesion in the distal femur of unclear etiology. Does the patient have a history of primary malignancy or metastatic disease? MRI LEFT LEG ([**2162-6-2**]): (wet read): Preliminary Report !! WET READ !! 18.7 cm hematoma in left vastus lateralis muscle. While this may reflect trauma and anticoagulation, an underlying neoplasm cannot be excluded and follow-up upon resolution (ie 4 months) is recommended. Bilateral femoral head avascular necrosis. Sclerotic femur diaphysis lesion atypical for metastasis though should be followed radiographically. MICRO DATA: -respiratory culture ([**2162-5-27**]): GRAM NEGATIVE ROD(S). SPARSE GROWTH. GRAM NEGATIVE ROD #2. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S -respiratory culture from ET tube ([**2162-5-19**]): SENSITIVITIES: MIC expressed in MCG/ML CITROBACTER FREUNDII COMPLEX | AEROMONAS HYDROPHILA | | AMPICILLIN/SULBACTAM-- <=8 S CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S <=2 S CEFTRIAXONE----------- <=1 S <=4 S CEFUROXIME------------ S CIPROFLOXACIN---------<=0.25 S <=0.5 S GENTAMICIN------------ <=1 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- S MEROPENEM-------------<=0.25 S S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=2 S -fecal culture ([**2162-5-18**]): FECAL CULTURE (Final [**2162-5-21**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2162-5-20**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2162-5-19**]): NO OVA AND PARASITES SEEN. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2162-5-18**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48228**] AT 13:15PM ON [**2162-5-18**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. -Blood and urine cultures: NEGATIVE on [**4-13**], [**5-21**], [**5-22**], [**5-25**], [**5-28**] Brief Hospital Course: A 67 yo man with history of NSCLC s/p resection, EtOH, h/o DVTs on coumadin until one month PTA, recent GIB, now transferred from OSH with respiratory distress and multiple bilateral pulmonary emboli. # Bilateral pulmonary emboli: He presented having a prior history of DVT, having previously been on coumadin. At the time of admission, he was in respiratory distress with evidence of right-heart strain on echo. Given lower extremity clot burden, IVC filter was placed. On [**5-17**], TPA was administered for suspected right atrial clot (later found to be lipomatous hypertrophy of interatrial septum). He was started on LMWH, awaiting EGD/colonoscopy before initiation of coumadin. He will continue on anticoagulation (now on heparin) until his colonoscopy/EGD. As long as there is no active bleeding, he can be switched to coumadin for long-term anticoagulation. # Alcohol withdrawal: He has a significant alcohol history. He was intubated during much of the period of anticipated withdrawal. After extubation, he was transferred to the floors (hospital day 10). Although he was tachycardic, he was not diaphoretic or agitated and his tachycardia was felt to be due to PE as above, rather than alcohol withdrawal. He did not require benzodiazepines or CIWA scale monitoring. # Ventilator associated pneumonia: He began spiking fevers on [**5-19**] with sputum growing GNR and staph (found to be pansensitive Citrobacter freundii, sparse Aeromonas and sparse coag+ staph). The ventilator associated pneumonia was treated with vancomycin and Zosyn for eight days; course was completed on [**5-28**]. # Clostridium dificile colitis: This was found on stool studies from [**5-18**]. He was treated with oral vancomycin during the VAP antibiotic course, and he should continue oral vancomycin to finish on [**6-7**]. # Recent GIB: Anticoagulation had been stopped one month PTA for GIB. Per patient his INR was supratherapeutic at that time. He was restarted on anticoagulation during this admission for DVT and PE. Plan is to continue heparin for three weeks to allow time for his pulmonary emboli to dissolve and his clinical status to stabilize, at which time EGD and colonoscopy can be done. Of note, he was found to be guiaic positive during this admission, with brown stools (non-melanotic, non-bloody). His hematocrit stablized in the mid to high 20s. Also, of note, he underwent abdominal ultrasound to evaluate extent of liver disease, also to evaluate for portal hypertension and assess risk for varices. The ultrasound showed no ascites, a diffusely fatter liver, and mild splenomegaly. # Anemia: This is a macrocytic anemia with stabilization of hematocrit in the mid to high 20s. Hemolytic work-up was negative. Reticulocyte count was 3.0. Iron was 19 with a TIBC of 166 and ferritin of 232, indicative of deficiency. Folate and vitamin B-12 were normal. As above, he was guiaic positive. His anemia is likely a combination of marrow suppression from acute illness and iron deficiency from recent GIB and poor nutrition. We have recommended for outpatient colonoscopy and EGD for further work-up. This is scheduled at [**Hospital1 18**]. He received one unit of PRBCs on [**6-3**]. # Nose bleed: This occurred in the setting of anticoagulation with Lovenox. Bleeding resolved after treatment with Afrin (several squirts) and holding pressure for 20 minutes. Due to persistent oozing from the left nostril, ENT was consulted. They recommended for preventative management with aggressive blood pressure control, saline nasal spray, bactroban vaseline ointment, and humidified air. If bleeding recurs, several sprays of Afrin can be delivered to the bleeding nostril, with pressure held for at least 15 minutes and patient leaning forward. # Hypoalbuminemia: Albumin was 1.9 on [**5-18**], down from 2.2 at admission; repeat albumin on [**6-2**] was 2.7. Tbili was 0.4 with PTT 27.1 and INR 1.0. As above, abdominal ultrasound did not show signs of cirrhosis; the liver was diffusely fatty. We added ensure supplement to his diet. Albumin can be followed up as outpatient. # Thrombocystosis: His platelet count was trending up to low 800s at time of discharge. We felt that this was likely secondary to infection and acute inflammatory response. Platelet levels can be followed up as outpatient after his infection has been treated. # Left leg pain and hematoma: He worked with physical therapy and complained of leg pain over the lateral aspect of his left thigh. On exam there was tenderness over the left lateral quadriceps muscle, with small amount of swelling/induration on left compared to right; there was no clear hematoma or skin discoloration. There was concern of extension of DVT versus fracture, given that he said he had fallen on his left leg prior to admission. Lower extremity doppler ultrasound showed stable DVT in left popliteal [**Month/Year (2) 5703**]. Plain films of the left hip and femur showed sclerotic lesion in the distal femur so MRI was done for further evaluation. This showed an 18 cm hematoma in the left lateralis muscle. The femoral sclerotic lesion was felt to be atypical for metastases, but radiology has recommended follow-up imaging in four months. In addition, vascular was curbsided and felt that the hematoma could be followed clinically. We have switched anticoagulation to heparin drip to allow for ease of stopping anticoagulation if the hematoma grows in size. Meanwhile, we have outlined the area of induration with marker (measuring 22cm in length and 8cm in width on our exam) and recommended that patient have follow-up imaging with ultrasound in 2 to 3 days to assess for interval change. Daily CBC monitoring as well will be important to assess for progression. # FEN: He was progressed to normal diet, with ground solids and nectar prethickend liquids. # Prophylaxis: Anticoagulated as above. # Code status: Full code. # Disposition: To rehabilitation facility. Medications on Admission: -Oxycodone-Acetaminophen [**1-15**] TAB PO Q6H:PRN pain -Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever -Piperacillin-Tazobactam Na 4.5 g IV Q8H -Bisacodyl 10 mg PO/PR DAILY:PRN Constipation -Enoxaparin Sodium 90 mg SC Q12H -Senna *NF* 8.8 mg/5 mL Oral [**Hospital1 **] PRN constipation -Fludrocortisone Acetate 0.1 mg PO DAILY -FoLIC Acid 1 mg PO/NG DAILY -Thiamine 100 mg PO/NG DAILY -Insulin SC (per Insulin Flowsheet) -Vancomycin 1000 mg IV Q 12H -Ipratropium Bromide Neb 1 NEB IH Q6H -Vancomycin Oral Liquid 125 mg PO Q6H -Lansoprazole Oral Disintegrating Tab 30 mg PO BID -Xopenex *NF* 0.63 mg/3 mL Inhalation q 4hrs prn sob/ wheeze -Miconazole Powder 2% 1 Appl TP QID:PRN rash -traZODONE 25 mg PO ONCE MR1 -Multiple Vitamins Liq. 5 ml NG DAILY Discharge Medications: 1. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath/wheezing. 7. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q 4hrs prn () as needed for sob/ wheeze. 8. Senna 8.8 mg/5 mL Syrup Sig: 8.8 MLs PO BID PRN () as needed for constipation. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Please continue through [**6-7**]. 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. Mupirocin Calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2 times a day) for 5 days. 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: Three (3) Spray Nasal TID (3 times a day). 15. Oxymetazoline 0.05 % Aerosol, Spray Sig: Three (3) Spray Nasal [**Hospital1 **] (2 times a day) as needed for nose bleed for 1 days. 16. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: ASDIR units Intravenous continuous: Heparin IV per Weight-Based Dosing Guidelines Start New Infusion Now. Diagnosis: Pulmonary Embolism Patient Weight: 90.2 kg No Initial Bolus Initial Infusion Rate: 1600 units/hr Target PTT: 60 - 100 seconds PTT <40: 3600 units Bolus then Increase infusion rate by 350 units/hr PTT 40 - 59: 1800 units Bolus then Increase infusion rate by 200 units/hr PTT 60 - 100*: PTT 101 - 120: Reduce infusion rate by 200 units/hr PTT >120: Hold 60 mins then Reduce infusion rate by 350 units/hr. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: PRIMARY DIAGNOSES Extensive bilateral pulmonary emboli Bilateral deep venous thrombi Ventilator-associated pneumonia Clostridium dificile colitis Left lateralis muscle hematoma SECONDAY DIAGNOSES History of non-small cell lung cancer s/p resection in [**2157**] History of gastrointestinal bleed in setting of supratherapeutic INR Deep venous thrombosis in [**2152**], on coumadin until one month PTA Hypertension History of heavy alcohol use History of alcohol-related hepatitis Discharge Condition: Vital signs stable. Afebrile. Satting well on room air. Discharge Instructions: You were admitted to the hospital for low oxygenation in the blood and respiratory distress. You were found to have extensive blood clots in the arteries in the lungs on both sides. You were intubated and treated with medicines to thin the blood and prevent new blood clots from forming. Furthermore, a filter was placed in a [**Year (4 digits) 5703**] in the abdomen to prevent more clots from traveling from the legs to the lungs. With the above treatments, your respiratory status improved. The hospital course was complicated by development of pneumonia (treated with antibiotics) and bacterial infection in the gut (also treated with antibiotics). Please complete a course of oral vancomycin to end on [**6-7**]. Please take all of your medicines as prescribed: -we added oral vancomycin, to finish on [**6-7**] -we added heparin, to be taken by continuous infusion -we added medicines to help prevent nose bleeds -we did not make any other changes to the medicines Please note your follow-up appointments below. Please call your doctor or return to the emergency room if you develop chest pain, shortness of breath, abdominal pain or distention, or any other new concerning symptoms. Followup Instructions: APPOINTMENTS OUTSIDE OF [**Hospital1 18**] -please schedule an appointment with your primary physician, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in the next 1-2 weeks, [**Telephone/Fax (1) 17753**]. APPOINTMENTS SCHEDULED AT [**Hospital1 18**] -follow-up for colonoscopy and upper endoscopy PAT RM 1 PAT-Date/Time:[**2162-7-5**] 11:30 [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2162-7-12**] 2:00 GI [**Apartment Address(1) 3921**] (ST-3) GI ROOMS Date/Time:[**2162-7-12**] 2:00 -follow-up for nose-bleeds in [**Hospital **] clinic: Call [**Telephone/Fax (1) 2349**] to schedule a follow up appointment with General ENT in [**3-17**] weeks. Completed by:[**2162-6-4**]

Admission Date: [**2182-2-3**] Discharge Date: [**2182-2-9**] Service: HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old female with a history of critical AS, paroxysmal atrial fibrillation, hypertension, tachy-brady syndrome, who presented to the Emergency Room with chest pain. In the ED, the blood pressure was noted to be elevated at 230-270 systolic. The patient was given sublingual nitroglycerin, hydralazine, and subsequently her blood pressure decreased into the 80s. The patient was then noted to have ST segments in V4 through V6 and substernal chest pain started after eating. The patient reports that the chest pain was [**10-13**], squeezing sensation. .................... The patient reports an episode of similar pain months ago. The patient denied any dyspnea on exertion, however, she does report lightheadedness. In the ED, the patient was subsequently started on Neo-Synephrine. PAST MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation. 2. SVT, tachy-brady syndrome. 3. Hypertension. 4. AS with valve area 0.7 cm squared. 5. Arthritis. 6. TR 2+. 7. MR 2+. ADMISSION MEDICATIONS: 1. Zantac 150 b.i.d. 2. Lisinopril 10. 3. Aspirin 325. 4. Betoptic. 5. .................... eyedrops. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives with her sister on a [**Location (un) 1773**] apartment. She denied any smoking, tobacco use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.8, blood pressure 130/50s, heart rate 80s, respiratory rate 20, saturating 100% on nonrebreather face mask. General: The patient is an elderly female. HEENT: Moist mucous membranes. Her neck was supple. There was slow upstroke and positive murmur bilaterally. Cardiac: Regular rate with a harsh 3/4 systolic ejection murmur at the right upper and lower sternal border. Respiratory: Clear to auscultation bilaterally. Abdomen: Normoactive bowel sounds with a transmitted murmur. Extremities: No clubbing, cyanosis or edema. Neurologic: Nonfocal. LABORATORY/RADIOLOGIC DATA: Chem-7 with a sodium of 134, potassium 4.9, chloride 97, bicarbonate 24, BUN 30, creatinine 1.0, glucose 121. White blood cell count 11.6, hematocrit 31.2, platelets 264,000, 92.8% neutrophils, no bands. On admission, her CK MB was 4. Her troponin was 1.01. A chest x-ray, AP portable, revealed questionable focal infiltrate. The EKG at admission was bradycardiac in the 40s, normal axis, biphasic T waves in V2, otherwise unchanged. HOSPITAL COURSE: The patient was with critical AS, hypertension, paroxysmal atrial fibrillation, presenting with substernal chest pain. The patient was admitted to the [**Hospital Unit Name 196**] Service for further evaluation and management. The patient was admitted to the [**Hospital Unit Name 196**] service and the cardiac enzymes were cycled and were negative. The [**Hospital 228**] hospital course has been complicated, while awaiting cardiac catheterization to evaluate valve for possible coronary artery disease, by an episode of rapid atrial fibrillation and hypotension. During the same time, the patient also developed a fever and an elevated white count and it was felt that this episode was due to urosepsis. Given persistent supraventricular tachycardia and hypotension, the patient was transferred to the CCU. The patient was started on IV Amiodarone and broad spectrum antibiotic therapy. The patient's heart rate was improved and the patient converted back to sinus rhythm. She was transitioned to p.o. Amiodarone and transferred back to the floor during this admission. Her urinary cultures subsequently grew out E. coli and her antibiotics were adjusted. The patient did convert back into atrial fibrillation and did have some pauses noted on telemetry. Electrophysiology service was recommended. Discontinue Amiodarone. They will determine the need for a pacemaker in the long run once the patient resolves her current medical issues. Furthermore, it was determined not to perform cardiac catheterization during admission. DISCHARGE DIAGNOSIS: 1. Critical aortic stenosis. 2. Urosepsis. 3. Tachy-brady syndrome. 4. Atrial fibrillation. DISCHARGE STATUS: The patient will be discharged to rehabilitation. DISCHARGE MEDICATIONS: Please refer to page one. FOLLOW-UP: The patient is to follow-up with Cardiology per page one. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern1) 4787**] MEDQUIST36 D: [**2182-2-8**] 10:14 T: [**2182-2-8**] 10:48 JOB#: [**Job Number 4788**]

Admission Date: [**2127-3-5**] Discharge Date: [**2127-3-7**] Date of Birth: [**2091-11-6**] Sex: F Service: CHIEF COMPLAINT: Dyspnea. HISTORY OF PRESENT ILLNESS: The patient is a 35 year-old female with the past medical history significant for morbid obesity. The patient underwent gastric restrictive surgery on [**2127-2-19**]. This was complicated by a staple line leak and required an exploratory laparotomy and oversew of the leak on [**2127-2-20**]. Her post-operative recovery was complicated by poor pulmonary status requiring prolonged ventilator requirement and a reintubation. She was discharged from [**Hospital1 190**] on [**2127-2-27**]. Following discharge the patient had three days of increasing chest pain. The patient presented to the Emergency Department for evaluation of shortness of breath and chest pain. She denied productive sputum, fevers or chills. She was tolerating the diet well on stage III diet. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. L5 S1 herniated disc with spinal stenosis. 3. Mild hypertension. PAST SURGICAL HISTORY: 1. Exploratory laparotomy for ectopic pregnancy. 2. Gastric bypass [**2127-2-19**] 3. Status post exploratory laparotomy on [**2127-2-20**] for anastomotic leak of the gastric bypass. MEDICATIONS: 1. Flexeril 10 milligrams po tid prn. 2. Roxicet Elixir po q four to six hours prn pain. 3. Zantac. ALLERGIES: No known medical allergies. REVIEW OF SYSTEMS: Cardiovascular - Positive chest pain times three days but slightly improving. Respiratory - Chest pain for three days left side greater than right. Gastrointestinal - Negative nausea and vomiting, positive bowel movements and flatus. Infectious Disease - Positive fevers but no night sweats or chills. PHYSICAL EXAMINATION: Respirations are 34, 02 saturation 88% on room air, 99 to 100% on face mask. Cardiovascular - Regular rate and rhythm. Respiratory - Decreased breath sounds on the left with wheezing, normal breath sounds on the right. Left bronchial breath sounds. Gastrointestinal - Obese, soft, nontender, positive bowel sounds. Genitourinary - Negative CVA tenderness. Extremities - Negative peripheral edema, negative calf tenderness. LABORATORY DATA: Chem 7 normal. Glucose of 110. ALT 26, AST 36, amylase 26, alkaline phosphatase 206, lipase 76, total bilirubin 0.6, albumin 3.2, white cell 20, crit 34.6, PT 13.5, PTT 28.5, INR 1.3. Chest x-ray showed a large left effusion. EKG was normal sinus rhythm. HOSPITAL COURSE: The patient was seen in the Emergency Department and was noticed to have a very large left effusion. The patient had an ultrasound guided thoracentesis in which 2.5 liters of serousanguinous fluid was removed. The patient was transferred to the ICU in stable condition. She was treated for a presumed pneumonia with IV Levaquin. Her respiratory status significantly improved. Physical therapy followed the patient throughout her hospital stay. She was treated for a small decubitus of her back with duoderm dressings. On [**2127-3-6**] the patient's chest x-ray was shown to be improved from the admission x-ray. At that time it was decided the patient may be transferred to the floor. On [**2127-3-7**] the patient had a repeat chest x-ray which showed resolution of the effusion. A pain consult was obtained for her chronic back pain and decreased resulting mobility. A duragelsic patch was recommended and started in the hospital. Throughout her stay, she tolerated stage III diet will. SHe was discharged home with [**Hospital 37739**] home health aid and VNA and will follow-up in the office in 3 weeks at which time her Gtube will be removed. slight improvement. She will be discharged on a 10 day course of po Levaquin. DISCHARGE PHYSICAL EXAMINATION: T max 99.6 F, current 98.7 F, [**Age over 90 **] F, 138/80, 22, 93 on room air. Alert and oriented, in no acute distress. Cardiovascular - Regular rate and rhythm. Respiratory - Clear to auscultation bilaterally. Abdomen - Soft, nontender, nondistended, positive bowel sounds. The incision is intact, clean and dry. The Gtube site is clean. DISCHARGE DIAGNOSIS: 1. Morbid obesity status post gastric bypass with anastomotic leak, status post exploratory laparotomy and oversew of the gastric staple line. 2. Large left pleural effusion, status post thoracentesis for presumed pneumonia. DISCHARGE CONDITION: Good. DISCHARGE DISPOSITION: Home. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13186**], M.D. [**MD Number(1) 13187**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2127-3-7**] 08:45 T: [**2127-3-7**] 09:31 JOB#: [**Job Number **]

Admission Date: [**2161-12-30**] Discharge Date: [**2162-4-25**] Date of Birth: [**2161-12-30**] Sex: F Service: Neonatology HISTORY: This is a 28 and [**1-6**] week twin female #2, delivered preterm by C-section due to progressive preterm labor. She was found to be severely growth restricted with a birth weight of 700 grams. Mother was a 31-year-old G-I, P-0, now II, blood type O positive, antibody negative, hepatitis B negative, rubella immune, RPR nonreactive, and GBS unknown. Rupture of membranes was at delivery and this was an IVF di/di twin gestation with discordant growth. Mother was admitted at 24 weeks with cervical shortening and funneling and found to be 5-6 cm dilated and was brought to section. This baby emerged with spontaneous cry, requiring only routine care in the operating room with no supplemental oxygen needed. Apgars were 8 and 9, and she was transferred to the NICU for management of her prematurity. In the NICU, she was initially intubated, given Surfactant, umbilical lines were placed. She was shortly thereafter extubated to CPAP and then had a prolonged stay in the NICU which was as follows. HOSPITAL COURSE: By systems: From a respiratory perspective, [**Known lastname **] was initially intubated and given 1 dose of Surfactant and was quickly extubated to CPAP on which she remained until day of life 28 when she went to nasal cannula and then she moved to room air on day of life 41 and has been in room air ever since. She had some apnea of prematurity and was on caffeine until day of life 43 after which her apnea of bradycardia resolved. She remains in room air without desaturation or respiratory symptoms to this day. Cardiovascular: From a cardiology perspective, she has had intermittent murmur throughout her hospitalization. On [**1-6**], she had an echo with a large PDA and PFO for which she received indomethacin and subsequently she had a follow-up echo on [**1-11**], which showed no PDA. As I mentioned, she has had an intermittent murmur throughout her hospitalization which is not heard on exam today. Fluid, electrolytes and nutrition: Initially, the baby was n.p.o. and was started on TPN and lipids. She slowly worked up on feeds and subsequently was found to be aspirating when she learned to orally feed. She had 3 swallowing studies in a row which showed aspiration with swallowing so a G-tube was placed by interventional radiology on [**4-16**], or day of life 107. She is receiving G-tube feeding only now and is continuing to follow with feeding team. GI: From a GI perspective, [**Known lastname **] had some mild hyperbilirubinemia for which she received phototherapy. Her peak bilirubin was 4.1 on day of life 1 and her hyperbilirubinemia resolved quickly. She has a G-tube that was placed on [**4-16**], and she had some preoperative labs done on the day of her G-tube placement on [**4-16**], with a bilirubin of 0.1, alkaline phosphatase of 488, ALT of 26, AST of 30, and she has chronic reflux for which she is on Prilosec 2.4 mg p.g. daily. She is also on Reglan 0.35 mg p.g. 3 times daily. She has nothing by mouth and working with feeding team. Hematology: From a hematologic perspective, she is on iron. Her last hematocrit was 32.7 on [**4-16**]. She is on 4 mg/kg/day of iron. She has not received a transfusion. She had coagulation studies done on the day of her surgery [**4-16**]. PT was 13.1, INR 1.1 and PTT 38.4. Infectious disease: From an infectious disease perspective, [**Known lastname **] initially received ampicillin and gentamicin for 48 hours when she was born. Her cultures did not grow any organisms and the antibiotics were stopped. Subsequently, only this week with the G-tube placement when she developed a cellulitis and some widening erythema as well as a bandemia, on [**4-17**], with the white blood cell count of 8.6, and 28 bands, 1 metamyelocyte and 1 myelocyte, she was started on vancomycin and gentamicin. A blood culture and a wound culture from her G-tube site were sent. The wound culture is growing is staph aureus as well as staph epi and her blood culture is no growth to date. She was started on vancomycin and gentamicin. She is completing a 7 day course. The erythema is resolving and the infant is stable. Neurology: From a neurologic perspective, [**Known lastname **] had 3 head ultrasounds which were all normal, one on [**1-7**], one on [**1-28**], and one on [**4-1**]. She seems to have some mild hypertonicity and is fussy at times but her exam is otherwise normal. It is recommended that she follow up with neonatal neurology at infant follow up clinic. Ophthalmology: From an ophthalmologic perspective, [**Known lastname **] developed some mild retinopathy of prematurity. Her most recent ophthalmologic exam was on [**3-22**], where she was mature bilaterally and was to follow up in 9 months. She never had laser surgery. Endocrinology: From an endocrinology perspective, [**Known lastname **] was found to have late onset hypothyroidism when her newborn screens persisted to be abnormal. She was started on Synthroid on [**3-5**] and her TFTs have normalized. Her most recent set were on [**4-16**], with a TSH of 4.1, T4 of 10.8 and a free T4 of 1.4. After speaking with the endocrinology fellow today, they recommend that she follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 1 month after discharge at [**Telephone/Fax (1) 37116**]. She does not need to have her thyroid studies checked between now and 1 month after discharge. She had a thyroid ultrasound that was normal. Orthopedics: From an orthopedic surgery perspective, [**Known lastname **] had some subluxation of her right hip on ultrasound on [**3-10**]. She had a follow-up hip ultrasound on [**4-15**], which was normal and orthopedic surgery fellow is to examine her 1 more time prior to discharge on [**4-22**], or [**4-23**] and subsequently she is to follow up in 1 month in orthopedic surgery clinic, [**Telephone/Fax (1) 38453**]. Feeding: From a feeding perspective, initially it was thought that [**Known lastname **] had a bit of an oral eversion. Subsequently she seemed to have aspiration and she had multiple swallowing studies, all of which showed aspiration, most recently on [**4-8**], when she continued to have aspiration. At that point, the decision was made to put in a G-tube which was done at interventional radiology. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17562**], [**Telephone/Fax (1) 42639**]. DISCHARGE PLANNING: 1. Her State screens were normal with the exception of the thyroid abnormality which is being treated. 2. Her vaccination status, she received her initial hepatitis B vaccine on [**1-29**]. Her subsequent 2 month vaccinations were given on [**3-2**], which included Pediarix, Prevnar and Hib. 3. She has not yet had her hearing test. That test result is __________. 4. [**Hospital1 69**] social work was involved with the family. The social worker name is [**Name (NI) **] [**Name (NI) **] and she can be reached at [**Telephone/Fax (1) **]. CARE RECOMMENDATIONS: 1. Feeds at discharge include breast milk as well as fortification with NeoSure to achieve 24 calories per ounce. Recommend 150 cc per kilogram per day given every 4 hours over an hour and a half through her G-tube. She needs to receive [**2-1**] mL of water before and after each feed through the G-tube and care of the G-tube will be dictated by the interventional radiology team which placed the tube. 2. Medications at discharge include Prilosec 2.4 mg daily, Reglan 0.35 mg daily, and Synthroid 25 mcg daily. She will continue her iron and multivitamin as well. Iron supplementation is recommended for preterm and low birth weight infants until 12 months of corrected age and all infants predominantly fed breast milk should receive vitamin D supplementation at 200 international units which may be provided as a multivitamin preparation daily until 12 months corrected age. 3. Her car seat should be in the back, facing the back, strapped in. 4. We recommend routine immunizations in addition: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 4 criteria: 1. Born at less than 32 weeks, 2. Born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, 3. Chronic lung disease or 4. Hemodynamically significant congenital heart 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. This infant has not received Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. 5. Follow up appointments scheduled are endocrinology 1 month after discharge, orthopedic surgery 1 month after discharge, pediatrician with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17562**] within the first week after discharge, feeding team within 3 weeks after discharge, and interventional radiology as directed. She also has been referred to early intervention and she will need ophthalmologic follow up in 9 months. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37928**] Dictated By:[**Last Name (NamePattern1) 71123**] MEDQUIST36 D: [**2162-4-21**] 16:36:45 T: [**2162-4-21**] 18:16:39 Job#: [**Job Number 71124**]

Admission Date: [**2155-1-9**] Discharge Date: [**2155-1-17**] Date of Birth: [**2155-1-9**] Sex: M HISTORY OF PRESENT ILLNESS: This is a 33 week male, Twin #2, with intrauterine growth retardation who was born to a 43 year old Gravida 4, Para 0 to 2 mother with the following prenatal screens - Blood type 0 positive, antibody negative, Rubella immune. The pregnancy was notable for - 1. In [**Last Name (un) 5153**] fertilization, donor egg; 2. Di-di twins; 3. Discordant growth with Twin A being significantly larger than Twin B; 4. Normal AFP and no amniocentesis done. The mother was admitted on the day prior to delivery due to preterm labor. She received two doses of betamethasone due to persistence of variables in Twin B with decelerations. The mother went to factors and rupture of membranes was at delivery. GBS status is unknown. In the Delivery Room this twin emerged crying and active. He required some Blow-by oxygen in the Delivery Room and received intermittent positive pressure ventilation due to decreased air entry. Apgars were 8 at one minute and 9 at five minutes. He was transported back to the Newborn Intensive Care Unit for further care. PHYSICAL EXAMINATION: Physical examination on admission revealed he had a weight of 1385 gm, length 39.5 cm and head circumference of 28 cm, all parameters between the 10th and 25th percentile. Heartrate was 160 and respiratory rate was 48 with a 100% oxygen saturation on room air. He is a well appearing infant, slightly ruddy. His head, eyes, ears, nose and throat examination showed his anterior fontanelle was open and flat. He had a normal palate, normal facies. Cardiovascular, he has normal S1 and S2 and no murmurs, well perfused. Lung examination showed breathsounds clear, bilaterally with no retractions. His abdomen was soft, nontender, nondistended with no hepatosplenomegaly and no masses. His extremities were warm and well perfused. Neurological examination showed tone appropriate for gestational age. Genitourinary examination showed testes that were palpable in the canal. His anus is patent. Spine is intact and hips are stable. HOSPITAL COURSE: 1. Respiratory - The patient remained on room air throughout his stay. 2. Cardiovascular - He never had issues with hypertension and has had no spells in the past several days. He is not on any caffeine. 3. Fluids, electrolytes and nutrition - The patient is initially made NPO with total fluid of 80 cc/kg/day. Feeds were started on day of life #1. He reached full feeds by day of life #6. On day of life #6 he had two episodes of hypoglycemia with blood sugars as low as 34. Intravenous fluids were continued due to this at 20 cc/kg/day on top of his feeds. In addition, Polycose was added to the formula to increase his glucose intake. His glucose normalized over the course of the following 24 hours and intravenous fluids were discontinued. He is currently on total fluids of 150 cc/kg/day, PE 2 2 cal/oz of which are Polycose. He is also receiving iron supplementation, all of his feeds are p.g. 4. Gastrointestinal - The patient was started on phototherapy on day of life 3 with a maximum bilirubin of 7.3. He continues on phototherapy now. 5. Heme - His complete blood count on admission showed a white count of 5.4, hematocrit 61.2 and platelet count of 151. He has had 53 neutrophils and 0 bands. He has had no heme issues during his stay. 6. Infectious disease - The patient was started on Ampicillin and gentamicin due to his prematurity and preterm labor. His blood cultures remained negative throughout his stay and the antibiotics were discontinued after 48 hours. 7. Neurology - He has had no neurologic issues during his stay. 8. Sensory - Hearing screen has not yet been performed. CONDITION AT DISCHARGE: The patient can be transferred to [**Location (un) 745**] [**Location (un) 3678**]. CONDITION ON DISCHARGE: Good. PRIMARY CARE PEDIATRICIAN: Not established. CARE RECOMMENDATIONS: 1. Feeds at discharge - Total fluids of 150 cc/kg/day of PE 26, 2 cal/oz of which are Polycose. 2. Medications - Iron 0.1 cc q. day which is equal to 2 mg/kg/day. 3. Newborn screen status - Pending. 4. Immunizations received - None. 5. Immunizations recommended - I. Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 958**] for infants who meet any of the following three criteria: A. Born at less than 32 weeks; B. Born between 32 and 35 weeks with plans for daycare during respiratory syncytial virus season, with a smoker in the household or with preschool siblings; or C. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age the family and other caregivers should be considered for immunization against influenza and to protect the infant. The patient needs a car seat test before discharge. DISCHARGE DIAGNOSIS: 1. Prematurity 2. Rule out sepsis 3. Intrauterine growth retardation [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**] Dictated By:[**Name8 (MD) 36241**] MEDQUIST36 D: [**2155-1-16**] 16:44 T: [**2155-1-16**] 18:08 JOB#: [**Job Number 38319**]

Admission Date: [**2116-5-21**] Discharge Date: [**2116-7-17**] Date of Birth: [**2064-4-13**] Sex: F Service: MEDICINE Allergies: Coconut Oil Attending:[**First Name3 (LF) 8388**] Chief Complaint: Altered mental status, hiatal hernia, hepatitis of unknown etiology Major Surgical or Invasive Procedure: 1. Several intubations for respiratory failure 2. [**2116-6-5**] laparoscopic reduction of hiatal hernia, repair of diaphragmatic defect with pledgeted sutures, pexy of stomach to diaphragm, and laparoscopic liver biopsy History of Present Illness: Ms. [**Known firstname **] [**Known lastname 85535**] is a 52 year old female with a history of mental retardation and migraine headaches who is transfered from [**Hospital 792**]Hospital for further management of hepatitis. She originally presented to [**Hospital **] Hospital on [**2116-4-28**] with an increase in the frequency of falls and confusion. Her sister and [**Name2 (NI) 802**] noted subtle changes in her behavior as far back as [**2115-10-13**] that became increasingly pronounced over the following months, viral hepatitis work-up was reportedly negative. At [**Hospital **] Hospital, the patient had a prolonged and complicated course with extensive evaluation of her elevated LFTs. She was noted to have hyperammonemia and was treated with lactulose for hepatic encephalopathy with some improvement in mental status. MRI abdomen was unremarkable. Ceruloplasmin, [**Doctor First Name **], AMA, [**Last Name (un) 15412**] were all normal. Viral hepatitis serologies were negative as was CMV PCR. Alpha-1 antitrypsin was elevated at 385. She underwent a liver biopsy on [**2116-4-5**] that showed "ongoing severe liver injury with extensive hepatocyte damage and resulting collapse. She underwent endoscopy that demonstrated a 10 cm hiatal hernia and gastric volvulus with edema and erythema of the stomach and an erosion at the GE junction. Colonoscopy showed grade IV internal hemorrhoids and 2 colonic ulcerations that were ischemic in nature and a 2 mm polyp that was resected. She required antibiotics (vancomycin and zosyn) to treat HAP and aspiration PNA. Her LFTs remained abnormal with AST of 146 and ALT 103. AP peaked at 457. She was transferred, at the request of her family, to [**Hospital1 18**] on [**2116-5-21**] for further evaluation as they were still seeking a diagnosis for her illness. The patient was admitted to the Medicine service on [**2116-5-21**] to evaluate her liver disease. While on the medicine service, her hospital course was complicated by ongoing aspiration events felt to be a result of her large hiatal hernia and esophageal dysmotility. On [**2116-5-28**], she was intubated and transferred to the MICU for increasing dyspnea and acute respiratory failure. She was extubated soon after on [**2116-5-29**] and was treated for HAP/aspiration pneumonia, but antibiotics were stopped on [**2116-6-1**]. On [**2116-6-5**], the patient was transferred to the thoracic surgery service and underwent laparascopic hiatal hernia reduction with percutaneous liver biospy. Past Medical History: - mental retardation of unknown etiology (some work-up at [**Hospital **] Hosp of [**Location (un) 86**] that was of unclear consequence) - history of migraine headaches that are associated with nausea and vomiting and can be debilitating. - hypercholesterolemia, was formerly on Lipitor. - history of self-mutilization characterized by picking at skin. - s/p right inner ear surgery x 2 with implant, [**2112**] and [**2107**] - ATN, AIN at [**Hospital **] hospital [**4-/2116**] Recent medical history during this hospitalization: - Recurrent aspiration pneumonia ([**5-28**] - 18 intubated for ARDS) - hiatal hernia s/p repair - gastric volvulus s/p repair - Right upper extremity phlebitis/cellulitis associated with PICC - NASH with Grade III-IV fibrosis - ARDS and intubation post operatively [**Date range (1) 85536**]/10 - ATN, CVVH with oliguric renal failure (Cr peaked at 3.5) - Coagulase negative staphylococcal bacteremia ([**6-16**]) - Persistent Leukocytosis of unclear etiology - Elevated alpha 1 antitrypsin Social History: She lives with her sister [**Name (NI) 17**], her [**Name (NI) 802**], and a Burmese mountain dog. She used to work at a daycare program where she did manual labor but then was switched to a group that manages dementia patients as it was thought she might be developing dementia. She has had diminished ability to perform her ADLs over the past few months. She has never smoked, no alcohol, and no drug use. Family History: - mother: breast CA at 76 - father: colorectal CA in his 60s, MI - 4 siblings: diabetes, hypertension, migraine headaches, vertigo/Meniere's disease Physical Exam: Vitals: T 99.1, BP 149/89, HR 80, RR 20, O2 sat 96% RA General: Morbidly obese, middle-aged, Caucasian female in NAD, voice is difficult to understand HEENT: dysmorphic facies, atraumatic, sclera anicteric, disconjugate gaze, unable to completely assess EOM d/t non-cooperation with exam, OP clear, MMM Neck: supple, no lymphadenopathy or thyromegaly Heart: RRR, normal s1 and s2, no murmurs Lungs: CTA anteriorly, laterally, and superiorly in the back. No w/r/r. Breathing comfortably without accessory muscle use. Abdomen: +BS, soft, obese, mild RUQ tenderness without rebound or guarding Extremities: 3+ edema in feet and ankles bilaterally. Neurological: Alert, oriented to self and family. Moves all 4 extremities. Difficult to assess due to lack of cooperation with exam. Pertinent Results: ADMISSION LABS: [**2116-5-21**] 09:32PM BLOOD WBC-14.5* RBC-3.89* Hgb-10.6* Hct-34.4* MCV-88 MCH-27.2 MCHC-30.9* RDW-15.8* Plt Ct-236 [**2116-5-22**] 05:53AM BLOOD Neuts-85.2* Lymphs-7.8* Monos-4.6 Eos-2.1 Baso-0.2 [**2116-5-21**] 09:32PM BLOOD PT-15.6* PTT-32.5 INR(PT)-1.4* [**2116-5-21**] 09:32PM BLOOD Glucose-101* UreaN-7 Creat-1.0 Na-140 K-3.9 Cl-108 HCO3-22 AnGap-14 [**2116-5-21**] 09:32PM BLOOD ALT-90* AST-145* LD(LDH)-229 AlkPhos-532* TotBili-0.8 [**2116-5-21**] 09:32PM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.3 Mg-1.8 LABS ON TRANSFER TO MICU: [**2116-5-28**] 04:58AM BLOOD WBC-22.5* RBC-3.51* Hgb-10.0* Hct-31.6* MCV-90 MCH-28.5 MCHC-31.7 RDW-15.9* Plt Ct-288# [**2116-5-28**] 12:48PM BLOOD Neuts-91.5* Lymphs-5.0* Monos-2.9 Eos-0.2 Baso-0.4 [**2116-5-28**] 04:58AM BLOOD PT-16.2* PTT-30.6 INR(PT)-1.4* [**2116-5-28**] 04:58AM BLOOD Glucose-124* UreaN-15 Creat-1.5* Na-146* K-3.6 Cl-111* HCO3-21* AnGap-18 [**2116-5-28**] 04:58AM BLOOD ALT-94* AST-132* LD(LDH)-312* AlkPhos-505* TotBili-0.8 [**2116-5-28**] 04:58AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.9 Mg-1.9 [**2116-5-28**] 10:26AM BLOOD Type-ART pO2-65* pCO2-30* pH-7.48* calTCO2-23 Base XS-0 [**2116-5-28**] 10:26AM BLOOD Lactate-3.4* BARIUM ESOPHAGRAM ([**2116-5-22**]): 1. Severe esophageal dysmotility and reflux. 2. Moderate hiatal hernia. LIVER BIOPSY, PATHOLOGY ([**2116-5-26**]): 1. Advanced fibrosis (stage 3-4) with extensive bridging, multifocal incomplete nodule formation (with a rare focus suggestive of complete nodule formation) and a prominent sinusoidal component. 2. Moderate lobular neutrophilic inflammation and mild portal mixed inflammation (score 2). 3. Foci of hepatocyte ballooning degeneration with associated intracytoplasmic hyalin (score 2). 4. Minimal steatosis (involving <5% of the core biopsy; score 0) 2D ECHO ([**2116-6-1**]): Mild regional left ventricular systolic dysfunction consistent with coronary artery disease. MRI ABDOMEN & PELVIS ([**2116-6-3**]): 1. No evidence of biliary obstruction. 2. Small amount of perihepatic ascites. 3. Significant dependent body wall edema indicative of "third-spacing". RENAL ULTRASOUND ([**2116-6-6**]): Essentially normal renal ultrasound. No evidence of hydronephrosis. DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US ([**2116-6-9**]): Major intrahepatic vasculature patent with normal direction of flow. Slightly coarsened and echogenic liver compatible with the history of autoimmune hepatitis. No intrahepatic or extrahepatic biliary ductal dilatation. CT CHEST/ABDOMEN/PELVIS ([**2116-6-14**]): 1. Improved aeration of lung parenchyma, with persistent predominantly basal consolidations and perihilar ground-glass opacities. 2. Small bilateral pleural effusions. 3. Diffuse body wall edema with mild abdominal and pelvic ascites without focal fluid collection. 4. Persistent geographic area of hypoattenuation involving the medial aspect of segment II and III of the liver of uncertain etiology. Edema or infarcts could be considered. When clinically appropriate, if the patient can have a contrast-enhanced CT or MR examination, depending patient factors, this appearance could be investigated further. Alternatively, a short-term follow-up with ultrasound might be able to provide some information and could provide a baseline for follow-up of the abnormality, if it is later visualized. Doppler features could also be reassessed in light of persistence of this abnormality. 5. Left PICC ends in the left brachiocephalic vein. 6. Thickening of the distal colon, involving the sigmoid and through the upper rectum, even allowing for underdistension. Differential considerations include colitis in the appropriate setting or sequelae of portal congestion. Since the upstream colon is mildly prominent, the fact that the distal is mild to moderately narrowed may be causing slight obstruction, although contrast passes entirely through the area. The whole segment was collapsed on the last examination, limiting assessment and comparison. Correlation with clinical factors is recommended. DUPLEX DOPP ABD/PEL PORT; LIVER OR GALLBLADDER US ([**2116-6-16**]): 1. Patent hepatic vasculature 2. No focal liver lesion and no biliary dilatation seen. 3. Minimal ascites. CT ABD/PELVIS ([**2116-6-25**]): 1. No evidence of abscess. Moderate amount of ascites, which has increased since the previous study. 2. Small bilateral pleural effusions, which have decreased in size since the previous study. Adjacent bibasilar atelectasis in addition to diffuse ground-glass and patchy opacities at the bases have improved. 3. Small areas of hypoenhancement within segment II and III of the liver with slight decrease in size of these segments likely reflects evolving infarct and subsequent scarring corresponding with the area of hypodensity noted on the previous noncontrast CT studies. 4. Possible bowel wall thickening of the cecum, new since the previous study. While this may be due to underdistended bowel, focal colitis cannot be excluded. Previously described thickening of the distal colon is not seen on today's study and may have been due to underdistension on the previous study. MR HEAD W/ & W/O CONTRAST ([**2116-6-28**]): Non-specific, nonenhancing focus of high signal on FLAIR and T2 weighted images in the left parietal lobe. The differential considerations are demyleination, vasculitis or sequlae of small vessel disease. MICROBIOLOGY: [**5-27**] HD catheter - Coag neg staph [**6-26**] HD catheter - Coag neg staph [**6-28**] Blood cultures - VRE Multiple sputum and urine cultures showing undifferentiated yeast. Brief Hospital Course: HOSPICE CARE: Ms. [**Known lastname 85535**] was initially admitted to the hospital from [**State 792**]after being diagnosed with hepatitis that was found to be end stage liver disease (cirrhosis) from NASH. Briefly, her hospitalization course was complicated by intubation for aspiration pneumonia with subsequent respiratory arrest. She also underwent a hiatal hernia repair to help decrease the risk of aspiration, she was in the ICU for transient shock liver and renal dysfunction. She also developed VRE sepsis and was finally extubated several prior to her transition to the floor. Unfortunately her course continued to deteriorate, she was noted to again be in respiratory distress likely a combination of aspiration from secretions and a hypervolemic state. She was also not tolerating oral, NG tube feeds. Following the onset of NGT feeding her abdomen would become distended, she would have a fever. After a discussion with health care proxy and family members the decision was made for her to be comfort measures only. All non-essential, non-comforting medications were discontinued. Pt was started on oral Morphine for pain, oral Ativan for anxiety, Scopolamine patch to minimize secretions from the Morphine. - please continue with 5-10mg PO Morpine every 4 hours as needed for comfort, this may need to be increased pending her discomfort - please continue with 1mg Ativan PO every 4 hours for anxiety - please continue with 3 Scopolamine patches to the neck to decrease secretions - please continue with Bisacodyl 10mg PR as needed if the pt does not have a bowel movement for several days and seems uncomfortable from constipation - please continue with Acetaminophen PR as needed for any fevers PRIOR TO TRANSFER TO THORACIC SURGERY SERVICE/MICU: # Elevated liver enzymes: liver biopsy pathology slides were obtained from [**Hospital **] Hospital and reviewed by [**Hospital1 18**] pathology. Full findings are above. Pathology was consistent with stage 3-4 fibrosis thought to be secondary to NASH. # Dysphagia, hoarse voice: barium study evaluation revealed a large hiatal hernia, and OSH upper endoscopy showed possible gastric volvulus. Patient was continued on PPI [**Hospital1 **] and thoracic surgery was consulted. # Respiratory distress, aspiration pneumonia: a respiratory code was called when patient became increasingly dyspneic and hypoxic to 85% on the non-rebreather on [**5-28**]. Patient was then transferred to the MICU and started on HAP coverage with vancomycin and Zosyn. She was extubated on [**5-29**]. Bronchoscopy specimens only grew yeast. # Coag negative staph bacteremia: On [**5-29**] bottle grew GPCs which turned out to be coag negative staph. Surveilance cultures were negative, and this was felt to be likely a contaminant. Patient was initially covered with vancomycin, but this was stopped on [**6-2**]. # Candiduria: Patient grew [**Female First Name (un) **] from urine, as well as bronch specimen. Patient received fluconazole IV x 3 days, and foley catheter was changed. # Nutrition: After above mentioned aspiration event, patient was made NPO. Initial speech and swallow found esophageal dismotility on barium swallow, without coughing and patient was placed on diet of thin liquids and pureed solids. # Cellulitis: she presented to the hospital from [**Hospital **] Hospital with a right arm cellulitis at the site of her previous PICC. We completed her 7-day course of antibiotics. There were no further issues. FROM TRANSFER TO THORACIC SURGERY SERVICE/SICU ([**2116-6-5**]): KEY EVENTS: [**6-6**]: Hepatology rec likely volume down, supportive care. Renal recs likely ATN from hypotension. Renal US no source. TPN. Vanco inc 1gm q48. [**6-7**]: Placement of R subclavian CVL, started levo for sbp support, adequate UO, one dose of lasix 20 mg IV in am, improved liver function, rising creatinine [**6-9**]: continues with minimal UOP. Started albumin 25g TID and lasix drip with improvement in UOP, low dose levophed started to increase renal perfusion. Fever, sent u/a, ucx, blood cx, cxr. Ordered for RUQ ultrasound with doppler. [**6-10**] started CVVH, CT torso, placed HD line, bedside ECHO [**6-11**] CVVH at bedside, Cr / BUN / weight trending down, INR stable at 1.5. started vanco, [**Last Name (un) 2830**], fluc. [**6-12**] continues on CVVH. Now on PSV 10/10 with plan to extubate [**6-13**] [**6-13**] off CVVH since am, minimal urine production, improving past midnight, no vasopressors, febrile to 103.2 -> Blcx, UClx, sputum, on cpap. Sputum gram stain no organisms. [**6-14**]: Paracentesis done, 1.5 L of transudative fluid removed. RIGHT SC removed and new triple lumen placed in LEFT subclavian. CT torso without obvious etiology of fevers. Increasing stools overnight, c. diff sent. [**6-15**]: had HD performed at bedside with 1.5 L removed. SBT with 5/0 settings. Patient did well for ~45 minutes, then became tachypnic with desaturation. NO extubation. Became febrile to 104 and received ice packs and fan. [**6-16**]: HD was cancelled [**1-14**] fever, HD planned for [**6-17**], may not need renal recs albumin and lasix in interim; we gave lasix 40 mg once with adequate response, hepatology - f/u LFTs, no acute events, afebrile > 24 hours, d/c'ed RIJ HD line. Patient extubated. [**6-17**]: Vancomycin started for coag neg staph on RIGHT IJ HD catheter. UOP improving, lasix PRN. Overall, pt clinically improving. [**6-18**]: Urine output continues to improve. Received lasix with good output, however, afternoon lytes with hypernatremia (147). Evening lasix held. [**6-19**]: we D/Ced Fluconazole given completion of course for yeast cultures. She was cleared for thin liquids and pureed foods with swallow eval. [**6-22**]: repeat swallow study was performed demonstrating poor interest in intake, no aspiration or mechanical issue with deglutition. [**6-23**]: last dose of Vancomycin was given in the AM. Blood cultures were drawn x 2. FROM TRANSFER TO MICU ON [**6-26**]: # Respiratory failure: Pt was transferred to the MICU on [**6-26**] for hypoxic respiratory failure and was intubated. Multiple sputum cultures and a mini-BAL were negative except for undifferentiated yeast. Her respiratory failure was multifactorial, with contributions from her deconditioning after a long hospital stay, increased intraabdominal pressure from ileus and ascites, a component of ARDS during her immediate post-op period, and significant fluid overload from aggressive rehydration. She was initially >14L positive on arrival to the MICU. With aggressive diuresis with lasix and metolazone her respiratory status improved tremendously and she was extubated to face mask on [**7-11**] and transferred to the floor on [**7-15**] on nasal cannula. # Fevers and persistent leukocytosis: Patient had multiple infectious workups including repeat negative blood/sputum/urine/catheter tip cultures, negative CT chest/abdomen/pelvis, negative CT neck, cardiac echo negative for vegetations. She did have one positive blood culture for VRE early in her MICU stay. She received a long course of multiple broad-spectrum antibiotics, including vancomycin, meropenem, daptomycin, linezolid, flagyl and micafungin. It was noted that her fevers appeared related temporally to tube feeds and her fevers seemed to resolve when she was transitioned to tpn. # Renal failure: Patient's creatinine was 1.2 upon admission to the MICU and improved without intervention. # Constipation/ileus/abdominal distension: Patient had difficulty with high residuals and persistent fevers seemingly associated with tube feeds. She had intermittent increased abdominal distension which was evaluated on multiple abdominal KUBs, ultrasounds, CT scans which did not show acute abdominal processes. Diagnostic paracenteses x2 did not demonstrate SBP and ascites did not increase drastically during her MICU stay. Thought likely due to ileus and the distension improved with tpn (tube feeds held,) and erythromycin. Initially lactulose was effective but this was also held as it was given per NGT and was poorly absorbed. # AMS: Presumably hepatic encephalopathy was the cause of altered MS that led to pt's initial presentation to OSH in mid [**Month (only) 116**], when pt was found to have elevated LFTs for the first time. Apparently pt able to communicate with her sister at baseline, but level/sophistication of this communication unclear. [**Name2 (NI) **] had repeat negative head CTs and an MRI negative for acute abnormalities. Her mental status improved only slightly after extubation; however she never fully regained the ability to communicate at her reported baseline. # Anemia: First established at OSH, where EGD/[**Last Name (un) **] negative. Fe studies consistent with anemia of chronic disease. Did decrease once during her MICU stay requiring 1U PRBC but remained stable throughout the rest of her stay in the low/mid 20s. Had one episode of blood in ETT but no overt signs of significant hemorrhage. # Liver fibrosis/NASH: Transaminitis relatively stable during MICU course, [**Name (NI) 3539**] actually improved while in the MICU. Paracentesis on [**6-14**] and [**6-30**] negative for SBP. She was continued on ursodiol and rifaximin for hepatic encephalopathy. She was initially receiving lactulose, but this was discontinued due to high residuals in her tube feeds and concern for worsening abdominal distension. # Coagulopathy: INR generally 1.5-1.8 with peak 2.1. Platelet counts normal. Patient most likely had Vit K deficiency from chronic antibiotics, NPO status, and malabsorption/ileus. There was no need for reversal of anticoagulation during her MICU stay. Medications on Admission: MEDICATIONS (pre-admission): - propranolol 20mg qday - atorvastatin 20mg qday - fluoxetine 80 mg qday - nortriptyline 75mg qday - Ativan 1mg prn anxiety . MEDICATIONS (on transfer to MICU [**6-26**]) - Miconazole Powder 2% 1 Appl TP TID:PRN yeast - Nortriptyline 75 mg PO/NG HS - Acetaminophen 325-650 mg PO/NG Q6H:PRN pain or fever - Olanzapine (Disintegrating Tablet) 5 mg PO TID:PRN anxiety - Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea - Ondansetron 4 mg IV Q8H:PRN nausea Order - Albuterol Inhaler 6 PUFF IH Q4H:PRN wheezing - Potassium Chloride 40 mEq / 500 ml D5W IV - Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea - Polyethylene Glycol 17 g NG [**Hospital1 **] constipation - Bisacodyl 10 mg PR HS:PRN constipation - Propranolol 20 mg PO/NG DAILY - Docusate Sodium 100 mg PO BID - Fluoxetine 80 mg PO/NG DAILY - Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation - Heparin 5000 UNIT SC TID - Ursodiol 300 mg PO BID - traZODONE 50 mg PO/NG HS:PRN for sleep - Lactulose 30 mL PO/NG TID Discharge Medications: 1. Scopolamine Base 1.5 mg Patch 72 hr Sig: Three (3) Patch 72 hr Transdermal ONCE (Once): to thin secretions. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: please place rectal suppository if constipated for more than 3 days. 3. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain/discomfort: Palliative Care. Disp:*500 mg* Refills:*0* 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: place under tongue. Disp:*30 Tablet(s)* Refills:*0* 5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed for fever. Discharge Disposition: Extended Care Facility: [**Location (un) **] care and rehab Discharge Diagnosis: Hypoxemic Respiratory Failure VRE Sepsis Hiatal Hernia Cirrhosis NASH Mental Retardation Hyperlipidemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic, intermittently arousable. Activity Status: Bedbound. Discharge Instructions: You were initially transferred to the hospital for management for your hepatitis. After being transferred to the hospital we noted that your hepatitis was actually end stage liver disease called cirrhosis. You had a complicated hospitalization which included several intubations after you developed a lung infection after aspirating, you also had a severe infection called sepsis and you were in the intensive care unit for a prolonged time. After your breathing tube was removed you unfortunately still remained very sick with difficulty breathing. After talking with your family it was decided that you should be comfortable and you transferred to comfort measures only. Followup Instructions: Discharge to Hospice

Admission Date: [**2119-1-31**] Discharge Date: [**2091-4-2**] Date of Birth: [**2059-12-22**] Sex: F Service: MEDICAL ICU HISTORY OF PRESENT ILLNESS: This is a 58 year-old female with a past medical history of type 1 diabetes mellitus, hypertension, hypercholesterolemia, end stage renal disease, coronary artery disease status post coronary artery bypass graft who presented from an outside hospital with hypotension likely secondary to sepsis. She was recently admitted at [**Hospital1 69**] from [**1-5**] to [**1-21**] when she had a coronary artery bypass graft done for three vessel disease with normal EF. Her postoperative course was complicated by respiratory failure requiring a tracheostomy, atrial fibrillation, renal failure, requiring hemodialysis and an embolic cerebrovascular accident diagnosed on the CT of the head as a right MCA inferior division stroke. The patient had a G tube placed and was discharged to [**Hospital3 7665**] [**Hospital3 417**] and as an outpatient she had been treated for an Enterobacter line infection with Vancomycin and Cefepime. Cultures seemed to have been negative. On the 29th the patient had fevers and hypotension. She was transferred from [**Hospital3 417**] to [**Hospital3 **]. A right femoral line was placed and cultures were done. The patient had ID consulted and they recommended discontinuing the dialysis line as they suspected that was the source of her sepsis and elevated white blood cell count. The patient was started on neo-synephrine for her hypotension and transferred to [**Hospital1 69**]. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus. 2. Hypertension. 3. Hypercholesterolemia. 4. End stage renal disease. 5. Transient ischemic attack eleven years ago. 6. C section. 7. History of AV fistula. 8. Coronary artery disease status post coronary artery bypass graft [**2119-1-2**]. 9. Cerebrovascular accident [**2119-1-6**]. 10. Tracheostomy [**2119-1-14**]. 11. G tube placed on [**2119-1-18**]. 12. Atrial fibrillation postop. 13. Legally blind. MEDICATIONS AT HOME: 1. Plavix 75 mg q.d. 2. Colace 100 mg b.i.d. 3. Vancomycin 500 q.d. 4. Vitamin B complex. 5. Prevacid 30 q day. 6. Keppra 500 b.i.d. 7. Albuterol and Atrovent nebs prn. 8. Amiodarone 200 q.d. 9. Aspirin 325 q.d. 10. Cefepime 1 gram q.d. 11. Heparin subq. 12. Reglan 10 mg q.d. 13. Sliding scale insulin. 14. K-phos. ALLERGIES: No known drug allergies. TUBE FEEDS: She was getting nephro feeds at 40 cc an hour. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She does not smoke, drink or use drugs. She lives at [**Hospital3 **]. PHYSICAL EXAMINATION: Vital signs on admission her temperature was 101. Blood pressure 120/40. Heart rate 85. Respiratory rate 14. She was 99% on room air. Her vent settings, she was on assist control 500 by 12 with an FIO2 of 40% and a PEEP of 5. In general, she was a pleasant female lying in bed. HEENT her sclera were anicteric. Her left eye was nonreactive. Her right eye had surgical cataract removal. Cardiovascular regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Lungs were clear to auscultation bilaterally. She had suturing staples intact. Her wound was dry. Abdomen was soft, nontender, nondistended. Bowel sounds are present. Extremities she had a right subclavian tunnel catheter and the left femoral catheter. Neurological she was sedated. She did not withdraw to pain. She did have doll's eye present. LABORATORIES ON ADMISSION: BUN and creatinine of 59 and 3.8 respectively. White blood cell count 23 with 78% polys, 4% lymphocytes, 10 bands. Liver function tests were within normal limits. Urinalysis was negative. Electrocardiogram was sinus at 80 beats per minute with a left bundle branch block and a normal axis. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit Service. 1. Sepsis: The source was initially felt to be a possible line infection. She was pancultured. It appeared that the source of her sepsis was an organism called actinobactor baummanni. She was placed on Ceptaz, Vancomycin, Flagyl initially once the organisms was speciated. She completed a fourteen day course of Unasyn. 2. Mental status: It appeared that her mental status waxed and waned throughout her admission. The patient did receive an LP and a repeat head CT, which were both negative. The Neurology Service was consulted and they felt that an electroencephalogram should be performed. The electroencephalogram showed no evidence of focal seizure activity. She was continued on her Keppra for her history of seizure disorder. Otherwise no changes were made. 3. Respiratory failure: She was continued on her ventilator settings throughout hospital admission. She was weaned to trach collar at the time of discharge. She intermittently needed to resume pressure support ventilation. However, on the Friday prior to discharge she did have what is likely an aspiration event. She was kept on assist control for three days and then transitioned back to trach collar, she tolerated well. 4. Diabetes mellitus: She was continued on sliding scale insulin for some period of time. She was on an insulin drip. Daily insulin requirements were converted to Glargine and sliding scale insulin. The patient's blood sugars were well controlled at the time of discharge. 5. Renal failure: The patient continued hemodialysis per her normal routine throughout her admission. A new tunneled left subclavian catheter was placed. 6. Coronary artery disease: The patient has a history of coronary artery disease. She was continued on her aspirin and Plavix. 7. History of atrial fibrillation: She was continued on her Amiodarone. 8. Fluids, electrolytes and nutrition: She was maintained on her tube feeds. The day prior to discharge the concentration of protein was increased in her tube feeds. 9. Surgical: During the [**Hospital 228**] hospital course the patient's sternotomy wound began to open. The patient was taken to the Operating Room for surgical debridement of her sternotomy wounds. The patient tolerated this procedure well. She had four JP drains in. These were followed by plastic surgery. The JP drains were discontinued when they put out less then 30 cc per day respectively. She will follow up with Plastic Surgery as an outpatient. 10. Prophylaxis: The patient had a left PICC line placed for intravenous antibiotics, which will be discontinued prior to discharge to rehab. The patient remained full code throughout her admission and communication was with her niece who is her health care proxy. DISCHARGE TO: The patient was discharged to an extended care facility. DISCHARGE INSTRUCTIONS: She is to follow up with her primary care physician in the next three to four weeks and follow up with surgery as directed. FINAL DIAGNOSES: 1. Septic shock. 2. Respiratory failure acute and chronic. 3. Chronic renal failure. 4. Coronary artery disease status post coronary artery bypass graft. 5. History of atrial fibrillation. 6. Coronary artery bypass graft wound dehiscence. 7. Type 1 diabetes mellitus with retinopathy nephropathy. 8. Hypertension. 9. Hyperlipidemia. 10. History of transient ischemic attack. 11. History of seizure disorder. 12. Aspiration. MAJOR SURGICAL AND INVASIVE PROCEDURES: She had the wound debridements and she had tunnel catheter placement for hemodialysis. She had a left PICC line placed. DISCHARGE CONDITION: She was stable on trach collar intermittently needing pressure support ventilation at night. DISCHARGE MEDICATIONS: Discharge medications will be dictated at the time of discharge. At this time it will be, 1. Plavix 75 mg po q.d. 2. Amiodarone 200 po q.d. 3. Colace and Senna. 4. Aspirin 325 q.d. 5. Vitamin B complex. 6. Keppra 500 mg po b.i.d. 7. Zinc sulfate 320 mg po q.d. 8. Vitamin C 500 mg po q.d. 9. Reglan 5 mg intravenously q 12. 10. Protonix 40 mg intravenously q.d. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Name8 (MD) 8736**] MEDQUIST36 D: [**2119-2-20**] 01:17 T: [**2119-2-20**] 07:35 JOB#: [**Job Number 31936**]

Admission Date: [**2121-11-10**] Discharge Date: [**2122-1-8**] Date of Birth: [**2055-12-25**] Sex: F Service: CARDIOTHORACIC Allergies: Diphenhydramine / Phenytoin / Heparin Agents Attending:[**First Name3 (LF) 4272**] Chief Complaint: Nausea, mental status changes Major Surgical or Invasive Procedure: [**2121-11-11**] Bronchoscopy [**2121-11-18**] Exploratory thoracotomy, bronchoscopy, placement of pleural drain. [**2121-11-25**] PICC placement History of Present Illness: This is a 65 year old female well known to the thoracic service with a complicated history who was recently discharged after operative repair of a Right bronchopleural fistula status-post a right upper lobectomy for recurrent lung cancer complicated by a R chest empyema. Repair was done on [**2121-10-16**] with rib resection and pleural drainage using a constructed Eloesser flap. She now presents with several days after her discharge with worsening nausea, shortness of breath, and general malaise. Her family caregivers have noted a change in her mental status over the last 36 hours, with the patient hallucinating and acting confused and aggitated. She has been without a bowel movement for 7 days. Past Medical History: Right upper chest Eloesser flap with rib resection and pleural drainage [**2121-10-16**] Right upper lobectomy [**8-30**] for recurrent lung cancer Thorascopic Drainage of Right Empyema [**8-30**] right frontal lobe tumor (benign) Acute tubular necrosis [**10-30**] (presumed secondary to Linezolid) seizure disorder DM2 History of heparin-induced thrombocytopenia [**8-30**] cholelithiasis legally blind in right eye s/p craniotomy s/p carpal tunnel release Social History: The patient denies alcohol use. She stopped smoking in [**2111**]. She is retired and lives with her fiancee. Family History: Non-contributory Physical Exam: On admission: V/S 97.8, 82, 160/56, 26, 99% on 35% face mask Gen: decreased alertness, not answering questions, drowsy, fatigued elderly female Neuro: CN 2-12 grossly intact, no focal abnormalities HEENT: dry mucous membranes, no icterus, PERRLA CV: regular rate and rhythm, distant heart sounds Pulm: Occasional rhoncherous breath sounds, Right chest wound packing intact without surrounding erythema or malodorous Abdomen: obese, soft, non-tender, non-distended, no masses Extr: warm, 1+ edema Pertinent Results: SEROLOGIES [**2121-11-10**] 12:20PM BLOOD WBC-9.5 RBC-2.97* Hgb-9.6* Hct-28.8* MCV-97 MCH-32.4* MCHC-33.4 RDW-17.9* Plt Ct-322# [**2121-11-11**] 05:19AM BLOOD WBC-9.4 RBC-2.71* Hgb-8.8* Hct-26.5* MCV-98 MCH-32.4* MCHC-33.2 RDW-17.6* Plt Ct-285 [**2121-11-13**] 03:27AM BLOOD WBC-11.6*# RBC-3.27* Hgb-10.3* Hct-29.8* MCV-91 MCH-31.6 MCHC-34.7 RDW-18.5* Plt Ct-188 [**2121-11-14**] 03:50AM BLOOD WBC-13.7* RBC-3.38* Hgb-10.4* Hct-30.5* MCV-90 MCH-30.6 MCHC-34.0 RDW-18.1* Plt Ct-175 [**2121-11-17**] 03:17AM BLOOD WBC-14.3* RBC-3.17* Hgb-9.8* Hct-29.3* MCV-93 MCH-30.9 MCHC-33.4 RDW-17.8* Plt Ct-151 [**2121-11-19**] 02:53AM BLOOD WBC-17.6* RBC-3.02* Hgb-9.2* Hct-27.7* MCV-92 MCH-30.3 MCHC-33.1 RDW-18.8* Plt Ct-167 [**2121-11-23**] 05:50AM BLOOD WBC-17.0* RBC-3.13* Hgb-9.8* Hct-29.1* MCV-93 MCH-31.3 MCHC-33.7 RDW-17.4* Plt Ct-205 [**2121-11-24**] 04:32AM BLOOD WBC-13.0* RBC-3.08* Hgb-9.5* Hct-28.9* MCV-94 MCH-30.7 MCHC-32.8 RDW-17.2* Plt Ct-201 [**2121-11-25**] 05:30AM BLOOD WBC-11.6* RBC-2.92* Hgb-9.0* Hct-27.2* MCV-93 MCH-31.0 MCHC-33.3 RDW-17.2* Plt Ct-206 [**2121-11-10**] 12:20PM BLOOD Neuts-85.9* Lymphs-7.4* Monos-5.3 Eos-1.1 Baso-0.3 [**2121-11-22**] 05:31AM BLOOD Neuts-88.6* Bands-0 Lymphs-6.2* Monos-3.6 Eos-1.4 Baso-0.1 [**2121-11-10**] 12:20PM BLOOD PT-23.1* PTT-38.8* INR(PT)-3.4 [**2121-11-11**] 05:19AM BLOOD PT-25.1* PTT-40.6* INR(PT)-4.0 [**2121-11-12**] 02:48AM BLOOD PT-15.4* PTT-29.3 INR(PT)-1.5 [**2121-11-13**] 05:22PM BLOOD PT-26.2* PTT-61.1* INR(PT)-4.3 [**2121-11-15**] 02:46PM BLOOD PT-24.4* PTT-62.3* INR(PT)-3.8 [**2121-11-16**] 09:29PM BLOOD PT-24.4* PTT-54.2* INR(PT)-3.8 [**2121-11-20**] 12:45AM BLOOD PT-17.8* PTT-45.9* INR(PT)-2.0 [**2121-11-23**] 05:50AM BLOOD PT-21.0* PTT-38.0* INR(PT)-2.8 [**2121-11-24**] 04:32AM BLOOD PT-21.4* PTT-40.6* INR(PT)-2.9 [**2121-11-25**] 05:30AM BLOOD PT-24.2* PTT-46.7* INR(PT)-3.7 [**2121-11-10**] 12:20PM BLOOD Glucose-119* UreaN-42* Creat-2.7* Na-139 K-4.5 Cl-102 HCO3-29 AnGap-13 [**2121-11-11**] 05:19AM BLOOD Glucose-105 UreaN-41* Creat-2.7* Na-141 K-4.6 Cl-104 HCO3-29 AnGap-13 [**2121-11-12**] 02:48AM BLOOD Glucose-65* UreaN-42* Creat-2.9* Na-140 K-3.8 Cl-106 HCO3-23 AnGap-15 [**2121-11-14**] 03:50AM BLOOD Glucose-159* UreaN-45* Creat-3.0* Na-140 K-2.8* Cl-103 HCO3-30* AnGap-10 [**2121-11-15**] 03:52AM BLOOD Glucose-135* UreaN-45* Creat-2.7* Na-146* K-3.3 Cl-110* HCO3-29 AnGap-10 [**2121-11-17**] 03:17AM BLOOD Glucose-162* UreaN-45* Creat-2.5* Na-150* K-3.5 Cl-112* HCO3-30* AnGap-12 [**2121-11-18**] 06:48PM BLOOD Glucose-84 UreaN-45* Creat-2.4* Na-145 K-3.8 Cl-108 HCO3-31* AnGap-10 [**2121-11-19**] 02:53AM BLOOD Glucose-77 UreaN-46* Creat-2.4* Na-144 K-3.5 Cl-106 HCO3-29 AnGap-13 [**2121-11-22**] 05:31AM BLOOD Glucose-76 UreaN-41* Creat-2.7* Na-141 K-3.5 Cl-102 HCO3-28 AnGap-15 [**2121-11-24**] 04:32AM BLOOD Glucose-67* UreaN-38* Creat-2.7* Na-141 K-4.1 Cl-103 HCO3-27 AnGap-15 [**2121-11-25**] 05:30AM BLOOD Glucose-69* UreaN-36* Creat-2.8* Na-135 K-3.7 Cl-99 HCO3-28 AnGap-12 [**2121-11-11**] 05:19AM BLOOD ALT-38 AST-23 CK(CPK)-19* AlkPhos-132* Amylase-32 TotBili-0.6 [**2121-11-19**] 02:53AM BLOOD ALT-9 AST-11 AlkPhos-75 Amylase-20 TotBili-0.7 [**2121-11-10**] 06:26PM BLOOD Calcium-8.5 Phos-4.9* Mg-2.2 [**2121-11-11**] 04:33PM BLOOD Calcium-7.2* Phos-3.6 Mg-1.8 [**2121-11-16**] 04:21AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.1 [**2121-11-20**] 12:45AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.3 [**2121-11-24**] 04:32AM BLOOD Calcium-7.6* Phos-4.4 Mg-2.2 [**2121-11-25**] 05:30AM BLOOD Albumin-2.2* Calcium-7.8* Phos-4.9* Mg-2.0 [**2121-11-14**] 11:32AM BLOOD Cortsol-44.6* [**2121-11-12**] 10:53PM BLOOD Vanco-19.9* [**2121-11-18**] 10:28AM BLOOD Vanco-13.4* [**2121-11-20**] 09:20PM BLOOD Vanco-15.7* [**2121-11-10**] 12:20PM BLOOD Phenyto-7.9* [**2121-11-12**] 02:48AM BLOOD Phenyto-3.6* [**2121-11-16**] 04:21AM BLOOD Phenyto-3.4* [**2121-11-17**] 03:17AM BLOOD Phenyto-3.9* [**2121-11-20**] 12:45AM BLOOD Phenyto-6.0* [**2121-11-20**] 08:39AM BLOOD Phenyto-3.6* [**2121-11-24**] 04:32AM BLOOD Phenyto-3.3* RADIOLOGY: [**2121-11-11**] Head CT: No acute intracranial hemorrhage or mass effect. Postsurgical changes in the frontal lobes bilaterally. [**2121-11-11**]: Normal bowel gas pattern. [**2121-11-12**] Upper Extremity Ultrasound: 1. Thrombosis of the right internal jugular vein with changes suggesting partial recanalization. 2. No evidence of thrombus within the right subclavian vein, left internal jugular vein, or left subclavian vein. [**2121-11-14**] Chest CT: 1. Unchanged appearance of a right upper lobe cavitary process with surrounding soft tissue thickening. There is a persistent loculated fluid collection with an adjacent pigtail catheter, unchanged. 2. Unchanged appearance of the right lateral ribs, which is worrisome for osteomyelitis. 3. Communication between the cavitary process with the subcutaneous tissues of the right chest, unchanged. 4. Pulmonary edema, worsened. 5. Development of patchy opacities bilaterally, worrisome for a multifocal pneumonia. [**2121-11-23**] Chest Xray: Right upper lobe cavity with an air fluid level. No interval change in right upper lobe consolidation with diffuse interstitial opacities and bilateral pleural effusions. BRONCHOSCOPY: [**2121-11-11**]: Right upper lobe stump intact, diffuse right middle lobe/right lower lobe malacia with moderate secretions. MICROBIOLOGY: [**2121-11-10**] Urine Cx: Klebsiella [**2121-11-10**] Blood Cx: Negative [**2121-11-11**] Sputum Cx: MRSA [**2121-11-14**] Blood Cx: Negative [**2121-11-17**] Blood Cx: Negative [**2121-11-17**] Urine Cx: Negative [**2121-11-18**] Pleural Fluid (operative) Cx: MRSA, Klebsiella [Zosyn] [**2121-11-18**] Pleural tissue (operative) Cx: MRSA, Klebsiella [**2121-11-23**] Pleural Fluid: Klebsiella, Gram + Cocci [**2121-12-3**] Sputum: Klebsiella [**2121-12-12**] Sputum: Coag+ Staph Aureus CT CHEST W/O CONTRAST [**2122-1-1**] 3:31 PM IMPRESSION: 1. Progression of disease compared to [**2121-11-12**], with marked bronchovascular thickening suggestive of worsening lymphangitic spread of disease. 2. Soft tissue mass in the right lower lobe (series 3 image 23) that is increased when compared to [**2121-11-12**]. 3. Tissue density within both hila and adjacent to the carina that have an appearance suggestive of lymphadenopathy that has worsened compared to the previous examination. 4. Unchanged destruction and soft tissue density involving 2 left-sided lateral ribs. 5. Slightly increased size of a left-sided pleural effusion with unchanged right-sided effusion/pleural thickening. The thick-walled air-filled cavity within the right lung apex has decreased in size compared to [**2121-11-12**], within both lungs suggestive of hydrostatic edema. 6. Several low attenuation lesions within the liver that are suspicious for metastatic disease. CT BONE BX SUPERFICIAL [**2122-1-2**] 2:07 PM IMPRESSION: 1. Successful 15-gauge core biopsy of a soft tissue mass within a left-sided rib, as discussed above. 2. Stable pleural effusions and diffuse lung disease within the partially imaged chest, as previously described on multiple recent chest CT exams. 3. Multiple low-attenuation masses within the partially imaged liver. Although this CT-guided biopsy procedure did not include an exhaustive evaluation of the liver parenchyma, these lesions are highly suspicious for metastatic disease. They do not appear significantly changed from the most recent chest CT exam, but they cannot be identified on the contrast-enhanced chest CT exam of [**2121-9-4**]. Clinical correlation and comparison with any previous outside exams is recommended. SPECIMEN SUBMITTED: RIB FNA BX DIAGNOSIS: Rib, FNA biopsy: Metastatic squamous cell carcinoma consistent with lung origin. Brief Hospital Course: This is a 65 year old female with a complicated thoracic history who was admitted with mental status changes and nausea several days after being discharged status-post an Eloesser flap closure of a right chest empyema. Cultures on admission were notable for Klebsiella in her urine and Klebsiella and MRSA in her sputum. Blood cultures were all negative while subsequent sputum cultures and culture of drainage fluid from her Right chest revealed continued Klebsiella and MRSA; a subseqenet urine culture after admission was negative. She was started on Zosyn and Vancomycin treatment. Her CT scan of her head was unremarkable. She had a creatinine of 2.7 on her admission which was not remarkable from her prior admission earlier in the month, and she had a dylantin level of 7.9. She was also noted to be hypoxia on admission with desaturation to 80% on maximum nasal canula flow; this improved when she was placed on a non-rebreather face mask. Her mental status improved with improvement in her respiratory status. She underwent a bronchoscopy on [**2121-11-11**] which demonstrated malacia and secretions in her right lower and right middle lobe. On [**2121-11-18**] she underwent exploratory right thoracotomy. This demonstrated an anterior compartment in the apex of her right pleural space that was well-healed and granulating, but a posterior compartment with moderate amount of debris not draining through a pigtail catheter. A Malecot catheter as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain were placed in the posterior compartment after decortication of tissue. She received irrigation of the posterior compartment through the [**Doctor Last Name 406**] drain for several days post-operatively, with drainage coming out of the Malecot drain; the [**Doctor Last Name 406**] drain was eventually removed and irrigation was continued intermittantly through the Malecot drain. Post-operatively the patient had good pain control. She did not pass her initial post-operative swallow studies, however she eventually demonstrated tolerance of thin liquids post-operatively and she was started on a regular diet. Her discharge plan was to continue with IV antibiotic coverage for Klebsiella and MRSA, coumadin for a right IJ clot diagnosed in early [**10-30**], intermittent irrigation of her apical right pleural compartment through her Malecot drain, and a regular diet in small meals. She will be discharged to rehab with planned follow-up with thoracic surgery. On [**11-26**], however, Pt had suddent onset of bleeding and hemoptysis with INR of 4.8. An anesthesia code called, pt intubated, given 3U PRBCs, 2U FFp, and factor VII given. Pt transferred to the CSRU. Bronchoscopy done on [**11-27**] with evidence of clot but no active bleeding in the LUL/LLL. Believed to be caused by erosion of the tube into the PA. Pt transferred to the SICU on [**11-28**]. Supportive care continued, with TF, mechanical ventilation, b-block for arrhythmia. Pt spiking fevers while in SICU, started on Vanc and Zosyn. Pt began to stabilize hemodynamically, however respiratory status continued to be unstable. Sputum cx after bronch on [**12-3**] and [**12-4**] positive for klebsiella pneumonia. Pt started on meropenem and continued on vanc. Pt began improving and after a successful spontaneous breathing trial pt extubated on [**12-10**]. A bedside swallow eval performed on [**12-10**], which the pt failed secondary to frequent coughing. Pt reintubated on [**12-12**] for increasing respiratory distress. A Bronch performed which showed mod mucous plugs and increased secretions. A specimen sent at that time was postivie for coag+ staph aureus. Pt then self-extubated on [**12-14**], but was able to tolerated extubation with aggressive pulmnary toilet. Pt with waxing and [**Doctor Last Name 688**] mentition at this time, attributed to ongoing pulmonary infections and medications. Pt then reintubated due to increased labored breathing on [**12-19**]. Bronch performed on [**12-20**] and [**12-22**] with bronchomalacia, however no stent placed at this time. A trach was placed on [**12-24**] due to hi-frequency pulmonary toilet and frequent intubations. Vanc and meropenem d/c'd on [**12-25**]. CT chest done on [**1-1**] with evidence of increasing mass lesion on two left lateral ribs. A biopsy was performed which showed metastatic disease. Family meeting convened with decision made to send patient home with home mechanical ventilation and comfort measures. Medications on Admission: 1. Oxygen Supply Tube Misc Miscell. 2. Oxygen-Air Delivery Systems Device 3. Albuterol 90 mcg/Actuation Aerosol 4. Levothyroxine Sodium 175 mcg Tablet oral daily 5. Docusate Sodium 100 mg oral [**Hospital1 **] 6. Phenytoin Sodium Extended 200 mg oral [**Hospital1 **] 7. Fluoxetine HCl 20 mg oral daily 8. Warfarin Sodium 2 mg oral QHS 9. Morphine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for for wound dressing changes. 10. Scopolamine Base 1.5 mg Patch every 72 hours for nausea 11. Metoprolol Tartrate 25 mg oral [**Hospital1 **] Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day): ** patient taking own medications **. 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*2* 3. Morphine Sulfate 10 mg/5 mL Solution Sig: One (1) PO every 4-6 hours as needed. Disp:*1 500ml* Refills:*1* 4. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*2* 5. Morphine Sulfate 10 mg/5 mL Solution Sig: Five (5) ml PO every four (4) hours. Disp:*600 ml* Refills:*2* 6. Compazine 5 mg Suppository Sig: One (1) supp Rectal every six (6) hours. Disp:*30 1* Refills:*2* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Phenytoin 100 mg/4 mL Suspension Sig: Eight (8) ml PO Q8H (every 8 hours). Disp:*300 ml* Refills:*2* 9. Fluoxetine HCl 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 10. Insulin Regular Human 100 unit/mL Solution Sig: per scale Injection ASDIR (AS DIRECTED). Disp:*30 100unts* Refills:*2* 11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily): elixir form please. Disp:*qs ML* Refills:*2* 12. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*qs container* Refills:*2* 14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*5* 15. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*5* 16. Regular Insulin Sliding Scale Check fingersticks QID & administer insulin as follows: <70, 4 oz juice; 121-160, 3 units; 161-200, 6 units; 201-240, 9 units; 241-280, 12 units; 281-320, 15 units; >320, contact MD. 17. Laxatives Take colace regularly, as well as dulcolax and/or milk of magnesia to prevent constipation. Discharge Disposition: Home With Service Facility: N. [**Hospital **] MEDICAL Discharge Diagnosis: Metastatic Squamous Cell Adenocarcinoma Broncho-pleural fistula Pulmonary Artery erosion Discharge Condition: Fair Discharge Instructions: Ventilatory care at home per instructions Take medications as directed Followup Instructions: Please contact the office of DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] to set up a followup appointment [**Telephone/Fax (1) 170**]. Completed by:[**2122-1-8**]

Admission Date: [**2120-6-26**] Discharge Date: [**2120-6-29**] Date of Birth: [**2058-11-15**] Sex: F Service: NEUROSURGERY Allergies: Fiorinal / Keflex / Iodine; Iodine Containing / Pollen Extracts Attending:[**First Name3 (LF) 1835**] Chief Complaint: PLANUM SPHENOIDAL MENINGIOMA Major Surgical or Invasive Procedure: [**6-27**]: Lt Craniotomy for Mass Resection History of Present Illness: 61-year-old female who is well-known to Dr. [**Last Name (STitle) **] from previous outpatient visits and outpatient complications. The patient has been followed longitudinally in the brain tumor clinics for a recently-diagnosed skull base lesion. The patient had shown progressive neurological deterioration of her vision, and was, therefore, felt to be a candidate for surgical decompression albeit the degree of compression of the optic nerve from the diagnosed lesion remained unclear. The patient was extensively counseled. The patient was consented. The patient was taken electively to the operating room. Past Medical History: MENINGIOMA, HYSTERECTOMY [**2101**], GLAUCOMA, INSOMNIA, DEPRESSION ASTHMA Social History: non-contributory Family History: non-contributory Physical Exam: On Discharge: AOx3, with a left [**Year (4 digits) **] field deficit, that is unchanged from pre-op. PERRL, EOMS intact. Face symmetric, tongue midline. No pronator drift. Strength is full throughout in upper and lower extremities. Incision is clean, dry, and intact, without erythema, or drainage. Pertinent Results: Labs on Admission: [**2120-6-26**] 01:12PM BLOOD WBC-11.8* RBC-4.04* Hgb-12.2 Hct-35.4* MCV-88 MCH-30.1 MCHC-34.3 RDW-13.7 Plt Ct-334 [**2120-6-26**] 01:12PM BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1 [**2120-6-26**] 01:12PM BLOOD Glucose-179* UreaN-16 Creat-0.9 Na-137 K-3.8 Cl-102 HCO3-24 AnGap-15 [**2120-6-26**] 01:12PM BLOOD Calcium-8.3* Phos-2.3* Mg-2.2 IMAGING: MRI (Head)[**2120-6-27**](post-resection): FINDINGS: A comprehensive evaluation of the brain was not performed with this study, which was targeted for pre-operative planning. There is a homogeneously enhancing extra-axial lesion arising from the left paramedian planum sphenoidale, medial to the pre-chiasmatic segment of the left optic nerve, unchanged since the previous study. It measures 6 mm AP x 5 mm transverse x 3 mm craniocaudad. There is no evidence of optic nerve displacement, although high-resolution imaging of the suprasellar region was not performed. There is an ill-defined subcentimeter enhancing lesion in the left centrum semiovale, unchanged dating back to [**2119-6-20**] (series 5, image 19, and series 4, image 22). Based on its signal characteristics on previous complete head MRIs, it may represent a vascular malformation such as a capillary telangiectasia. IMPRESSION: 1. Small extra-axial mass arising from the left paramedian centrum semiovale is again demonstrated for pre-operative planning. It is most compatible with a meningioma. 2. Unchanged ill-defined contrast-enhancing lesion in the left centrum semiovale, most likely representing a vascular malformation such as a capillary telangiectasia. CT Head [**2120-6-26**]: FINDINGS: In the region of the sella is amorphous hyperdense material (70 [**Doctor Last Name **]) in the expected location of the pituitary gland. The presence of hyperdense material in this region is concerning for pituitary hemorrhage. Additional possibilities include hemorrhage from adjacent vessels into this region or retained Surgicel or other surgical packing material. No other areas concerning for acute hemorrhage are present. Patient is status post left frontal craniotomy with a small volume right and moderate volume left frontal pneumocephalus and possible packing material along the left frontal convexity, causing mild degree of sulcal and gyral effacement. There is no shift of normally-midline structures. Ventricles and sulci appear unchanged in size or configuration compared to pre-operative MRI examination. There are no foci concerning for acute territorial ischemia. Surgical staples are noted along the left frontotemporal scalp with underlying subcutaneous emphysema in the soft tissues, not unexpected post-surgical finding. Osseous structures are otherwise intact. Paranasal sinuses and mastoid and ethmoid air cells are well aerated. IMPRESSION: 1. Hyperdensity in the sella in the region of the pituitary gland, concerning for pituitary hemorrhage. Alternative diagnoses include hemorrhage from adjacent vessels into this region or retained surgical packing material. No other findings concerning for acute hemorrhage are present. 2. Bifrontal pneumocephalus, left greater than right. Left frontal pneumocephalus causes mild sulcal and gyral effacement. There is no shift of midline structures and no herniation. 3. Left frontal craniectomy with overlying subcutaneous gas in the soft tissue. Brief Hospital Course: This patient was admitted to the neurosurgery service electively for a meningiom resection. She had no complications in the OR and went to the ICU post-operatively. The following day the patient had nausea and vomiting as well as a severe headache. Her pain medications were adjusted and she was given antiemetics. Her nausea resolved and her headache improved. The patient was then transferred to the neurosurgical floor on [**6-27**]. Her post-op MRI showed no infarction and the resection appeared to be complete. On [**6-28**] the patient had some drainage from the incision so there were staples added to the wound closure. The patient remained neurologically stable and physical therapy felt that she was safe to be discharged to home. She was discharged with her family on [**2120-6-29**]. Medications on Admission: amytriptyline, ambien, albuterol, latanoprost, desipramine, bupropion Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Amitriptyline 10 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic QPM (once a day (in the evening)). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Desipramine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydromorphone 2 mg Tablet Sig: 1-3 tabs(2-6mg) Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain . Disp:*45 Tablet(s)* Refills:*0* 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Caution not to exceed more than 4gm apap in 24h. 13. Bupropion HCl 75 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 14. Ketoprofen 75 mg Capsule Sig: One (1) Capsule PO twice a day: NOT TO BE USED CONCURRENTLY WITH TORADOL. Disp:*60 Capsule(s)* Refills:*0* 15. Toradol 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours: Max of 40mg per day. NOT TO BE USED CONCURRENTLY WITH KETOPROFEN. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PLANUM SPHENOIDAL MENINGIOMA Discharge Condition: Neurologically stable Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**7-26**] days (from your date of surgery) for removal of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2120-7-22**] 1pm with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain, as this was completed during your acute hospitalization. The following appointments have been arranged for your convenience: Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2120-7-16**] 9:30 Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2120-7-16**] 9:45 Provider: [**Name10 (NameIs) **] FIELD SCREENING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2120-7-16**] 10:00 Completed by:[**2120-7-2**]

Admission Date: [**2164-3-25**] Discharge Date: [**2164-3-28**] Date of Birth: [**2108-3-28**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 55 year old male with a past medical history significant for end-stage renal disease on hemodialysis, Hepatitis C, and Hepatitis B, hypertension, poly-substance abuse found down, on admission here with a finger stick of 68. The patient was unable to provide any history on presentation. The patient was unintelligible and flailing limbs in the Emergency Department. Temperature was 100.2 F., and more than 103.0 F. rectally in the Emergency Department with systolic blood pressure of 200 and with heart rate in the 120s. The patient's labs were notable for a creatinine of 6.2; no urine output when Foley catheter was placed. He had arterial blood gas of 7.51, 44, 74. A lumbar puncture was performed, showing 6 white blood cells with 93% neutrophils and 31 red blood cells; no organisms on Gram Stain. The patient received ceftriaxone 2 grams, Vancomycin 1 gram and a total of 6 mg of Ativan and 5 mg of Haldol, Tylenol and the patient was admitted to [**Hospital Unit Name 153**] secondary to unstable oxygen saturation. PAST MEDICAL HISTORY: Obtained from [**Hospital6 **]. 1. End-stage renal disease on hemodialysis. 2. Chronic anemia, secondary to renal disease. Baseline hematocrit of 28 to 32. 3. Chronic thrombocytopenia, baseline platelets between 70 to 80. 4. Hypertension. 5. Hepatitis B and C. 6. Myocardial infarction at age 21. 7. Peripheral vascular disease. 8. Abdominal aortic aneurysm 3.9 cm measured in [**2163-3-24**]. 9. Status post appendectomy. 10. Cholelithiasis. OUTPATIENT MEDICATIONS: 1. Nephrocaps one capsule p.o. q. day. 2. Pantoprazole 40 mg p.o. q. day. 3. Sevelamer 400 mg p.o. three times a day. 4. Amlodipine 10 mg p.o. q. day. 5. Docusate 100 mg p.o. twice a day. 6. Percocet p.r.n. PHYSICAL EXAMINATION: On admission, temperature 98.4 F.; blood pressure 134/75; heart rate ranging between 91 to 126; respiratory rate 18; O2 saturation 92% on room air. The patient was a confused, cachectic, combative male. Pupils about 3 mm. There is a question of being unreactive. Unable to assess oral cavity. Neck is difficult to examination with a question of stiffness. Lungs clear to auscultation bilaterally. Heart: Regular rate, S1, S2, no murmur. Belly is soft, nontender, nondistended; positive bowel sounds. Has several old scars. Rectal examination is guaiac positive. Extremities have left fistula with thrill and bruit and has a right surgical incision oozing serosanguinous fluid and indurated. Neurologic examination was difficult as the patient was uncooperative, somnolent, but easily aroused, agitated, nonverbal, moving all four extremities. Strength intact; three plus reflexes throughout. No clonus. Toes were downward. LABORATORY: On admission, pertinent labs included white blood cell count 11.1, hematocrit 32.4, platelets 95, MCV of 103. Chem-10 was sodium of 139, potassium 4.7, chloride 92; bicarbonate 25, BUN 11, creatinine 6.2, glucose 100, anion gap of 22, INR of 1.1. CK 107, troponin 0.03. Serum toxicology was negative. The patient had an EKG showing sinus tachycardia at 122; normal axis and intervals. Has left ventricular hypertrophy by voltage, one to two mm ST depression in V4 through V6 and II. No Qs. Chest x-ray was clear but has motion artifacts. MRI of the head on [**3-25**], showing chronic microvascular infarction; no acute infarction. CT scan of the head on [**3-24**], was negative for hemorrhage. His white matter change was consistent with microvascular angiopathy. The patient had an echocardiogram done on [**3-27**] showing there is a mild symmetric left ventricular hypertrophy and overall left ventricular systolic function is normal. Left ventricular ejection fraction greater than 55%. Mild aortic regurgitation and trivial mitral regurgitation. No evidence of endocarditis seen. HOSPITAL COURSE: 1. ALTERED MENTAL STATUS: Differential diagnosis including syncope, seizures, stroke, HSV encephalitis, alcohol withdrawal or illicit drug use. The patient improved back to his baseline after staying in the Intensive Care Unit for two days and then was transferred to the floor. Both CT scan and MRI of the head showing old infarction; no acute hemorrhage or infarction. Given his history of poly-substance abuse, this could be from the drug use, although the serum toxicology was negative. The lumbar puncture was negative for bacterial culture and viral culture and later returned also negative. The patient was originally started on Acyclovir due to suspicion of possible HSV infection, encephalitis and was discharged after viral culture returned to be negative. 2. RULE OUT MYOCARDIAL INFARCTION: The patient has [**Street Address(2) 4793**] depression V4 through V6 and II, but has three sets of stable CK and troponin. The echocardiogram showed normal left ventricular function with only one plus AR and trivial mitral regurgitation; otherwise unremarkable. 3. GUAIAC POSITIVE STOOL: The patient had a hematocrit drop slightly below 25 from a baseline of 28. Was transfused with one unit of packed red blood cells. We recommend outpatient endoscopy and colonoscopy. Given that the patient is a regular [**Hospital6 **] patient, it would be more beneficial for him to go to the [**Hospital6 **] system so the record will stay there. 4. END-STAGE RENAL DISEASE ON HEMODIALYSIS: He has received hemodialysis on Monday and Wednesday during his hospital stay. 5. THROMBOCYTOPENIA OF UNKNOWN CAUSE: This has been a chronic problem for the patient. At discharge, platelet level is 78. 6. ANEMIA: The patient has chronic anemia secondary to end-stage renal disease. Iron studies are consistent with anemia of chronic disease. Has normal folate and B12 levels. Will just continue monitoring and transfuse if less than 25. 7. HYPERTENSION: The patient's blood pressure was on the higher end and only on Amlodipine 10 mg p.o. q. day. Will recommend him to add another [**Doctor Last Name 360**]. His primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 56081**], was notified by his nurse in the [**Location (un) 56082**] Center. The patient had a high blood pressure while in the hospital and recommend monitoring and adding another [**Doctor Last Name 360**] for better control of his blood pressure. DISCHARGE DIAGNOSES: 1. Syncope. 2. End-stage renal disease on hemodialysis. 3. Hypertension. 4. Peripheral vascular disease. 5. Abdominal aortic aneurysm. 6. Poly-substance abuse. 7. Hepatitis B and C. DISCHARGE STATUS: To home. CONDITION AT DISCHARGE: Vitals stable, ambulating, eating. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q. day. 2. Sevelamer 400 mg p.o. three times a day. 3. B complex. 4. Vitamin C. 5. Folic acid 1 mg p.o. q. day. 6. Amlodipine 10 mg p.o. q. day. 7. Docusate 100 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient should call his primary doctor, Dr. [**Last Name (STitle) 56081**], for follow-up within the week. 2. He should also follow-up with hemodialysis center as he is routinely scheduled and the next one is this Friday. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Name8 (MD) 18513**] MEDQUIST36 D: [**2164-3-28**] 16:07 T: [**2164-3-29**] 19:12 JOB#: [**Job Number 56083**]

Admission Date: [**2161-10-12**] Discharge Date: [**2161-10-15**] Date of Birth: [**2077-8-10**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1436**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 33681**] is a 84 year old male with severe aortic stenosis (valve area of 0.9 cm2; LVEF of 50-55%; peak velocity of 2.0 m/s based on TTE on [**2160-6-9**]) and [**Year (4 digits) **] III/IV COPD (FEV1 46% of predicted on [**4-/2160**] PFTs), Coronary artery disease s/p NSTEMI with peaked troponin of 0.23 in [**7-/2159**] and inferior wall motion abnormality in TTE (08/[**2158**]). . He presents to the ED with two day history of shortness of breath. He reports having increased lower extremity swelling, paroxysmal noctural dyspnea, two pillow orthopnea, whitish productive sputum and abdominal distention over past two days. He does not report fever, chills, pleuritic chest pain, palpatations, dizziness, syncope or sick contacts. [**Name (NI) **] reports he has been using his inhaler more frequently yesterday without any help. Of note they were at his son's house for [**Holiday **] dinner. Patient and family do not report any sick contacts or high salt intake. No history of eating outside. . In the ED, initial VS were: 98.2 97 131/61 30 96%. EKG showed sinus rhythm at rate of 90 with prolong AV delay and LBBB which is similar to his previous EKG (01/[**2159**]). No ST-T changes compared to prior. CXR showed pulmonary vascular congestion with cephalization of vessels. Labs significant for normal WBC, creatinine at baseline of 2.3, troponin of 0.07, BNP of 2776, Mg of 1.4 and lactate of 4.0 . He was treated for COPD exacerbation with IV methylprednisolone 125 mg x 1; azithromycin 500 mg IV x 1; albuterol/ipratropium q1 nebs. He also received IV lasix 20 mg x 1 for acute on chronic systolic heart failure though no urine output was noted. CPAP with 4LNC was started to help with respiratory distress from acute on chronic systolic heart failure and COPD exacerbation. He was transferred for further evaluation and management of hypoxemic respiratory distress. His vitals prior to transfer were afebrile 87 127/72 24 99-100% CPAP 4LNC. . On arrival to the MICU, he reports feeling better after CPAP and therapeutic regimen in the ED. Extensive discussion revealed he would not like to be intubated or have cardiac resuscitation which was confirmed with wife and HCP [**Doctor First Name 12239**] at bedside. He is ok with noninvasive positive pressure ventilation mask like CPAP and BPAP. He reports having daily bowel movement. His baseline shortness of breath is with walking to the bathroom which has worsened to any activity over past two days. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. COPD Stage III (FEV1 46% expected [**4-/2160**]) 2. Severe aortic stenosis with valve area of 0.9 cm2 and mitral reguritation (moderate) 3. coronary artery disease: Regional WMA on TTE 4. hypertension 5. hypercholesterolemia 6. chronic kidney disease with h/o uretral stones 7. benign prostatic hyperplasia 8. colonic adenomas ([**2158**]) Social History: - Tobacco: > 60 pack year history of smoking. Quit in [**2152**]. - Alcohol: Significant alcohol use in the past. Rare intake over past several years. Had a glass of wine over [**Holiday **] - Illicits: None Lives with his wife in [**Name (NI) 3494**]. Has 2 kids and 6 grandkids. Originally from [**Country 6257**]. Emigrated in [**2103**]. Used to work in the foundry. He is able to do his of ADLS. His wife does most of his [**Name (NI) 4461**] including bills, shopping, laundry and houswork. Family History: Not relevant at this age. Physical Exam: Admission Physical Exam: Vitals: T:97.9 BP:137-67 P:99 R:26 O2:96%6LNC GENERAL: Elderly gentleman in moderate respiratory distress whose speech is punctuated by brief, forceful inspirations. NECK: No jugular venous distention appreciated though difficult to ascertain with thick neck, CARDIAC: Difficult to hear over audible wheezing but late peaking systolic murmur with absent S2 noted over subxiphoid process. LUNGS: Using accessory muscles. Inspiratory and expiratory wheezes with minimal air movement. Prolonged expiratory phase. ABDOMEN: Soft and nontender. Distended. No hepatosplenomegaly appreciated. No shifting dullness noted. BACK: No concerning lesions, no CVA tenderness. EXTREMITIES: 2+ pedal edema bilaterally. 1+ edema to knee bilaterally. Appropriate temperature to touch at distal extremities. PULSES: 1+ femoral and PD pulses. Regular radial pulse NEURO: Alert and oriented x 3. Did not ascertain muscle strength due to shortness of breath. 98.6 129/77 (119-139) 92% 1L 189.6 --> 189 --> 186lbs I/O: [**Telephone/Fax (1) 106145**] GENERAL: Patient comfortable NECK: No JVP appreciated [**12-17**] neck habitus. CARDIAC: Distant heart sounds. II/VI systolic, late peaking crescendo/decrescendo murmur heard best in L sternal and RUS border. No appreciable radiation. Carotid pulse unremarkable. LUNGS: Inspiratory and expiratory wheezes and rhonchi. Moderate air movement. ABDOMEN: Soft and nontender. Distended. No hepatosplenomegaly appreciated. No shifting dullness noted. EXTREMITIES: 1+ LE edema bilaterally to ankle. Warm lower extremities. PULSES: Regular radial pulses. Distal pedal pulses present to palpation. NEURO: Alert and oriented x 3. Pertinent Results: ADMISSION LABS: [**2161-10-12**] 07:40AM BLOOD WBC-7.7 RBC-3.31* Hgb-8.6* Hct-27.1* MCV-82 MCH-26.0* MCHC-31.7 RDW-14.7 Plt Ct-160 [**2161-10-12**] 07:40AM BLOOD Neuts-77.0* Lymphs-14.4* Monos-5.6 Eos-2.6 Baso-0.4 [**2161-10-12**] 07:40AM BLOOD Glucose-126* UreaN-43* Creat-2.3* Na-134 K-4.2 Cl-95* HCO3-27 AnGap-16 [**2161-10-12**] 07:40AM BLOOD ALT-27 AST-27 LD(LDH)-288* CK(CPK)-772* AlkPhos-89 TotBili-0.2 [**2161-10-12**] 07:40AM BLOOD CK-MB-19* MB Indx-2.5 proBNP-2776* [**2161-10-12**] 07:40AM BLOOD cTropnT-0.07* [**2161-10-12**] 07:40AM BLOOD Albumin-4.2 Calcium-8.7 Phos-4.1 Mg-1.4* [**2161-10-13**] 04:17AM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-62* pCO2-50* pH-7.39 calTCO2-31* Base XS-3 [**2161-10-12**] 07:48AM BLOOD Lactate-4.0* PERTINENT INTERVAL LABS: [**2161-10-14**] 07:30AM BLOOD Glucose-88 UreaN-76* Creat-3.0* Na-138 K-3.7 Cl-93* HCO3-36* AnGap-13 [**2161-10-14**] 07:30AM BLOOD LD(LDH)-238 CK(CPK)-511* [**2161-10-12**] 07:40AM BLOOD cTropnT-0.07* [**2161-10-12**] 08:04PM BLOOD CK-MB-14* MB Indx-1.9 cTropnT-0.05* [**2161-10-13**] 02:59PM BLOOD CK-MB-9 cTropnT-0.08* [**2161-10-14**] 07:30AM BLOOD CK-MB-7 cTropnT-0.11* [**2161-10-13**] 04:17AM BLOOD Lactate-1.0 [**2161-10-14**] 07:30AM BLOOD Ret Aut-1.9 [**2161-10-14**] 07:30AM BLOOD LD(LDH)-238 CK(CPK)-511* [**2161-10-14**] 07:30AM BLOOD calTIBC-371 Hapto-292* Ferritn-14* TRF-285 [**2161-10-14**] 07:30AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.2 Iron-23* DISCHARGE LABS: [**2161-10-15**] 07:35AM BLOOD WBC-7.7 RBC-3.27* Hgb-8.5* Hct-27.1* MCV-83 MCH-26.0* MCHC-31.4 RDW-15.2 Plt Ct-182 [**2161-10-15**] 07:35AM BLOOD Glucose-86 UreaN-85* Creat-3.0* Na-141 K-4.1 Cl-98 HCO3-34* AnGap-13 [**2161-10-15**] 07:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1 URINE [**2161-10-12**] 02:22PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2161-10-12**] 02:22PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG MICRO: Blood Cultures ([**2161-10-12**]) x2: NGTD Urine Culture ([**10-12**]): No growth MRSA screen: negative STUDIES: ECG ([**10-12**]): Moderate baseline artifact. Because of the baseline artifact, it is difficult to identify atrial activity. The rhythm is regular at a rate of 98 beats per minute. Probably normal sinus rhythm. Complete left bundle-branch block. Possible prolonged A-V conduction. Compared to the previous tracing of [**2159-8-8**] no diagnostic interval change. CXR Portable ([**10-12**]): FINDINGS: There is a focal area of hazy opacity in the left lower lobe with loss of the left cardiac margin. This finding appears unchanged when compared to prior radiographs on NCT. There is prominent bronchopulmonary vascular markings with possible interstitial edema in the peripheral interlobular septa. There is no pleural effusion or pneumothorax. The imaged osseous structures are intact. There is no free air below the right hemidiaphragm. IMPRESSION: Mild pulmonary vascular congestion and interstitial edema compatible with CHF. ECHO ([**10-13**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal to mid inferolateral hypokinesis. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened with mild to moderate aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2160-6-9**], the left ventricular wall motion abnormality is new and there is now associated prominent mitral regurgitation that is likely ischemic (post-infarction). CXR ([**10-14**]): FINDINGS: PA and lateral views of the chest. Mild cardiomegaly, compared with [**2157**], the heart size has increased and the left atrium and left ventricle are more prominent. Previously seen mild interstitial pulmonary edema has decreased compared with [**2161-10-12**]. Aortic valve calcifications. No pleural effusion. No pneumothorax. No infiltration. The mediastinal and hilar contours are normal. IMPRESSION: 1. Decrease in pulmonary edema compared with [**2161-10-12**]. No infiltrate. 2. Mild cardiomegaly, compared with [**2157**], the heart size has increased and the left atrium and left ventricle are more prominent. Brief Hospital Course: ======================= BRIEF HOSPITAL SUMMARY ======================= Mr. [**Known lastname 33681**] is a 84 year old male with severe aortic stenosis, COPD, CAD s/p NSTEMI in [**2158**] p/w shortness of breath, most likely from COPD exacerbation. ======================= ACTIVE ISSUES ======================= # COPD excacerbation: Pt was treated with levalbuterol and ipratropium nebs, azithromycin x 5 days and prednisone 40mg daily x 5 days. He has 2 days remaining at time of discharge. Lung symptoms improved. He was still wheezing at discharge, but per patient and family, he was improved compared to his baseline. Pt was sent home on ambulatory O2 of 1L when ambulating. # Shortness of breath/acute on chronic systolic CHF: The patient's shortness of breath most likely due to COPD exacerbation. He also had a smaller component of pulmonary edema from acute on chronic systolic heart failure. He was initialy admitted to the MICU where the patient was intially started on diueresis with Lasix bolus of 40 mg IV, but was soon started on a Lasix drip with goal net negative output of 2 liter. He was also given prednisone 40mg daily and azithromycin along with levalbuterol and ipratropium nebs for COPD. The patient's O2 requirement improved with his diueresis and upon transfer to the floor, he was breathing comfortably on nasal cannula. While being diuresed, [**Hospital1 **] lytes were checked and repleted. His rate control was also increased, as metoprolol was started at 25 mg q8, with target heart rate in the 80s to ensure adequate time for diastolic filling. This was then stopped as it seemed to exacerbate his underlying lung disease. # Severe aortic stenosis and diastolic dysfunction/CAD: Pt declines any invasive procedures or surgical interventions. Troponin were elevated, appropriate for his renal failure. MB was flat. His echo showed some inferolateral hypokinesis which likely reflects a prior MI within the last year ([**2159**] echo negative). Pt does not want any cardiac catheterization procedures. Continued on ASA 81. Pt declines to take his statin. Stopped his metoprolol on this admission since it seemed to exacerbate his COPD symptoms. # Lactic acidosis: Lactate initialy 4.0, improved to 1.0. Likely due to acute low perfusion state from acute on chronic systolic heart failure and severe aortic stenosis. Acute Renal Failure/ CKD: Baseline Cr 2.2-2.5. While in MICu, he was started n lasix drip for pulmonary congestion. His symptoms improved and lasix drip was stopped. While on drip, Cr increased, bicarb increased, K decreased, suggesting over-diuresis. Lasix was stoped and Cr stabalized at 3.0. He has renal follow up. # HTN: Stopped his home HCTZ on this admission since BP stable on current medications. Also stopped his metoprolol since seemed to exacerbate his COPD. Continued his amlodipine 10mg daily. Lasix was held and may be resumed when Cr improves to baseline. #Anemia: Pt found to have anemia that is likely combination of Fe def anemia and from CKD. [**Name (NI) **] pt start ferrous sulfate [**Hospital1 **] and will fu with nephrologist to discuss if he would benefit from Epo supplementation. Workup for iron deficiency can be considered outpatient, although pt and family do not want any invasive procedures. ========================== INACTIVE ISSUES ========================== 7. HLD: Atoravastatin discontinued during last admission. Appropriate considering age and comorbidity with risk/benefit. Pt does not wish take his statin. 8. BPH: Continued tamsulosin 0.4 mg po qhs ============================= TRANSITIONAL ISSUES ============================= 1. Fe Deficiency anemia: can discuss with pt whether or not to work this up. Started Ferrous Sulfate 2. Acute Renal Failure: [**Hospital1 **] checking Cr on post-discharge visit to see if it trends down. Pt's ARF likely from over-diuresis. 3. MEDICATION CHANGES: STOP: Metoprolol, this is likely making your wheezing and lung COPD worse. STOP: Hydrochlorothiazide, your blood pressures do well without this medication. Your primary care doctor can consider restarting this medication outpatient. STOP: stop Lasix for now. You have no fluid in your lungs and you do not need this at this time. However, your primary care doctor may wish to resume this medication when your kidney function returns to normal. START: Iron supplentation: you have anemia from low iron and we recommend you take iron supplements START: Azithromycin- this is an antibiotic for your reason lung infection. You will take this for 2 more days. START: Prednisone 40mg daily. This is for your emphysema flair. You will take this for 2 more days. START: LevAbluterol nebulizer. You can take this instead of your albuterol inhaler since it is easier to take and allows more of the medicine to go to your lungs. You can take the ipratropium nebulizer instead of your atrovent inhaler and instead of the combivent inhaler. Medications on Admission: Albuterol sulfate 90 mcg HFA Aerosol inhaler [**11-16**] puff q4-6 Amlodipine 10 mg po qdaily Lasix 20 mg po prn edema (patient reports not taking any) HCTZ 25 mg po qdaily Atrovent HFA 17 mcg/actuation HFA Aersol 2 puffs q6 Combivent 18 mcg-103 mcg (90 mcg) 2pff QID Latanoprost 0.005% drops 1 drop both eyes at bedtime Metoprolol 50 mg ER po qdaily Omeprazole 40 mg po qdaily Tamsulosin 0.4 mg ER po qhs Aspirin 81 mg po qdaily Fish oil-DHA-EPA 1,200 mg-144 mg-216 mg Capsule po BID Discharge Medications: 1. Home oxygen Sig: One (1) When Ambulating only: 1-2 L when ambulating only. Ambulatory O2 RA=85%. Ambulatory O2 with 1L NC: 89%. Dx: COPD. Disp:*1 1* Refills:*0* 2. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. Disp:*300 ml* Refills:*3* 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. nebulizer & compressor Device Sig: One (1) Miscellaneous every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 u* Refills:*0* 5. nebulizer accessories Kit Sig: One (1) Miscellaneous every four (4) hours as needed for nausea. Disp:*1 unit* Refills:*0* 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*300 ml* Refills:*2* 7. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation four times a day. 9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 15. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 16. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: primary diagnoses: COPD exacerbation Acute on chronic heart diastolic failure secondary to aortic stenosis Acute Kidney Injury Iron Deficiency Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 33681**], It was a pleasure taking care of you. You were admitted to the hospital for shortness of breath. We treated you for both an exacerbation of COPD and also for an acute on chronic episode of heart failure. While in the hospital, you had an echocardiogram. We diuresed you (removed fluid) and gave you nebulized breathing treatments and azithromycin; and your breathing improved significantly. You should weigh yourself every day, and call your doctor if you gain more than 2 pounds in one day. Your kidney function is a little worse then usual but is stable these last 2 days of your hospitalization. We anticipate that it will improve over the next few days now that you are no longer on the lasix medication. Please make sure to follow with your primary care doctor who will check your kidney function. We scheduled an appointment for you to see a kidney doctor in the next 2 weeks. You should continue taking all of your medications as you had prior to your hospitalization, except: STOP: Metoprolol, this is likely making your wheezing and lung COPD worse. STOP: Hydrochlorothiazide, your blood pressures do well without this medication. Your primary care doctor can consider restarting this medication outpatient. STOP: Lasix for now. You have no fluid in your lungs and you do not need this at this time. However, your primary care doctor may wish to resume this medication when your kidney function returns to normal. START: Iron supplentation: you have anemia from low iron and we recommend you take iron supplements START: Azithromycin- this is an antibiotic for your reason lung infection. You will take this for 2 more days. START: Prednisone 40mg daily. This is for your emphysema flair. You will take this for 2 more days. START: LevAbluterol nebulizer. You can take this instead of your albuterol inhaler since it is easier to take and allows more of the medicine to go to your lungs. You can take the ipratropium nebulizer instead of your atrovent inhaler and instead of the combivent inhaler. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2161-10-20**] at 8:40 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC/NEPRHOLOGY When: TUESDAY [**2161-10-27**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [**2161-10-29**] at 1:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2161-10-29**] at 2:00 PM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *This appointment is with a specialist who will focus directly on COPD management as you transition from the hospital to home. After this visit, you will be scheduled with Dr. [**Last Name (STitle) **] or with a new pulmonologist who will follow you. Department: CARDIAC SERVICES When: MONDAY [**2161-11-23**] at 9:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Unit No: [**Numeric Identifier 73747**] Admission Date: [**2124-7-25**] Discharge Date: [**2124-8-8**] Date of Birth: [**2124-7-25**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] is the 2.385 kg product of a 34 week gestation, born to a 34 year-old, G4, P2 now 3 mother. Prenatal screens: 0 positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, Rubella immune, GBS unknown. Maternal OB history of 2 term deliveries. No recorded maternal conditions or medications. This pregnancy was uncomplicated until she presented on day of delivery with spontaneous preterm delivery. No maternal fever. Rupture of membranes at delivery with clear fluid. Maternal anesthesia by combined spinal epidural. Infant delivered by repeat Cesarean section. Apgars were 8 and 8. PHYSICAL EXAMINATION: Discharge physical revealed pink, anterior fontanel, open and flat. Breath sounds clear and equal. Easy work of breathing. No murmur. Abdomen soft, nondistended, positive bowel sounds, active, appropriate for gestational age, tone. HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Doctor Last Name **] was admitted to the NICU requiring nasal cannula oxygen, maintained 02 saturations. Chest x-ray at that time was respiratory distress syndrome versus TTN. Infant remained on nasal cannula 02 until day of life 5 at which time he transitioned to room air. He has been stable in room air since that time. He has no history of apnea and bradycardia. Cardiovascular: He has been cardiovascularly stable without a murmur. Heart rates have been 120s to 150s. Fluids, electrolytes and nutrition: Birth weight was 2.385 kg. Length was 44.5 cm and head circumference was 33.5 cm. Discharge weight is 2390g. Infant was initially started on 60 cc/kg per day of D-10-W. Enteral feedings were initiated on day of life 3. Full enteral feedings were achieved by day of life 7. The infant is currently ad lib feeding breast milk 24 calorie or Similac 24 calorie to maintain weight gain. Gastrointestinal: Peak bilirubin was on day of life 4 of 12.1 over 0.4. He was treated with phototherapy and issue has resolved. Hematology: Hematocrit on admission was 45.4. He has not required any blood transfusions. Infectious disease: CBC and blood culture obtained on admission. CBC was benign and blood cultures remained negative at 48 hours at which time ampicillin and gentamycin were discontinued. Neurologic: The infant has been appropriate for gestational age. Sensory: Hearing screen was performed with automated auditory brain stem responses and infant passed both ears. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 37193**] [**Last Name (NamePattern1) 42940**], [**Hospital1 2025**]-[**Location (un) **], telephone number [**Telephone/Fax (1) 43818**]. CARE RECOMMENDATIONS: Continue breast milk 24 calorie or Similar 24 calorie. MEDICATIONS: Ferrous sulfate supplementation Multi-vitamins 1 ml p.o. daily. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u. (may be provided as a multi-vitamin preparation) daily until 12 months corrected age. Car seat position screening was performed and the infant . State newborn screen was sent on [**2124-8-6**]. Infant received hepatitis B vaccine on [**2124-8-6**]. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following four 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 or (4) hemodynamically significant congenital heart 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. This infant has not received ROTA virus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. DISCHARGE DIAGNOSES: 1. Premature infant born at 34 weeks. 2. Respiratory distress syndrome. 3. Rule out sepsis with antibiotics. 4. Hyperbilirubinemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2124-8-8**] 01:15:56 T: [**2124-8-8**] 04:29:03 Job#: [**Job Number 73748**]

Admission Date: [**2146-2-7**] Discharge Date: [**2146-2-24**] Date of Birth: [**2078-3-18**] Sex: M Service: MEDICINE Allergies: Amitriptyline / Norvasc Attending:[**First Name3 (LF) 613**] Chief Complaint: lethargy x 4-5 days Major Surgical or Invasive Procedure: - Intubation [**2146-2-17**] - Extubation [**2146-2-18**] - PICC placement [**2146-2-18**] - PICC removal [**2146-2-21**] History of Present Illness: 67 y/oM with PMH CAD, afib, DM, spinal cord atrophy who presented to the ED with lethargy x 4-5 days and was found to be hypoxic with presumed multifocal PNA and afib in RVR. For the past 4-5 days, patient has been complaining of fatigue with decreased PO intake. Also developed wet cough productive of clear sputum. On the day prior to admission, his caregiver found him unable to get off the commode and tilting to the left. Today, he was too tired to get out of bed so his partner [**Name (NI) 4662**] him to the [**Name (NI) **]. In the ED, initial VS: 13 98.8 104 139/98 32 86% 4L NC. He triggered for hypoxia and was placed on 100%NRB with sats rising to 100%. CXR revealed multiple patchy opacities in left lung, blood and urine cultures were drawn and patient was given dose of vancomycin/ levofloxacin. Neurology was consulted given trunchal ataxia on exam and did not feel that presentation was consistant with an acute intracranial event, recommending treating underlying illness. ED course c/b development of afib with RVR with HR in the 160-180s. Despite 50mg total of diltiazem IV, HR did not improve significantly. Given hemodynamic instability, patient admitted to the ICU for further monitoring. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: # CAD s/p PCI x 2 with a history of MI and angioplasty 12 years ago. His most recent cardiac catheterization was in [**Month (only) 216**] of [**2140**] at [**Hospital6 1708**] which revealed non-flow limiting three-vessel disease and no intervention was performed at that time # Atrial flutter/atrial tachycardia status post ablation in [**2140-9-5**] with breakthrough atrial tachycardia and atrial flutter # Type 2 diabetes on insulin-followed by Dr.[**Doctor Last Name 4849**]- [**2145-4-20**] visit A1C 7.5 # PVD followed by Dr. [**First Name (STitle) **] # Colon Ca -- s/p partial colectomy [**2125**], no radiation or chemotherapy # Neuropathy -- progressing to R arm now; legs unchanged, uses wheelchair # Spinal stenosis -- MRI performed [**5-/2141**], no emergent issues, but some retrolisthesis of L4-5, status post laminectomy at L4-L5. # Alcohol abuse # History of mechanical falls. Social History: - Retired and lives at [**Hospital1 1426**]/[**Location (un) **] with friend/partner [**Name (NI) 61893**] [**Name (NI) **] ([**Telephone/Fax (1) 61891**]). - He is disabled and wheelchair bound. - Reports consuming 1-2 drinks/day for years. Denies problems with alcohol, but concern for abuse per previous notes. No h/o withdrawal, DTs or seizure. - Smokes 1 [**2-6**] PPD for 60 pack-year smoking history. - Reports remote marijuana. Family History: No history of premature cardiac disease. Physical Exam: Physical Exam Vitals: T: 96.5 BP: 78/61 P: 135 R: 23 O2: 95% on 100% NRB General: cachextic elderly male; drowsy, oriented HEENT: Sclera anicteric, dry oral mucosa, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardia, irregular Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: 2+ pulses, no clubbing, cyanosis or edema Neuro: difficult to assess given mental status, moving all extremities. Decreased sensation in LE b/l Physical Exam on Discharge: VS: HR 80, RR 20, 92% on 2L General: well-appearing, NAD, comfortable HEENT: sclera anicteric, pale conjunctivae, mucous membrane dry Neck: supple Lung: CTAB in anteriorly but crackles posteriorly up to mid-lung field CV: irregularly irreguar, non-tachycardic, no m/r/g Abd: soft, NT, ND, no guarding, BS present Extremities: no cyanosis or edema, 2+ dorsalis pedis pulses bilaterally GU: mild edematous only on posterior aspect of distal shaft and non-erythematous foreskin, glans appear well-perfused and non-cyanotic, minimal pain with palpation, no catheter, no rash Neuro: awake, alert and oriented to place ([**Hospital1 18**]), time ([**2146-2-24**]), person (president [**Last Name (un) 2753**]) Skin: small 1x1cm ulcer on the left buttock, clean without drainage or erythema around Pertinent Results: Admission Labs [**2146-2-7**] 04:00PM BLOOD WBC-5.3# RBC-4.61# Hgb-14.9# Hct-43.3# MCV-94 MCH-32.2* MCHC-34.3 RDW-13.1 Plt Ct-324 [**2146-2-7**] 04:00PM BLOOD Neuts-62 Bands-5 Lymphs-22 Monos-5 Eos-0 Baso-0 Atyps-4* Metas-2* Myelos-0 [**2146-2-7**] 04:00PM BLOOD PT-12.0 PTT-24.0 INR(PT)-1.0 [**2146-2-7**] 04:00PM BLOOD Glucose-272* UreaN-21* Creat-0.8 Na-130* K-4.4 Cl-95* HCO3-22 AnGap-17 [**2146-2-7**] 04:00PM BLOOD ALT-6 AST-11 CK(CPK)-22* AlkPhos-88 TotBili-0.8 . Pertinent Labs [**2146-2-7**] 04:00PM BLOOD CK-MB-2 [**2146-2-7**] 04:00PM BLOOD cTropnT-<0.01 [**2146-2-8**] 03:43AM BLOOD cTropnT-<0.01 [**2146-2-9**] 12:02AM BLOOD TSH-1.1 [**2146-2-7**] 04:00PM BLOOD Cortsol-55.9* [**2146-2-8**] 03:43AM BLOOD Cortsol-19.5 [**2146-2-7**] 04:00PM BLOOD Digoxin-0.7* [**2146-2-7**] 06:17PM BLOOD Lactate-1.7 . [**2146-2-7**] 04:30PM URINE RBC-0-2 WBC-0 Bacteri-OCC Yeast-NONE Epi-0-2 [**2146-2-7**] 04:30PM URINE Blood-SM Nitrite-NEG Protein-75 Glucose-250 Ketone-15 Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG [**2146-2-7**] 04:54PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Microbiology [**2146-2-7**] Urine culture: negative [**2146-2-7**] Blood culture x2: negative [**2146-2-7**] MRSA screen: negative [**2146-2-7**] Urine legionella antigen: negative [**2146-2-8**] Influenza A and B antigens: negative [**2146-2-9**] Sputum culture: contaminated. Legionella culture negative [**2146-2-17**] Sputum culture: >25 PMNs and <10 epithelial cells/100X field. No microorganisms seen. Commensal flora absent. 2 morphologies of yeast. Imagings CXR ([**2146-2-7**]): Markedly limited study. There is suggestion of a dense consolidation of the left lower and mid lung zones. This may represent pneumonia. If clinically feasible, consider PA and lateral views in the radiology suite for better characterization. CT Head ([**2146-2-7**]): 1. Prominent ventricles, non-[**Last Name (LF) 61910**], [**First Name3 (LF) **] represent normal pressure hydrocephalus in the appropriate clinical setting. Clinical correlation recommended. 2. No other acute intracranial process identified. TTE ([**2146-2-9**]): Mild symmetric LVH with normal regional and global biventricular systolic function. Moderate tricuspid regurgitation. Mild pulmonary artery systolic hypertension. CXR ([**2146-2-10**]): Worsening right upper lobe and left mid and lower lung opacities, consistent with worsening pneumonia. CXR ([**2146-2-18**]): As compared to the previous radiograph, there is minimal improvement of the pre-existing mainly perihilar and left lateral parenchymal opacities. The extent of the retrocardiac atelectasis, potentially combined with a small pleural effusion, is unchanged. On the right, the parenchymal opacities have apparently decreased in extent. No evidence of newly appeared parenchymal opacities. Unchanged size of the cardiac silhouette. Unchanged position of the endotracheal tube and the nasogastric tube. Brief Hospital Course: 67 year old male with coronary artery disease s/p PCI, atrial tachycardia s/p failed ablation, diabetes mellitus type II complicated by neuropathy leading to spinal cord atrophy who presented to the ED with lethargy x 4-5 days and was found to be hypoxic with presumed multifocal PNA and atrial fibrillation/tachycardia with RVR. # Hypotension, resolved: BP on arrival to ICU was 70/50 in the setting of likely multifocal pneumonia seen on CXR and volume depletion in the setting of poor oral intake. Bedside echo showing hyperdynamic ventricles and respiratory variation in IVC filling pressures on admission consitent with hypovolemia. He was aggressively fluid resuscitated by early goal directed protocol with MAP > 65. He was started on Levaquin for community acquired pneumonia and cefepime for Gram negative coverage in setting of chronic aspiration. He was ruled out for ACS with three sets of enzymes. Random and am cortisol showed appropriate adrenal function. His hypotension resolved with fluid resuscitation and never needed pressors. He was normotensive off medications. # Hypoxia, resolved: Persistent hypoxia to mid-80s on RA in the ED, likely [**3-9**] underlying multifocal PNA which is visualized on CXR. Hx of recurrent PNA suggestive of repeat aspiration events. Alternatively, patient with risk factors, peripheral neuropathy and multiple bacterial infections is also at risk of HIV which was sent. He was started on levaquin for CAP and cefepime for gram negative coverage in setting of chronic aspiration. Pt improved and was called out to the floor on [**2-9**]. On the floor he maintained his blood pressure and heart rate but required continued oxygen with saturations in the low to mid 90's on 3L NC. On [**2-10**], he triggered for mental status changes with orientation to self. He had significant rhonchi on exam at that time and respiratory was called; deep suction removed large amounts of mucous which were sent for culture. Later that evening, the patient was noted to have worsnening oxygen requirement with 93% oxygen on 5 liters and 97% on a nonrebreather. Deep suction was attempted but the patient had desaturation in this context. Received zydis 2.5 mg for agitation and paranoia. ABG 7.48/25/71. Transferred back to MICU for respiratory evaluation. On [**2-11**], he continued to require deep suctioning for large amount of secretions. He continued to get chest physical therapy with deep suctioning for large amount of secretions on [**2-12**] as well. On [**2146-2-16**], he was noted to have increased requirement in his venti mask from 50% to 100% with whiteout of left lung bases concerning for mucous plug. He was intubated for respiratory distress on [**2146-2-17**]. He was extubated on [**2146-2-18**] when goals of care were changed to comfort measures only (see below). Since then, he has been on minimal oxygen and morphine intermittently for comfort and maintaining O2 saturation in mid 90% on RA. # Leukocytosis: His WBC increased on [**2-11**] and continued to rise on [**2-12**]. He was started on vancomycin/flagyl while levaquin and cefepime were continued as he was clinically getting worse. IV Vancomycin/flagyl/levaquin and cefepime were discontinued on [**2146-2-19**] when he was made CMO # Delirium. Resolving. He was noted to be agitated and paranoid while being transferred back to the MICU. Likely secondary to hypoxia, improved with deep suctioning and respirator stabilization. His agitation has been managed by olanzepine rapid disintegrating tab. He has not had episodes of agitation since being on olanzepine. Upon discharge, he is oriented to person, place, and time. # Atrial fibrillation with RVR: on initial arrival to ICU, HR in 150-160s and irregular. Underlying process of pneumonia is likely the driving force for it. Patient was on anticoagulation alone with aspirin and plavix given history of multiple falls. He was started on amiodarone and over the next few days was weaned off metoprolol and digoxin. TTE was performed which showed LVH and no clots. Amiodarone IV changed to PO on [**2-9**], and then changed to home metoprolol. He remained stable in AFib without RVR. He was noted to have RVR on [**2-11**] and was restarted on amiodarone while metoprolol was discontinued. On [**2-12**], he continued to be in RVR with rates in 120s so metoprolol was added for rate control with amiodarone. However, because he was made CMO, his AFib medications were discontinued. His HR has been mostly < 100 per minute off of medications. # Truncal ataxia: per ED evaluation, patient persistently leaning towards left. CT head was negative. Per neurology, there was no acute process. # H/o CAD: He denied angina. EKG was without acute ST changes. Cardiac enzymes were negative x 3. Initially, he was continued on aspirin, Plavix, and metoprolol as mentioned above. However, after he was made CMO, these medications were held. # H/o ETOH abuse. There was no h/o withdrawal seizures. He did not have evidence of active withdrawal while in the hospital. # Type II DM: No evidence of DKA by labs. Patient was managed by insulin sliding scale. However, with CMO status, finger stick and insulin administration were held. # Malnutrition: Albumin of 2.1. Per speech and swallow, NPO with crushed meds in apple sauce with concern for chronic aspiration and will need to be reevaluted once off of face mask for oxygen. NG tube placed on [**2146-2-9**] and tube feeds started with nutritions help. Tube feeds held on [**2-10**] in the setting of desaturation and copious secretions, due to concern for aspiration. Restarted [**2-11**] as it seemed that secretions were mucous and not gastric contents. However, with CMO status, patient resumed regular diet per his preference and nutritional supplement was added. # Left buttock ulcer. 1 cm x 1 cm. Area does not appear to be infected. This should continue to be monitored with regular repositioning every 2 hours and daily wound care. # Comfort measures only: On [**2146-2-19**] after extensive discussion with his health care proxy, it was decided to make the patient comfort measures only and was extubated on [**2146-2-19**]. Antibiotics were discontinued. He was transitioned to narcotics as needed for shortness of breath and pain. He was discharged on oral morphine solution as his Foley catheter and PICC were removed on [**2146-2-20**] and [**2146-2-21**] respectively. He will be followed by hospice. It will be important to continue the discussion of Do Not Hospitalize with patient and his health care proxy. Medications on Admission: levothyroxine 25 mcg daily amlodipine 5 mg daily metoprolol succinate 50 mg daily bupropion 150 mg daily lisinopril 10 mg daily ipratropium-albuterol (duoneb) [**Hospital1 **] allopurinol 100 mg [**Hospital1 **] advair 250-50 q12h tylenol 1000 mg [**Hospital1 **] simethicone 1 tablet [**Hospital1 **] gabapentin 300 mg TID ASA 81 mg daily fluticason 2 sprays each nostril daily artificial tears at bedtime docusate 200 mg qhs miralax 17 g qhs prn senna 2 tabs qhs Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*30 neb* Refills:*0* 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 3. bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(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. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*30 neb* Refills:*0* 6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. Disp:*30 packet* Refills:*0* 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 9. morphine 10 mg/5 mL Solution Sig: Five (5) mL PO Q1-2 hour as needed for pain or shortness of breath. Disp:*1000 mL* Refills:*2* 10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 3 weeks: Continue for another two weeks before tapering to 14 mg/24 hour patch. Disp:*21 Patch 24 hr(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Primary diagnoses: - Multifocal pneumonia - Atrial fibrillation with rapid ventricular rate Secondary diagnoses: - Delirium - spinal atrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 6955**], It was a pleasure to take care of you at [**Hospital1 827**]. You were admitted to the hospital for pneumonia and fast irregular heart rate. You were treated with antibiotics for the pneumonia as well as medications to help controlling your heart. Because of your worsening breathing, you were on a ventilator (a machine that help to breath for you) for a short period of time. After a discussion between your health care proxy and your intensive care team, it was decided that you would prefer to live with dignity and would prefer not to have invasive procedures done such as a PEG tube (feeding tube) or a tracheostomy (more permanent breathing tube). You did very well after they remove the ventilator and required minimal oxygen. The medical team discussed with you about hospice. You and your health care proxy both decided that you want to ultimately be home with hospice. Hospice nurse and social workers came and explored with you regarding your options and necessary support that you may need. While resources at home get set up, it is thought that you can go to inpatient hospice for a period of time. Please note the following changes in your medications: - Please START Tylenol 325 mg tab, 1-2 tabs, every 6 hours as needed for pain or fever - Please START albuterol nebulizer, 1 neb, every 4-6 hours as needed for shortness of breath or wheeze - Please START bisacodyl 10 mg, 1 tab, by mouth, once a day as needed for constipation - Please START docusate 100 mg, 1 tab, by mouth, twice a day to soften your stool - Please START ipratropium neb, 1 neb, every 4-6 hours as needed for shortness of breath or wheeze - Please START Miralax, 1 packet, by mouth, once a day as needed for constipation - Please START morphine 10mg/5mL, 5mL, by mouth, every 1-2 hours as needed for pain or shortness of breath. - Please START olanzapine zydus 5 mg, 1 tab, by mouth, once a day in the evening. - Please START senna, 1 tab, by mouth, once a day as needed for constipation - Please DISCONTINUE mirtazipine 30 mg at night prior to bed time - Please DISCONTINUE Flomax 0.4 mg once a day - Please DISCONTINUE Plavix 75 mg once a day - Please DISCONTINUE calcium carbonate with vitamin D 600 mg-400 units - Please DISCONTINUE Humulin 70/30 insulin - Please DISCONTINUE Aspirin 325 mg once a day - Please DISCONTINUE digoxin 125 mcg once a day - Please DISCONTINUE Megace 20 mL once a day - Please DISCONTINUE metoprolol 75 mg three times a day - Please DISCONTINUE macrodantin 100 mg twice a day - Please DISCONTINUE flunase 50 mcg 2 sprays twice a day - Please DISCONTINUE gabapentin 300 mg 4 times a day - Please DISCONTINUE multivitamin once a day - Please DISCONTINUE folic acid once a day Followup Instructions: Please call your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] at [**Telephone/Fax (1) 133**] to set up an appointment for follow-up of the recent hospitalization. You can also reach your hospice nurse by calling [**Telephone/Fax (1) 61911**]. You can also call your hospice social work by calling [**Hospital 3005**] Hospice [**Telephone/Fax (1) 61912**] or Toll Free [**Telephone/Fax (1) 61913**]. Their fax number is [**0-0-**]. Their website is [**URL 61914**] Department: CARDIAC SERVICES When: WEDNESDAY [**2146-3-23**] at 2:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: THURSDAY [**2146-4-28**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19249**], MD [**Telephone/Fax (1) 44**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2146-2-24**]

Admission Date: [**2186-7-18**] Discharge Date: [**2186-7-24**] Date of Birth: [**2121-5-30**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 165**] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: [**2186-7-20**] Urgent off-pump coronary artery bypass graft x1, left internal mammary artery to left anterior descending artery. History of Present Illness: 65 year old female with left breast lumpectomy and left axillary lymphnode dissection followed by radiation and chemo for cancer. Family history of heart disease who presented to [**Hospital3 110856**] Emergency Department with chest pain on exertion for 1 month,retrosternal with radiation to her jaw, neck, and left shoulder, associated with shortness of breath. Positive Troponin. She was cathed and Plavix loaded. Cardiac cath revealed 99% proximal LAD dz. She was transferred to [**Hospital1 18**] for cardiac surgery evaluation for coronary revascularization. Past Medical History: Coronary Artery Disease left Breast Cancer s/p chemo and radiation Past Surgical History Left breast lumpectomy and left axillary lymphnode dissection Right rotator cuff Surgery Social History: Lives with: 3 women from her church- 2 are in their 30's and are supportive. Daughter lives in [**Country **]. Patient cares for her 6 year old grand daughter Contact: Phone # Occupation: Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [x] [**3-7**] drinks/week [] >8 drinks/week [] Illicit drug use Family History: Grandfather died 54yo "heart problems" Physical Exam: Pulse: 79 Resp: 18 O2 sat: 99%RA B/P Right:120/73 Left: Height: 5' 4" Weight:147 pounds Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x-occasional left sided pain w/ diverticular flare] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [] none____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left:+2 DP Right: +2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right:cath site Left:+2 Carotid Bruit none Right: Left: Pertinent Results: [**2186-7-22**] TEE Conclusions Overall left ventricular systolic function is low normal (LVEF 50-55%). There is hypokinesis of the mid to distal anteroseptal segments with borderline dyskinesis distally. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal study. Low normal left ventricular global systolic function with regional wall motion abnormalities as described above. Normal pulmonary artery systolic pressure. Compared with the prior study (TEE - images unavailable for review) of [**2186-7-21**], the left ventricular regional systolic dysfunction appears similar. Given the limited nature of the current study a comparison of all previously measured parameters could not be made. . [**2186-7-24**] 04:33AM BLOOD WBC-7.8 RBC-2.94* Hgb-8.7* Hct-26.5* MCV-90 MCH-29.6 MCHC-32.9 RDW-14.2 Plt Ct-178 [**2186-7-23**] 04:40AM BLOOD WBC-7.6 RBC-2.97* Hgb-9.0* Hct-26.5* MCV-89 MCH-30.2 MCHC-33.8 RDW-14.4 Plt Ct-109* [**2186-7-22**] 02:07AM BLOOD WBC-11.2* RBC-3.01* Hgb-9.1* Hct-26.9* MCV-89 MCH-30.3 MCHC-33.9 RDW-14.2 Plt Ct-129* [**2186-7-20**] 01:45PM BLOOD PT-14.7* PTT-23.2* INR(PT)-1.4* [**2186-7-20**] 12:00PM BLOOD PT-15.0* PTT-24.5* INR(PT)-1.4* [**2186-7-20**] 03:32AM BLOOD PT-11.3 PTT-56.6* INR(PT)-1.0 [**2186-7-24**] 04:33AM BLOOD Glucose-86 UreaN-12 Creat-0.5 Na-139 K-3.7 Cl-101 HCO3-34* AnGap-8 [**2186-7-23**] 04:40AM BLOOD Glucose-93 UreaN-10 Creat-0.5 Na-139 K-3.8 Cl-103 HCO3-31 AnGap-9 [**2186-7-22**] 02:07AM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-141 K-4.2 Cl-109* HCO3-28 AnGap-8 Brief Hospital Course: The patient was brought to the Operating Room on [**2186-7-20**] where the patient underwent OPCABG x 1 (LIMA-LAD) with Dr. [**First Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact. She was kept on Neo for hypotension and weaned from this by POD 2. She received 5 units of cells in the post-op period and she still remains anemic but is not significantly symptomatic. Post-op echo was unremarkable. While at rehab she will need her Hct monitored. She was started on isordil and later transitined to Imdur for prevention of LIMA spasm this will need to be continued for 3 months.Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating wiht assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital **] [**Hospital 5028**] rehab in good condition with appropriate follow up instructions. Of note Pt was started on plavix due to being done off Pump and this will need to be continue for 3 months also. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Aspirin EC 81 mg PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. AcetaZOLamide 250 mg PO Q12H Duration: 2 Days 3. Atorvastatin 20 mg PO DAILY 4. Bisacodyl 10 mg PR DAILY:PRN constipation 5. Clopidogrel 75 MG PO DAILY off-pump x 3 months 6. Furosemide 20 mg PO DAILY Duration: 3 Days 7. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY Hold if BP <95 for 3 months 8. Metoprolol Tartrate 12.5 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. 9. Multivitamins 1 TAB PO DAILY 10. Ranitidine 150 mg PO BID 11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 Tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 12. Colace 100mg po bid 13. senokot 1-2 tabs po bid Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Coronary Artery Disease left Breast Cancer s/p chemo and radiation Past Surgical History Left breast lumpectomy and left axillary lymphnode dissection Right rotator cuff Surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage No edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2186-8-3**] 10:00 Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**], [**2186-8-22**] 1:30 Please call to schedule the following: Cardiologist Dr. [**Last Name (STitle) 4922**] will call rehab with appt date Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 63309**] in [**5-4**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2186-7-24**]

Admission Date: [**2148-4-25**] Discharge Date: [**2148-5-2**] Date of Birth: [**2148-4-25**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Infant's last name at discharge is [**Name (NI) 47795**]. Baby [**Name (NI) **] [**Known lastname 4597**]-[**Known lastname **] was the 3390 gm product of 38 [**3-18**] week gestation born to a 31 year old Gravida 3, Para 0, now 1 Mom. Prenatal screens - Blood type 0 positive, antibody negative, Rubella immune, RPR nonreactive, Hepatitis surface antigen negative, Group B Streptotoccus status unknown. Primary cesarean section under combined epidural spinal anesthesia. The infant's Apgars were 9 and 9. In the Newborn Nursery the infant was breastfeeding well, noted to have spitting of old blood and abdominal distention and was transferred to the NICU for assessment. He had passed stool times two at this time. PHYSICAL EXAMINATION ON ADMISSION: Term, appropriate for gestational male. Pink, comfortable in room air. Anterior fontanelle soft, flat, nondysmorphic intact palate. Nevus flammeus on forehead. Clear breathsounds. No murmur. Tender abdomen. Hyperactive bowel sounds. No hepatosplenomegaly. Normal male genitalia. Testes descended. Patent anus. No hip click, no sacral dimple, positive mongolian spot, normal tone. HOSPITAL COURSE: Respiratory - [**Location (un) **] has remained stable in room air without any respiratory issues. Cardiovascular - [**Location (un) **] has remained without cardiovascular issues, normal blood pressures and heartrate. Fluids and electrolytes - His birthweight was 3,390 gm. His discharge weight is 3385gm. [**Location (un) **] initially arrived and was made NPO at 80 cc/kg of D10/W. Following his barium enema the infant proceeded to ad lib enteral feeding of Enfamil 20 calorie or breastmilk 20 calorie. Gastrointestinal - Infant admitted to the Newborn Intensive Care Unit for abdominal distention. Went to [**Hospital3 18242**] for a contrast enema which revealed a meconium plug, also noted left side of colon slightly small. Infant had passed the meconium plug and has had no further issues with stooling or enteral feeding. Recommendation at this time is for a follow up sweat test for cystic fibrosis. The cystic fibrosis clinic at [**Hospital3 1810**], phone [**Telephone/Fax (1) 36136**]. Hematology - Complete blood count and blood culture were obtained on admission which revealed severe neutroeni with a white count of 4.9, hematocrit of 43.6, platelets of 170. He had 1 poly and 0 bands. In response to his low neutropenia, repeat complete blood count was performed later in the day revealing 5 polys. His complete blood count on [**4-28**] had a white count of 5,800, hematocrit of 43.4, platelets 170, 0 polys 0 bands, 74 lymphs. His most recent complete blood count on [**5-2**] is wbc 8,400 0P 0B 70L 27M 3E, Hct 46% plat 254,000. Hematology was consulted from [**Hospital3 1810**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47796**] is the attending hematologist and the Hematology Fellow's name is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47797**] who will be following [**Location (un) **] outpatient. At this time the working diagnosis includes alloimmune neutropenia. Mother's bloodwork has been sent off to [**State 3706**] Southwest Bloodbank, telephone #1-[**Telephone/Fax (1) 47798**]87, and there are specifically looking for neutrophil antibodies. This bloodwork was sent on [**2148-5-1**]. Secondary differentials include Kostmanns syndrome or infection. Mother has been taking no medications that produce neutropenia. The recommended plan at this time is to repeat a complete blood count with differential on [**5-7**] and inform Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47797**] of the information. At that time they can determine if the infant should have a bone marrow aspiration or further testing. Infectious disease - In light of the neutropenia, the infant was started on ampicillin and gentamicin which were discontinued on day of life #5 as there was no positive blood culture and no clinical sepsis risk factors. A lumbar puncture was performed which revealed a white blood cell count of 5, a red blood cell count of 1, protein of 85 and glucose of 32. Mother and father were both instructed of the increased need for diligence around the infant with infection control issues. Sensory - Audiology, automated auditory brain stem responses were performed and the infant passed both ears. Psychosocial - A [**Hospital6 256**] social worker has been involved with this family. The contact social worker's name is [**Name (NI) **] [**Name (NI) 47799**], pager #[**Numeric Identifier 45733**] which can be reached at [**Telephone/Fax (1) 8717**]. Please feel free to contact [**Name (NI) **] [**Last Name (NamePattern1) 47799**] or the Newborn Intensive Care Unit and speak with either the nurse practitioners service or the attending at that time. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home DISCHARGE WEIGHT: 3385gm PRIMARY CARE PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 13788**] [**Name (STitle) 47800**], [**Hospital 5164**] Medical Associates, phone #[**Telephone/Fax (1) 3183**]. CARE RECOMMENDATIONS: 1. Feeds at discharge - Continue adlib breastmilk or Enfamil 20. 2. Medications - Not applicable. 3. State newborn screens - Sent per protocol. 4. Immunizations received - Infant received his hepatitis B vaccine on [**2148-5-1**]. FOLLOW UP APPOINTMENTS RECOMMENDED: 1. Cystic fibrosis clinic for sweat test at one month of age, telephone #[**Telephone/Fax (1) 36136**]. 2. [**Hospital **] Clinic, #[**Telephone/Fax (1) 47801**]. 3. Schedule appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47797**], phone #[**Telephone/Fax (1) 47802**], pager [**Numeric Identifier 47803**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**] Dictated By:[**Last Name (NamePattern1) 38294**] MEDQUIST36 D: 05/01/1900 T: [**2148-5-1**] 18:23 JOB#: [**Job Number 47804**]

Admission Date: [**2139-12-9**] Discharge Date: [**2139-12-26**] Date of Birth: [**2093-11-21**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: Cerebral angiogram History of Present Illness: The pt is a 46 year-old right-handed man with a PMH of DM and HTN off medications who was transferred from [**Hospital3 **] today. Mr. [**Known lastname **] states that he was in his USOH this morning. He came home around noon and felt tired so he took a nap. When he woke around 1 or 1:30 he noticed that his entire left arm and hand were "numb". He was unable to feel the arm but denied paresthesias. He was also unable to move the arm at all. He was also unable to move the hand or fingers but felt that the leg was normal. He was unaware of any facial problems though his wife noticed that his left side face was droopy. He tried to drink water and the water spilled out of the left side of his mouth. His speech was also very hard to understand and "garbled". He was aware of what he wanted to say and was able to speak fluently but had difficulty articulating the words. His comprehension was normal. He went to [**Hospital6 5016**] where he was evaluated with screening labs with platelets of 255, a glucose of 188, nl LFT's, INR of 1 and a Cr of 1. His troponin was 0.04 and the CK was 76. His ECG showed SR and no ST changes. A head CT was done which was read as negative, however on review on the images here, I am concerned for a R parietal area of hypodensity. Clinically, Mr. [**Known lastname **] states that his R arm improved over half an hour. He was gradually able to raise it above his head and the numbness improved. His facial weakness and speech also improved. He was given ASA 325 per report and transferred here for further care. Of note, Mr. [**Known lastname **] states that he had had an episode of L hand numbness and weakness last week. He recalls that he was playing pool and dropped his pool stick. He went to pick it up and his L hand felt numb and weak. He was unable to move his fingers. He waited a few minutes and the symptom resolved. ROS: The pt denied headache, loss of vision, blurred vision, diplopia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denied difficulties comprehending speech. Denied paraesthesia. No bowel or bladder incontinence or retention. Denied difficulty with gait. The pt denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: 1. DM 2. HTN 3. boil removed Social History: -EtOh: [**1-20**] drinks per week -tobacco: 1 PPD x 30 years -drugs: denies -sells sporting equipment Family History: -mother: DM, died of heart problems -father: died of heart problems Physical Exam: NIH SS: 2 1a. Level of Consciousness: 0 1b. LOC questions: 0 1c. LOC commands: 0 2. Best gaze: 0 3. Visual: 0 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb ataxia: 0 8. Sensory: 0 9. Best language: 0 10. Dysarthria: 1 11. Extinction and inattention: 0 Vitals: T: 98.4 P: 104 R: 16 BP: 189/91 SaO2: 96% 2L General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: slight basilar crackles bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No edema Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was mildly dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. CN I: not tested II,III: VFF to confrontation, pupils 4mm->2mm bilaterally, fundi normal III,IV,V: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: L facial droop, symm forehead wrinkling VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**3-22**] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk and tone; no asterixis or myoclonus. No pronator drift. Delt [**Hospital1 **] Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 5- 5 5 5 5 5 5 R 5 5 5 5 5 5 5 IP Quad Hamst DF [**Last Name (un) 938**] PF L2 L3 L4-S1 L4 L5 S1/S2 L 5 5 5 5 5 5 R 5 5 5 5 5 5 Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 1------------ 0 Flexor R 1------------ 0 Flexor -Sensory: No deficits to light touch, pinprick, cold sensation or proprioception throughout. Slightly decreased vibratory sense in LE bilaterally. No extinction to DSS. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: deferred in the context of acute stroke Pertinent Results: [**2139-12-9**] 06:25PM BLOOD WBC-9.2 RBC-4.68 Hgb-14.8 Hct-39.7* MCV-85 MCH-31.6 MCHC-37.3* RDW-13.4 Plt Ct-272 [**2139-12-9**] 06:25PM BLOOD PT-12.4 PTT-25.7 INR(PT)-1.0 [**2139-12-13**] 01:41AM BLOOD ESR-13 [**2139-12-9**] 06:25PM BLOOD Glucose-131* UreaN-12 Creat-1.0 Na-134 K-4.1 Cl-96 HCO3-28 AnGap-14 [**2139-12-9**] 06:25PM BLOOD cTropnT-<0.01 [**2139-12-10**] 05:20AM BLOOD cTropnT-<0.01 [**2139-12-13**] 02:57PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2139-12-10**] 05:20AM BLOOD %HbA1c-6.9* [**2139-12-10**] 05:20AM BLOOD Triglyc-206* HDL-42 CHOL/HD-4.9 LDLcalc-123 [**2139-12-13**] 01:41AM BLOOD TSH-10* [**2139-12-14**] 03:35PM BLOOD T4-7.7 T3-98 [**2139-12-9**] 06:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2139-12-13**] 01:41AM BLOOD PEP-NO SPECIFI IgG-1038 IgA-124 IgM-97 IFE-NO MONOCLO CT BRAIN PERFUSION: 1. Right MCA territory infarct, with abrupt cut off of the right MCA in the region of its bifurcation, with M1 segment not identified. M2 branches are seen, suggesting a nearly occlusive filling defect/embolus within the right M1 segment. Corresponding increased transit time is identified in the right MCA territory. 2. No acute hemorrhage. 3. Diminuative A1 vessels, with poor filling of the proximal A2 branches. Better filling is identified in the more distal A2 vessels, suggesting posterior pericallosal collateral filling. 4. Stenosis at the origin of the left vertebral artery, which arises from the aortic arch. MRI/A of HEAD: 1. Findings consistent with infarcts in the right MCA territory, with abrupt cutoff of the right MCA identified on MRA at the bifurcation. Findings on previously performed CTA suggest that there is collateral filling of more distal M2 branches, although those are not identified on this study. 2. A1 and A2 branches not identified on the current MRA, although findings on prior CTA suggest posterior pericallosal collateral filling of the distal A2 vessels. 3. No acute hemorrhage. ECHO: Severe regional left ventricular systolic dysfunction (LVEF 30%) not consistent with ischemic cardiomyopathy. Severe diastolic dysfunction. Mild mitral regurgitation. No PFO/ASD identified. ANGIOGRAM: R MCA occlusion and both ACAs not visualized. Unable to stent ot intervene otherwise. Brief Hospital Course: The pt is a 46 year-old RH man with a PMH of DM and HTN, untreated. He developed left arm weakness and numbness as well as a facial droop with gradual improvement of his symtpoms. On arrival, in the ED, his BP ranged between 170-200's and he was in sinus tachycardia with a rate of 100's. His exam was notable for a L facial droop, mild dysarthria and slight L deltoid weakness (-5). He did not have any extinction or sensory loss and no drift. His leg was normal. His NIHSS was 2. He was taken urgently to CT/CTA and CTP which showed an evolving hypodensity on the R parietal lobe and an M1 cut off on CTA. His CTP showed a delay in MTT and a decrease in both CBV and CBF however with a mismatch, concerning for a residual penumbra. These results were reviewed with the O/C radiologist, as well as the stroke fellow who discussed the results with the Stroke attg. As his symptoms improved clinically with little deficit, he was not given IA tPA and admitted to the ICU with heparin drip. Patient was also found to have cardiomyopathy with LVEF of 30% - echo was most consistent with restrictive cardiomyopathy but not in coronary distribution hence cardiology consult recommended initial labs that were all normal except for elevated TSH. However, free T4 and T3 were within normal range hence this is expected in acute illness. Cardiology agreed with plan for repeat echo in 2 months. During the ICU stay, he continued to have mildly fluctuating mental status with transient worsening of left sided weakness. He was successfully transferred to the step-down unit where he was noticed to have significant but transient change in confusion, facial droop and weakness in the setting of receiving anti-hyperntensive [**Doctor Last Name 360**]. He had repeat scan which showed expansion of ischemia and he underwent repeat angiogram which showed R MCA occlusion without visualization of both ACAs but no intervention was possible. Given such finding, his episodes of confusion and worsening weakness most likely due to hypoperfusion of his ACAs in the setting lower blood pressure hence he was treated with goal SBP ~150 with IVF and bedrest. On [**12-21**], he was also started on low dose Midodrine, 2.5mg [**Hospital1 **] for increased BP with parameters to prevent supine HTN. He remained stable and he began working with PT to ambulate assistance on [**12-24**] without adverse reaction. As for his R MCA occlusion and underperfusion of both ACAs, Dr. [**Last Name (STitle) 81712**] at [**Hospital1 2025**] was contact[**Name (NI) **] for possible consideration of bypass surgery who felt that the surgery was viable and safe but unclear of its efficacy. Upon discussing with family of the surgery option, family decided that they would like to proceed with this and transfer was facilitated. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. Midodrine 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Discharge Disposition: Extended Care Discharge Diagnosis: R M1 MCA occlusion Hypertension Diabetes mellitus Discharge Condition: Stable but transiently increased confusion, worsening of L facial droop with weakness usually in the setting of lower blood pressure or standing. Discharge Instructions: You presented with L arm weakness and numbness as well as a facial droop with gradual improvement of your symtpoms. Upon arrival, your exam was notable for a L facial droop, mild dysarthria and slight L deltoid weakness (-5) and your NIHSS was 2. You were taken urgently to CT/CTA and CTP which showed an evolving hypodensity on the R parietal lobe and an M1 cut off on CTA but given that your symptoms improved clinically with little deficit, you did not get IA tPA and you were admitted to the ICU with heparin drip. You remained stable but with fluctuating exam including confusion, left facial droop with left sided weakness. After being transferred the neurology floor, you had an episode of prolonged confusion with definite L facial droop hence you had urgent imaging showing worsening of infarct and repeat angiogram showed R MCA occlusion plus non-visualization of both ACAs but due to the location and already completed infarct, no intervention was possible. You remained in the neurology floor with goal of SBP 150~180. Given the findings, Dr. [**Last Name (STitle) **] at [**Hospital1 2025**] was contact[**Name (NI) **] for possible bypass surgery and upon reviewing the films plus history, Dr. [**Last Name (STitle) **] consented to transfer of the patient for possible consideration of the surgery given likely low risk although efficacy unclear. You continued to have fluctuating exam in the setting of decreased BP or standing position. To increase blood pressure in hopes of ensuring adquate cerebral perfusion, midodrine was started on [**12-21**] with parameters to prevent supine hypertension. You have also been started on Coumadin with heparin bridging and your INR has been therapeutic over 1 week by the time of your discharge. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13960**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2140-2-25**] 11:00 Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2140-2-11**] 3:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Admission Date: [**2132-2-11**] Discharge Date: [**2132-2-15**] Date of Birth: [**2080-12-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Fatigue/Dyspnea on exertion Major Surgical or Invasive Procedure: [**2132-2-11**] Minimal Invasive Mitral Valve Repair (32mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **]) History of Present Illness: 51 year old male with known mitral valve prolapse and mitral regurgitation followed by serial echocardiograms. Most recent echocardiogram has shown progression of his mitral regurgitation to moderate/severe with a flail posterior leaflet. The patient, complaining of fatigue and some dyspnea on exertion, presents for surgical evaluation for mitral valve repair versus replacement. Past Medical History: Mitral Valve Prolapse/Mitral Regurgitation Hypertension Arthritis Past Surgical History: s/p inguinal herniorrhaphy s/p femoral herniorrhaphy s/p left knee surgery s/p skin grafts for fingers on left had following traumatic injury s/p removal of basal cell carcinoma from forehead Social History: Race: Caucasian Last Dental Exam: 2 years ago Lives with: Wife Occupation: Retired but works as delivery driver Tobacco: Denies ETOH: Several/wk Family History: Family History: Father with MI age 51 s/p CABG @ 55 Physical Exam: Pulse: 70 Resp: 16 O2 sat: 98% B/P Right: 129/83 Left: 139/85 Height: 6' Weight: 204 lbs General: well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [**3-4**] holosystolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right/Left: 2+ DP Right/Left: 2+ PT [**Name (NI) 167**]/Left: 2+ Radial Right/Left: 2+ Carotid Bruit Right/Left: none Pertinent Results: [**2132-2-11**] Echo: Pre-bypass: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is posterior mitral leaflet flail at the P2 scallop. An eccentric, anteriorly directed jet of Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is no pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. An annuloplasty ring is well-seated in the mitral position and there is trace valvular regurgitation. There is a mean transmitral pressure gradient of 3 mm Hg at a cardiac output of 6.3 L/min. There is evidence of systolic anterior motion of the anterior mitral leaflet, but there is not evidence of outflow tract obstruction or pressure gradient. Biventricular systolic function is preserved. All other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings were communicated to the surgeon. [**2132-2-14**] 05:25AM BLOOD WBC-8.3 RBC-3.55* Hgb-10.5* Hct-30.4* MCV-86 MCH-29.5 MCHC-34.4 RDW-12.6 Plt Ct-193 [**2132-2-11**] 04:14PM BLOOD PT-12.5 PTT-32.5 INR(PT)-1.1 [**Known lastname 86724**],[**Known firstname 488**] [**Age over 90 86725**] M 51 [**2080-12-24**] Radiology Report CHEST (PA & LAT) Study Date of [**2132-2-14**] 9:49 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2132-2-14**] 9:49 AM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 86726**] Reason: eval for effusion [**Hospital 93**] MEDICAL CONDITION: 51 year old man s/p mini mv repair REASON FOR THIS EXAMINATION: eval for effusion Final Report CHEST RADIOGRAPH INDICATION: Evaluation for pleural effusion. COMPARISON: [**2132-2-12**]. FINDINGS: As compared to the previous radiograph, the extent of the right-sided pleural effusion has minimally increased. As a consequence, the right basal areas of atelectasis have also increased. On the other hand, the ventilation of the left lung base is slightly improved. Unchanged size of the cardiac silhouette, no evidence of newly appeared focal parenchymal opacities indicative of pneumonia. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] [**2132-2-15**] 06:45AM BLOOD Glucose-105* UreaN-12 Creat-0.8 Na-138 K-4.2 Cl-98 HCO3-35* AnGap-9 Brief Hospital Course: Mr. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [**2-11**] he was brought to the operating room where he underwent a minimal invasive mitral valve repair. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Chest tubes were removed per cardiac surgery protocol. He was transferred to the step down unit on post operative day 1 in stable condition. He was started on Neurontin with plans for increased titration as needed due to right medial thigh numbness and tingling (right groin cannulation.) He was able to ambulate and weight bear with this numbness. He continued to work with physical therapy to increase strength and endurance. He was tolerating a full po diet, ambulating well and his incision was healing well. His CXR revealed a question of a moderate right pleural effusion and he had an ultrasound which showed less than 300 cc of fluid and he did not undergo thoracentesis. He was encouraged to continue frequent IS use. It was felt that he was safe for discharge home on post operative day 4. Medications on Admission: Carvedilol 12.5mg po BID Quinapril 40mg po daily Aspirin 91mg daily Discharge Medications: 1. 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* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. 5. Quinapril 10 mg PO daily. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 1 months: Take with food. Disp:*120 Tablet(s)* Refills:*0* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral Valve Prolapse/Mitral Regurgitation s/p Mitral Valve Repair Hypertension Arthritis Past Surgical History: s/p inguinal herniorrhaphy s/p femoral herniorrhaphy s/p left knee surgery s/p skin grafts for fingers on left had following traumatic injury s/p removal of basal cell carcinoma from forehead Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**3-20**] at 1:00 PM Primary Care Dr. [**Last Name (STitle) 4541**] in [**12-1**] weeks Cardiologist Dr. [**Last Name (STitle) **] in [**12-1**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2132-2-15**]

Admission Date: [**2188-6-22**] Discharge Date: [**2188-6-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8790**] Chief Complaint: lower extremity weakness, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 8789**] is an 87-yo man with history of colon cancer (refusing treatment), PAF, CHF with chronic pleural effusions who presented with lower extremity weakness and was found to be hypoxic with O2 sat in the 80s requiring NRB and MICU admission. . The patient was mostly recently admitted on [**2188-6-20**] for hypotension likely from dehydration. He was given IVF and was discharged on [**2188-6-21**] with amox-clav for UTI. A day later, on the day of this admission, he felt as if his legs were "rubbery" and that he had difficulty ambulating even with his walker. He denies dyspnea, chest pain, lightheadedness, or worsening of his leg edema. He denies fevers, chills, coughs, abdominal pain, diarrhea, constipatin, dysuria. . On arrival to the ED, T 101.2, BP 117/50, HR 76, RR 22, 89%RA. His CEs were negative x 1. CXR revealed worsening R pleural effusion. He received 1 liter NS, ceftriaxone 2 grams, levofloxacin 750 mg. Due to his hypoxia, he required NRB and was admitted to the MICU for further management. Past Medical History: Colonoscopy [**2184-3-25**]: >Polyp in the transverse colon (polypectomy) - adenoma >Polyps in the sigmoid colon (polypectomy)- Colonic mucosa with focal hyperplastic features >Polypoid, ulcerated mass in the hepatic flexure (biopsy) - Superficial fragments of colonic mucosa with ulceration, marked acute inflammation, and highly atypical glands, suspicious for carcinoma. Past history: # Colon mass during colonoscopy for guaiac positive stools in [**2184**]. Pathology was worrisome for carcinoma. Although the patient was offered resection by Dr. [**Last Name (STitle) **], he declined # hematuria/BPH - traumatic foley insertion and manipulation [**3-16**] lead to urosepsis and subsequent urinary retention # sick sinus syndrome and bifascicular block s/p pacemaker [**2184**] # PAF - on amiodarone, not on coumadin d/t concern for malignancy # H/O SVT # Atrial flutter status post ablation [**2-/2186**] - not on anticoagulation d/t concern for malignancy # Anemia - on arenesp and iron # Echo [**2186**]: mild-to-moderate mitral regurgitation, RA and LA # BPH s/p TURMP [**2187**] # b/l edema with skin changes # hard of hearing # hx of guiaic positive stools/GI bleeding # osteoarthritis # osteoporosis # subclinical hypothyroid state as per record # [**Year (4 digits) **] insufficiency # right pleural effusion - Found on CT on [**2188-2-25**] for increasing DOE. [**3-6**] and [**3-18**] thoracentesis c/w transudative. Workup during last admission revealed RV diastolic dysfunction. Concern was for PE as etiology, but unable to get CTA d/w ARF and V/Q not helpful. Not anticoagulated due to h/o GIB, pleurodesis not an option d/t transudative. # Tibial talar dislocation with comminuted distal tib fib fracture status post surgery [**2181**] # hx syncope in [**2181**], unclear etiology Social History: living at lone at home with VNA, Former smoker with 35-pk-yrs, quit 50-55 yrs ago. Social ETOH. Family History: brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82 Sister died from heart attack. Also had an unknown cancer. Mother died from an unknown cancer. Neice has unknown cancer. Physical Exam: VS: T 98.6, 105/58, HR 74, RR 13, SpO2 99% on 100% NRB Gen: Very pleasant older gentleman, talking clearly and in full sentences, lying flat in bed. HEENT: Sclera anicteric, conjunctiva pale, OP clear, no exudates or erythema. Skin coloring good. MMM. No JVD. No carotid bruits. CV: RR, NL S1, S2. No murmurs, rubs or gallops. Lungs: Crackles at L base, decreased BS at R base. Otherwise clear, no wheezes or rhonchi. ABD: Soft, NT, ND. Hyperactive BS. No masses, no HSM. EXT: 1+ edema to mid-shins bilaterally. 2+ DP pulses BL. SKIN: No rash but chronic venous stasis changes to LE bilaterally. NEURO: AAOx3, appropriate. CN II-XII grossly intact. . VS: T 97.6, 98/58, HR 74, RR 13, SpO2 94% on RA NRB Gen: Very pleasant older gentleman, talking clearly and in full sentences, lying flat in bed. HEENT: Sclera anicteric, conjunctiva pale, OP clear, no exudates or erythema. Skin coloring good. MMM. No JVD. No carotid bruits. CV: RR, NL S1, S2. No murmurs, rubs or gallops. Lungs: CTAb, no labored breathing ABD: Soft, NT, ND. Hyperactive BS. No masses, no HSM. EXT: trace edema to mid-shins bilaterally. 2+ DP pulses BL. SKIN: No rash but chronic venous stasis changes to LE bilaterally. NEURO: AAOx3, appropriate. CN II-XII grossly intact. Pertinent Results: [**2188-6-21**] 07:35AM BLOOD WBC-5.4 RBC-3.35* Hgb-8.9* Hct-30.5* MCV-91 MCH-26.5* MCHC-29.1* RDW-16.0* Plt Ct-235 [**2188-6-23**] 05:10AM BLOOD WBC-10.3 RBC-3.02* Hgb-8.3* Hct-26.1* MCV-87 MCH-27.3 MCHC-31.6 RDW-16.6* Plt Ct-240 [**2188-6-23**] 04:25PM BLOOD Hct-28.1* [**2188-6-24**] 05:45AM BLOOD WBC-9.3 RBC-3.19* Hgb-8.7* Hct-27.7* MCV-87 MCH-27.2 MCHC-31.3 RDW-16.2* Plt Ct-230 [**2188-6-24**] 01:20PM BLOOD Hct-27.3* [**2188-6-25**] 05:45AM BLOOD WBC-8.4 RBC-3.63* Hgb-10.3* Hct-31.3* MCV-86 MCH-28.3 MCHC-32.9 RDW-16.0* Plt Ct-231 [**2188-6-26**] 05:00AM BLOOD WBC-9.0 RBC-3.92* Hgb-11.0* Hct-34.3* MCV-87 MCH-28.0 MCHC-32.0 RDW-16.3* Plt Ct-222 [**2188-6-27**] 06:40AM BLOOD WBC-8.6 RBC-3.73* Hgb-10.2* Hct-32.3* MCV-87 MCH-27.4 MCHC-31.6 RDW-16.1* Plt Ct-213 . Chem 7 [**2188-6-23**] 05:10AM BLOOD Glucose-88 UreaN-22* Creat-1.3* Na-140 K-3.6 Cl-107 HCO3-25 AnGap-12 [**2188-6-24**] 05:45AM BLOOD Glucose-87 UreaN-20 Creat-1.2 Na-139 K-3.5 Cl-105 HCO3-27 AnGap-11 [**2188-6-25**] 05:45AM BLOOD Glucose-88 UreaN-18 Creat-1.1 Na-139 K-3.5 Cl-105 HCO3-27 AnGap-11 [**2188-6-25**] 05:10PM BLOOD Glucose-94 UreaN-18 Creat-1.2 Na-138 K-3.6 Cl-104 HCO3-25 AnGap-13 [**2188-6-26**] 05:00AM BLOOD Glucose-93 UreaN-17 Creat-1.2 Na-139 K-3.5 Cl-104 HCO3-27 AnGap-12 [**2188-6-27**] 06:40AM BLOOD Glucose-87 UreaN-17 Creat-1.1 Na-137 K-4.0 Cl-103 HCO3-27 AnGap-11 [**2188-6-25**] 05:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9 [**2188-6-25**] 05:10PM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9 [**2188-6-26**] 05:00AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 [**2188-6-27**] 06:40AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.9 . Misc [**2188-6-23**] 05:10AM BLOOD TSH-1.7 Brief Hospital Course: The patient was admitted with hypoxia and was intially sent to the ICU. He was diuresed, but also started on Vanc, Flagyl and Levofloxacin empirically. After diuresis, his oxygenation improved and he was transfered to the floor. He was continued on abx empirically but they were discontinued after 48hours of negative cultures. He was then switched back to Augmentin to complete a course for UTI started on last admssion. It is likely that he experienced a CHF exacerbation [**2-23**] to the IVF given on last admission and [**2-23**] to decreased lasix on discharge. His "weakness" was consistent with deconditioning and poor cardiopulmonary status on admission rather than focal leg weakness. On exam, strength was [**5-26**] in LE and his walked very well with PT. His ambulation improved with diuresis. TSH was normal. Diuresis was continued. His hypoxia continued to improve with 90-94% RA and on ambulation. He continued to refuse thoracentesis. He did have rare desturations at night to 87% and may benefit from O2 at night in the future. He also received 2 units pRBC's for HCT below baseline. He was discharged without shortness of breath or hypoxia on his orginal home dose of lasix 40mg daily. Medications on Admission: . Amiodarone 200 mg Tablet PO DAILY 2. Finasteride 5 mg PO DAILY 3. Omeprazole 20 mg Capsule PO DAILY 4. Toprol XL 25 mg [**Last Name (un) **] 5. Ferrous Sulfate 325 mg daily 6. Aspirin 81 mg Tablet once a day. 7. Terazosin 5 mg PO once a day. 8. Lasix 20 mg once a day 9. Multiple Vitamins once a day. 10. Augmentin 500-125 mg [**Hospital1 **] (Day 1=[**6-21**]) Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*3* 5. Terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1.5 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: CHF exacerbation UTI Discharge Condition: improved Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . If you have difficulty breathing, light-headeness, chest pain or fever, you should return to the emergency room. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**] [**Telephone/Fax (1) 1713**] [**2188-7-21**] 2:00pm Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2188-7-14**] 11:20 Provider: [**Name10 (NameIs) 2793**] Ultrasound [**Telephone/Fax (1) 327**] [**2188-8-25**] 1:15pm [**Hospital Ward Name 452**] 3 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3748**] ([**Telephone/Fax (1) 8791**] [**2188-8-28**] 11:00am . . If you are interterested in finding a primary care physician in [**Name9 (PRE) **], we would recommend Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1579**]). He comes highly recommended from physicians here, works at [**Hospital1 18**] [**Location (un) **] and has agreed to see Mr. [**Known lastname 8789**].

Admission Date: [**2189-7-6**] Discharge Date: [**2189-7-13**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1515**] Chief Complaint: CoreValve placement Major Surgical or Invasive Procedure: CoreValve placement Repeat Right and Left heart catheterization Temporary pacemaker placement History of Present Illness: [**Age over 90 **]-year-old caucasian female with CAD, NSTEMI [**2189-5-6**] pulmonary HTN, and known critical aortic stenosis (AoVA = 0.6cm2, EF 40%) now symptomatic with increasing chest pain, SOB, and dizziness. Patient had been seen in [**2185**] and declined surgical intervention at that time. She was also admitted for CHF exacerbation 20 lbs over her baseline in [**2189-5-13**] and considered for valvuloplasty, however this was not done due to concerns regarding significant aortic regurgitation. She underwent a complete evaluation for TAVI during the stay including carotid ultrasound, presantine perfusion scan, dipyridamole stress, and CT of the chest/ abdomen/ and pelvis. Recently, the patient has been experiencing decline in her functional status due to worsening SOB and lightheadedness and is limited to walking to the bathroom. (Adapted from Aortic Valve Service History & Physical) At baseline, patient has a history of anxiety. NYHA Class: III Aortic valve replacement was uneventful and the LVEDP was measured at 33. The patient required 2 units of PRBCs. Upon arriving to the floor, patient became acutely dyspnic, gasping for breath with saturations in the mid 80s. Simultaneously, the patient had increased blood pressures measured at 200s/100s by arterial line. Initial ABG was drawn and demonstrated 7.29/52/72 (pH/pCO2/pO2). An urgent chest x-ray demonstrated acute pulmonary edema with no evidence of pneumothorax and was treated with 40mg lasix IV. Echo showed [**12-14**]+ AR/MR and mild paravalvular leak. Patient was given albuterol and ipratropium nebulizer treatments followed by 125mg methylprednisolone and patient was put on a non-rebreather mask. Patient was also given 0.5mg morphine sulfate, 0.5mg lorazepam. Repeat ABG demonstrated increasing academia and hypercarbia (7.20/73/108) and patient was transitioned to BiPAP 15/5. Repeat ABG after 30 minutes of BiPAP showed 7.40/ 40/97 and patient was weaned off the BiPAP. Past Medical History: 1. CARDIAC RISK FACTORS: - Hypertension - Hyperlipidemia 2. CARDIAC HISTORY: - Critical Aortic Stenosis - Severe two-vessel CAD s/p NSTEMI ([**2189-2-6**]) - Congestive Heart Failure 3. OTHER PAST MEDICAL HISTORY: - Pulmonary Hypertension - Asthma - Anemia - Depression - h/o right leg fracture s/p ORIF - s/p knee replacement Social History: Lives at [**Hospital **] Nursing Home. Limited ambulation. Daughter supportive, lives about 20 min away. Retired from clerical work. Denies alcohol and tobacco. Family History: Mother died at age [**Age over 90 **] and father died at 78 from heart disease. Physical Exam: Admisson Exam: Tmax: 35.9 ??????C (96.7 ??????F) HR: 53 (53 - 58) bpm BP: 109/43(65) {109/43(65) - 158/59(94)} mmHg RR: 24 (8 - 24) insp/min SpO2: 100% HEENT: NC/AT sclera anicteric, MMM, pupils dilated JVP: Unable to assess with pacing wire in right neck, but appears flat on left Lungs: Patient is gasping for air with labored breathing. Upper airway sounds present with poor air movement. Cardiac: Tachycardic, with no murmurs heard. Abdomen: Soft, non-tender, non distended. Positive bowel sounds. Extremities: No edema, pulses 2+ dp/pt. No edema. . Discharge Exam: GENERAL: Comfortable in no acute distress HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP non elevated. Right next with mod bruising and 2 cm hematoma from large central line that is slowly resolving CHEST: CTABL no wheezes, no rales, no rhonchi, [**Month (only) **] at bases. CV: S1 S2 nl, 2/6 systolic murmur at RUSB. ABD: soft, non-tender, non-distended, BS normoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs 2+. NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). SKIN: no rash Pertinent Results: ADMISSION LABS: [**2189-7-6**] 02:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2189-7-6**] 05:45PM WBC-7.1 RBC-3.52* HGB-10.2* HCT-30.3* MCV-86 MCH-29.0 MCHC-33.7 RDW-16.9* [**2189-7-6**] 05:45PM PLT COUNT-212 [**2189-7-6**] 05:45PM PT-12.6 PTT-21.6* INR(PT)-1.1 [**2189-7-6**] 05:45PM ALBUMIN-4.1 CALCIUM-9.6 [**2189-7-6**] 05:45PM CK-MB-3 proBNP-[**Numeric Identifier **]* [**2189-7-6**] 05:45PM ALT(SGPT)-18 AST(SGOT)-26 CK(CPK)-70 ALK PHOS-66 TOT BILI-0.6 . DISCHARGE LABS: . PERTINENT STUDIES: TTE ([**2189-7-7**]): The left atrium is dilated. Overall left ventricular systolic function is mildly depressed with basal inferior and basal to mid lateral hypokinesis (LVEF= 50 %). Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present. The transaortic gradient is normal for this prosthesis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-14**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . TTE ([**2189-7-8**]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal inferior and basal to mid inferolateral hypokinesis. The remaining segments contract normally (LVEF = 50 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is mildly dilated and free wall motion is normal. The diameters of aorta at the sinus, ascending and arch levels are normal. An aortic CoreValve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2189-7-7**], the severity of tricuspid and mitral regurgitation have increased. The trans-Corevalve gradient is higher while the severity of aortic regurgitation is unchanged. Pericardial effusion is smaller. The right ventricle appears mildly dilated. . TTE ([**2189-7-9**]): Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Right ventricular chamber size is normal. with borderline normal free wall function. An aortic CoreValve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. A paravalvular aortic valve leak is present. Mild to moderate ([**12-14**]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric. Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . Cardiac Cath ([**2189-7-9**]): 1. Elevated LVEDP 2. Mild to moderate aortic insufficiency 3. No gradient across the Corevalve (no aortic stenosis) 4. Mild to moderate pulmonary hypertension (from diastolic dysfunction) Brief Hospital Course: PRIMARY REASON FOR ADMISSION: [**Age over 90 **]-year-old caucasian female with CAD, NSTEMI [**2189-5-6**] pulmonary HTN, and known critical aortic stenosis (AoVA = 0.6cm2, EF 40%) s/p corevalve. Active Diagnoses: . # COREVALVE Patient's perioperative course was complicated by flash pulmonary edema after 2 units PRBCs in the cath lab. She was treated with diuresis and BiPAP, with succesful weaning onto nasal canula. 24 hours after placement, [**7-8**] Echo demonstrated high trans gradients and continued aortic regurgitation. The picture was complicated by decreased MAPs below 65 and urine output to 15-20 cc/h and creatinine increasing to 1.6. Patient was clinically stable throughout with no further episodes of dyspnea. Patient was started on Dopamine drip at 2mcg/kg/min with increase in UOP and MAPs above 65. On [**7-9**] reassessment in cath lab with PCWP was 20-22 mmHg and the PA systolic pressure was < 50 mmHg. The RA pressure was [**9-23**]. The LVED was 30 mmHg (due to diastolic dysfunction and unchanged from pre) and there was a minimal trans-aortic gradient. Patient began to clinically improve with activity around the CCU including walking. She was weaned of the dopamine gtt. Subsequent TTE showed continued AR, but the patient remained stable and was transferred to the floor and then rehab. # WENCHIBACH WITH PERSISTENT BRADYCARDIA Likely etiolgy is sick sinus syndrome. Patient was evaluated by EP team with decision made to not place a pace maker. # CAD Patient was continued on Aspirin 81 mg daily, Plavix 75mg daily and Crestor 20 mg daily. She was not on BB secondary to sinus bradycardia. # ASTHMA Pt was continued on Fluticasone-Salmeterol Diskus (250/50) and Montelukast 10 mg daily. # CHF Furosemide 20mg was started within 48 hours of CoreValve placement with Spironolactone 25. HCTZ 25 was discontinued. She was started on lisinopril 10mg/day during this admission. # GERIATRIC CARE: Pt was continued on home trazadone for sleep throughout her course. She intermittently required benzos for anxiety, which she tolerated well. #ANXIETY/ INSOMNIA We continued home escitalopram and trazadone. Trazodone was briefly discontinued due to prolongation of QT on one EKG, but was restarted with no incident. Medications on Admission: Medications - Prescription ALPRAZOLAM - 0.25 mg Tablet - one Tablet(s) by mouth twice daily ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - Dosage uncertain FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other Provider) - Dosage uncertain FUROSEMIDE - 20 mg Tablet - one Tablet(s) by mouth daily ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day SPIRONOLACTON-HYDROCHLOROTHIAZ [ALDACTAZIDE] - (Prescribed by Other Provider) - 25 mg-25 mg Tablet - 1 Tablet(s) by mouth once a day TRAZODONE - 50 mg Tablet - one Tablet(s) by mouth at bedtime Medications - OTC ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth once a day ASPIRIN - (Prescribed by Other Provider; OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day VITAMIN E - (Prescribed by Other Provider) - 600 unit Capsule - 2 Capsule(s) by mouth once a day Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 3. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) **] at [**Location (un) 701**] Discharge Diagnosis: Critical Aortic Stenosis Coronary Artery Disease Systolic congestive heart failure Hypertension Anemia Bradycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You had a percutaneous replacement of your aortic valve. The procedure went well and the valve is functioning appropriately. You had some slow heart rhythms after the procedure that has now resolved. We expect that the shortness of breath with gradually improve over the next month. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. Stop taking Imdur, aldactazide, Vitamin c and Vitamin E. 2. STart Lisinopril to help your heart pump better 3. Change Aprazolam to Lorazepam to treat your anxiety Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2189-8-7**] at 12:00 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2189-8-7**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2134-6-24**] Discharge Date: [**2134-7-8**] Date of Birth: [**2069-1-30**] Sex: F Service: MEDICINE Allergies: acetaminophen / Codeine / Erythromycin Base / Methadone / morphine / propoxyphene / Penicillins / Meperidine / macrolides / ketolides Attending:[**First Name3 (LF) 2297**] Chief Complaint: Fatigue and Confusion. hypercalcemia Major Surgical or Invasive Procedure: [**2134-6-30**] OPERATION: Removal of large parathyroid adenoma, status post 2 prior neck explorations. History of Present Illness: 65F woman with history of etoh abuse, primary hyperparathyroidism s/p resection for adenomas, and AF with pacer presented with hypercalcemia and elevated troponin. She was seen at [**Hospital1 **] today, initally stating she had back pain; however, she was found to be confused. She had a steroid injection in [**Month (only) 116**]. At [**Hospital1 **], patient was noted to have TropT 0.32 (no previous), BNP 1170 (no previous) and Ca [**40**] (last known value = 10.3), Cr 1.8 from baseline 1.2. She was given 40mg lasix and 2L NS bolus and transferred. Pt noted to not have taken medications "in a long time." Initial VS in the ED: 97.7 130/60 60 20 100ra. Exam notable for normal rectal tone and moving all extremities. Labs notable for Cr = 1.6, Ca = 20.1, Mg = 1.3, TropT = 0.12, hct = 32.8 with MCV = 112. Patient was given 1L NS infusing at 250cc/h. VS prior to transfer: 98.0 129/65 62 16 100ra. On the floor, 98.1, 131/70 53 18 100ra. Patient was lethargic and confused. Review of systems: Unable to ascertain secondary to patient's MS. Past Medical History: -seizure disorder -cardiomyopathy (EF = 30%, [**2130**]) -atrial fibrillation with ventricular pacer -diabetes mellitus type 2 -hyperlipidemia -gastrointestinal bleed -left breast cancer status post mastectomy - T3a N0 M0 infiltrating ductal carcinoma, ER/PR and HER2-negative -primary hyperparathyroidism s/p resection with residual hypercalcemia -s/p lumbar laminectomy [**2130**], hysterectomy, appendectomy, tonsillectomy. Social History: The patient is single, disabled, non-smoker, and has been sober for ~8 years. Family History: Her mother had diabetes and father had hypertension and back pain. Physical Exam: ADMISSION: Vitals: T: 98.1 BP:131/70 P:53 R:18 O2:100ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, palpable smooth, non-tender 3cm nodule over left neck Neck: supple, JVD to 1 cm above corner of mandible, no LAD Lungs: Crackles lower and mid posterior L lung CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 3+ pitting edema Skin: stage 1 sacral ulcer Neuro: FROM, MAE; 5/5 strength in arm flexion/extension, [**2-8**] in finger adduction, 3+ in leg flexion, other muscle groups unable to tested; no clonus; 3+ reflexes patellar and biceps bilaterally Mental Status: Confused, somnolent, oriented to name only, unabel to name president Recall: [**12-8**] at registration, 0/3 at 5 minutes Calculations: 5 quarters = 22-[**2121**] Praxis: Intact DISCHARGE: Vitals:Tmax: 37.1 ??????C (98.8 ??????F)Tcurrent: 36.7 ??????C (98.1 ??????F)HR: 60 (60 - 62) bpm BP: 84/42(53) {80/32(40) - 132/80(90)} mmHg RR: 15 (9 - 21) insp/min SpO2: 99% Heart rhythm: V Paced Wgt (current): 55.3 kg (admission): 59.3 kg General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), RRR Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bilaterally), no rales/rhonchi Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+ Skin: Not assessed Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Pertinent Results: ADMISSION: [**2134-6-24**] 05:14PM BLOOD WBC-6.8 RBC-2.94* Hgb-9.9* Hct-32.8* MCV-112* MCH-33.6* MCHC-30.1* RDW-18.8* Plt Ct-245 [**2134-6-24**] 05:14PM BLOOD Neuts-80.9* Lymphs-13.3* Monos-4.1 Eos-1.3 Baso-0.4 [**2134-6-24**] 05:14PM BLOOD PT-11.8 PTT-18.8* INR(PT)-1.1 [**2134-6-24**] 05:14PM BLOOD Plt Ct-245 [**2134-6-24**] 05:14PM BLOOD Glucose-121* UreaN-19 Creat-1.6* Na-135 K-4.4 Cl-107 HCO3-19* AnGap-13 [**2134-6-24**] 09:51PM BLOOD Glucose-116* UreaN-18 Creat-1.6* Na-136 K-4.4 Cl-109* HCO3-17* AnGap-14 [**2134-6-24**] 05:14PM BLOOD ALT-29 AST-39 CK(CPK)-263* AlkPhos-74 TotBili-0.4 [**2134-6-24**] 09:51PM BLOOD CK(CPK)-194 [**2134-6-24**] 05:14PM BLOOD Lipase-50 [**2134-6-24**] 09:51PM BLOOD CK-MB-5 cTropnT-0.13* [**2134-6-24**] 05:14PM BLOOD cTropnT-0.12* [**2134-6-24**] 05:14PM BLOOD CK-MB-6 [**2134-6-24**] 09:51PM BLOOD Calcium-20.4* Phos-3.6 Mg-1.4* [**2134-6-24**] 05:14PM BLOOD Albumin-3.8 Calcium-20.1* Phos-3.8 Mg-1.3* [**2134-6-24**] 05:14PM BLOOD PTH-1360* [**2134-6-24**] 05:14PM BLOOD Carbamz-<0.5* Other Pertinent Labs: [**2134-6-25**] 07:40AM BLOOD CK-MB-4 cTropnT-0.12* [**2134-6-25**] 07:40AM BLOOD ALT-27 AST-27 AlkPhos-80 TotBili-0.4 [**2134-6-25**] 07:40AM BLOOD 25VitD-16* [**2134-6-25**] 07:40AM BLOOD VitB12-GREATER TH Folate-6.2 [**2134-6-28**] 07:15AM BLOOD Ret Aut-3.5* [**2134-6-30**] 03:00PM BLOOD PTH-1428* DISCHARGE: [**2134-7-7**] 03:25AM BLOOD WBC-8.1 RBC-2.98* Hgb-9.5* Hct-29.1* MCV-98 MCH-32.0 MCHC-32.7 RDW-17.1* Plt Ct-221 [**2134-7-7**] 03:25AM BLOOD PT-11.9 PTT-27.3 INR(PT)-1.1 [**2134-7-7**] 03:25AM BLOOD Glucose-122* UreaN-25* Creat-1.5* Na-132* K-3.3 Cl-96 HCO3-30 AnGap-9 [**2134-7-7**] 03:25AM BLOOD Albumin-2.6* Calcium-8.9 Phos-2.7 Mg-2.0 [**2134-7-7**] 03:25AM BLOOD PTH-113* [**2134-7-5**] 01:08AM BLOOD freeCa-1.42* [**2134-7-7**] 03:25AM BLOOD COLLAGEN TYPE I C-TELOPEPTIDE (CTx)-PND [**2134-7-2**] 03:04AM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND ECG: - [**6-24**]: Ventricularly paced rhythm. Occasional ventricular premature beats. The underlying rhythm appears to be sinus with A-V block. Clinical correlation is suggested. No previous tracing available for comparison. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 63 0 162 454/459 0 -58 -66 PATHOLOGY: IMAGING: [**2134-6-24**] - Portable CXR: A pacemaker/ICD device has two ventricular leads and a single right atrial lead. The device projects over the right upper hemithorax. The heart is moderate-to-severely enlarged. The main pulmonary artery contour is prominent. The aortic arch is calcified. The diaphragmatic contour on the left is indistinct but the significance is difficult to judge given cardiomegaly. The lungs are difficult to assess in this area and it is also difficult to exclude a small left-sided pleural effusion. However, there is no evidence for pleural effusion on the right. Otherwise, aside from streaky lingular atelectasis, the visualized lungs appear clear. Mild rightward convex is curvature centered along the mid thoracic spine. Surgical clips project along the left axilla. IMPRESSION: Somewhat limited examination, but substantial cardiomegaly without definite evidence for acute disease. [**2134-6-25**] - Transthoracic Echo: Intravenous administration of echo contrast was used due to poor native endocardial border definition. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Dilated coronary sinus (diameter >15mm). LEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe global LV hypokinesis. Relatively preserved apical LV contraction. Estimated cardiac index is depressed (<2.0L/min/m2). No LV mass/thrombus. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. Focal basal hypokinesis of RV free wall. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Very small pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor apical views. Conclusions The left atrium is mildly dilated. The coronary sinus is dilated (diameter >15mm). Left ventricular wall thicknesses and cavity size are normal with severe global hypokinesis (LVEF = 25 %). Systolic function of apical segments is relatively preserved. The estimated cardiac index is depressed (<2.0L/min/m2). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with focal basal free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present.No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Normal left ventricular cavity size with severe global hyopokinesis suggestive of a non-ischemic cardiomyopathy. Depressed cardiac output/index. Pulmonary artery hypertension. Increased PCWP. Dilated coronary sinus (is there evidence for persistance of left SVC?). - LENIS RLE: Grayscale, color and Doppler images were obtained of the right common femoral, femoral and popliteal veins. Note is made that despite diligent effort the right calf veins could not be visualized. Normal flow, compression and augmentation is seen in all of the visualized veins. Superficial edema within the soft tissues is seen in the right calf. IMPRESSION: No evidence of deep vein thrombosis from the right common femoral through the right popliteal veins. Note is made that the right calf veins could not be visualized. - X ray, L spine and T spine: AP and lateral views of the thoracic and lumbar spine were reviewed. There is no evidence of fracture, lytic or sclerotic lesions demonstrated. There is lumbar dextroscoliosis. Otherwise, no appreciable findings seen. If clinically warranted, correlation with cross-sectional imaging dedicated to the area of pain demonstrated. [**2134-6-28**] - Thyroid U/S: There has been prior left thyroidectomy. The right thyroid lobe measures 1.6 x 2.5 x 4.4 cm. The thyroid isthmus measures 7 mm. Remaining thyroid parenchyma shows a homogeneous echotexture without evidence of focal nodules. In the anterior midline, extending slightly to the left of midline, adjacent to but appearing separate from the thyroid isthmus, is a lobulated, heterogeneously, predominantly hypoechoic mass which measures 3.3 x 1.2 x 2.4 cm. Internal vascularity is demonstrated with color Doppler imaging. This is new compared to the examination of [**2133-5-21**]. The appearance is suggestive of either an abnormal lymph node or other heterogeneous solitary mass. Survey views throughout the remainder of the neck show no evidence of additional lymphadenopathy. IMPRESSION: 3.3 cm heterogeneously hypoechoic mass, anterior midline of neck, appearing separate from the thyroid remnant. This may represent an abnormal lymph node or other solitary mass. If surgically appropriate, this is amenable to fine-needle aspiration. The results were discussed via telephone with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at 10:45 a.m. on [**2134-6-28**] by Dr. [**First Name (STitle) **]. In addition, results were discussed with [**Doctor Last Name **] Baidal, Endocrinology fellow, in person at 10:45 a.m. on the same date. - Parathyroid scan with 21.1 mCi Tc-[**Age over 90 **]m Sestamibi: Following the intravenous injection of tracer, images of the neck including anterior, pinhole and marker views were obtained at 20 minutes and 2 hours. Initial and delayed images show intense activity overlying the left side of the thyroid bed. SPECT/CT images show a soft tissue focus with intense activity overlying the left thyroid bed. This focus appears larger and more intense in comparison to the prior study from [**2129-11-25**]. It also appears to be about 2cm lower than the focus seen on the prior scan. The left thyroid lobe is absent. CT images of the lungs show bilateral pleural effusions and bilateral patchy areas of atelectasis of the right lower lobe as well as of the left upper and lower lobes. IMPRESSION: 1- Intense focal tracer uptake overlying the left thyroid bed consistent with a large left parathyroid adenoma, increased in size and intensity when compared to the prior study. 2- Bilateral pleural effusions and atelectasis of the right lower lobe and the left upper and lower lobes [**2134-6-29**] - CT neck with contrast: The patient is status post left hemithyroidectomy. The right thyroid lobe is grossly unremarkable, but better assessed on the preceding thyroid ultrasound. There is a high-attenuation mass in the strap muscles to the left of midline, separate from the right-sided isthmus remnant, which corresponds to the mass seen on the prior ultrasound. It measures 2.6 x 1.5 x 3.3 cm on the present study. Of note, this was thought to be consistent with a parathyroid tumor on the nuclear medicine parathyroid scan. There is a 1-cm lymph node between levels III and IV on the left (image 2:56), at the upper limit of normal size. No other enlarged cervical lymph nodes are seen. There is no evidence of an exophytic mucosal mass. The salivary glands appear unremarkable. There is calcified plaque in the aortic arch. There is calcified and noncalcified plaque at the origins of the internal carotid arteries, without evidence of hemodynamically significant stenoses. The distal cervical right internal carotid artery is medialized, indenting the posterior pharyngeal wall. There are ground-glass opacities at the imaged lung apices, better assessed on the concurrent torso CT. The right mastoid is under-pneumatized and sclerotic, suggesting prior infections. There are no lytic or sclerotic bone lesions suspicious for malignancy. There are degenerative changes in the cervical spine. IMPRESSION: 1. Mass in the strap muscles to the left of midline, corresponding to the lesion seen on the preceding ultrasound, separate from the residual thyroid isthmus. This was thought to represent a parathyroid tumor on the preceding nuclear medicine study. Its CT characteristics are nonspecific. 2. 10-mm lymph node between levels III and IV on the left, at the upper limit of normal size. 3. Ground glass opacities at the imaged lung apices, better assessed on the concurrent torso CT. - CT Torso with and without contrast: CT CHEST: There is a 1.5 x 2.5 cm enhancing mass superior and anterior to the residual right lobe of the thyroid gland compatible with known parathyroid adenoma. There is no supraclavicular, axillary, mediastinal or hilar lymphadenopathy. There are clips in the left axilla. The heart is markedly enlarged with predominantly right-sided involvement. There is a moderate pericardial effusion. The aorta is normal in caliber. The main pulmonary artery measures 3.7 mm and is dilated. Pacemaker leads are present. Small bilateral pleural effusions are noted. There is no definite focal consolidation or pneumothorax. Ground-glass opacity at the bases most likely represent atelectasis. The airways are patent to the subsegmental levels. There is no large central pulmonary embolus. CT ABDOMEN WITH AND WITHOUT CONTRAST: There is heterogeneous appearance to the liver with prominent hepatic veins, most consistent with hepatic congestion from fluid overload. There are no focal liver lesions and the portal vein is patent. There is no intra- or extra-hepatic biliary dilatation. The gallbladder, pancreas and spleen are unremarkable. The right adrenal gland is unremarkable. There is thickening of the anteromedial limb of the left adrenal gland, which may represent hyperplasia or adenoma and less likely malignant involvement. The kidneys enhance and excrete contrast symmetrically without any hydronephrosis. There is bilateral scarring. The stomach, small and intra-abdominal large bowel are unremarkable. A small amount of perihepatic ascites is present. The abdominal vasculature including the aorta and its major branches are patent. There are calcifications involving the iliac arteries. CT PELVIS: There is a small amount of free fluid within the pelvis. The bladder is collapsed and there is a Foley catheter. The rectum and sigmoid colon are unremarkable. There is no lymphadenopathy or free air within the abdomen or pelvis. OSSEOUS STRUCTURES AND SOFT TISSUES: There is no suspicious lytic or sclerotic lesion. The patient is status post laminectomy at L3 and L4. There is diffuse anasarca. IMPRESSION: 1. 2.8 cm enhancing mass anterior to the residual thyroid consistent with known parathyroid adenoma. 2. Findings consistent with fluid overload including cardiomegaly, moderate pericardial effusion, bilateral pleural effusions, hepatic congestion, small amount of free fluid in the abdomen and pelvis as well as anasarca. 3. Enlarged main pulmonary artery which is suggestive of pulmonary hypertension. 4. Thickened appearance to the medial and anterior limb of the left adrenal which may represent hyperplasia, or an adenoma and less likely malignant involvement. PROCEDURES/INTERVENTIONS: [**2134-6-29**] - Right basilic vein approach- double lumen PICC placement under IR guidance [**2134-6-30**] -CXR: FINDINGS: In comparison with the earlier study of this date, there has been placement of an OG tube that extends well into the distal stomach. Endotracheal tube tip is approximately 5.1 cm above the carina. The lung volumes are substantially improved. This may account for the apparent improvement in pulmonary vascularity, which now is essentially within radiographic limits of normal. CXR [**7-1**]: IMPRESSION: Interval removal of lines and tubes. Increased bibasilar opacities suggestive of atelectasis and/or consolidation. PARATHYROID SCAN Study Date of [**2134-7-5**] RADIOPHARMACEUTICAL DATA: 21.5 mCi Tc-[**Age over 90 **]m Sestamibi ([**2134-7-5**]); INTERPRETATION: Following the intravenous injection of tracer, images of the neck including anterior, pinhole and marker views were obtained at 20 minutes and 2 hours. SPECT/CT images were obtained after the 20 minute images. Initial images show uptake in the right thyroid lobe. Delayed images show some washout from the right thyroid lobe. No foci of uptake consistent with parathyroid tissue are seen on either image. The patient is status post left thyroidectomy. A SPECT/CT was performed. Again, no foci of uptake consistent with parathyroid tissue are seen on either image. There are post-operative changes including small gas collections. There are small bilateral pleural effusions and bibasilar atelectasis. A right pacemaker is in place. Compared to the study of [**2134-6-28**], there has been a marked change. The intensely avid midline mass is surgically absent. There is no evidence of residual tissue related to that mass, and there is no other mass identified. IMPRESSION: No foci of uptake to suggest residual parathyroid tissue. Brief Hospital Course: 65 year old woman with past medical history of etoh abuse, primary hyperparathyroidism s/p left thyroidectomy and parathyroid adenoma resection in [**2127**], AF and sCHF p/w hypercalcemia, [**Last Name (un) **], elevated troponin, ruled out for ACS with hypercalcemia of unclear etiology. Improved with IV fluids and lasix. Discharged to rehab in stable condition. MEDICINE FLOOR [**0-0-**] # Hypercalcemia/Primary hyperparathyroidism. she has a known baseline of hypercalcemia between [**10-19**]. She presented with significantly high Ca and elevated PTH > 1300. Her [**Last Name (un) **] and sCHF complicated her treatment. She was treated with calcitonin, cinacalcet, brief course of hydrocortisone (100 mg q8h) as well as aggressive IVF balanced with lasix (for volume). She was placed on a low calcium diet. She subsequently underwent further imaging with thyroid ultrasound and parathyroid scan which showed a large left parathyroid adenoma. T spine and L spine did not show any fractures, lytic or sclerotic lesions. She subsequently underwent contrasted CT neck and torso to better characterize the tumor involvement. Her previous left thyroidectomy and parathyroid adenoma resection operative reports and surgical pathology from [**Hospital3 **] were reviewed among her inpatient and outpatient endocrinologists, surgery, and radiology. The decision was made to pursue an exploratory surgery for resection of the neck tumor on [**2134-6-30**] rather than FNA alone, for concern of possible seeding if it were to be a malignant tumor and the ultimate goal of treatment. Patient was transferred to the [**Hospital Ward Name 516**] for surgery. Postoperatively, pt was monitored with daily serum PTH measurements and q6--8hr serum calcium checks. Pt was maintained on IVF and intermittent lasix dosing, to gently diurese and allow for slow calcium excretion. Calcium was downward trending and had dropped to 8.9 on discharge. **Note: Patient's calcium took several days to normalize post-surgery, which was unusual as per Endocrinology. Her normocalcemia was most likely secondary to surgery but could be also due to the cinacalcet. A decision was made to stop her cinacalcet given her calcium normalization and to monitor her calcium daily at rehab. Her calcium values will be faxed to her Endocrinologist, Dr. [**Last Name (STitle) **]. She also has follow-up scheduled with her endocrinologist. #Respiratory failure: After extubation from surgery, patient developed respiratory distress with O2 sat approaching 60% and hypotension with BP 80s/50s. She was subsequently re-intubated and started on dopamine drip. Pt previously had a PICC line, but was found to be not working well. A Central venous line was therefore placed. When she came to the MICU, dopamine was weaned off, and subsquently extubated the next morning. The etiology of hypoxemia was unclear. CXR did not show worsening pulmonary edema. Most likely diagnosis was post-op apnea from anesthesia. Hypotension was unlikely acute coronary syndrome with troponin downtrending since admission. Felt most likely related with hypoxia vascular constriction causing right heart strain, in the setting of severely impaired LVEF. This could have been exacerbated in the setting of intubation and initiation of propofol. . # Acute on chronic systolic CHF. Patient has history of cardiomyopathy with EF=30% in [**2130**]. Exam consistent with right-sided failure at admission (JVD, LE edema) and repeat echocardiogram showed non-ischemic cardiomyopathy and EF = 25%. She received large volume IVF for treatment of hypercalcemia with frequent dosing of Lasix. Her I/O were kept even. However, her lasix was held on the day of the CT neck/torso for renal protection given the contrast load, and the rate of the fluid was decreased slightly to avoid acute exacerbation. Her CT neck/torso revealed pericardial effusion, pleural effusion, and anasarca. However, her pulsus was 8 mmHg on [**2134-6-30**]. The patient was diuresed with IV Lasix. She was restarted on 40 mg PO Lasix and 6.25 mg PO carvedilol, but her blood pressure dropped to the 80's, likely secondary to aggressive diuresis. These medications were held on discharge, but can be restarted as needed. Her baseline SBP was ranging 80's-100's. # Elevated troponin: Patient had TropT = 0.13 at arrival. She did not have cardiac complaints. Her MB was negative. It is thought that elevated troponin was likely due to decreased clearance in setting of heart failure. # Acute renal failure on chronic kidney disease. Patient has a baseline creatinine of around 1.2. Her creatinine was up to 1.8 on admission. It improved while she was on treatment for hypercalcium, likely due to improved forward flow. Medications were dosed renally. Lasix was held on the day of her CT neck/torso given contrast dye being a nephrotoxin. Creatinine stable at 1.5 on discharge. # Altered mental status/Delirium. She presented with lethargy and some confusion. Carbamazpine was subtherapeutic on level. The confusion improved as hypercalcemia improved. However, she remained somewhat lethargic with decreased motivation while on the medicine floor. Her mental status improved in the ICU. # Macrocytic anemia. Noted on admission. Patient had normal B12 and folate. She was noted to have increased reticulocyte counts. CHRONIC ISSUES: # Atrial fibrillation on warfarin. She is ventricularly paced. She has not taken warfarin for about 1 month prior to admission. Her INR on admission was 1.1. She has a CHADs = 2. She was started on ASA instead. Patient was monitored on telemetry during hospital course. Pt was restarted on coumadin post-operatively and will need follow up. # Seizures. Patient reports history of seizures when she was drinking EtOH. Carbamazepine was initially held given underlying AMS, but it was restarted as her confusion was resolving. # Type 2 Diabetes. Her home medications were held. She was placed on insulin sliding scale. She is discharged on her home anti-diabetic agents except for metformin given her kidney disease and Cr 1.5 on discharge. # History of Breast Cancer, s/p left mastectomy. Raloxifene was held. # GERD: Stable. Continued pantoprazole. TRANSITIONAL ISSUES: -daily Ca and PTH for 5 days after discharge -fax results to Dr. [**Last Name (STitle) **] in [**Hospital1 **] -follow up with surgery as directed -Full code -Coumadin restarted -> continued INR monitoring as outpt -home carvedilol 6.25 mg PO BID and furosemide 40 mg PO daily were discontinued due to borderline blood pressure (SBP 80's-90's) after aggressive diuresis, may need to restart Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PCP. 1. Furosemide 40 mg PO DAILY 2. Evista *NF* (raloxifene) 60 mg Oral daily 3. Carvedilol 25 mg PO BID 4. Carbamazepine (Extended-Release) 200 mg PO HS 5. Pantoprazole 40 mg PO Q24H 6. Januvia *NF* (sitaGLIPtin) 50 mg Oral daily 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Warfarin 5 mg PO DAILY16 9. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. Senna 1 TAB PO BID:PRN constipation 2. Carbamazepine (Extended-Release) 200 mg PO HS 3. Evista *NF* (raloxifene) 60 mg Oral daily 4. Januvia *NF* (sitaGLIPtin) 50 mg Oral daily 5. Pantoprazole 40 mg PO Q24H 7. FoLIC Acid 1 mg PO DAILY 8. Vancomycin 1000 mg IV Q48H Last day [**2134-7-15**]. 9. Aspirin 325 mg PO DAILY 10. Docusate Sodium 100 mg PO BID:PRN constipation 11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 15. Outpatient Lab Work Please draw daily Calcium, Albumin, Phosphate from [**7-8**] and fax results to:[**Telephone/Fax (1) 39839**] (Dr. [**Last Name (STitle) **]. 16. Outpatient Lab Work Vancomycin: Please check Vancomycin trough level Mondfay [**7-12**], [**2133**]. 17. Warfarin 2 mg PO DAILY16 Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**] Discharge Diagnosis: Primary Primary Hyperparathyroidism R-sided heart failure Secondary Diabetes Atrial fibrillation Breast cancer Seizure disorder NOS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 5051**]: It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted because of concern for your heart and for high calcium levels in your blood. Tests determined that you have a condition called primary hyperparathyroidism. This was treated with fluids, lasix, and several other medications. The endocrine experts evaluated you and suggested further imaging which found a parathyroid adenoma. You had a surgery to remove the adenoma and your blood levels were checked daily. You will need to follow up with your endocrinologist Dr. [**Last Name (STitle) **] and with the general surgen who did your surgery. Followup Instructions: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: [**Street Address(2) 4472**], [**Apartment Address(1) 14327**], [**Hospital1 **],[**Numeric Identifier 4474**] Phone: [**Telephone/Fax (1) 53156**] Appt: [**7-13**] at 12:40pm ***Please make sure to contact your pcps office and obtain an insurance referral for this visit. Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: [**Street Address(2) 2687**],STE 6B, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 9**] Appt: [**7-19**] at 4pm Completed by:[**2134-7-9**]

Admission Date: [**2183-12-31**] Discharge Date: [**2184-1-11**] Service: ADMISSION DIAGNOSIS: Right colon cancer. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old woman with a history of diabetes mellitus, hypertension and elevated cholesterol who, on an evaluation as an outpatient, was found to be anemic and a colonoscopy revealed a right colon cancer in [**2183-12-18**]. The patient was then scheduled for elective right colectomy. PAST MEDICAL HISTORY: As above. MEDICATIONS ON ADMISSION: Procardia 60 mg p.o. q.d. Captopril 50 mg p.o. t.i.d. Lipitor 10 mg p.o. q.d. Insulin 409 units of NPH q.a.m. PAST SURGICAL HISTORY: The patient had an open cholecystectomy in [**2162**]. ALLERGIES: The patient had an allergy to penicillin. PHYSICAL EXAMINATION: Vital signs revealed a temperature of 98.8??????F, a heart rate of 100, a blood pressure of 136/59, respirations of 18 and an oxygen saturation of 100% on room air. In general, the patient was a pleasant, obese, elderly woman. On head, eyes, ears, nose and throat examination, the mucous membranes were moist. The neck had no lymphadenopathy. The heart had a regular rate and rhythm. The lungs were clear. The abdomen was soft. There was mild right sided tenderness and the abdomen was nondistended. LABORATORY: The patient had a white blood cell count of 13,100 with a hematocrit of 35.5 and a platelet count of 543,000. Potassium was 4.0. BUN was 12 and creatinine was 0.7. Glucose was 130. RADIOLOGY: A chest x-ray showed no evidence of infiltrate or metastatic disease. ELECTROCARDIOGRAM: An electrocardiogram had sinus rhythm at 100. HOSPITAL COURSE: The patient was admitted for bowel prep and tolerated the bowel prep. On [**2184-1-2**], she underwent right colectomy without complications. Postoperatively on that night, the patient was stable. However, she required intravenous fluid bolus for low urine output. On postoperative day #1, the patient continued to require intravenous fluid boluses for urine output and developed a persistent tachycardia. After receiving intravenous fluid resuscitating without good response to intravenous fluid bolus, the patient became short of breath and was transferred to the Intensive Care Unit for further management. The patient was treated for congestive heart failure and was ruled in for a myocardial infarction with electrocardiogram changes and elevated levels of troponin. A cardiology consultation was requested and an echocardiogram was performed, which revealed a significantly decreased ejection fraction of approximately 15% with severe hypokinesis and akinesis of the inferior and lateral walls. The patient was started on beta blocker and ACE inhibitor for afterload reduction to optimize her hemodynamics. The patient was also started on aspirin. Once her hemodynamics were optimized and diuresis of fluid was initiated, the patient improved and, on postoperative day #4, she was transferred back to the hospital floor. The patient then soon passed flatus and was slowly advanced to a regular diet. She was continued on Lasix diuresis as well as beta blockade, afterload reduction and aspirin. The patient continued to do well with good response to diuresis and improved pulmonary function and was saturating well on room air and breathing comfortably. On postoperative day #9, the patient was tolerating a regular diet and was ambulatory with physical therapy. However, the patient required significant assistance, which indicated a rehabilitation transfer. On postoperative day #7, an ultrasound of the right upper extremity was performed, which showed a cephalic vein deep vein thrombosis, and the patient was started on Coumadin at that time for treatment of the deep vein thrombosis as well as for prophylaxis for the severe wall motion abnormality of the heart. DISCHARGE DIAGNOSIS: 1. Right colon cancer. 2. Status post right colectomy on [**2184-1-2**]. 3. Postoperative myocardial infarction. 4. Diabetes mellitus. 5. Hypertension. 6. Elevated cholesterol. 7. Right cephalic vein deep vein thrombosis. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Captopril 50 mg p.o. t.i.d. 3. Coumadin, adjust for INR of 2 to 3. 4. Lasix 40 mg p.o. b.i.d. 5. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. 6. Percocet one to two tablets p.o. every three to four hours p.r.n. for pain. 7. Aspirin. 8. Clonidine patch. 9. Subcutaneous heparin. 10. Insulin sliding scale. [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**] Dictated By:[**Name8 (MD) 26116**] MEDQUIST36 D: [**2184-1-10**] 22:06 T: [**2184-1-10**] 22:56 JOB#: [**Job Number 104767**]

Admission Date: [**2199-2-19**] Discharge Date: [**2199-2-26**] Date of Birth: [**2133-2-9**] Sex: F Service: CSU CHIEF COMPLAINT: Blurry vision. HISTORY OF PRESENT ILLNESS: Patient is a 66-year-old woman with a history of hypertension who presented to [**Hospital3 6265**] on [**2199-2-15**] with blurry vision, lightheadedness, and unsteady gait. A MRI done on [**2199-2-16**] demonstrated multiple small infarcts in the cerebellar hemisphere, left occipital, medial, left temporal lobe consistent with embolic events. A transesophageal echocardiogram demonstrated a large myxoma of the left atrium, and she was transferred to [**Hospital1 18**] for further care. At the outside hospital, she was anticoagulated and otherwise remained stable. PAST MEDICAL HISTORY: Significant for dyslipidemia, borderline hypertension. PAST SURGICAL HISTORY: None. MEDICATIONS AT HOME: Include MVI. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother has a history of hypertension. Father had history of asthma. SOCIAL HISTORY: No EtOH. Remote history of smoking. She lives at home with her husband. PHYSICAL EXAM: Temperature is 97.3, heart rate 79, blood pressure 150/46. She is [**Age over 90 **]% on room air. She is in no acute distress, appearing well. There is no JVD. No carotid bruits. Heart is regular with no murmurs. Her lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended. She has 2+ distal pulses with no edema in the extremities. She is alert and oriented times three and demonstrated a nonfocal neurologic exam. Laboratory values include a white count of 3.7, hematocrit of 31, platelets of 182. INR was 1.1. BUN was 10, creatinine was 0.7. Rest of her labs were unremarkable. For imaging studies, she had a MRI done on [**2199-2-16**], which demonstrated multiple small acute and subacute infarcts in the cerebellar hemispheres, left occipital lobe, the left medial/left temporal lobe, the left thalamus, and the right midbrain consistent with shower embolic infarcts in the posterior circulation. No hemorrhage. She also had a TEE on [**2199-2-18**] which demonstrated a 3 cm x 3 cm mass extending from the high intra-atrial septum of the left atrium. There is no prolapse to the mitral valve. It is multilobular and very mobile. It does not extend across the intra-atrial septum. There was good left ventricular function. She had underwent cardiac catheterization which demonstrated normal coronary arteries, normal cardiac index. Echocardiogram done [**2199-2-19**] here demonstrated an EF of 60%, a mass in the left atrium, normal wall motion. Chest x-ray had no congestion and no infiltrate. HOSPITAL COURSE: After her workup by the neurology service, the stroke service, the cardiology team, and cardiac surgery team, patient was taken to the operating room on [**2199-2-21**], where she underwent an atrial myxoma removal and primary repair of intra-atrial septum. She tolerated this procedure well. She postoperatively was transferred to the cardiac surgery intensive care unit. Patient was extubated, remained hemodynamic normal. Was weaned off all pressors. She was transferred to the floor on postoperative day #1. After removal of tubes and wires, she was anticoagulated with Coumadin. Postoperatively, she did have a right hand thrombophlebitis from an old IV site which was monitored and treated with a course of Keflex. She was seen by physical therapy and has passed a level 5 evaluation. She has been stable and is now ready for discharge to home, where she will be anticoagulated and followed by her primary cardiologist. DISCHARGE DIAGNOSES: Embolic stroke. Left atrial myxoma. Hypertension. Right hand thrombophlebitis. Hypercholesterolemia. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. b.i.d. 2. Aspirin 81 mg daily. 3. Percocet 5/325 [**11-18**] p.o. q.4h. p.r.n. 4. Keflex 500 mg 1 q.6. x7 days. 5. Lasix 20 mg p.o. daily for 10 days. 6. Potassium chloride 20 mEq p.o. daily for 10 days. 7. Coumadin 2 mg per day and this will be adjusted according to an INR level and discussed with Dr. [**Last Name (STitle) 61120**]. DISPOSITION: The patient is being discharged home with VNA services who will monitor wound healing and assess cardiopulmonary status. Encourage ambulation and check INR on [**2-28**] and [**3-4**]. Results will be called to Dr. [**Last Name (STitle) 61120**] at [**Telephone/Fax (1) 61121**]. She will follow up with Dr. [**Last Name (STitle) 61120**] in 2 weeks. Call for an appointment with Dr. [**Last Name (STitle) **] in 4 weeks. DISCHARGE CONDITION: Good. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) 8958**] MEDQUIST36 D: [**2199-2-26**] 15:03:52 T: [**2199-2-26**] 16:40:02 Job#: [**Job Number 61122**]

Admission Date: [**2160-8-1**] Discharge Date: [**2160-9-8**] Date of Birth: [**2093-10-4**] Sex: M Service: NEUROSURGERY Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 2724**] Chief Complaint: back pain Major Surgical or Invasive Procedure: Resection of T5 tumor, lateral extra cavitary T9 vertebrectomy, and posterior instrumented fusion from T2-T11. Left-sided thoracentesis tracheotomy Peg placement History of Present Illness: 66 year old male with known metastatic thyroid CA to spine, brain, ribs presented to Dr.[**Name (NI) 6767**] office for routine follow-up today. The patient has back pain but no numbness or tingling. The pain in his back is more of a dull ache and is not nearly as painful as the pain he had in his neck prior to the cyberknife treatment he had at C1 in [**Month (only) 958**] of this year. He has not had any urinary incontinence but did notice stool staining in his underwear twice this week when he woke up in the morning. He has had controlled bowel movements since then and reports no loss of sensation in the groin or buttock region. The patient noticed that his right leg felt slightly weaker recently, but he had a right hip replacement and attributed the weakness to that surgery. The patient had an MRI of the thoracic spine which showed a new large lesion almost completely occluding the canal. Dr. [**Last Name (STitle) 724**] sent him to the ER for neurosurgical evaluation. Past Medical History: Metastatic Thyroid Ca HTN Atrial Fibrillation Pulmonary Embolus [**1-28**] - Anticoagulated with coumadin; has two small lesions on MRI head c/w mets but not contraindications to anticoag. Hypothyroidism Social History: Lives with wife. [**Name (NI) 1403**] part time in real estate building and development and is still currently working. Retired from full time work in [**2157-9-22**]. Smoked approximately 30 years ago (quit in [**2126**]) EtOH: drinks 1 glass wine/day Family History: Mother with h/o emphysema. Physical Exam: PHYSICAL EXAM: T:98.2 BP:125/60 HR:54 RR:16 O2Sats:95% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs-intact Neck: In cervical collar. Surgical incision well-healed. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Spine: No point tenderness. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G R 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch bilaterally. No sensory loss in thoracic region or in legs. Reflexes: Pa Ac Right 2+ 1+ Left 3+ 1+ Toes downgoing bilaterally No clonus Pertinent Results: MRI of the thoracic and lumbar spine. [**2160-8-1**] IMPRESSION: Bony metastatic disease involving the T4, T5, T9, and T10 vertebrae. Spinous process metastasis at T5 indents the spinal cord and results in 50% narrowing of the spinal canal with slight indentation on the spinal cord. Epidural metastasis on the right side of the spinal canal at T9 level displaces the spinal cord to the left side and results in slightly more than 50% narrowing of the spinal canal with moderate cord compression. Other changes as described above. IMPRESSION: Bony metastasis to right pedicle and body of the L1 and superior portion of L2 vertebra as described above. No evidence of epidural mass or spinal cord compression. BONE SCAN. [**8-4**] IMPRESSION: 1. Osseous metastasis in multiple levels of the thoracic and lumbar spine as described above. Uptake in some vertebrae might be related to degenerative changes but a differentiation cannot be made on the base of this study. 2. Osseous metastasis involving multiple bilateral ribs. 3. Osseous metastasis involving bilateral distal femora. 4. Increased uptake surrounding the femoral component of the right hip prosthesis in the right acetabulum likely related to post-operative changes. However, residual underlying metastasis cannot be ruled out completely. [**2160-9-8**] 05:30AM BLOOD WBC-7.3 RBC-3.72* Hgb-10.8* Hct-32.0* MCV-86 MCH-29.0 MCHC-33.7 RDW-17.3* Plt Ct-74* [**2160-9-2**] 06:15AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL [**2160-9-8**] 05:30AM BLOOD Plt Ct-74* [**2160-9-8**] 05:30AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-131* K-4.5 Cl-97 HCO3-27 AnGap-12 [**2160-9-4**] 04:02AM BLOOD ALT-65* AST-22 AlkPhos-59 TotBili-0.5 [**2160-9-3**] 02:10AM BLOOD proBNP-1249* [**2160-9-8**] 05:30AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.2 [**2160-8-18**] 03:18PM BLOOD Hapto-165 [**2160-8-14**] 04:02AM BLOOD Homocys-7.8 [**2160-8-14**] 02:49PM BLOOD Ammonia-<6 [**2160-8-14**] 02:49PM BLOOD T4-4.7 T3-24* [**2160-8-15**] 12:05PM BLOOD Cortsol-20.7* [**2160-8-24**] 02:44AM BLOOD Digoxin-1.0 Brief Hospital Course: The patient was admitted to the neurological surgery service on [**8-1**] for treatment. On admission, he was started on dexamethasone, maintained on levonox fo prior history of pulmonary embolism and maintained in a TLSO. In preparation for surgery on [**8-4**], a medicine consultation was obtained for surgical risk stratification. CT exam also showed a T9 destructive lesion. Also, bone scan showed evidience of mets at multiple levels of the thoracic and lumbar spine, ribs, and femurs. On [**8-5**] he had an embolization by Dr. [**First Name (STitle) **] and on [**8-7**] he had T1-T12 Fusion. On [**8-8**] he had good strength but was not following commands. He received 2u PRBC and his repeat HCT was 28.9 On [**8-10**] Sputum Cx sent. SVT w/[**Month/Year (2) 5509**] so a dilt drip was started. One drain was removed. On [**8-12**] bilateral pleural effusions were tapped by IR and on the following day the 2nd drain out was removed and he was extubated. On [**8-14**] he was re-intubated. The next day his mental status improved, was following some commands and went to the OR for trach/peg. He tolerated the procedure well and was transitioned to a trach mask on [**8-16**]. On [**8-18**] he had A-fib with rapid rate and was on esmolol drip. Staples were removed that day. The esmolol was turned off on [**8-19**] and he was transferred to the step down unit. The patient had drainage from the JP site so a chest CT was obtained which did not show pleural or thoracic fistula. On [**8-21**] he was in a-fib again with [**Month/Day (4) 5509**] and was sent back to the ICU. Cardiology was consulted to help manage his heart rate/rhythm. He converted to sinus rhythm while in the ICU. The patient had drainage from his JP site on [**8-24**] that was purulent, tan, thick material. On [**8-25**] thoracics was consulted and they determined that there was no indication for surgery since the pleural effusions were improved. It appeared that the drainage was only from the JP site and not from the previous thoracentesis site. The JP site was still leaking but the drainage was thin and yellowish. Dr. [**Last Name (STitle) 548**] placed new sutures over the area and by the next day ([**8-26**]) the site was completely dry the sutures need to stay in place until [**9-12**] On [**8-24**] a sputum culture came bac positive for pseudomonas so Zosyn was started. ID was consulted and agreed that this should be continued for 7 days. The drainage from the JP site grew out proteus for which Zosyn was also appropriate. Mr. [**Known lastname 20598**] was treated for HSV 1 infection on his lips with acyclovir as well. He was transferred to step down unit again on [**8-26**] but then to the MICU on [**8-28**] for lower GI bleed and melena. Pt was transfused 1 U prbcs and underwent a colonoscopy which showed:Polyp in the ascending colon, Diverticulosis of the left > right, Ulcers in the distal rectum (biopsy. Recommendations from GI were: Follow-up pathology results. Hold anticoagulation for now and avoid rectal tubes. He was transferred to the MICU service on two different occassions due to a GI bleed and atrial fibrillation. Brief MICU course: # Afib with [**Month/Day (4) 5509**]. Has had intermittent Afib in past, on amio for rhythm control as well as metoprolol. Metoprolol just restarted today. Precipitant now unclear - hypovolemia, hypervolemia, infection/sepsis, PE, other pulmonary disease, hyperthyroidism. Appears slightly dry on exam (crackles asymmetric). Getting T4 replacement though not currently, appears to have been lost during transfer (last [**8-21**]). Has been on dilt gtt in past during admit. Did not respond to 10 IV dilt and 10 IV lopressor. BP holding >90. BP responsive to 500 cc bolus. Initially on esmolol gtt, now d/c??????d and getting Metoprolol PO. Echo showed no effusion, EF 55%, leaflets normal but limited study. On readmission to MICU, his TSH was found to be 15. There was concern for PE given the patient's history, but LENIs were negative. Pt had another episode of rapid rates to 180s on the morning of [**9-3**] which transiently decreased with lopressor and resolved after 750 mL NS bolus. Amiodarone was returned to former dosing of 200 mg [**Hospital1 **]. . #Hypothyroidism. Current transfer meds did not include levothyroxine and apparently this med had been held since transfer on [**8-21**] (not reordered in transfer orders). Continued Synthroid at home dosing plus 200mcg daily. Will need close f/u of TSH in coming days and weeks to correctly dose levothyroxine. # Hypoxemia. After transfer to the MICU, was requiring more O2 than prior transfer (50% TM at the time, now 70-100%). Desat to 80s on [**9-2**], improved after Atrovent neb. Over remainder of stay requred 50-70% FiO2 on trach mask. There was intially concern for infiltrate on his CXR, so his Zosyn was continued until [**2160-9-4**]. An intial BNP 1727, which decreased to 1200s the next day. Given concern for PE, LENIs were performed and were negative. - Also tried to wean sedating meds including neuroleptics and pain meds. . #Metastatic papillary CA: S/p recent T1-T12 palliative decompression and fusion on [**2160-8-7**] with known brain, bone and soft tissue mets. -No active treatment for now, long-term plan of care per Neurosurgery . # LGIB: In the setting of anticoagulation with Lovenox (60mg [**Hospital1 **]) for a history of PE in the past. 3 unit PRBC transfusion but now stable. Ulcers on colonoscopy, bx showed no evidence of malignancy, but acute and chronic inflammation consistent with ulcer. Pt has been continued on [**Hospital1 **] PPI as per GI recs. Daily Hcts have been stable in MICU. . # Pseudomonas VAP: Pt with Pseudomonas in sputum from [**8-25**] and on Zosyn since [**8-23**]. 10 day course extended until [**9-4**] given hypoxemia and concern for infiltrate on CXR. Added vanc/cipro [**2160-8-31**], d/c'd cipro [**2160-9-2**]. Vancomycin was d/c'd on [**9-3**] when the sputum culture from [**9-1**] failed to show any growth. # Delirium: Pt with history of delirium that began this admission. Previously had been working. requires frequent reorientation. Has been getting zyprexa prn, however attempting to decrease amount of sedation. . # Leukocytosis: Stable in the 10K range. . # h/o PE: Pt with history of DVT/PE in [**2159-1-22**]. On anticoag at therapeutic dosing earlier during admit (when had GIB); also with history of hemoptysis presumably from lung mets; also known brain mets. Given his recent GI bleed and hemoptysis we decided to use heparin sq only #Thrombocytopenia: Plt count recovering from nadir of 38LK --> 89K, now 74K Unclear if thrombocytopenia was medication related. Stable. . #Prophy: Pneumoboots, PPI.# . #Code: FULL . Goals of care when speaking with Mrs [**Known lastname 20598**] is to get Mr [**Known lastname 20598**] home with services if possible. We discussed possible Hospice but she does not want to consider that option at this point. On discharge Mr [**Known lastname 20598**] was awake, alert, orientated x3 comfortable with full strenght in his lower extremities, his wound was healing no erthyema. He had low grade temps 99 range he had full work up given his complicated medical history. His UA and CXR were negative for infection, blood cultures are pending. He continues to receive tube feeds but has also passed a swallow test for ground food. His trach can be down sized. Medications on Admission: AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth once a day ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once a day ENOXAPARIN [LOVENOX]- 40 mg/0.4 mL Syringe GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth twice a day LEVOTHYROXINE - 200 mcg Tablet - 1 Tablet(s) by mouth once a day LEVOTHYROXINE - 25 mcg Tablet - 0.5 (One half) Tablet(s) by mouth Mon, Wed, Fri OXYCODONE [OXYCONTIN] - 40 mg Tablet SustSR 12 hr - 1 Tablet(s) by mouth three times a day DOCUSATE SODIUM - 100 mg - 1 Capsule(s) by mouth twice a day Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Known lastname **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution [**Known lastname **]: One (1) Injection TID (3 times a day). 3. Senna 8.6 mg Tablet [**Known lastname **]: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Known lastname **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Docusate Sodium 50 mg/5 mL Liquid [**Known lastname **]: One (1) PO BID (2 times a day). 6. Gabapentin 250 mg/5 mL Solution [**Known lastname **]: One (1) PO BID (2 times a day). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 9. Mupirocin Calcium 2 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation QID (4 times a day) as needed for wheeze or shortness of breath. 11. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 12. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a day). 14. Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q3H (every 3 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Metastatic thyroid cancer to spine HSV 1 infection on lips Pseudomonas infection in sputum Intermittent a-fib with rapid ventricular rate Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up. ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Wear cervical collar as instructed ?????? You may shower briefly without the collar unless instructed otherwise ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS. Have you drain sutures in the back removed on [**9-12**] you may do that at rehab Completed by:[**2160-9-8**]

Admission Date: [**2191-1-22**] Discharge Date: [**2191-1-23**] Date of Birth: [**2118-11-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72-year-old female with a history of non-small cell lung cancer (diagnosed in [**2178**]), non-massive hemoptysis (s/p right fifth posterior intercostal artery embolization on [**2191-1-12**]), and recent admission for weakness ([**2191-1-14**] to [**2191-1-18**]). She presents from home today following dyspnea at home. Patient reportedly had been found to be confused at home with with O2Sat 50% on room air, which then came up to 99% on NRB. In the field, intial BP was 80/palp, so patient received 200 mL NS enroute to the ED. [**Name (NI) **] son is concerned that patient's new medication, levothyroxine, is the reason for presentation since the patient became acutely ill 2 hours following the first time she took the medicine the morning prior to presentation. Patient was reportedly doing well and had breakfast without difficulty, though after taking her medication with Ensure was found to have white frothy secretions. . Vitals upon presentation to the ED were: T 99.8, HR 84, BP 109/60, RR 16, O2Sat 75% RA. Patient was given levofloxacin and Zosyn. Family refusing translator in the ED. Patient is DNI, though family was not ready to have CMO discussion according to ED resident. Prior to transfer to the unit, vitals were: T 99.9, HR 73, BP 77/47, RR 12, O2Sat 100% NRB. Past Medical History: 1) Stage IV NSCLC - thoracotomy with biopsy and partial resection ([**2178**]) - XRT to right chest wall + mediastinum ([**2178**]) - 6 cycles of carboplatin/gemcitabine or cisplatin/paclitaxel (between [**2184**] and [**2185**]) - 2 cycles of possible vinorelbine ([**2187**]) - 6 cycles of pemetrexed 500 mg/m2 ([**2188**]) - erlotinib 150 mg/day ([**Month (only) 404**] to [**2189-4-28**]) - 2 cycles of docetaxel 35 mg/m2 and cetuximab 250 mg/m2 weekly between [**2189-10-28**] and [**2190-11-28**] - 1 cycle of carboplatin 5 AUC D1 and gemcitabine 1000 mg/m2 D1 of 21 day cycle in [**2190-3-28**] ([**2190-4-21**]) - palliative chest radiotherapy to [**2181**] cGy completed ([**2190-6-2**]) 2) Hypertension 3) GERD 4) Anxiety 5) Palpitations 6) Hypothyroidism 7) Hypercholesterolemia 8) s/p resection of colonic polyps Social History: The patient is originally from [**Location (un) 6847**]. She has been in the United States since [**84**]/[**2187**]. She denies exposure to heavy chemicals of asbestos. Tobacco: Denies, though was exposed to fumes during her work as a cook back in [**Location (un) 6847**]. EtOH: Denies. Illicits: Denies. Patient has 4 children. Family History: Non-contributory. Physical Exam: VS: T 97.1, HR 81, BP 112/57, RR 21, O2Sat 94% on 95% facemask with 5L NC GEN: Somnolent HEENT: PERRL, EOMI, oral mucosa slightly dry NECK: Supple, no [**Doctor First Name **] PULM: Minimal breath sound on right, left side with coarse breath sounds and basilar crackles CARD: RR, nl S1, nl S2, no M/R/G ABD: BS+, soft, NT, ND, non-tympanitic EXT: no peripheral edema, significant clubbing of bilateral fingernails SKIN: no rashes NEURO: Oriented x 3, somnolent, difficult to perform full neuro exam in setting of language barrier and somnolence Pertinent Results: Lab results on admission: [**2191-1-21**] 11:25PM WBC-8.9 RBC-3.91* HGB-10.4* HCT-33.2* MCV-85 MCH-26.5* MCHC-31.2 RDW-17.9* [**2191-1-21**] 11:25PM NEUTS-84.8* LYMPHS-10.8* MONOS-3.7 EOS-0.4 BASOS-0.3 [**2191-1-21**] 11:25PM PLT COUNT-358 [**2191-1-21**] 11:25PM GLUCOSE-108* UREA N-40* CREAT-1.0 SODIUM-135 POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 [**2191-1-21**] 11:29PM TYPE-ART PO2-215* PCO2-59* PH-7.30* TOTAL CO2-30 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP [**2191-1-21**] 11:25PM PT-13.4 PTT-27.7 INR(PT)-1.1 [**2191-1-21**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 LEUK-MOD [**2191-1-21**] 11:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2191-1-21**] CXR: IMPRESSION: Increased airspace consolidation overlying the left lower lung zone. Likely pneumonia or aspiration. Otherwise stable appearance with stents overlying the right mid lung zone and near entire collapse of the right hemithorax from known squamous cell malignancy. Brief Hospital Course: This is a 72-year-old female with a history of non-small cell lung cancer (diagnosed in [**2178**]), non-massive hemoptysis (s/p right fifth posterior intercostal artery embolization on [**2191-1-12**]), and recent admission for weakness ([**2191-1-14**] to [**2191-1-18**]). . #. Hypoxia: Most likely related to new LLL infiltrate on chest xray, though other possibilities include aspiration event or health-care associated/community acquired PNA. As such, Ms. [**Known lastname **] was covered broadly with vancomycin/zosyn/levofloxacin. She was also treated for influenza with oseltamivir given her poor pulmonary reserve. A DFA for flu and urine legionella antigen were sent. However, despite the antibiotics and IVF, Ms. [**Known lastname **] continued to be hypoxic. She was given maximal 02 with venti mask, but still had increased work of breathing. After long discussions with family, it was decided to make patient DNR/DNI and not place invasive central venous catheters for pressure support. Throughout the night on [**1-23**] patient had increasingly labored breathing and the family was called to the bedside. Ms. [**Known lastname **] eventually passed surrounded by family. . #. Hypotension: This was concerning for sepsis, even though Ms. [**Known lastname **] was initially fluid responsive. She was continued on fluids (as her 02 sats tolerated) and antibiotics. Moreover, she developed a pronounced cardiac arrhythmia toward the end of her life, which also contributed to her poor cardiac output. . #. Urinary tract infection: UTI on admission might also be contributing to septic picture and altered mental status. Again, antibiotic coverage with Vancomycin, Zosyn, Levofloxacin. . #. Somnolence: Multifactorial, with etiologies including sepsis, hypotension, hypoxia, and hypercarbia. An ABG in ED showed respiratory acidosis at 7.30/59/215. Patient was ventilated maximally with venti mask, though no invasive ventilation pursued as above. . #. NSCLC: Patient has survived well beyond the documented expectations of her physicians. Most recently has had course complicated by non-massive hemoptysis s/p embolization. She has been on home hospice for approximately a year. Family understood gravity of the situation and Ms. [**Known lastname 68912**] strength thus far, but still hoped for a miracle. Medications on Admission: *per discharge on [**2191-1-19**]* 1) Acetaminophen 325-650 mg PO Q6H:PRN pain 2) Amiodarone 200 mg PO DAILY 3) Prednisone 5 mg PO DAILY 4) Metoprolol Succinate 25 mg PO DAILY 5) Pantoprazole 40 mg PO Q24H 6) Pravastatin 40 mg PO DAILY 7) Ranitidine HCl 150 mg PO HS 8) Morphine SR 15 mg PO Q12H 9) Docusate Sodium 100 mg PO BID 10) Multivitamin PO DAILY 11) Aspirin 81 mg PO DAILY 12) Ibuprofen 400 mg PO Q8H:PRN pain 13) Fentanyl 50 mcg/hr Patch Transdermal Q72H 14) Lasix 20 mg PO DAILY 15) Levothyroxine 100 mcg PO DAILY 17) Potassium Chloride PO Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Patient expired. Discharge Condition: Patient expired. Discharge Instructions: Patient expired.

Admission Date: [**2182-5-19**] Discharge Date: [**2182-5-24**] Date of Birth: [**2132-9-19**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 2901**] Chief Complaint: Cardiac arrest Major Surgical or Invasive Procedure: Intubation Hemodialysis Central line placement History of Present Illness: This is a 49 year-old male with history of diabetes, hypertension, and end stage renal disease who was transfered from an outside hospital after a PEA arrest. For the past week, he has been feeling unwell. One week ago, he underwent placement of a perotoneal dialysis catheter. At that time, he required hospital admission for 2 days due to hyperkalemia and hyperglycemia. He was not dialysed at that time. He had persistent nausea. The day prior to admission, he was back to his baseline health, which is severe fatigue with ambulation of a few yards. The morning of presentation, he began to feel nauseated. Per report, he fell from his chair and was unresponsive. He had some jerking movements of his arms that were similar to his hypoglycemic episodes. Shortly thereafter, he was responsive but then became unresponsive again. When EMS arrived, he was found to be bradycardic in PEA arrest. He received epi and atropine. He subsequently became hypotensive to the 60s systolic and was asystolic. He was transcutaneously paced. He was taken to an outside hospital where he continued to be hypotensive. He received 4 L of IV fluid resuscitation. A temporary pacer was placed, and he was paced at 80 beats per minute. Without pacing, he had only rare junctional escape beats. His labs were notable for hyperkalemia to 6.2, hyperglycemia to the 700s, and acidemia with a pH of 7.03. Cardiac enzymes were negative and his BNP was elevated to [**2175**]. An echocardiogram revealed an EF of 15-20% with global hypokinesis and decreased right ventricular function. He was transfered to the [**Hospital1 18**] for further management. On transfer, his vent settings were noted to be incorrect and he was found to be hypoxic to the 50s on 2 separate gases about 1.5 hours apart. On arrival he was oxygenating well. He was on 5 mcg of levophed to maintain his blood pressure. He was intially unresponsive, with fixed dilated pupils, with an absent corneal and gag reflex. An initial potassium was 6.4. He received calcium, bicarb, insulin, and kayexelate. He was admitted to the CCU. Past Medical History: 1. Insulin dependant diabetes diagnosed 20 years ago. 2. End stage renal disease for about 1.5 years with plans to start perironeal dialysis next month. A PD catheter was placed last week. 3. Hypertension 4. Hyperlipidemia 5. History of lens removal in left eye. 6. History of TIA Social History: He is currently not working. He is married and has 2 children. He smokes 1 pack per day. He doesn't drink alcohol. Family History: His mother has a triple bypass in her 60s. She also has diabetes and hypertension. Physical Exam: Vitals: Temperature:34 rectal Blood Pressure:121/72 on levophed Pulse:80 V-paced Respiratory:16 Rate: Oxygen Saturation:99% on vent. General: Intubated in no acute distress. HEENT: Left pupil surgical fixed at 8mm, right pupil surgical at 6mm, moist mucous membranes. Cardiac: Regular rhythm, paced, S1, S1, no murmurs, rubs, gallops. Pulmonary: Clear to auscultation bilaterally. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended, healing surgical incision. Extremities: Cool to touch, 2+ radilal and dorsalis pedis pulses. Left cortis dressing intact. Neuro: Spontaneous eye opening, tracking to voice, moving all 4 extremities. Pertinent Results: Outside Hospital: 1. Chest x-ray: Cardiomegally, pacer wires coiled in the right ventricle, pulmonary edema, widened mediastinum. 2. Head CT: Negative for acute bleed or mass effect. 3. Echocardiogram: EF 15-20% with global hypokinesis. Decreased right ventricular systolic function. . [**Hospital1 18**]: 1. Chest x-ray: Cardiomegally, pacer wires coiled in right ventricle, widened mediastinum, pulmonary edema. 2. Chest CTA: No pulmonary emboli, no aortic dissection, pulmonary edema with bilateral pleural effusions, coronary arteries grossly clean. . EKG: Ventricular paced at 80 bpm with left bundle morphology. EKG with underlying rhythm: narrow complex escape beats at 50-60. . TTE [**2182-5-21**]: Conclusions: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. LVEF 40% Distal anterior, apical, and distal inferior hypokinesis is present. 3. The aortic root is mildly dilated. 4. The mitral valve leaflets are mildly thickened. 5. There is mild pulmonary artery systolic hypertension. 6. There is a small pericardial effusion. . . Exercise stress test: [**2182-5-22**] The baseline EKG showed prominant voltage, diffuse STT wave abnormalities and LAE. No additional, significant ST segment changes over baseline were observed during the infusion or in recovery. The rhythm was sinus with no ectopy. Appropriate blood pressure response to the infusion; blunted heart rate response. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or significant EKG changes over baseline. Nuclear report sent separately. . PERSANTINE MIBI [**2182-5-22**] RADIOPHARMECEUTICAL DATA: 3.1 mCi Tl-201 Thallous Chloride; 21.0 mCi Tc-[**Age over 90 **]m Sestamibi; HISTORY: Diabetes, ESRD, and hypertension, status post hyperkalemia-related cardiac arrest. CAD evaluation. SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 milligram/kilogram/min. Two minutes after the cessation of infusion, Tc-99m sestamibi was administered IV. INTERPRETATION: Image Protocol: Gated SPECT Resting perfusion images were obtained with thallium. Tracer was injected 15 minutes prior to obtaining the resting images. This study was interpreted using the 17-segment myocardial perfusion model. The image quality is adequate. Left ventricular cavity size is dilated, and more dilated at stress than at rest. Resting and stress perfusion images reveal uniform tracer uptake throughout the myocardium. Gated images reveal diffuse hypokinesis without focal wall motion abnormalities.The calculated left ventricular ejection fraction is 48% IMPRESSION: 1. Normal myocardial perfusion. 2. Transient dilitation of the left ventricle during dipyridamole (stress) images compared to rest, with a baseline dilated left ventricle. Brief Hospital Course: 49 year-old male with diabetes, end-stage renal disease, hypertension, hyperlipidemia admitted with cardiac arrest likely secondary to hyperkalemia and acidemia. . 1. Cardiac arrest: Patient had an asystolic arrest in the setting of hyperkalemia to 6.4 and acidemia to 7.0. On arrival, he was 100% paced with an underlying rhythm of 50-60s junctional escapes. He was also hypotensive requiring Levophed. He was treated for hyperkalemia in the emergency department with calcium gluconate, bicarb, insulin, and Kayexalate. His mental status improved with treatment of hyperkalemia. His EKG with back-up pacing at a rate of 40 showed heart block with occasional conducted beats with AV delay. There was also some inappropriate pacing spikes. The sensing was decreased with good effect. He subsequently converted to normal sinus rhythm without AV delay as his potassium was corrected. His blood pressure also improved with treatment of his hyperkalemia. He is currently off of Levophed. Patient had a repeat TTE which demonstrated an improvement in his EF to 40%. Temporary pacer was discontinued on [**2182-5-20**]. Patient did not have further evidence of arrythmia. He will have close follow-up locally and he will have his PCP refer him to a local cardiologist. . 2. Chronic renal failure: secondary to diabetes and hypertension. At the OSH the patient had a catheter placed with the goal of starting peritoneal dialysis in 1 month. However, during that hospitalization, he then developed hyperkalemia and subsequent PEA arrest, which required transfer to [**Hospital1 18**].He was dialyzed on the night of admission and had two additional sessions of hemodialysis while in-house. Tunneled dialysis line placed [**5-22**] and out-pt hemodialysis was coordinated; he has follow-up with Dr. [**Last Name (STitle) **] his nephrologist on [**2182-5-25**]. . 3. Diabetes: He was hyperglycemic to 700s initially without any evidence of ketosis. He received insulin and was started on an insulin drip. He was requiring 1 unit per hour. On hospital day 2, he was transitioned to NPH and the insulin drip was weaned off. He was discharged on a regimen of glargine and lispro. . 3. Congestive Heart Failure: At the outside hospital, he had an echocardiogram that showed diffused hypokinesis with an ejection fraction of 15-20%. It also showed decreased right ventricular function. According to his wife, he had a normal echocardiogram on month prior. Repeat ECHO at [**Hospital1 18**] showed at EF of 40%. His EF may continue to improve following this event. He should have a repeat ECHO in the next several months. . 4. Elevation in cardiac enzymes: On admit, he had a troponin leak that was likely secondary to hypotension in the setting of his arrest. Also, noted to have elevated CK-MB. Enzymes trended down during his admission. He did not have a cath while he was here. He will discuss elective cardiac catheterization at follow-up with his PCP and primary cardiologist. . 6. Hypertension: Was briefly on pressors, then as pressure came up required Nitro for blood pressure control (initially avoiding nodal blocking agents). Additional agents were slowly added back and he was discharged on a regimen of Procardia, labetalol and lisinopril. Blood pressure will be followed by PCP and [**Name9 (PRE) **] regimen will be titrated up as necessary. . 7. Intubation: He was intubated for airway protection at the OSH. As his electrolyte disturbances resolved, ventilation and sedation were weaned. He was extubated on hospital day 2. He did not have any additional respiratory issues. Medications on Admission: 1. Lantus 2. Novalog 3. Lipitor 4. Labetalol 5. Norvasc 6. Lasix 7. Metolazone 8. Neurontin 9. Thiamine 10. Folate 11. B12 12. Procrit 13. Calcium Carbonate Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 6. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous Q am. 7. Insulin Lispro (Human) 100 unit/mL Solution Sig: as dir units Subcutaneous four times a day: as per sliding scale. 8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID PRN (). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 13. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. Epoetin Alfa 10,000 unit/mL Solution Sig: as directed units Injection ASDIR (AS DIRECTED): at HD. 15. Procardia 10 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - PEA arrest - hyperkalemia - ESRD with hemodialysis initiation - CHF SECONDARY: - Insulin dependant diabetes - End stage renal disease - Hypertension - Hyperlipidemia - History of lens removal in left eye. - History of TIA Discharge Condition: - stable to home, with outpatient hemodialysis Discharge Instructions: - Take medications as directed. - Follow up as scheduled. - Follow up with Dr. [**Last Name (STitle) **]. You have been started on dialysis - follow up for dialysis as scheduled. Followup Instructions: Follow up with your kidney doctor (Dr. [**Last Name (STitle) **] as scheduled. Follow up for hemodialysis on Saturday, [**5-25**] at the Kidney Center. Dr.[**Name (NI) 67911**] office should call you on Friday (tomorrow). Call him if you do not hear from him tomorrow. His number is [**Telephone/Fax (1) 67912**]. Youi can speak with im or his assistant [**Doctor First Name **]. Follow up with your PCP [**Name Initial (PRE) 176**] 1 week. Your PCP should follow your blood pressure as changes have been made to your blood pressure regimen and further changes may be needed as you continue with dialysis. You should discuss finding a local cardiologist with your PCP. [**Name10 (NameIs) **] may need to have a cardiac catheterization at some point in the future. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

Admission Date: [**2169-9-3**] Discharge Date: [**2169-9-15**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 82 year-old gentleman admitted on [**9-3**] with altered neurologic status. The patient and daughters were visiting in the [**Name (NI) 86**] area for a whale watch from [**State 531**]. The daughter noticed the change in speech and behavior and went to an outside hospital where a head CT showed bifrontal subdural hematoma. The patient was transferred to [**Hospital1 188**] for further management. The patient's subdural hematoma noted on head CT with some shift and mass effect with no invasive intervention required. Did not require intubation and no seizures were detected. The patient was placed on prophylactic Dilantin. The patient was on some intravenous nitroprusside to keep his blood pressure less then 150, but was successfully weaned off on [**9-6**]. He remained in the Neurological Intensive Care Unit until [**2169-9-5**]. He had an attempted arteriogram, which was not completed secondary to an incidental finding of a 4 by 5 cm AAA. Therefore vascular surgery was consulted. A CTA was done to measure the AAA. The patient also had an episode of acute renal failure most likely related to the dye from CT scan. Also post obstructive from inability to void. The patient's BUN and creatinine climbed to 60 and 3.6. Currently his creatinine is down to 2.5, BUN is 50. Vascular surgery will follow him as an outpatient for workup for this AAA and he will actually probably be referred to a doctor in [**State 531**] for further treatment of that. His renal failure is resolving at this time. He was seen by speech and swallow. The patient is able to tolerate a regular diet. He also developed a rash on [**2169-9-12**] on just his back. Dermatology was consulted and they felt it was heat rash, although Dilantin was discontinued and the patient also had complaints of fever. Fever workup to this point is negative. Chest x-ray is negative. Urine negative and blood cultures are pending. The patient was transferred to the regular floor on [**2169-9-6**] and was evaluated by physical therapy and occupational therapy and found to require rehab prior to discharge to home. He is being screened for a rehab in [**State 531**]. MEDICATIONS ON DISCHARGE: Azithromycin 250 mg po q 24 hours for nine days, which was started on [**2169-9-13**]. MOM 30 cc po q 6 hours prn, Simethicone 40 to 80 mg po q.i.d. prn. Miconazole powder 2% one application to the groin and the back of the neck b.i.d. Albuterol nebulizers one nebulizer inhaler q 6 hours prn. Protonix 40 mg po q 24 hours, Colace 100 mg po b.i.d., Hydrocortisone ointment one application q.i.d. to his back. Atenolol 50 mg po b.i.d. CONDITION ON DISCHARGE: Stable. He will follow up with his primary care physician and neurologist in [**State 531**] for further management. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2169-9-14**] 11:43 T: [**2169-9-14**] 12:29 JOB#: [**Job Number 44343**]

Admission Date: [**2162-12-24**] Discharge Date: [**2163-1-21**] Date of Birth: [**2098-5-17**] Sex: M Service: Neurosurgery. HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male who was admitted to [**Hospital1 69**] from [**Hospital6 5016**] on [**2162-12-24**] status post a headache with vomiting. Head CT showed a frontal subarachnoid hemorrhage. The patient was intubated at the outside hospital and transferred to [**Hospital1 190**] for further management. HOSPITAL COURSE: On admission, the subarachnoid hemorrhage extended into the pons. He had evidence of hydrocephalus, and a vent drain was placed. He went to arteriogram which showed no evidence of a source of bleeding. He had his blood pressure controlled with Nipride and labetalol. He was started on an insulin drip for high blood sugars. He was extubated on [**2162-12-25**]. He had a repeat head CT which showed no changes. He was awake, alert, moving all extremities, and following commands bilaterally. On [**2162-12-26**], he had a repeat head CT which showed intraventricular blood with intracerebral blood continuing. His labetalol drip was discontinued, and he was continued on a Nipride drip. He had an increase in creatinine up to 2.1. Admission creatinine was 1.0. He had Lopressor added for blood pressure control, and Nipride was discontinued. He was continued on nimodipine for prevention of vasospasm. The Renal Service was consulted due to his acute renal failure. He was placed on a Lasix drip which started on [**2162-12-28**] and was discontinued on [**2163-1-1**]. He continued to be on an insulin drip to keep his blood sugars under control. Neurologically, he was alert, following commands, moving all extremities but confused and disoriented to place and time. He was occasionally agitated with tremors. He was also placed on renal dose Dopamine to help with kidney perfusion and urine output. On [**2162-12-28**], he also had difficulty with respiratory distress and was intubated. He was put on propofol and sedated. He remained intubated until [**2163-1-4**] and then was extubated again. His neurologic status waxed and waned. He had episodes where he was very lethargic and not moving his extremities very well. He had CT and MRI of the C-spine which showed no evidence of cord compression. On [**2163-1-8**], his BUN and creatinine were 59 and 1.8. At this point, he was off Lasix drip. Neurologically, he was awake, moved his right arm against gravity. He was impersistently following commands and externally rotated both his lower extremities with some withdrawal to noxious stimulation. He continued to have a ventilator drain in place. He became hypernatremic with sodiums of 149-150. His BUN and creatinine continued to be 59 and 1.8. He had Methicillin resistant Staphylococcus aureus in his sputum. The patient was started on Lasix 40 mg p.o. t.i.d. for fluid overload. The patient's drain was raised to 15 cm above the tragus on [**2163-1-11**] which he tolerated. He continued to have high sodium levels of 152. He continued on Lasix t.i.d. for fluid overload. He had a bed-side swallow evaluation on which he had some oral apraxia, but they obtained a video swallow, which he did pass. However, post procedure, he did vomit. It was felt that because his mental status was not completely improved, he should hold off on feeding. Mental status did improve, and he did start on a regular diet. On [**2163-1-14**], the patient's drain had been clamped for 24 hours. He had a head CT which showed mild to moderate ventricular dilatation. The patient's drain was then left clamped until [**2163-1-16**] when a repeat head CT showed no further dilatation, and the drain was discontinued. The patient had his diet advanced, was to be out of bed with Physical Therapy and was transferred to the regular floor on [**2163-1-17**]. He has remained neurologically stable with stable vital signs. He has tolerated a regular diet. He has been out of bed with physical therapy and requires acute rehabilitation. DISCHARGE MEDICATIONS: 1. Metoprolol 125 mg p.o. b.i.d., hold for heart rate less than 50, systolic blood pressure less than 100. 2. Bacitracin ointment to his head suture site t.i.d. 3. Insulin sliding scale. 4. Levofloxacin 500 mg p.o. q.24 hours. 5. Famotidine 20 mg p.o. q.day. 6. Epogen 40,000 units once a week intravenously. 7. Venlafaxine 37.5 mg p.o. b.i.d. 8. Heparin 5000 units subcutaneously q.12 hours. 9. Nimodipine 60 mg p.o. q.4 hours. 10. Albuterol inhaler one to two puffs q.6 hours p.r.n. CONDITION: The patient's condition is stable. FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1132**] in one month with repeat head CT at that time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2163-1-20**] 15:19 T: [**2163-1-20**] 15:34 JOB#: [**Job Number 52658**]

Admission Date: [**2139-5-18**] Discharge Date: [**2139-6-1**] Date of Birth: [**2060-11-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 78 yo Russian speaking F with h/o pulmonary HTN, CHF, OSA on home O2 who initially admitted on [**2139-5-18**] from home with vomiting, loss of appetite x 1 month. Diarrhea x 1 week. Per ED notes, pt also c/o RLQ/RUQ pain; rates pain as [**8-26**] lasting several days. Pt is also chronically on home O2 2-3L NC for OSA, CHF and pulmonary hypertension. . ED COURESE: VS afebrile, HR 62, BP 144/85, RR 20, 95% RA. Exam notable for RUQ/RLQ tenderness to palp, guaic neg. Given zofran 8 mg IV x 1 with improvement in sxs. CT showed no new changes. Ready for d/c but then nauseous. No abx in ED. Given 10 mg compazine as well. . Admitted to medicine for diarrhea. On arrival, hx obtained from interpreter. Pt c/o of right > left abd pain for unclear duration of time, also with nausea/vomiting; diarrhea 3-4 days ago but none since. No chest pain/pressure, SOB, cough. No GU sxs. Poor appetite for several weeks. On floor pt found to be hypoxic on O2 4LNC O2 sats 85%, CXR c/w pulm edema, she was given 40mg IV x 2, nebs, and put out 1.5L UOP, she was also put on a NRB with improvement in O2 Sats to 95%. However, patient kept trying to pull off her NRB mask leading to [**Last Name (LF) 15780**], [**First Name3 (LF) **] was transferred to the [**Hospital Unit Name 153**] for more intensive care and monitoring. Past Medical History: 1.Atrial septal defect repair [**6-17**] complicated by sinus arrest with PPM placement. 2. CHF 3. AF s/p cardioversion x 2 (on amiodarone) 4. HTN 5. GERD 6. TAH/BSO ('[**33**]) for fibroids 7. ?CVA 8. Pulm HTN 9. CRI (baseline 1.5) 10. OSA on home O2 (2-3L NC) 11. s/p APPY, s/p CCY ('[**33**]) 12. Gallstone pancreatitis s/p ERCP, sphincterotomy 13. Elevated alk phos secondary to amiodarone (All above per hospital records) Social History: Lives alone in senior living housing, has daughter in law who brings her groceries, has VNA once a week. No tob, EtOH, IVDU Family History: NC Physical Exam: ON ADMIT VS: T 98.1, 91-95% on NRB, HR 60-74, 116/48, RR 22-26 Gen: Russian speaking woman, lying in bed comfortable, not using accessory muscles, breathing comfortably on NRB HEENT: PERRL, + periorbital edema, JVP hard to assess [**12-19**] thick neck CV: RRR, nl s1/s2 LUNGS: pronounced crackles bilaterally 1/2way up lungs, R>L ABD: obese, soft, +BS, + discomfort with palp, no rebound/guarding, EXT: no LE pitting edema Pertinent Results: ECHO BUBBLE STUDY -negative for shunt CR: Brief Hospital Course: resp failure -rx'd multifact -chf, pulm htn, pna CHF -diastolic ef 75% -diuresed lasix gtt, til cr bumped PULM HTN - no shunt on bubble study, pulm to see for any other recs ?PNA -RLL opacity, zosyn started, though no wbc count, may stop since cr bumped AFIB -paced, not on anticoag due to h/o hemorrhagic stroke, CKD -1.8-2ish, now up 2.4 after lasix gtt, holding, good uop CHEST PAIN -cm's negative x5, always resolves with gi cocktail DISP -> rehab, usually goes home, then fails, ?placement ______________________________________bt/[**5-28**]/ 1) N/V/D -- likely viral gastroenteritis, resolved with supportive care. Unfortunately, iatrogenic CHF exacerbation after aggressive fluid resucitation. See the following course. 2)Respiratory Distress: Transferred to the [**Hospital Unit Name 153**] from the floor for acute worsingin hypoxia. Acute pulmonary edema s/p fluid hydration for viral gastroenteritis in baseline severe pulmonary HTN (worse on ECHO from [**5-21**], 75 to 90 mm Hg), +/- worsening pulm HTN, +/- PNEUMONIA. Improved over several days with diuresis and BIPAP use. Transferred back to 11 [**Hospital Ward Name 1827**] when she became stable on nasal canula. Slowly weaned to baseline home oxygen requirement of 4 liters. Additionally treated with Zosyn for concern of hospital acquired pneumonia, but unconvincing clinical picture without fever or elevated WBC. Zosyn was discontinued 24 hours prior to discharge without event. The pulmonary team consulted regarding her pulmonary hypertension, and recommended avoiding afterload reduction and possible future evaluation for OSA. Pt refused BiPAP repeatedly and an evaluation was deferred until she may be more compliant with the treatment. 3)CHF EXACERBATION [**Hospital 15781**] transfer to the ICU, was diuresed with a lasix gtt with improvement in symptoms. 02 sats 91-95% on 6L, up from her 4Lbaseline. -spent several days in the unit getting diuresed. Lasix was held for about three days as patient creatine increased. her respiratory status remained stable, bubble study was negative for shunt. Ultimately patient was transferred back to the floor, with pulmonary consult for consideration of interventions or other treatments for her severe pulm HTN. . . -creatine stabilized, home dose lasix was restarted without event. . . 4)CKD: baseline cr 1.8 ~2.1, peaked at 2.4 after diuresis. diuresis was held, patient continued to have good urine output. cr returned to baseline, was 1.7 on discharge. . 5)ATRIAL FIBRILLATION -rate controlled in 60s. metoprolol and amiodarone was continued per her home dosing. The ICU team inquired about her [**Hospital **] status, and after discussion with PCP, [**Name10 (NameIs) **] it was deemed [**Name10 (NameIs) **] is contraindicated due to her past history of hemorrhagic stroke. . 7)Hypothyroidism: levothyroxine continued. Medications on Admission: Meds: (per old d/c summary) home oxygen 2-3L amiodarone 200 mg qd lasix 40 mg qam/20 mg qpm paroxetine 10 mg qd ASA 81 mg qd atorvastatin vit toprol XL 25 mg qd levothyroxine 75 mcg qd PPI oxycodone 5 mg prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q 1400 (). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: hypoxia chf exacervation pulmonary hyptertension pneumonia Discharge Condition: stable, on home oxygen of 4 Lpm nasal canula Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 liters Followup Instructions: Please follow up with your primary physician within two weeks, and appointment

Admission Date: [**2171-1-30**] Discharge Date: [**2171-2-21**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fall Major Surgical or Invasive Procedure: [**2171-2-2**] EVD placement in OR [**2171-2-8**] Floroscopic placement of Dobhoff Tube PICC placement/replacement History of Present Illness: [**Age over 90 **] year-old female with PAF on coumadin, diastolic dysfunction, multiple valvular abnormalities (TR, MR, AR) admitted to neurosurgical service [**2171-1-30**] for ICH, and transferred to MICU [**2171-2-9**] for lethargy, hypoxia, and hypotension. . She was transferred [**2171-1-30**] from OSH after presenting with fall backwards onto her occiput from 2 stair height without reported LOC. She was on coumadin at that time. On presentation to OSH GCS 15 and head CT showed significant SAH. She was transferred to [**Hospital1 18**] for further care. . She was admitted to TICU [**2171-1-30**] for neurologic monitoring. INR was reversed with FFP and Vitamin K. While in the TICU, the patient became increasingly lethargic and was only intermittently oriented A&Ox3. She was found to have hydrocephalus and underwent external ventricular drain placement [**2171-2-2**]. She underwent Dobhoff placement under fluoro [**2171-2-8**]. . During her hospitalization, chest radiograph with pulmonary edema, basilar crackles and patient was diuresed with Lasix. She became hypoxic with decrease in blood pressures from baseline, and she went to the SICU [**2-3**] for a Lasix drip. Subsequently, she was called out [**2-5**] and her standing home Lasix dose was increased. On [**2-8**], she was noted to have increased respiratory effort with a "wet" cough, with PO2 88-96% and tachycardia. LENIs were negative. She received 300cc free water boluses for tachycardia and subsequently for hypotension in the 80's. Medicine was called and on review of the imaging studies and given the patient's hypoxia and hypotension, recommended initiating Vanc/Cefepime/Flagyl for possible aspiration pneumonia as well as a 250cc bolus x2 for SBP 70's-80's. A discussion of possible intubation was held with the son and the patient was made DNR/DNI. Lasix was d/c'ed. Cultures were drawn, and ABG showed 7.51/40/105/33 with a lactate of 2.7. . Of note, during the hospital course, the patient had loose stool [**2-6**] and had C. diff x3 which were negative. Her standing bowel regimen was d/c'ed. Of note, she was started on tube feeds on [**2-4**]. . This morning, [**2171-2-9**], the patient was found to have BP 70/30s and somnolent, minimally responsive to noxious stimuli. MERIT was called for further management and potential transfer to medicine service. On evaluation, the patient somnolent and a hct drop from 36 -> 31 was noted. She was written for 1 unit PRBC and 250cc bolus NS was initiated in the interim. Oxygen saturation fluctuated between high 80's-100% on high flow face mask. Of note, per neurosurgery, external ventricular drain at 10 open. . On evaluation in the MICU, she is nonverbal. She moans to sternal rub and does hold her son's hand. Past Medical History: - PAfib on Coumadin - Diastolic dysfunction, preserved EF, 3+MR, 2+TR, 2+AI - CAD - HTN - GERD Social History: Lives with her daughter. Requires assistance with all ADLs. No alcohol, tobacco, or illicit drug use. Family History: non-contributory Physical Exam: ADMISSION EXAM: 98 55 118/70 18 93% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: reactive bilateally EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ 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 date. Recall: [**2-7**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-11**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: ADMISSION LABS: [**2171-1-29**] 22:30 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 14.5* 4.42 13.1 39.7 90 29.6 33.0 16.2* 195 Glucose UreaN Creat Na K Cl HCO3 AnGap 171*1 18 1.1 144 3.5 105 25 18 . DISCHARGE LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 9.6 3.65* 10.8* 33.4* 92 29.5 32.2 17.2* 312 Glucose UreaN Creat Na K Cl HCO3 AnGap 83 17 0.8 152*2 4.0 114* 24 18 . MICROBIOLOGY: [**2-6**] Stool Cx: C. diff negative 3/5 Blood Cx: negative [**2-9**] Urine Cx: negative [**2-9**] Fungal Blood Cx: negative [**2-9**] CSF: negative [**2-9**] Stool Cx: C. diff negative [**2-10**] Sputum Cx: coag + Staph aureus CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S . IMAGING: [**1-29**] Head CT: 1. Multicompartmental hemorrhage with bifrontal intraparenchymal hemorrhage, extensive subarachnoid hemorrhage layering along the basilar cisterns, and a small amount of intraventricular hemorrhage layering along the occipital horns. 2. Left occipital fracture. Note that the reference CT was made available after initial review, and the bifrontal areas of intraparenchymal hemorrhage are new since the reference CT. In addition, the intraventricular hemorrhage is new since reference CT and the layering subarachnoid hemorrhage has increased. . [**1-30**] Head CT: IMPRESSION: 1. Increased size and surrounding edema of the right frontal lobe intraparenchymal hemorrhage. 2. Increased intraventricular hemorrhage in the right frontal [**Doctor Last Name 534**] and bilateral occipital horns. 3. Unchanged inferior left frontal lobe intraparenchymal hemorrhage, right frontal lobe subarachnoid hemorrhage, and basal cistern subarachnoid hemorrhage. 4. Left occipital fracture, better visualized on CT from [**2171-1-29**]. . [**1-31**] Head CT: 1. Unchanged size of right frontal lobe intraparenchymal hemorrhage and surrounding edema. 2. Increased hemorrhage in the bilateral occipital horns of the lateral ventricles compared to [**2171-1-30**]. 3. Unchanged inferior left frontal lobe intraparenchymal hemorrhage, right frontal lobe subarachnoid hemorrhage, bilateral superior parietal subarachnoid hemorrhage, and basal cistern subarachnoid hemorrhage. 4. Left occipital fracture, better visualized on CT from [**2171-1-29**]. . [**2-2**] Head CT: 1. Increased ventricular size indicating hydrocephalus since [revopis study. 2. No new hemorrhage. 3. Allowing for differences in technique, little change in known large right frontal intraparenchymal hemorrhage with surrounding edema and associated slight subfalcine herniation. 4. Unchanged diffuse subarachnoid hemorrhage and intraventricular hemorrhage. . [**2-4**] ECHO: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Moderate-severe mitral regurgitation. Moderate pulmonary hypertension. Moderate aortic regurgitation. Moderate tricuspid regurgitation. Mild aortic valve stenosis. . [**2-7**] CT Head: 1. Slight decrease in the degree of hydrocephalus compared to [**2171-2-2**]. 2. Unchanged size of the right frontal lobe intraparenchymal hemorrhage, surrounding edema, and degree of mild leftward subfalcine herniation. 3. Unchanged right superior frontal lobe and left frontal/parietal subarachnoid hemorrhage. Further workup for underlyign cause after clinical correlation, as clinically indicated. . [**2-8**] CT Head: 1. Unchanged size of the right frontal lobe intraparenchymal hemorrhage, surrounding edema, and extent of leftward shift of normally midline structures. 2. No significant change in ventricular enlargement. . [**2-8**] LENI: No DVT. . [**2-13**] CT Head: 1. No significant change in the size of the right frontal lobe parenchymal hemorrhage, surrounding edema, or associated mass effect, including the slight leftward shift of normally-midline structures. 2. Near-complete interval resorption or drainage of intraventricular hemorrhage. Ventricular size is not significantly changed. . [**2-14**] CT Head: 1. Moderate right frontal intraparenchymal hematoma with surrounding vasogenic edema and effacement of the cerebral sulci and mild leftward shift of midline structures in the frontal region as before. No new acute intracranial hemorrhage noted. Intraventricular hemorrhage in the occipital horns unchanged. Continued close follow up as clinically indicated. While this may relate to trauma, underlying vascular/ neoplastic cause can be excluded after appropriate workup as felt necessary. 2. Persistent moderate dilation of the lateral ventricles, which has mildly increased from the prior study. Accurate assessment and comparison is limited due to the differences in position between the two studies and motion-related artifacts on the present study. Continued close follow up as clinically indicated. 3. Moderate mucosal thickening in the ethmoid and the sphenoid sinuses with small amount of fluid. . [**2-15**] CT Head: 1. Unchanged right frontal intraparenchymal hematoma with surrounding vasogenic edema, resulting in effacement of neighboring sulci and mild leftward shift of midline structures. 2. No new hemorrhage or large vascular territorial infarction seen. 3. Unchanged trace hemorrhage within the left occipital [**Doctor Last Name 534**]. 4. Unchanged mild ethmoid and sphenoid sinus disease. . CXR [**2-19**] IMPRESSION: Similar moderate-to-extensive bilateral hazy opacities, with persistent bibasilar opacities, likely combination of pneumonia and pulmonary edema. Mild cardiomegaly stable. Brief Hospital Course: Brief hospital course: . # Intracranial hemorrhage: Patient was admitted post fall as a transfer from OSH with large frontal IPH. Patient's coagulopathy was reversed with Por 9, Vit K and FFP. She was admitted to the ICU for Q1 hour neurochecks, systolic blood pressure control less than 140 and ICU care. Her occipital scalp laceration was stapled and she was started on Ancef IV in setting of open occipital fracture. She was loaded and started on Dilantin for seizure prophylaxis. Repeat Head CT on [**1-30**] showed mild increase in the size of hemorrhage with extension into the ventricular system. Repeat head CT on [**1-31**] was stable, she was started on SC heparin TID, restarted on her home Lasix dose of 40mg TID and she was transferred to the step down unit. On [**2-1**] she remained neurologically stable. On [**2-1**] she remained neurologically stable.On [**2-2**] she was lethargic and only arousable to sternal rub. A head CT showed hydrocephalus and an EVD was emergently placed in the OR. Her EVD was found to not be draining and it was drawn back 1cm with good results. On [**2-8**] Head CT demonstrated slight enlargement of ventricles an so EVD was opened at 10cm above the tragus. Drain clamped [**2171-2-13**], and CT head following day demonstrated stable findings. Drain removed [**2171-2-14**]. . # Respiratory failure: On [**1-31**], patient developed respiratory distress and desaturations to the upper 80's. She was given lasix x1 and a CXR was obtained. This revealed bilateral pleural effusions and vascular congestion. On [**2-2**] she was lethargic and only arousable to sternal rub. A head CT showed hydrocephalus and an EVD was emergently placed in the OR. She was also noted to have pulmonary edema and was given lasix. On [**2-3**] she was transferred to the ICU for diuresis. She was transfered back to the step down unit the following day. On [**2-8**], oxygen requirement increased again to 6L with a CXR consistent with pulmonary edema. Her lasix was increased to TID. She was started on and Cefipime/Vancomycin/Flagyl for presumed pneumonia. On [**2-9**], her care was transitioned to the MICU team. Hypoxia was felt to be due to aspiration and pulmonary edema. She was continued on broad-spectrum antibiotics initiated [**2171-2-9**] - vancomycin, cefepime, metronidazole. Metronidazole d/c'd [**2171-2-10**]. Sputum culture positive for MRSA. Patient steadily improved on antibiotic therapy, with decreased dyspnea. Plan was for 14 day total course of treatment, and all antibiotics were stopped on [**2-19**]. O2 weaned to 4-5L NC. . # Hypotension: Was felt to be secondary to intravascular volume depletion in the setting of diuresis, as evidenced by metabolic alkalosis (contraction alkalosis). Concern for peri-sepsis component given patient needed multiple boluses to maintain BP in 80's-90's, initially 100's-130's on transfer to [**Hospital1 18**]. Patient continued on 250cc boluses to maintain SBP >90, and diuretics, beta blockers held. She was on broad spectrum antibitics as above, and pan-cultured to look for etiology of infection. As above, sputum positive for MRSA PNA. Hypotension resolved with continued antibiotic treatment. . # Goals of care / Altered mental status: Patient was called out to the floor on [**2-14**], but she became progressive lethargic and was sent back to the ICU on [**2-17**]. [**Month (only) 116**] have been related to infection, hypernatremia (mild), delirium from complicated medical course. Mental status improved with antibiotic course, free water flushes, and reorientation. CSF fluid was sent for analysis, but was not concerning for infectious process. Mental status did not improve, and a family meeting was held on [**2-19**] with the decision to pursue comfort measures only care. As such, she is being transferred to hospice care. Palliative care consult was initiated on [**2-20**] and advised Zydis 5mg Q 12 hrs on as needed basis to decrease agitation (as opposed to scheduled dosing-- he'd rather she not be overly sedated if possible, does want to treatsymptoms), and discussed using MS 2.5-5 mg SL (5mg/ml concentration) Q 3 hrs as needed to ease respiratory distress. Would consider scopolamine patch 1.5 mg patch Q 3 days if secretions increase (recognizing that this may contribute to sedation as well). Medications on Admission: 1. Metoprolol 25mg [**Hospital1 **] 2. Diovan 20mg Daily 3. Furosemide 40mg TID 4. Ranitidine 150mg daily Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob, wheeze. 2. timolol maleate 0.25 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 3. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for pruritis. 4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing, sob. 6. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 2.5-5 mg PO Q3H (every 3 hours) as needed for dyspnea. 7. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 8. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day): please hold for SBP <100, HR <60. 9. ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 10. acetaminophen 650 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Traumatic Intraparenchymal Hemorrhage Occipital skull fracture Exacerbation of CHF ARDS Discharge Condition: Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital after a fall, and were found to have a hemorrhage inside of your head. You required a drain to be temporarily placed in your head to relieve the pressure from this bleed. Your course was complicated by pneumonia and fluid in your lungs. Your family decided to focus your goals on comfort, and as such you are being transferred to a hospice facility. Followup Instructions: Please follow up with your primary care doctor on an as needed basis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2171-2-21**]

Admission Date: [**2147-1-16**] Discharge Date: [**2147-1-26**] Date of Birth: [**2068-12-12**] Sex: F Service: SURGERY Allergies: Penicillins / Iodine Attending:[**First Name3 (LF) 2836**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Exploratory laparotomy with lysis of adhesions and [**Location (un) **] patch closure of perforated duodenal ulcer - [**2147-1-19**]. History of Present Illness: 78 year old female with moderate AS, mild COPD, HTN, and remote history of PUD and with a known stable thoracoabdiminal aneurysm, admitted today for URI symptoms, who developed melenic stools and coffee-ground emeses with Hct 27 (down from 34 last [**Month (only) 958**]). She was transferred to the MICU hemodynamically stable, diaphoretic and nauseous. Repeat HCT 20, received 4u PRBCs. Large bore IVs placed as well as central line. Intubated for airway protection in setting of profuse vomiting and for EGD, which showed large clot in pyloris, unable to visualize around clot or dislodge clot. Placed on protonix IV with plan for re-scope in AM. She has a history of chronic abdominal pain with an EGD in [**2142**] that showed mild gastritis. Past Medical History: PMHx: HTN, COPD, Aortic stenosis mild-mod, hypercholesterolemia, depression, 3.5cm AAA, GERD, CVA (lacunes, residual right hand weakness, numbness, right leg), , gallstones, PUD, chronic lower back pain, osteopenia, multinodular goiter, cavernous hemangioma, colon polyps, hyperparathyoidism. . PSHx: TAH, TAA s/p repair. Social History: She quit smoking 30 years ago. She used to smoke "a couple" packs of cigarettes a day. She admits to occasional EtOH intake. She denies any illicit drug use. Family History: The patient does not report anything. Physical Exam: On Admission: VS: T 98.2, BP 123/52, HR 78, RR 18, SaO2 100% on RA. GENERAL: Uncomfortable; Complaining of significant nausea; Alert HEENT: NC/AT; PERRL/EOMI. Dry MM. OP clear. CARDIAC: RRR. II/VI systolic murmur at the RUSB. No r/g appreciated. LUNGS: CTAB, ?decreased BS at the left base. ABDOMEN: BS+; S/NT/ND; No masses appreciated. EXTREMITIES: No LE edema noted. NEURO: Alert; No gross neurologic deficits noted. . At Discharge: VS: 99.8 PO, 82, 147/47, 16, 99% RA GEN: Pleasant elderly female in NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. LUNGS: CTA(B) COR: RRR; nl S1/S2 with II/VI SEM @ LSB. No click/rubs. ABD: Upper midline incision with staples c/d/i. Prior JP drain site (now d/c'd) healing with DSD. BSX4. Appropriately tender to palpation along incision, otherwise soft/NT/ND. EXTREM: No c/c/e NEURO: A+Ox3. Deconditioned, otherwise NF/grossly intact. Pertinent Results: On Admission: [**2147-1-16**] 12:50PM BLOOD WBC-12.7*# RBC-3.22* Hgb-9.5* Hct-27.8* MCV-86 MCH-29.6 MCHC-34.3 RDW-13.3 Plt Ct-405# [**2147-1-16**] 12:50PM BLOOD Neuts-77.8* Lymphs-19.4 Monos-2.3 Eos-0.2 Baso-0.4 [**2147-1-16**] 12:50PM BLOOD Plt Ct-405# [**2147-1-16**] 12:50PM BLOOD Glucose-116* UreaN-38* Creat-0.8 Na-141 K-5.0 Cl-104 HCO3-26 AnGap-16 [**2147-1-16**] 12:52PM BLOOD Lactate-1.9 [**2147-1-16**] 12:50PM GLUCOSE-116* UREA N-38* CREAT-0.8 SODIUM-141 POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16 [**2147-1-16**] 12:50PM CK(CPK)-37 [**2147-1-16**] 12:50PM cTropnT-<0.01 [**2147-1-16**] 12:50PM WBC-12.7*# RBC-3.22* HGB-9.5* HCT-27.8* MCV-86 MCH-29.6 MCHC-34.3 RDW-13.3 [**2147-1-16**] 12:50PM NEUTS-77.8* LYMPHS-19.4 MONOS-2.3 EOS-0.2 BASOS-0.4 [**2147-1-16**] 12:50PM PLT COUNT-405# . Throid Studies: [**2147-1-24**] 08:08AM BLOOD TSH-<0.02* [**2147-1-18**] 04:18AM BLOOD TSH-0.029* [**2147-1-25**] 04:47PM BLOOD T4-8.2 T3-122 calcTBG-0.82 TUptake-1.22 T4Index-10.0 Free T4-2.0* [**2147-1-18**] 04:18AM BLOOD Free T4-1.5 . Prior to Discharge: [**2147-1-24**] 08:08AM BLOOD WBC-5.3 RBC-3.01* Hgb-8.7* Hct-26.9* MCV-89 MCH-29.0 MCHC-32.4 RDW-14.5 Plt Ct-222 [**2147-1-24**] 08:08AM BLOOD Plt Ct-222 [**2147-1-24**] 08:08AM BLOOD Glucose-136* UreaN-18 Creat-0.5 Na-139 K-3.9 Cl-100 HCO3-31 AnGap-12 [**2147-1-22**] 02:25AM BLOOD ALT-17 AST-17 AlkPhos-38* TotBili-0.5 [**2147-1-24**] 08:08AM BLOOD Albumin-2.5* Calcium-8.1* Phos-4.8* Mg-1.9 Iron-11* [**2147-1-24**] 08:08AM BLOOD calTIBC-146* Ferritn-703* TRF-112* [**2147-1-24**] 08:08AM BLOOD Triglyc-116 . IMAGING: [**2147-1-16**] CXR: No acute intrathoracic process. . [**2147-1-19**] Abdominal X-Ray (KUB): Large amounts of free air in the abdomen. Potential additional moderate distension of small bowel loops. Gas markings in the bowel and rectum. . [**2147-1-24**] BAS/UGI AIR/SBFT: FINDINGS: Scout views demonstrate no free air under the diaphragm. Surgical clips are seen around the area of the duodenal bulb. Surgical staples are seen along the left paramedian abdomen. A nasogastric tube is seen terminating in the stomach. A drain is seen terminating in the right middle quadrant. The examination was performed in the upright and supine position. Conray followed by barium was used in this study. Contrast was noted to flow freely through the esophagus into the stomach and into the duodenal bulb and C-sweep. There was no evidence of extraluminal escape of contrast. IMPRESSION: Status post [**Location (un) **] patch procedure for duodenal perforation without evidence of leak. . MICROBIOLOGY: [**2147-1-17**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2147-1-18**]): NEGATIVE BY EIA. (Reference Range-Negative). Brief Hospital Course: ADMISSION [**2147-1-19**]: . Upon arrival in the [**Hospital1 18**] Emergency Department, the patient's VS were T 95.4 oral, HR 70, BP 146/48, RR 18, SaO2 99%2LNC. She was noted to appear dry and pale. In the ED, she complained that she had been having some diarrhea since taking the sennokot. She also complained on some blood on her stool. Also, her HCT was 28 from a baseline in the mid-30s. She refused a rectal. She also complained of a mild cough but no fever or recent travel. She complained on three days of intermittend chest heaviness. She complained on this chest heaviness this am upon awakening. CXR showed no focal consolidation. She was noted to have an increased BUN. Her first set of cardiac enzymes was negative. She was given NTG, morphine, and ASA 325mg with no relief. Her VS prior to transfer were P 71, SaO2 98%RA, BP 128/47, RR 24, Afebrile. . On arrival to the floor, the patient's VS were T 98.2, BP 123/52, HR 78, RR 18, SaO2 100% on RA. She was looking more pale and uncomfortable and started vomiting coffee grounds as well as passing melena. CXR showed tortuous aorta with no focal consolidation. First set enzymes negative with lactate 1.7. Hct went from low 30's baseline, to 27.8 at 12:50 pm to 20.0 at 8:30. At that point, she was ordered for emergency release blood and was transferred to the MICU. . MICU COURSE [**1-17**] - [**2147-1-19**]: . Upon arrival in the MICU, the patient received received 4 units of unmatched blood emergently with appropriate bump in Hct from 20 to 31 plus. She was intubated to protect her airway. Gastroenterology was emergently consulted, and an EGD was performed which revealed a massive dark colored mass-like lesion near duodenal bulb; the stomach was clear. She was started on IV Protonix, folic acid, Vitamin C, B12, and folate. A repeat EGD revealed 3 ulcers of the duodenal bulb. The patient was stabilized. . On [**2147-1-18**], the patient went into new atrial fibrillation with RVR 120-140's, felt diaphoretic without chest pain, SOB, palpitations, lightheadedness. She was given Metoprolol 5mg IV x3 with minimal response. Finally, responded to Diltiazem 10mg IV once with a HR to the 90's. The patient experienced melena in the morning. She received 6 units of PRBCs and 2 units of FFP. Later, she underwent Angiogram which demonstrated no definite focus of active extravasation seen on SMA, celiac, and selective gastroduodenal artery (GDA) arteriograms. The GDA branches supplying region of endoscopic vascular clipping within known duodenal bulb ulcer were identified, and the GDA was successful embolized using microcoils and Gelfoam. . On [**2147-1-19**], the patient experienced persistent abdominal pain, decreased bowel sounds, and no flatus. A portable KUB was performed, which demonstrated large amounts of free air in the abdomen, potential additional moderate distension of small bowel loops, and gas markings in the bowel and rectum. Lactate level was 0.9. General Surgery was called, and the patietn was taken to the Operating Room within an hour for bowel perforation. . POST-OPERATIVE COURSE [**1-19**] - [**2147-1-26**]: . On [**2147-1-19**], the patient underwent exploratory laparotomy with lysis of adhesions and [**Location (un) **] patch closure of perforated duodenal ulcer, which went well without complication (reader referred to the Operative Note for details). Extubated in the OR. After a brief, uneventful stay in the PACU, the patient arrived in the SICU NPO with an NG tube in place, on IV fluids, with a foley catheter and JP drain in place, and initially either Morphine or Dilaudid IV PRN for pain control. She was started on IV Flagyl, Levofloxacin, and Fluconazole. IV Protonix was continued. The patient was hemodynamically stable. The patient was transferred to the inpatient floor on POD#3. . Neuro: Initially, the patient received IV Morphine or Dilaudid PRN for pain, which was converted to a Dilaudid PCA on POD#2. Whe tolerating a clear diet, the PCA was discontinued, and the patient started on oral pain medications with continued good pain control. She remained neurologically intact during hospitalization. . CV: On POD#1, the patient experienced atrial fibrillation with RVR with a troponin bump to 0.14. She was started on a Diltiazem drip with good response and rate control. Cardiology was consulted. Previous transthoracic echocardiogram and PERSANTINE persantine stress tests were reviewed. EF was 55%. Use of anti-coagulation therapy was deemed contra-indicated at this time due to the GI bleed. The patient's TSH was found to be suppressed at less than less than 0.02 consistent with hyperthyroidism. Endocrinology consult was recommended. Ultimately, able to transition the patient off Diltiazem to IV Metoprolol enabling transfer to the inpatient unit on POD#3. Once able to tolerate a diet, the patient was transtiotned back to her outpatient Atenolol 100mg [**Hospital1 **] for rate control and other anti-hypertensives for BP control with good effect. . Pulmonary: Intubated for airway protection as above, ultiamtely extubed after surgery on [**2147-1-19**]. The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. . GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. In the SICU, she required a number of IV fluid boluses totalling 2 liters for low urine output with ultimate good response. On POD#1, she was started on TPN for nutrition. The foley catheter was discontinued on POD#3; she was subsequently able to void without problem. After an upper GI study with barium swallow and small bowel follow through demonstrated no leak, the NG tube was discontinued and the patient started on sips of clears on POD#5. Diet was progressively advanced to regular by POD#7, which was well tolerated. The patient was weaned off TPN on POD#7. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. JP discontinued on POD#7. . ID: Placed on empiric IV Flagyl, Levofloxacin and Fluconazole post-operatively. H. pylori screen was negative. Fluconazole was discontinued on POD#3 with Flagyl and Levofloxacin continued. At discharge, the patient was sent out on an additional 10 days of oral Levofloxacin and Flagyl. Of note, routine MRSA screen was negative. The patient's white blood count and fever curves were closely watched for signs of infection. Midline surgical incision with staples remained clean and intact. Staples can be removed, and steri-strips placed at the ouitpatient nursing facility on POD#10 (1/1/3/09). . Endocrine: As above, Endocrinology was consulted given the finding of a suppressed TSH of less than 0.02 in the context of atrial fibrillation. The patient has a history of multinodular goiter. Futher thyroid studies were evaluated. She was started on Methimazole (Tapazole) 20mg PO daily, an anti-thyroid medication, for biochemical thyrotoxicosis. Of note, the risks of this medication are rare hepatic failure and agranulocytosis. Patient should be instructed that if she develops a fever or sore throat, she should stop the methimazole immediately and have a CBC checked. There is not a need for surveillance CBC or LFT's as these reactions are acute. A thyroid scan was ruled out given the patient recent high IV contrast burden to avoid renal impact. The aptient will follow-up with Endocrine as an outpatient in 4 weeks, at which time repeat Thyroid functiontests will be performed. The patient's blood sugar was monitored throughout his stay; sliding scale insulin was administered accordingly. She did not require exogenous insulin at discharge. . Hematology: During this admission, the patient received a total of 13 units of PRBCs and 3 untis of FFP. HCT prior to discharge was 26.9. . Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with assitance, voiding without assistance, and pain was well controlled. She was discharged to an extended care facility for further nursing care and rehabilitation. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day ATENOLOL - 100 mg Tablet - 1 Tablet(s) by mouth twice a day DIAZEPAM [VALIUM] - 10 mg Tablet - 1 Tablet(s) by mouth once a day as needed for anxiety - No Substitution EZETIMIBE - 10 mg Tablet - 1 Tablet(s) by mouth once a day FLUOXETINE - 40 mg Capsule - 1 Capsule(s) by mouth once a day for depression, anxiety IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90mcg)/Actuation Aerosol - 2 puffs(s) inhaled every six (6) hours as needed for for sob, or cough ISOSORBIDE MONONITRATE - 30 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1 puff inhaled twice a day for shortness of breath SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day chol ZOLPIDEM [AMBIEN] - 10 mg Tablet - 1 to 2 Tablet(s) by mouth at bedtime . Medications - OTC CALCIUM CARBONATE [CALTRATE 600] - 600 mg-200 unit-[**Unit Number **] mg Tablet - 1 Tablet(s) by mouth twice a day prevention MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - 1 Tablet(s) by mouth once a day OMEGA-3 FATTY ACIDS [FISH OIL] - Dosage uncertain Discharge Medications: 1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): Needs to be continued for lifetime. 5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Methimazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-28**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 14. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 15. Caltrate 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 16. Omega-3 Fish Oil Oral 17. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days: Completion Date: [**2147-2-4**]. Tablet(s) 19. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days: Completion date: [**2147-2-4**]. 20. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 21. Atenolol 100 mg Tablet Sig: One (1) Tablet PO twice a day. 22. Valium 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for Anxiety. 23. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 24. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day: Take with source of Vitamin C such as OJ. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: Primary: 1. Perforated duodenal ulcer 2. Multinodular goiter with associated hyperthyroidism 3. Anemia Secondary: 1. HTN 2. H/O mild lacuna CVA 3. COPD Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-5**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment with Dr. [**First Name (STitle) **] (Surgery) in 2 weeks. . Please call ([**Telephone/Fax (1) 75101**] to schedule a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7747**] (Endocrinology) in [**3-30**] weeks. You will have your thyroid function tests repeated at this visit. . Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD (PCP) Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2147-2-22**] 1:30. Completed by:[**2147-1-26**]

Admission Date: [**2162-1-4**] Discharge Date: [**2162-1-8**] Date of Birth: [**2091-4-13**] Sex: F Service: CARDIOTHORACIC Allergies: morphine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Orthostatic lightheadedness Major Surgical or Invasive Procedure: [**2162-1-4**] Aortic Valve Replacement(#21 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue) History of Present Illness: 70 year old female with reports of occasional orthostatic lightheadedness. An echo [**2161-11-24**] revealed moderate to severe aortic stenosis with peak gradient 85 mmHg, mean 48, [**Location (un) 109**] 0.6 cm2, and good LV function with an EF of 55%. She was referred for a diagnostic right and left heart catheterization. She was found to have severe aortic stenosis and is now being referred to cardiac surgery for evaluation of an aortic valve replacement. Past Medical History: Aortic stenosis s/p Aortic valve replacement Hypertension Dyslipidemia MVC with right leg/ankle fracture History of anemia Anxiety Depression Early glaucoma Hemorrhoids Appendectomy Hysterectomy Social History: Race:Hispanic Last Dental Exam:1 months ago Lives with:son Contact:[**Name (NI) **] [**Name (NI) 91967**], [**First Name3 (LF) **]. C: [**Telephone/Fax (1) 91968**] [**Name2 (NI) **]ation:retired Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [] [**2-2**] drinks/week [x] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- Father had heart disease, died at age 85; one brother died of heart attack at age 62; Another brother with heart disease and emphysema died at 70; Sister with heart attack at age 72. Physical Exam: Pulse:79 Resp:13 O2 sat:97/RA B/P Right:162/82 Left:156/74 Height:5'3" Weight:204 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade 3-4/6 SEM to neck Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]well healed scars from hysterectomy & appy Extremities: Warm [x], well-perfused [x] Edema [n] _____ Varicosities: None [x] Neuro: Grossly intact [] Pulses: Femoral Right:2 Left:2 DP Right: 1 Left:1 PT [**Name (NI) 167**]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Right: n Left:n transmitted cardiac murmur Pertinent Results: [**2162-1-8**] 06:45AM BLOOD WBC-10.0 RBC-3.24* Hgb-9.4* Hct-27.9* MCV-86 MCH-29.0 MCHC-33.7 RDW-13.7 Plt Ct-282 [**2162-1-8**] 06:45AM BLOOD Plt Ct-282 [**2162-1-8**] 06:45AM BLOOD PT-13.5* INR(PT)-1.3* [**2162-1-8**] 06:45AM BLOOD UreaN-13 Creat-0.5 Na-138 K-4.4 Cl-101 [**2162-1-8**] 06:45AM BLOOD Mg-2.2 TEE [**2162-1-4**]:PRE-CPB: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. 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. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The three aortic valve leaflets are severely thickened/deformed. A small, filamentous, mobile mass is seen on the aortic side of the non-coronary cusp. Significant aortic stenosis is present (not quantified). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST-CPB: A bioprostheticvalve is seen in the aortic position. The valve appears to be well seated with normal leaflet mobility. There are no paravalvular leaks. There is no AI. The peak gradient across the aortic valve is 23mmHg, and the mean gradient is 11mmHg with CO of 3.2L/min. The LV chamber size is small, consistent with hypovolemic state. The LV systolic function remains normal, EF>55%. There is no evidence of aortic dissection. Dr. [**Last Name (STitle) **] was notified in person of the results at time of study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2162-1-6**] 17:18 Brief Hospital Course: Mrs. [**Known lastname 91969**] was a same day admission to the operating room for aortic valve replacement with Dr [**Last Name (STitle) **]. Prior to admission she underwent pre-operative work-up including cardiac catheterization. On [**1-4**] she was brought to the operating room please see operative report for details, in summary she had: aortic valve replacement with #21 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve. Her bypass time was 79 minutes with a crossclamp time of 62 minutes. She tolerated the operation well and following surgery she was transferred to the CVICU in stable condition for invasive monitoring. In the immediate post-op period she remained hemodynamically stable, was weaned from sedation, awoke neurologically intact and extubated. On POD1 she continued to be hemodynamically stable and was transferred to stepdown floor for continued post-op care. All tubes lines and drains were removed according to cardiac surgery protocol without complication. She went into a rapid atrial fibrillation on POD 1 night and was given increased dose of Lopressor, IV amiodarone/ po Amiodarone and converted to sinus rhythm at 3 AM on POD2. She remained hemodynamically stable throughout remainder of hospital course. She was diuresed with Lasix toward preoperative weight. Once on the stepdown floor she worked with nursing and physical therapy to improve strength and mobility. The remainder of her hospital course was uneventful. On POD #4 she was tolerating a full oral diet, her incision was healing well and she was ambulating with assistance. She was cleared for discharge to [**Location (un) **] House rehab. All follow up appointments were advised. Target INR 2.0-2.5 for A Fib. First INR check tomorrow at rehab. Medications on Admission: AMLODIPINE 10 mg Daily BENAZEPRIL 20 mg Daily FLUTICASONE 50 mcg Spray, two sprays via both nostrils at bedtime HYDROCHLOROTHIAZIDE 25 mg PRN LATANOPROST 0.005 % Drops - one drop each eye at bedtime LORAZEPAM 0.5 mg PRN METOPROLOL SUCCINATE 100 mg Daily PRAVASTATIN 80 mg daily TRAMADOL 50 mg PRN ASPIRIN 81 mg Daily IBUPROFEN 200-600 mg PRN Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP < 100. 6. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: 400 mg [**Hospital1 **] through [**1-12**]. 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: 200 mg [**Hospital1 **] [**1-13**] through [**1-20**]. 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: 200 mg daily starting [**1-21**] ongoing. 11. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily): NU daily. 12. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): both eyes. 13. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 15. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Tablet Extended Release PO once a day for 2 weeks. 16. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 days: dose for today [**1-8**] is 2.5 mg; all further daily dosing per rehab provider;target INR 2.0-2.5 for A Fib. Discharge Disposition: Extended Care Facility: [**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement postop A Fib Past medical history: Hypertension Dyslipidemia MVC with right leg/ankle fracture History of anemia Anxiety Depression Early glaucoma Hemorrhoids Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication A Fib Goal INR 2.0-2.5 First draw tomorrow [**1-9**] ****please arrange for coumadin/INR f/u prior to discharge from rehab Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**2162-2-3**] at 1:00 PM Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7526**] on [**2162-1-26**] at 11:30 AM Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22235**] in [**4-1**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication A Fib Goal INR 2.0-2.5 First draw tomorrow [**1-9**] ****please arrange for coumadin/INR f/u prior to discharge from rehab Completed by:[**2162-1-8**]

Admission Date: [**2188-2-27**] Discharge Date: [**2188-3-2**] Date of Birth: [**2168-9-15**] Sex: M Service: TRAUMA HISTORY OF PRESENT ILLNESS: The patient is a 19 year old male who was in his otherwise usual state of good health until the Sunday, [**2188-2-25**], when he was involved in an altercation with an acquaintance where he was struck by a baseball bat with a single strike to the left flank and midaxilla over the tenth, eleventh and twelfth ribs. The patient sustained a significant amount of pain, however, he opted to return home, having some intermittent shortness of breath and difficulty taking deep breaths, and pleuritic type pain. He was seen at [**Hospital **] [**Hospital **] Hospital on [**2188-2-26**], and diagnosed with a left hemopneumothorax as well as CT scan of the abdomen revealing a severe splenic laceration. His admission hematocrit at the outside hospital was 38.0. He was placed in Intensive Care Unit, placed on serial hematocrit values. He did have a small left apical hemopneumothorax requiring insertion of a left anterior chest wall dart tube thoracostomy with good resolution of his pneumothorax. Over the ensuing 72 hours, the patient stayed in the hospital and had serial hematocrit levels. His blood count dropped to 26.0 on [**2188-2-26**], and he was transfused a single unit of packed red blood cells with good response bringing his hematocrit up to around the 31.0 mark. However, on the day following on Wednesday, [**2188-2-28**], the patient experienced the acute onset of severe left chest pain, dyspnea and left flank pain. This prompted a repeat CAT scan of the chest and abdomen. The outside hospital radiologist felt that there may or may not have been evidence of a possible aortic injury at this time prompting a transfer to [**Hospital1 69**] for further evaluation. The patient was brought in by ground, hemodynamically stable, complaining of left sided chest pain. The remainder of his hospital course will be described further. PAST MEDICAL HISTORY: None. MEDICATIONS ON ADMISSION: The patient takes no medications at home. ALLERGIES: He has no allergies. SOCIAL HISTORY: The patient denies smoking or drinking alcohol. He is single and has a girlfriend. [**Name (NI) **] works as a landscaper. REVIEW OF SYSTEMS: Otherwise negative up until the time of this event, he was well. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On presentation, his temperature was 98.2, heart rate 88, blood pressure 112/70 and he was breathing 18, oxygen saturation 96% in room air. He was in no acute distress complaining of left sided chest pain and pain on deep inspiration. He had an obvious left anterior tube thoracostomy in place with no evidence of air leak through the Heimlich valve. His trachea was midline. There was no crepitus on either chest wall and his chest was without heaves. His heart was regular. Lungs were clear bilaterally, decreased at the left base. There were no crackles, rubs or rhonchi. His abdomen was soft, tender in the left upper quadrant. There was some mild left flank ecchymosis. There was no obvious crepitus. There were no peritoneal signs. Bowel sounds were hypoactive. His rectal examination was guaiac negative, normal tone. Extremities were unremarkable and without any deformity. He had normal pulses throughout. His neurosensory examination was otherwise unremarkable and his pupillary examination again was noted to be normal. LABORATORY DATA: Admission hematocrit here was noted to be 31.0. HOSPITAL COURSE: The patient was placed on conservative grade IV splenic laceration protocol with serial q4hour hematocrit checks and an Intensive Care Unit admission. Admission chest x-ray showed that he had fairly good expansion of his left chest, however, there was a small left hemothorax and discussion was held as to whether or not the patient should undergo a larger tube thoracostomy for empiric drainage of this blood, however, it was decided that the patient was stable and we would not pursue this matter unless the patient needed to go to the operating room. The patient's hematocrit did drop to as low as 26.0 while in the hospital here. He was not transfused any blood products. This bottomed out on Thursday, [**2188-2-28**], and thereafter his hematocrit increased on its own. He did not ultimately require an operation and his symptoms improved. He was making excellent urine. He made the excellent progress as he was made NPO with serial hematocrit to the point of [**2188-3-1**], when his hematocrit was up to 31.0 and stable that we opted to give him a clear liquid diet. His Foley catheter had previously been removed. On the following day on [**2188-3-2**], the patient's hematocrit was up to 33.0 and he was making excellent urine and tolerating liquids ad lib and his diet was therefore advanced to a house diet as tolerated. It was deemed that the patient had now progressed approximately seven days postinjury without any hemodynamic instability and his hematocrit was improving. He was felt symptomatically and vascularly improved and follow-up chest x-ray that was done post tube thoracostomy removal showed no evidence of residual pneumothorax. There was a very small minimal left hemothorax that was left in place. It was opted that the patient did not require further tube thoracostomy under the care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] covering for Dr. [**Last Name (STitle) **]. The patient was counseled on possible presentation of delayed splenic bleed including the warning signs of dizziness, left upper quadrant pain, new bruising, lightheadedness or syncope. The patient understood the instructions to immediately go to the nearest Emergency Room if any of these symptoms were to return. He will follow-up in the Trauma Clinic in approximately two to four weeks. He is instructed not to undergo any strenuous lifting or activity. His job as a landscaper should be postponed until he is seen in follow-up in the clinic setting. He will not engage in any contact sports for at least six weeks. He will not ride in ATV or drive a motorcycle for an additional six weeks as well. MEDICATIONS ON DISCHARGE: 1. Tylenol as needed. 2. Colace 100 mg p.o. twice a day as stool softener. 3. Dilaudid 2 mg tablets one to two tablets every three to four hours as needed for breakthrough pain. DISCHARGE DIAGNOSIS: 1. Grade IV splenic laceration with active blush on CT angiography on admission CAT scan on [**2188-2-27**]. 2. Hemoperitoneum. 3. Blood loss anemia. 4. Left hemopneumothorax, status post anterior left tube thoracostomy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern4) 4437**] MEDQUIST36 D: [**2188-3-2**] 11:47 T: [**2188-3-2**] 13:04 JOB#: [**Job Number 54554**]

Admission Date: [**2122-1-26**] [**Year/Month/Day **] Date: [**2122-2-2**] Date of Birth: [**2056-2-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: paracentesis (10L removed) History of Present Illness: This is a 65 year old male with a history of end-stage renal disease (on HD), cirrhosis secondary to alcohol with multiple complications (see below) and insulin dependant diabetes who presents with abdominal pain and malaise. For the past couple days, his wife noted that he was increasingly lethargic and that he was complaining of abdominal pain. 4 days prior to presentation, he had been tapped therapeutically and 12 L of fluid was drained; he does get weekly paracenteses for recurrent ascites following a failed TIPS. He was initiated on HD in [**2121-9-20**] for hepatorenal syndrome, the hemodialysis being a bridge until he gets a transplant. Initially he was getting tapped twice a week; the frequency of his taps has decreased to once a week. In the emergency department, diagnostic paracentesis revealed > 4000 WBCs in para fluid suggestive of spontaneous bacterial peritonitis. Vancomycin and zosyn were administered. Nephrology and hepatology were consulted. Lactate was noted to be 6. At time of transfer to the MICU, vitals were: 98.2 105/74 18. Past Medical History: -Alcohol-related cirrhosis complicated by esophageal varices, encephalopathy, refractory ascites s/p TIPS which is likely no longer patent, h/o hepato-renal syndrome requiring admission to [**Hospital1 18**] from [**2121-4-18**] to [**2121-4-30**], and h/o SBP on Cipro ppx. Sober since [**2117**]. On transplant list for combined liver-kidney. -IDDM -Hypothyroid -Pituitary mass -h/o nephrolithiasis -h/o +PPD -ESRD on HD MWF, initiated [**2121-9-20**] Social History: Lives w/ wife at home. Independent in ADLs and ambulation. Quit smoking [**2121-6-20**]. No alcohol since [**2118-10-22**]. Denies IVDU. Family History: Mother deceased, age 50, CVA. Father deceased, age 62, stomach problems. One brother living and in good health. Two sisters, both living and in good health. Physical Exam: ADMISSION PHYSICAL EXAM VS: SBP 93/55, HR 99, SpO2 99% RA, temp 98, RR 12 Gen: Portuguese-speaking male, dark-skinned, drowsy, but otherwise arousable and oriented, in no apparent distress Cardiac: Nl s1/s2 RRR, no murmurs appreciable Pulm: clear bilaterally, no accessory muscle use Abd: grossly distended with dullness to percussion throughout consistent with significant ascites Ext: 1+ edema bilaterally, warm [**Year (4 digits) 894**] PHYSICAL EXAM General Appearance: Thin, with protuberant abdomen. Moaning. Eyes / Conjunctiva: scleral icterus Head, Ears, Nose, Throat: Normocephalic, NG tube Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bibasilar) Abdominal: Bowel sounds present, extremely Distended, Tender-diffusely Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+ Musculoskeletal: Muscle wasting Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): self, place, year, month not date, Movement: Purposeful, Tone: Normal Pertinent Results: ADMISSION LABS [**2122-1-26**] 03:15PM BLOOD WBC-7.4 RBC-3.12* Hgb-8.7* Hct-28.1* MCV-90 MCH-28.0 MCHC-31.1 RDW-17.0* Plt Ct-223 [**2122-1-26**] 03:15PM BLOOD Neuts-92.5* Lymphs-3.7* Monos-3.3 Eos-0.3 Baso-0.2 [**2122-1-26**] 03:15PM BLOOD PT-14.6* PTT-25.7 INR(PT)-1.4* [**2122-1-26**] 03:50PM BLOOD Glucose-294* UreaN-75* Creat-6.1*# Na-125* K-4.6 Cl-86* HCO3-17* AnGap-27* [**2122-1-26**] 03:50PM BLOOD ALT-17 AST-32 CK(CPK)-48 AlkPhos-231* TotBili-0.9 [**2122-1-26**] 03:50PM BLOOD Lipase-42 [**2122-1-26**] 03:50PM BLOOD CK-MB-6 cTropnT-0.28* [**2122-1-26**] 03:50PM BLOOD Albumin-2.9* Calcium-8.2* Phos-7.7*# Mg-2.9* [**2122-1-26**] 03:34PM BLOOD Glucose-294* Lactate-6.4* Na-126* K-4.4 Cl-89* calHCO3-16* CXR [**2122-1-26**] Portable AP upright chest radiograph obtained. A left IJ tunneled dialysis catheter is again noted with its tip residing in the expected location of the right atrium. Lung volumes are low. Previously noted right PICC line has been removed. Given the low lung volumes, evaluation of the lung bases is limited. There is linear opacity in the left retrocardiac space, likely representing atelectasis. No definite signs of pneumonia or CHF. No pleural effusion or pneumothorax. The heart size cannot be readily assessed. Mediastinal contour appears stable with atherosclerotic calcifications along the aortic knob. Bony structures are intact. IMPRESSION: Basilar atelectasis without definite signs of pneumonia. CT ABD/PELVIS [**2122-1-27**] 1. No evidence of perforation, abscess formation or hemorrhage. 2. Severe liver cirrhosis with splenomegaly and large amount of ascites. 3. Filling defect is seen in the distal SMV, at the portal confluence, the proximal portal vein, and the TIPS stent, representing thrombosis or flow artifact. Evaluation is limited due to lack of multiphase imaging. Further workup with Doppler liver vascular ultrasound should be considered. TIPS [**2122-1-28**] 1. Occluded TIPS shunt. This is a change from the ultrasound of [**2121-11-19**]. The portal veins and hepatic veins are patent. 2. Massive ascites. 3. Cirrhotic appearing liver with splenomegaly. PORTABLE ABDOMEN [**2122-1-29**] 1. Technically limited study, demonstrating diffuse gaseous distention of the large and small bowel, most consistent with ileus. 2. Apparent nasogastric tube should be advanced for optimal positioning. CXR [**2122-1-29**] The patient is severely rotated, distorting anatomical landmarks. The examination was performed at near expiration, which crowds and dilates pulmonary vasculature and is responsible for severe left lower lobe atelectasis. The upper lungs are probably clear. Cardiac size cannot be assessed. Left subclavian dialysis catheter ends in the right atrium. Nasogastric tube passes to the lower esophagus and out of view. There is no pneumothorax. PERITONEAL FLUID [**2122-1-26**] AND [**2122-1-27**] ESCHERICHIA COLI AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: 65 year old male with a history of EtOh-cirrhosis, on transplant list, complicated by hepato-renal syndrome on HD, presenting with worsening abdominal pain and fatigue. . # Transition to Comfort Care: the patient's TIPS was found to be not patent and the patient was not considered a transplant candidate in the near future. The family opted to focus on comfort. He was transitioned to CMO and passed away at 6:30 am on [**2122-2-2**]. . # Sepsis - Abdominal pain is present on review of systems; diagnostic paracentesis reveals a WBC count of >4000 with >90% polys consistent with either SBP or secondary bacterial peritonitis (given repeated taps), but no perforation or abscess seen on CT abdomen. Lipase and LFTs are within normal limits making other abdominal sources unlikely. Alkaline phosphatase is elevated which could be secondary to TIPS. There is concern that a clot in the TIPS could be infected. He was treated empirically initially with vanc and zosyn, the vancomycin was changed to daptomycin for VRE given hx of VRE in peritoneal fluid in [**2119**] and chronic thrombocytopenia (so avoid linezolid). The fluid culture revealed GNRs. He did receive albumin for SBP despite already having HRS and being on HD. The fluid culture grew e.coli which was resistant to zosyn, which he had been treated with, and he was transitioned to ceftriaxone, which the e.coli was sensitive to. . # Hypotension: blood pressure was in the range of SBP 80s at night; then increased during the day to the 100s. He was started on midodrine but was unable to take this secondary to his ileus, which was causing him not to absorb PO medications. At time of transition to CMO, the patient's blood pressure was 60/40. . # Ileus: the patient developed a severe ileus, which was thought to be [**1-22**] his peritonitis and his ascites. An NGT was placed with relief of nausea and vomiting, and he was discharged with this tube to hospice for intermittent suctioning. At time of [**Month/Day (2) **], less than 500cc per day was being aspirated, which was mostly the food that he was eating for comfort. He did stool very small amounts even with lactulose. . # Anemia: the patient has had an acute hematocrit drop from 28 to 21. The patient has baseline anemia, likely secondary to kidney disease and liver disease; prior iron studies consistent with anemia of chronic disease. In the setting of acute hematocrit drop, concern for bleed; no signs of acute bleeding despite history of varices. No signs of hemorrhage on CT abd. . # Cirrhosis - Secondary to EtOH. He is no longer drinking. Listed for transplant. Complicated by esophageal varices, hepatic encephalopathy, and refractory ascites s/p TIPS that is no longer patent. Continued lactulose and rifaximin. On prophylactic bactrim for SBP, which was held during his treatment of SBP. He did receive a therapeutic paracentesis with removal of 10L of fluid on [**2122-1-28**]. After that point, although he was in pain with his distension, the patient could not have another paracentesis as his hypotension was preventative. . # End stage renal disease - Hemodialysis for hepatorenal syndrome in setting of cirrhosis. The patient missed HD on day of admission (Monday, [**1-27**]) so recieved an extra session on [**1-28**], in which 1L was removed. Sevelamer and calcium acetate were continued. . #IDDM - continue home lantus and sliding scale. . #. Ventral Hernia: Per records this is not reducible but not changed from prior. No evidence of incarceration/strangulation. This has been one of the patient's most significant sources of discomfort and embarassment for several years however he has been told that he is not a candidate for surgical repair until after he has a liver transplant. . #. Hypothyroidism: Chronic. Continue Levothyroxine at home dose. . # CONTACT: WIFE : [**Telephone/Fax (1) 68125**], [**Telephone/Fax (1) 68133**]; sister [**Telephone/Fax (1) 68134**] Medications on Admission: 1. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. lactulose 10 gram/15 mL Syrup Sig: One (1) ML PO three times a day: take as needed to maintain [**2-22**] Bowel Movements per day. 8. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime: please follow your sugars closely, you may need this dose to be increased if your sugars are high. 9. insulin lispro 100 unit/mL Solution Sig: please see below units Subcutaneous four times a day: as directed 4 times a day per sliding scale sliding scale: (<70) no insulin. (71-100)8 units before meals.(101-150)10 units before meals.(151-200) 12 units before meals.(201-250)14 units before meals, 2 at HS.(251-300)16 units before meals, 3 units @HS. (301-350)18 units before meals, 4 units @HS. (351-400)20 units before meals,5 units @HS. (>401) give 22 units before meals, 6 units @HS and [**Name8 (MD) 138**] MD. . 10. VITAMIN D2 Sig: 50,000 units once a week. 11. B-complex with vitamin C Tablet Sig: One (1) Tablet PO once a day. 12. CALCIUM CARBONATE [TUMS] - (OTC) - 200 mg calcium (500 mg) Sig: One (1) tablet once a day. 13. CLOTRIMAZOLE Sig: Ten (10) troche PO dissolve in mouth 5x/day. [**Name8 (MD) **] Medications: 1. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*0* 2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: One (1) bottle PO Q1H (every hour) as needed for pain: Use for breakthrough pain. Hold for sedation. Hold for respiratory rate less than 12. Disp:*2 bottle* Refills:*0* [**Name8 (MD) **] Disposition: Home with Service [**Name8 (MD) **] Diagnosis: patient expired Primary Diagnosis: alcoholic cirrhosis hepatorenal syndrome on hemodialysis hepatic encephalopathy Secondary diagnosis: hypothyroidism insulin dependent diabetes [**Name8 (MD) **] Condition: patient expired. [**Name8 (MD) **] Instructions: patient expired Dear Mr. [**Known lastname 16651**], You were admitted to the hospital for your liver and kidney disease. We wish you all the best. It was a pleasure taking care of you. Please note to stop taking all of your medications except the following: - Morphine by mouth 5-10mg every one hour as needed for pain. - Fentanyl patch every 72 hours. You will have a nurse to help you with your general care at home as well as the following: - Suction your nasogastric tube as needed. Followup Instructions: None. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Admission Date: [**2151-3-5**] Discharge Date: [**2151-3-6**] Date of Birth: [**2067-9-21**] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 28994**] Chief Complaint: SAH Major Surgical or Invasive Procedure: None History of Present Illness: Per Neurosurgery note. 83-year-old female transferred from OSH with SAH. . Of note, the patient contact[**Name (NI) **] EMS for flank pain. Enroute to OSH with EMS she suddently complained of a severe headache and then became unresponsive. Upon presentation to the OSH she was unresponsive to any stimuli. She was found to have SAH. She received dilantin, decadron, mannitol and dopamine and then transferred to [**Hospital1 18**]. . Upon arrival to [**Hospital1 18**] EW, initial vitals were: BP 110/72, HR 55, RR 15-20, SaO2 100%. Neurosurgery evaluated the patient and CT findings. They found devastating SAH Hunt [**Doctor Last Name 9381**] grade 5, [**Doctor Last Name **] grade 4, no withdrawal to pain, no corneals, gag or cough. The neurosurgery team discussed with her son who stated that her mother would not want to be resuscitated or live with the complications of this. The decision was to make the patient comfort measures only. Past Medical History: - HTN - CAD with cardiac stents Social History: Lives in [**Location **] cares for mentally retarded daughter, husband deceased has son making decisions today Family History: Unknown Physical Exam: Per Neurosurg Report Hunt and [**Doctor Last Name 9381**]: 5 [**Doctor Last Name **]: 4 GCS3 E: 1 V: 1 Motor 1 No eye opening No response to pain in any extremity Pupils on right 7 surgical left 5 non reactive No gag, cough or corneal Breathes over the vent No response in any extemity to pain Pertinent Results: [**2151-3-5**] 05:30PM WBC-30.3* RBC-5.03 HGB-14.8 HCT-42.2 MCV-84 MCH-29.4 MCHC-35.0 RDW-14.1 [**2151-3-5**] 05:41PM LACTATE-3.5* [**2151-3-5**] 05:30PM FIBRINOGE-320 [**2151-3-5**] 05:30PM PT-11.8 PTT-23.7 INR(PT)-1.0 [**2151-3-5**] 05:30PM PLT COUNT-271 OSH CT: SAH around circle of [**Location (un) **] Brief Hospital Course: # Goals of care: The neurosurgery team had a discussion with son [**Name (NI) 382**] who decided that his mother would not want to live like this and be dependent on others. Neurosurgery had nothing to offer. The patient was made comfort measures only. She was extubated and dopamine was stopped. Started on morphine, ativan and scopolamine. She passed away with family at bedside. # Subarachnoid Hemorrhage: The patient has a massive SAH with no neurologic signs suggestive of recovery. Neurosurgery evaluated the patient and felt that surgical intervent or medical therapy would be futile at this point. She was made CMO. Medications on Admission: Unknown Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: SAH Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

Admission Date: [**2147-6-28**] Discharge Date: [**2147-7-14**] Date of Birth: [**2068-2-6**] Sex: M Service: MEDICINE Allergies: Ambien Attending:[**First Name3 (LF) 2698**] Chief Complaint: Acute renal failure Major Surgical or Invasive Procedure: Angiography of lower limbs History of Present Illness: Mr. [**Known lastname 28624**] is a 79 year old male with past medical history of congestive heart failure, coronary artery disease, COPD, and diabetes mellitus who was transferred to [**Hospital1 18**] for further management after being found to have hyperkalemia, worsening renal function, and hypotension. . He presented to [**Hospital6 17032**] today after being referred there when routine laboratory draw revealed abnormalities. His potassium was found to be 6.1, and creatinine 4.7. Blood pressure there was noted to be 83/42. He was given an albuterol nebulizer, 1 amp of calcium gluconate, 10 units of regular insulin, 1 amp of D50, and 30 mg of kayexalate, as well as 500 cc of normal saline. . In the ED here at [**Hospital1 18**], initial vital signs were: blood pressure of 91/54, heart rate of 76, respiratory rate of 22, and oxygen saturation of 90%. A right femoral central line was placed for initiation of pressors, and he was started on neo. He was given 1 gram of vancomycin and 4.5 grams of zosyn for possible urinary tract infection. He received 1 gram of calcium gluconate, 1 amp of D5, and 10 units of regular insulin as well for hyperkalemia. Renal and cardiology were consulted. . On the floor, he reports he has to move his bowels, but otherwise denies any shortness of breath or other complaints. Of note, has highly variable BP readings depending on position, alternating in rapid sequence from 70-110's systolic. . Of note, he was recently admitted to [**Hospital1 18**] cardiology service from [**2147-6-10**] until [**2147-6-16**] after being transferred from [**Hospital6 27369**]. At that time, he had acute on chronic renal insufficiency, as well as hypotension. He was diuresed with a lasix drip, which was switched to torsemide. EP also followed the patient, and his ICD was re-programmed to allow for native conduction, with consideration of up-grade to [**Hospital1 **]-ventricular pacer in future, as this was deferred given improvement in his symptoms with diuresis. His blood pressure was noted to be 70-100 systolic during that admission with normal mentation. Elevated creatinine was felt to be secondary to poor forward flow, and LFT elevations secondary to congestion. . He states that since his admission, he has been at rehabilitation. He reports he gained about 10 pounds since discharge, though he's not sure how. On [**2147-6-28**] he presented to [**Hospital6 17032**] for hyperkalemia, worsening renal function, and hypotension. Past Medical History: 1. CARDIAC RISK FACTORS: -Coronary Artery Disease (s/p MI x2) -Diabetes (Type 2 insulin-dependant) -Dyslipidemia -Hypertension 2. CARDIAC HISTORY: -CABG: -s/p CABG in [**2139**] (LIMA->diag, SVG->OM1, SVG->LAD) -PERCUTANEOUS CORONARY INTERVENTIONS: -s/p prior LAD stent and PTCA of diag -s/p [**Year (4 digits) **] to RCA in [**2146**] -PPM/ICD: - Ischemic cardiomyopathy, s/p ICD implantation [**2141-7-14**] - PPM (unclear when placed) -OTHER CARDIAC HISTORY: - Paroxysmal atrial fibrillation - Nonsustained ventricular tachycardia - Chronic systolic CHF [**2-14**] ischemic cardiomyopathy(last EF 20%) - Mitral regurgitation - Pulmonary Hypertension 3. OTHER PAST MEDICAL HISTORY: -Chronic Obstructive Pulmonary Disease on 3L home O2 since [**2146**] -Chronic Renal Insufficiency (baseline creatinine 1.5-1.8) -s/p right renal artery stent -Severe Peripheral Vascular Disease, s/p left fem-[**Doctor Last Name **] bypass [**2137**] -Obstructive sleep apnea intolerant to CPAP -GERD -Anxiety -Depression -Post Traumatic Stress Disorder Social History: Married and lives with his wife. Retired from Army. Most recently worked as a cook at the [**Hospital **] [**Hospital6 28623**]. He used to drink alcohol heavily, but has had none in 40 years. 40+ pack year h/o smoking, quit 40 years ago. Family History: Father died of an MI at age 48. Brother died of an MI at age 64. Physical Exam: Afebrile, BP 116/53, HR 91, RR 28, Oxygen saturation 98% on 3L General: Male resting in bed, intermittently trying to sit up, then asleep, appearing mildly distressed HEENT: NC/AT, PERRL, EOMI, slightly dry MM Neck: Supple, JVP elevated to ear Lungs: Decreased BS over bases, right > left, no wheezes or rales Cardiac: Irregularly irregular, though regular at times Abd: Soft, NT, ND, +BS Extr: Pitting edema bilaterally, improved from prior, eschar over right heel and right lateral foot below metatarsal. Skin: Fragile skin tears Neuro: Awake, though unable to assess if oriented to place--oriented to self, speech slightly dysarthritic at times, poor attention Able to follow some commands. Occasional myoclonic shaking when awakening. Psych: Agitated. Pertinent Results: Admission Labs: [**2147-6-28**] 03:30PM BLOOD WBC-10.4 RBC-4.28* Hgb-13.0* Hct-40.8 MCV-95 MCH-30.3 MCHC-31.7 RDW-17.2* Plt Ct-244 [**2147-6-28**] 03:30PM BLOOD Neuts-79.3* Lymphs-9.6* Monos-9.4 Eos-1.2 Baso-0.5 [**2147-6-28**] 05:18PM BLOOD PT-25.7* PTT-33.0 INR(PT)-2.5* [**2147-6-28**] 03:30PM BLOOD Glucose-204* UreaN-77* Creat-4.4*# Na-130* K-5.9* Cl-92* HCO3-21* AnGap-23* [**2147-6-28**] 09:00PM BLOOD ALT-120* AST-250* LD(LDH)-353* CK(CPK)-127 AlkPhos-58 TotBili-1.1 [**2147-6-28**] 09:00PM BLOOD Albumin-3.6 Calcium-8.6 Phos-7.0*# Mg-2.8* Cardiac Biomarkers: [**2147-6-28**] 03:30PM BLOOD cTropnT-0.07* [**2147-6-28**] 09:00PM BLOOD CK-MB-9 cTropnT-0.08* [**2147-6-29**] 04:12AM BLOOD CK-MB-8 cTropnT-0.09* [**2147-7-5**] 03:14AM BLOOD CK-MB-4 cTropnT-0.05* [**2147-6-28**] 03:30PM BLOOD proBNP-7763* U/A [**2147-6-28**] 03:48PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.016 [**2147-6-28**] 03:48PM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-4* pH-6.5 Leuks-SM [**2147-6-28**] 03:48PM URINE RBC-[**12-2**]* WBC-21-50* Bacteri-MOD Yeast-NONE Epi-0 [**2147-6-28**] 03:48PM URINE CastGr-0-2 CastHy-[**6-22**]* BCx negati x 2 Recent Labs prior to discharge: [**2147-7-10**] 02:16PM BLOOD WBC-8.9 RBC-4.37* Hgb-12.9* Hct-39.1* MCV-90 MCH-29.5 MCHC-32.9 RDW-16.1* Plt Ct-263 [**2147-7-11**] 06:14AM BLOOD WBC-9.6 RBC-4.37* Hgb-12.4* Hct-38.4* MCV-88 MCH-28.5 MCHC-32.4 RDW-16.3* Plt Ct-264 [**2147-7-12**] 05:48AM BLOOD WBC-10.1 RBC-4.30* Hgb-12.5* Hct-37.8* MCV-88 MCH-29.0 MCHC-33.0 RDW-16.1* Plt Ct-246 [**2147-7-13**] 09:21AM BLOOD WBC-9.5 RBC-4.53* Hgb-12.8* Hct-39.5* MCV-87 MCH-28.3 MCHC-32.4 RDW-16.3* Plt Ct-263 [**2147-7-13**] 02:43PM BLOOD WBC-9.5 RBC-4.56* Hgb-13.3* Hct-40.0 MCV-88 MCH-29.1 MCHC-33.2 RDW-16.0* Plt Ct-231 [**2147-7-14**] 05:43AM BLOOD WBC-10.2 RBC-4.48* Hgb-13.2* Hct-39.5* MCV-88 MCH-29.3 MCHC-33.3 RDW-16.2* Plt Ct-242 [**2147-7-5**] 03:14AM BLOOD Neuts-74.0* Lymphs-13.7* Monos-10.1 Eos-1.9 Baso-0.3 [**2147-7-12**] 05:48AM BLOOD Neuts-77.3* Lymphs-11.0* Monos-9.4 Eos-1.7 Baso-0.7 [**2147-7-13**] 09:21AM BLOOD PT-26.5* PTT-33.6 INR(PT)-2.6* [**2147-7-13**] 09:21AM BLOOD Plt Ct-263 [**2147-7-13**] 02:43PM BLOOD PT-25.3* PTT-31.0 INR(PT)-2.4* [**2147-7-13**] 02:43PM BLOOD Plt Ct-231 [**2147-7-14**] 05:43AM BLOOD PT-27.3* PTT-31.4 INR(PT)-2.7* [**2147-7-14**] 05:43AM BLOOD Plt Ct-242 [**2147-7-8**] 02:34PM BLOOD Glucose-196* UreaN-36* Creat-1.7* Na-136 K-4.3 Cl-97 HCO3-29 AnGap-14 [**2147-7-9**] 05:52AM BLOOD Glucose-101* UreaN-35* Creat-1.7* Na-137 K-3.9 Cl-98 HCO3-31 AnGap-12 [**2147-7-9**] 02:58PM BLOOD Glucose-246* UreaN-35* Creat-1.7* Na-137 K-4.0 Cl-97 HCO3-29 AnGap-15 [**2147-7-10**] 02:45AM BLOOD Glucose-142* UreaN-34* Creat-1.8* Na-138 K-3.7 Cl-98 HCO3-32 AnGap-12 [**2147-7-10**] 02:16PM BLOOD Glucose-171* UreaN-32* Creat-1.6* Na-135 K-4.7 Cl-96 HCO3-33* AnGap-11 [**2147-7-11**] 06:14AM BLOOD Glucose-150* UreaN-31* Creat-1.8* Na-136 K-3.8 Cl-94* HCO3-34* AnGap-12 [**2147-7-12**] 05:48AM BLOOD Glucose-103* UreaN-29* Creat-1.9* Na-137 K-4.0 Cl-93* HCO3-33* AnGap-15 [**2147-7-12**] 02:44PM BLOOD Glucose-250* UreaN-33* Creat-1.9* Na-134 K-3.6 Cl-90* HCO3-34* AnGap-14 [**2147-7-13**] 09:21AM BLOOD Glucose-164* UreaN-30* Creat-1.8* Na-135 K-3.9 Cl-89* HCO3-37* AnGap-13 [**2147-7-13**] 02:43PM BLOOD Glucose-195* UreaN-30* Creat-1.9* Na-132* K-3.3 Cl-86* HCO3-37* AnGap-12 [**2147-7-14**] 05:43AM BLOOD Glucose-198* UreaN-32* Creat-1.9* Na-136 K-2.9* Cl-86* HCO3-38* AnGap-15 [**2147-7-11**] 06:14AM BLOOD ALT-22 AST-23 AlkPhos-46 TotBili-1.2 [**2147-7-5**] 03:14AM BLOOD CK-MB-4 cTropnT-0.05* [**2147-7-14**] 05:43AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9 ART DUP EXT LO UNI;F/U LEFT Preliminary report only. Chest Xray [**7-5**]: IMPRESSION: AP chest compared to [**7-4**]. Lateral aspect right lower chest is excluded from the examination. New hazy opacification at the right lung base could be due to either recent aspiration or developing asymmetric edema. Moderate cardiomegaly and mediastinal vascular engorgement have both increased. Small left pleural effusion is unchanged. Right PICC line ends in the SVC and a transvenous right atrial pacer and right ventricular pacer defibrillator leads are in standard placements, unchanged. No pneumothorax. Cardiology Report ECG Study Date of [**2147-7-5**] 12:19:20 AM Atrial paced rhythm with intrinsic A-V conduction, frequent ventricular ectopy and fusion beat. Compared to the previous tracing of [**2147-6-29**] there is frequent ventricular ectopy. Otherwise, no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 0 132 418/453 0 -29 139 URINE CULTURE (Final [**2147-7-9**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | GENTAMICIN------------ 8 I <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R NITROFURANTOIN-------- <=16 S <=16 S OXACILLIN------------- =>4 R <=0.25 S TETRACYCLINE---------- =>16 R 2 S VANCOMYCIN------------ 2 S 1 S Brief Hospital Course: He was transferred to [**Hospital1 18**] ED where he was triaged as septic, given neosynephrine, vancomycin, zosyn, and treated for hyperkalemia. . In MICU, he was diuresed on lasix drip and noted to have baseline SBPs 70s-80s in acute on chronic systolic congestive heart failure with EF 20%. With diuresis he was able to maintain SBPs off pressors in 80s and his renal function improved. His infectious work-up was negative. He was transferred to cardiology floor on a lasix drip for diuresis. Overnight [**Date range (1) 28625**], he was reported to be agitated and intermittently hypoxic to 80s after which he would awaken and be startled. He was transferred to the MICU for higher level of nursing care. Assessment there suggested multiple factors including adverse reaction to sleep aide (ambien), high dose ciprofloxacin (for empiric UTI treatment), haldol and hypoxia in setting of known sleep apnea not on BiPAP. With observation and cessation of medications the patient's mental status improved to baseline and he was no longer hypoxic. Ambien was felt to be the primary cause and should not be given again; avoid in the future. . He was seen by vascular surgery and podiatry for his severe peripheral vascular disease and chronic ulcers. No current inpatient managment was felt necessary at that time given CHF exacerbation. However, during agressive diuresis of the patient, Mr. [**Known lastname 28624**] developed cellulitis of his right lower limb. Due to the edema and poor blood supply to the legs given his vascular disease, the pt developed an infection of the skin and healing ulcers on his feet. He was given broad spectrum IV antibiotics to treat the infection (vancomycin, cipro and flagyl x7days). . In addition, given the development of infection, vascular surgery performed an angiography in an attempt to improve blood flow to in order to facility abx treatment. The legs showed significant blockages which require correction; however, vascular surgery was not able to perform any stenting due to patient movement. Thus, vascular surgery arranged to use general anesthesia for the procudure balloon or stenting of the leg blood vessels; tentatively vascular surgery will perform this on [**7-18**]. . Although there was as strong preference by all care providers involved that the patient remain at [**Hospital1 18**] while completing IV antibiotics and awaiting surgery, the patient was adament that he be moved closer to home to [**Location (un) 25576**] to complete IV antibiotics until the time of the vascular intervention. Arrangements were made and the pt was transferred to [**Location (un) 28626**]. . PLEASE NOTE THAT AMBIEN HAS BEEN ADDED TO PT'S LIST OF ALLERGIES. Medications on Admission: - Albuterol nebulizer Q2 hours PRN - Amiodarone 100 mg daily - Ascorbic acid 500 mg daily - Aspirin 325 mg - Fenofibrate 145 mg QHS - Fluticasone/Salmeterol 250/50 [**Hospital1 **] - Laisx daily--? dose - Humalog mix 50/50 - Levothyroxine 25 mcg - Metoprolol Succinate 25 mg + 50 mg daily - Multiple vitamin - Polyethylene glycol daily - Ranitidine 150 mg daily - Senna [**Hospital1 **] - Simvastatin 10 mg - Bactrim DS [**Hospital1 **] - Tramadol 50 mg Q8H - Trazodone 50 mg QHS - Valsartan 40 mg daily - Velafaxine ER 75 mg QHS ** Of note, discharge summary from [**2147-6-16**] as the following medications listed differently: - Venlafaxine 75 mg--1.5 tablets daily - Torsemide 100 mg daily - Metoprolol Succinate 50 mg daily - Warfarin Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheeze, shortness of breath. 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 9. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 14. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 4 days: Pt should complete 7 day course to end on [**7-18**]. 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 18. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) unit Subcutaneous ASDIR: See attached sheet. 19. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: Six (6) unit Subcutaneous ASDIR: See attached sheet. 20. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 22. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 23. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 26. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 27. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 28. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 29. Dextrose 50% in Water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 30. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Congestive Heart Failure Acute renal failure Secondary Diagnosis: Hyperkalemia (high potassium, electrolyte imbalance) Coronary artery disease COPD diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital because you had gained 10 pounds and were experiencing with difficult breathing and substantially increased swelling of you lower legs. You were found to have dnagerous electrolyte imbalances, worsening kidney function and very low blood pressure. This was an exacerbation of your chronic heart failure and there was concern for infection. . While in the hospital, your symptoms worsened and you were transferred to the ICU and received antibiotics. Although there was concern for infection, tests were negative. After further investigation it was felt that Ambien (a medication you received) caused significant unexpected adverse side effects in you. We recommend that you never take Ambien again and have listed it as a medication [**Location (un) **] in your record. Please be sure to alert you PCP and other doctors of this [**Name5 (PTitle) **]. . To treat your heart failure you received medications to remove excess fluid that had accumlated in your body. With the removal of this fluid your symptoms improved. However, due to the edema and poor blood supply to your legs due to vascular disease, you developed an infection of the skin and healing ulcers on your feet. You were given IV antibiotics to treat this infection. You responded well but require continued treatment of the infection with IV antibiotics. . In addition, vascular surgery performed an angiography and other tests of you blood vessels in you legs which showed significant blockages which require correction; if these are not corrected you risk continued life threatening infections of the legs and ampulation. Correction of these blockages was attempted while you were here but was not success in the setting of only partial sedation during the procedure. Thus, vascular surgery will be arranging to use general anesthesia (complete sedation) for the procudure to open the leg blood vessels; you have an appointment with vascular surgery on [**7-18**] to further address this issue. . Given your strong preference to be closer to your family, you were transferred to an outside care facility ([**Location (un) 25576**]) once you stablized in order to continue the removal of the remaining fluid you had accumulated and the complete your course of IV antibiotics for the treatment for your infection. . The following changes were made you your medications: - Please CONTINUE taking Furosemide 160mg PO twice daily. - Please CONTINUE taking Metolazone 5mg daily. - Please CONTINUE taking Vancomycin 1000 mg IV Q 24H - Please CONTINUE taking MetRONIDAZOLE (FLagyl) 500 mg PO/NG Q8H - Please CONTINUE taking Ciprofloxacin HCl 500 mg PO/NG Q12H - Please continue to take all of your other home medications as prescribed. . Please be sure to take all medication as prescribed. . Please be sure to weigh yourself daily and record your weight. If you have more than a 3lb increase in your weight, please call you doctor immediately. . Please be sure to keep all follow-up appointments with your PCP and heart doctor. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your PCP and heart doctor. Department: CARDIAC SERVICES When: THURSDAY [**2147-7-20**] at 9:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] Department: Vascular Surgery When: Tuesday [**2147-7-18**] 10:00AM Location: [**Last Name (NamePattern1) 439**] [**Hospital Unit Name **] [**Location (un) **] Suite C, [**Location (un) 86**] [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 1393**] Completed by:[**2147-7-16**]

Admission Date: [**2125-9-1**] Discharge Date: [**2125-9-4**] Date of Birth: [**2068-10-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Head trauma s/p motorcycle accident Major Surgical or Invasive Procedure: None, only angiography, CT scans, xrays and MRI History of Present Illness: 56M s/p motorcycle vs. car, tx from [**Hospital3 **]. TBI c/ sm SDH, mult facial fx. + LOC, amnestic of events. Pt ran into an auto going 30-40 mph and flew 50 feet, per report. Wearing a helmet, but landed on R face. Suffered road rash over R side of body, mainly RUE. Past Medical History: HTN Social History: Lives with wife, social EtOH, no smoking, no illicit drugs Family History: NC Physical Exam: GEN: In distress, verbally responsive HEENT: PERRL, R temporal abrasion, OP clear Neck: trach midline PULM: CTAB CV: RRR GI: soft, ND GU: Foley in Neuro: grossly intact Psych: appropriate Pertinent Results: [**2125-9-1**] 04:57PM TYPE-ART TEMP-37.1 RATES-/16 O2 FLOW-3 PO2-85 PCO2-41 PH-7.46* TOTAL CO2-30 BASE XS-4 INTUBATED-NOT INTUBA [**2125-9-1**] 04:57PM GLUCOSE-117* LACTATE-1.9 [**2125-9-1**] 04:57PM freeCa-1.05* [**2125-9-1**] 04:39PM GLUCOSE-120* UREA N-10 CREAT-0.8 SODIUM-138 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 [**2125-9-1**] 04:39PM CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-2.1 [**2125-9-1**] 04:39PM WBC-10.5 RBC-3.94* HGB-12.1* HCT-35.0* MCV-89 MCH-30.6 MCHC-34.5 RDW-13.5 [**2125-9-1**] 04:39PM PLT COUNT-263 [**2125-9-1**] 04:39PM PT-12.5 PTT-24.2 INR(PT)-1.1 [**2125-9-1**] 08:29AM GLUCOSE-190* UREA N-10 CREAT-1.0 SODIUM-138 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17 [**2125-9-1**] 08:29AM CALCIUM-8.4 PHOSPHATE-2.5* MAGNESIUM-2.0 [**2125-9-1**] 08:29AM WBC-12.5* RBC-4.30* HGB-13.1* HCT-37.4* MCV-87 MCH-30.5 MCHC-35.0 RDW-13.6 [**2125-9-1**] 08:29AM PLT COUNT-286 [**2125-9-1**] 08:29AM PT-12.8 PTT-20.9* INR(PT)-1.1 [**2125-9-1**] 02:35AM GLUCOSE-186* UREA N-10 CREAT-0.9 SODIUM-138 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-18 [**2125-9-1**] 02:35AM CALCIUM-8.7 PHOSPHATE-2.1* MAGNESIUM-2.0 [**2125-9-1**] 02:35AM WBC-16.8* RBC-4.53* HGB-13.8* HCT-40.0 MCV-88 MCH-30.3 MCHC-34.4 RDW-13.3 [**2125-9-1**] 02:35AM PLT COUNT-325 [**2125-9-1**] 12:21AM COMMENTS-GREEN TOP [**2125-9-1**] 12:21AM GLUCOSE-186* LACTATE-3.4* NA+-139 K+-4.1 CL--97* [**2125-9-1**] 12:21AM HGB-14.7 calcHCT-44 O2 SAT-97 [**2125-9-1**] 12:21AM freeCa-1.05* [**2125-9-1**] 12:05AM GLUCOSE-200* UREA N-12 CREAT-1.1 SODIUM-139 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-28 ANION GAP-17 [**2125-9-1**] 12:05AM estGFR-Using this [**2125-9-1**] 12:05AM AMYLASE-24 [**2125-9-1**] 12:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2125-9-1**] 12:05AM URINE HOURS-RANDOM [**2125-9-1**] 12:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2125-9-1**] 12:05AM WBC-20.9* RBC-4.48* HGB-13.6* HCT-39.3* MCV-88 MCH-30.4 MCHC-34.7 RDW-13.6 [**2125-9-1**] 12:05AM PLT COUNT-310 [**2125-9-1**] 12:05AM PT-12.3 PTT-20.5* INR(PT)-1.0 [**2125-9-1**] 12:05AM FIBRINOGE-392 [**2125-9-1**] 12:05AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2125-9-1**] 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2125-9-1**] 12:05AM URINE RBC-1 WBC-1 BACTERIA-RARE YEAST-NONE EPI-0 RENAL EPI-[**4-4**] [**2125-9-1**] 12:05AM URINE MUCOUS-RARE [**2125-9-1**] 12:05AM URINE HYALINE-0-2 [**9-1**] CT head: 1. Multiple right-sided facial fractures, small right subdural hematoma within the right middle cranial fossa. Extensive hemorrhage within the maxillary sinuses and sphenoid sinuses. 2. Fracture line extending into the sella turcica is concerning for injury to the carotid arteries. [**9-1**] CT torso: 1. No acute intrathoracic, abdominal or pelvic injury. 2. Fatty infiltration of the liver. 3. Diverticulosis. [**9-1**] Ct C-spine: Possible widening of the anterior interspace at the C5-6 level. If there is any concern for cervical spine injury, an MRI of the cervical spine is recommended. Apparent fracture of the anterior portion of the vertebral artery canal at the level of C2. CTA of the neck is recommended to exclude vertebral artery injury. [**9-1**] CT face: 1. Multiple facial fractures, predominantly right-sided. Concerning fracture to the sella and area of the cavernous sinus. This raises concern for carotid injury. Followup CTA of the head and neck is recommended. 2. Nondisplaced right lateral wall orbital fracture with tiny foci of intraorbital air. [**9-1**] Xray pelvis, R femur, R knee, R tib/fib: no fx [**9-1**] CTA head/neck: Irregular and diminutive caliber of the right cavernous and supraclinoid ICA concerning for vascular injury. Numerous skull base and facial fractures as detailed on the recent CT of the facial bones. Stable right middle fossa subdural hematoma without significant mass effect on the underlying brain. [**9-1**] B/l carotid imaging: Very slight narrowing of a portion of the right cavernous carotid artery without evidence of intimal flap or pseudoaneurysm formation. Although considered unlikely, dissection is not entirely excluded. The left internal carotid artery and left vertebral arteries are normal. [**9-2**] xray R shoulder: Moderate glenohumeral joint osteoarthritis. [**9-2**] MRI lumbar spine: The lumbar vertebral bodies are normal in signal intensity, morphology and alignment. The conus is grossly unremarkable. There is no evidence for epidural hematoma or compression. No significant canal stenosis is seen. There is mild lumbar spondylosis in the lower lumber spine. No acute posttraumatic sequela in the lumbar spine seen. [**9-2**] MRI C-Spine: The study is somewhat motion degraded. Within limits of this examination, there is no evidence for compression fracture or abnormal marrow signal. No evidence for ligamentous injury or cord contusion is seen. There is a left paracentral disk protrusion at C5- C6 which narrows the left neural foramen. There are and disk-osteophyte complexes at C3-C4 and C4-C5 without significant stenosis. No evidence for acute posttraumatic injury to the cervical spine. Cervical spondylosis most prominent at C5-C6. Brief Hospital Course: Pt was transferred by [**Location (un) **] to the [**Hospital1 18**] ED and admitted to the Trauma Surgery service under Attending physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. The patient spent the first night in the TSICU for frequent neuro checks. He was not intubated at any time. He was loaded on Dilantin for small SDH. There was initial concern for carotid injury per the intial Ct Scan of the head and neck, but further angiography and finally MRI was able to deny the presence of carotid injury. The patient's spine was cleared clinically and he was transferred to the floor without incident. Did well the following day and PT was consulted and recommended no rehab at this time. The patient had Plastic surgery, Ortho spine and Neurosurg consults, and each service will follow the patient as an outpatient. His facial fractures were non-operative at this time. Medications on Admission: Unk HTN medication Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*40 Capsule(s)* Refills:*2* 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 5 days. Disp:*15 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Large R frontal subgaleal hematoma R greater sphenoid [**Doctor First Name 362**] fx extending into the sellae 1.7 cm fragment fx of the right temporal process Small right SDH in middle cranial fossa Mult facial fx, predominantly R-sided, incl. fx of the right zygomatic arch and pterygoid plates. Nondisplaced R lat wall maxillary sinus fx with tiny foci of intraorbital air. Discharge Condition: Good, tolerating po, ambulating and voiding without difficulty, pain well-controlled Discharge Instructions: Please be careful when riding your motorcycle. Always wear a helmet. Please take your medications as directed. You need to take Dilantin for 5 more days to prevent seizures. Call your doctor or return to the Emergency Department right away if any of the following problems develop: * Prolonged nausea * Vomiting * Confusion, drowsiness, change in normal behavior * Trouble walking, or speaking (slurred speech) * Numbness or weakness of an arm or leg. * Severe headache * Convulsions or seizures * Any other worrisome symptoms Followup Instructions: Please call to make an appointment with Dr. [**Last Name (STitle) **] in the trauma clinic in [**1-31**] weeks to assess your injuries. The number is ([**Telephone/Fax (1) 41065**]. Please call the Plastic Surgery clinic to schedule a follow up appointment for this Friday ([**2125-9-6**]) to recheck your facial fractures. The number is ([**Telephone/Fax (1) 50951**]. Also tell them that you need to have the stitches taken out of your leg. Please make a follow up appointment with [**Hospital 4695**] Clinic, Dr. [**Last Name (STitle) **], in 8 weeks to get a repeat Cat Scan of your head to make sure your recovery is progressing. You need to tell the office that they need to order a 'non-contrast head CT with 2.5 millimeter cuts'. The number is: ([**Telephone/Fax (1) 88**]. Completed by:[**2125-9-4**]

Admission Date: [**2133-4-8**] Discharge Date: [**2133-4-29**] Date of Birth: [**2133-4-4**] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 29469**], twin I, was a 36-week, 2795-gram [**Known lastname 43610**] product of a 30-year-old gravida 4, para 0 to 2 mother with serologies O positive, antibody negative, Rubella immune, rapid plasma reagin nonreactive, hepatitis B not detected, group B strep status negative. Delivery was by cesarean section secondary to spontaneous rupture of this twin and breech positioning. There were no septic risk factors. Baby girl [**Known lastname 29469**] was in the Newborn Nursery when she was noted to have a dusky episode associated with apnea for which she was admitted to the Neonatal Intensive Care Unit. PHYSICAL EXAMINATION ON PRESENTATION: Weight was 2795 grams (50 percentile), length was 19 inches, 48 centimeters (50-75 percentile), and head circumference was 32.5 cm (50 percentile). This was a well-developed [**Known lastname 43610**] given gestational age. Her anterior fontanel was soft and flat. Her face was symmetric. Her nares appeared patent. Her oropharynx was moist and pink with palate intact. Her tinea were well formed. Her neck was supple without pits or masses. Her heart was in a regular rate and rhythm without murmurs. Her lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, and nondistended. She had no hepatosplenomegaly. This was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 33542**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 43610**]. The anus was patent. She had no hair [**Hospital1 **] or sacral dimple on her back. All extremities were intact. She had equal movement. Tone was appropriate for gestational age. SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: Baby girl [**Known lastname 29469**] remained on room air throughout her hospital stay. She had dusky episodes, primarily associated with feedings. She would choke and desaturate as low as the 40s, and her heart rate dipped as low as 59 beats per minute. Throughout her hospital course as her feeding coordination improved, these episodes became less frequent. Her last bout was on [**2133-4-22**]. She has subsequently done well without any noted apnea or bradycardia. She is taking oral intake well without notable color changes during feedings. The parents are comfortable with her feeding. 2. CARDIOVASCULAR ISSUES: Baby girl [**Known lastname 29469**] has been cardiovascularly stable with the exception of bradycardias associated with feedings per above. 3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: Baby girl [**Known lastname 29469**] has been maintained breast milk 20 and Enfamil 20 throughout her hospital course. She is currently feeding by mouth ad lib, exceeding 120 cc/kg per day. Weight on discharge was 3325 grams, length 54 centimeters, head circumference 35 centimeters. 4. GASTROINTESTINAL ISSUES: Baby girl [**Known lastname 29469**] was treated with phototherapy for hyperbilirubinemia. She reached a peak bilirubin of 15.8 and a direct bilirubin of 0.2 on [**4-9**]. She was treated with phototherapy for two days. Her last bilirubin on [**4-13**] was 9.2/0.4. 5. HEMATOLOGIC ISSUES: Baby girl [**Known lastname 54939**] initial complete blood count was notable for a white blood cell count of 9.4, with a differential of 0 bands and 44 segmented neutrophils. Her initial hematocrit was 49, and her platelets were 393. She received no transfusions during her admission, and her most recent hematocrit was 33.8 on [**2133-4-20**]. 6. INFECTIOUS DISEASE ISSUES: An initial blood culture was sent on admission on [**4-8**] which was negative. She was treated with ampicillin and gentamicin for 48 hours which was discontinued after the cultures were negative. She showed no further signs of infection. 7. NEUROLOGIC ISSUES: Given the apnea and dusky episodes, she had an initial head ultrasound which showed bilateral choroid plexus blood. A repeat head ultrasound done on [**4-20**] was normal. Otherwise, she has been neurologically stable throughout her hospitalization. 8. SENSORY/AUDIOLOGY ISSUES: Hearing screening was performed with automated auditory brain stem responses, and she passed on [**2133-4-8**]. 9. OPHTHALMOLOGIC ISSUES: Eye examination was not necessary due to her gestational age. 10. PSYCHOSOCIAL ISSUES: [**Hospital1 188**] Social Work was involved with the family. The contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**], and she can be reached at telephone number [**Telephone/Fax (1) **]. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24613**] with [**Hospital 2312**] Pediatrics (office telephone number [**Telephone/Fax (1) 37109**]; fax number [**Telephone/Fax (1) 37110**]). CARE AND RECOMMENDATIONS: 1. Feedings at discharge: Breast milk/Enfamil 20 by mouth ad lib. 2. Medications at discharge: Tri-Vi-[**Male First Name (un) **] 1 cc by mouth once per day and Desitin to diaper area as needed. 3. Car seat position screening. 4. Newborn state screens were sent; most recent on [**2133-4-8**] and were normal. 5. Hepatitis B vaccination was given on [**2133-4-7**]. IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks gestation with 2/3 of the following: plans for day care during respiratory syncytial virus season, with a smoker in the household, neuromuscular disease, airway abnormalities, or with school-age siblings; and/or (3) with chronic lung disease. Influenza immunization should be considered annually in the Fall for preterm infants with chronic lung disease once they reach six 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 to protect the infant. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24613**] on [**2133-5-1**]. 2. Care Group [**Hospital6 407**] to visit the home on [**2133-4-30**] (contact telephone number [**Telephone/Fax (1) 37503**]). DISCHARGE DIAGNOSES: 1. Apnea of prematurity. 2. Feeding immaturity. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**] Dictated By:[**Last Name (NamePattern1) 54940**] MEDQUIST36 D: [**2133-4-28**] 17:35 T: [**2133-4-28**] 18:58 JOB#: [**Job Number 54941**]

Admission Date: [**2150-3-27**] Discharge Date: [**2150-4-29**] Service: NEUROLOGY Allergies: Dyazide / Norvasc / Methimazole / propoxyphene N-acetaminophen Attending:[**First Name3 (LF) 5831**] Chief Complaint: Shortness of breath, dysphagia, weakness and fatigue Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 47342**] is an 86 y/o right-handed woman who was referred to [**Hospital1 18**] with complaints of dysarthria, dysphagia and fatigue, which her outpatient neurologist found concerning for myasthenia [**Last Name (un) 2902**]. Ms. [**Known lastname 47342**] explained that over the year prior to admission she had noticed progressive weakness and fatigue, with difficulty swallowing and speaking, increased napping, and new-onset dyspnea. Her weakness seemed to develop over her entire body simultaneously, with no discernable pattern of spread. Symptoms are somwehat worse as the day goes on, and are not relieved by resting. She reports increasing dysphagia (solids>liquids) with a 20lb weight loss since the start of [**2149**]. She cannot drink through a straw. She has also had to start using a walker since [**Month (only) 404**]. Prior to begining to use the walker, she had three falls in the preceding year, including one in which she fractured her left wrist. Additionally, Ms. [**Known lastname 47342**] reports that she now naps much of the day, and as a consequence has been sleeping less at night--with trouble both falling asleep and staying asleep. She sleeps an average of 5 hours qNight. Ms. [**Known lastname 47342**] [**Last Name (Titles) **] that shortly before she began to feel week, she was hospitalized for PNA, in [**2149-2-17**] (I have been unable to find mention of this in her online medical record). She thinks she initially recovered from that but is unsure she ever returned to baseline before she began developing her current symptoms. On ROS, she admitted to dyspnea on exertion (such as taking a shower or getting dressed), and occasional dysuria, but denies chest pain, palpitations, cough, fevers/chills, abdominal pain, n/v/d, constipation, hematuri, melena and hematochezia. On Neuro ROS, she admitted to occasional diplopia (horizontal), which seems to come and go each day, as well as gait-unsteadiness, but denied vertigo and fasciculations. Past Medical History: PAST MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation requiring three prior cardioversions in the past and previously treated with Amiodarone and now Dronedarone starting 10/[**2147**]. 2. Hypertension. 3. Dyslipidemia. 4. [**Doctor Last Name 933**] disease. 5. Hyponatremia. 6. Rheumatoid arthritis. 7. TIA s/p left CEA 8. TAH 9. GERD 10. Cervical Spondylosis 11. Hx of falls, s/p left hip fracture (no surgery) 12. Remote TB, s/p partial right lung lobectomy 14. Fracture of left wrist s/p fall approximately 10 weeks ago 15. Laryngitis from GERD Social History: Has her own [**Last Name (un) **] but has recently been living with a boyfriend in his home. The two spent the past three months together in [**State 108**], as she typically does each winter. ETOH: [**12-21**] glasses wine qDay, stopped 2 months ago due to dysphagia Cigs: never smoked Drugs: Denies Family History: No family history of neuromuscular disease, but both parents had CAD. Mother- died in her 50's "high blood pressure" Father- died of MI in his 50's Sister- 75, healthy Physical Exam: Physical Examination; VS; T 99.4 BP 145/64 RR 20 95% RA General: Awake, frail elderly woman, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: No nuchal rigidity Pulmonary: Diffuse wheezes. Able to count to 10 in one breath. Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name DOY backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not hypophonic and hoarse. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. No diplopia or ptosis with sustained upgaze, although patient blinks frequently during attempts. V: Facial sensation intact to light touch. VII: Moderate bifacial weakness. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Decreased bulk, tone throughout. No pronator drift bilaterally. No tremor, asterixis, myoclonus, or fasiculations. Neck flexors [**3-24**], neck extensors [**3-24**] Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 4 5- 5- 5 5 5- 4 5 5 5 5 4+ 4+ R 4+ 5- 5- 5 5 5- 4 5 5 4 5 4- 4- After repetitive stimulation of R deltoid (20 contractions) strength diminished from 4+ to 4- -Sensory: Intact to light touch, pinprick, and proprioception, Diminished vibration at toes and medial malleolus. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 1 0 R 2 2 2 1 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: mild wide-base but able to ambulate unassisted. Discharge Exam: diminished breath sounds at bases significant dysphonia 5-/5 neck flexor weakness Pertinent Results: [**2150-3-31**] 16:00 MUSK ANTIBODY Test Name --------- MuSK Quantitative Titers Antibody MuSK Antibody Interpretation: Negative This individual is negative for muscle-specific receptor tyrosine kinase (MuSK) antibodies that are associated with Myasthenia [**Last Name (un) 2902**] syndrome (MG). Technical Results ----------------- MuSK Antibody Titer: <10 MuSK antibody Reference Range (titer) Negative Borderline Positive <10 10 > or = 20 [**2150-3-27**] 17:28 ACETYLCHOLINE RECEPTOR ANTIBODY Test Result Reference Range/Units ACETYLCHOLINE REC BINDING <0.30 <=0.30 nmol/L Reference Range: Negative: <=0.30 nmol/L Equivocal: 0.31-0.49 nmol/L Positive: >=0.50 nmol/L Brief Hospital Course: Ms. [**Known lastname 47342**] was admitted to the neurology service after progressive shortness of breath, fatigue, facial weakness and double vision developed over the last 6-12 months. Based on her clinical exam (with neck flexor/extensor weakness, bifacial weakness, on diplopia on upgaze, shortness of breath with sentences all of which worsened over the course of the day), she was diagnosed with myasthenia [**Last Name (un) 2902**]. Because of her tenous cardiac health and the need for anticoagulation, she was initially treated with 2 course of IVIG and mestinon with mild improvement of her symptoms. After consulting with her primary cardiologist, it was determined that the potential benefits outweighed any risks for clot, so her coumadin was discontinued and she completed plasmapheresis x 5. Her anti-AchR antibodies and anti-Musk antibodies were negative, suggesting that she has seronegative myasthenia [**Last Name (un) 2902**]. She had EMG performed and Dr. [**Last Name (STitle) 1206**] felt that there was a strong suggestion of myasthenia. She intermittently had labile blood pressures and required uptitration of her blood pressure medication. In addition, she developed sustained atrial fibrillation after the 2nd plasmapheresis cycle and was started on amiodarone on the recommendation of cardiology. She returned to sinus rhythm. Psychiatry and Palliative Care were consulted when she expressed that she no longer wanted to continue with aggressive care. She had developed a pneumonia and urinary tract infection. A family meeting was held and she opted to not continue with aggressive care. She had taken out her NG tube and did not want it replaced. We offered her oral medications as she could tolerate, but she opted to go home with hospice. A prescription for cefpodoxime was given on discharge. She was given scripts for SL morphine and Ativan. Medications on Admission: - Carvedilol 6.25mg PO BID - Diltiazem 120mg PO daily - Levothyroxine 112ug 6 days/wk, 168ug on the 7th day - Lisinopril 60mg PO daily - Losartan 100mg daily - Omeprazole 20mg [**Hospital1 **] - Warfarin 2mg PO QD - Zolpidem 5mg PO QHS prn sleep - APAP 325mg PO TID prn - Tums 2.5g PO daily - Vit D3 400u PO daily - MVI daily Discharge Disposition: Home With Service Facility: [**Last Name (un) **] VNA Discharge Diagnosis: myasthenia [**Last Name (un) 2902**] crisis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname 47342**] you were admitted to the neurology service after you had months of progressive weakness, slurred speech, fatigue and double vision. You were diagnosed with myasthenia [**Last Name (un) 2902**] and treated for myasthenia [**Last Name (un) 2902**] crisis initially with IVIG and then with plasmapheresis. Although you showed some initial improvement, your course was complicated by difficulty with respirations and you required intermittent BiPAP for support. Pulmonary was involved and recommended tracheostomy with mechanical ventilation but you were opposed to this. We'd asked palliative care and psychiatry to be involved and you felt strongly that you did not wish to continue aggressive measures. You were made CMO and hospice was arranged. You will be discharged with prescriptions for your medications and can take them with apple sauce if needed Followup Instructions: Going home with hospice Completed by:[**2150-4-29**]

Admission Date: [**2157-8-1**] Discharge Date: [**2157-8-5**] Date of Birth: [**2088-4-2**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: arm pain Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->Diag,SVG to OM) [**2157-8-1**] History of Present Illness: 69 yo male with history of arm pain and abnormal ETT with a hypotensive response to exercise. Referred for cath which showed LAD and CX disease. Then referred for CABG. Past Medical History: HTN elev. chol. polio ( no residual) PSH: tonsillectomy, LIH repair Social History: retired analyst lives with wife rare ETOH never used tobacco Family History: non-contrib. Physical Exam: 180 cm 78 kg HR 52 RR 18 145/75 98% RA sat. lying flat after cath, NAD skin/HEENT unremarkable neck supple, full ROM, no carotid bruits CTAB RRR, no murmur sift, NT, ND, + BS extrems wwarm, no edema or varicosities noted neuro grossly intact 2+ bil. fem/DP/PT/radials Pertinent Results: [**2157-8-4**] 05:55AM BLOOD WBC-12.1* RBC-3.64* Hgb-10.6* Hct-30.5* MCV-84 MCH-29.0 MCHC-34.5 RDW-13.9 Plt Ct-156 [**2157-8-5**] 06:25AM BLOOD Hct-30.9* [**2157-8-4**] 05:55AM BLOOD Plt Ct-156 [**2157-8-4**] 05:55AM BLOOD UreaN-22* Creat-1.1 K-4.1 [**2157-8-5**] 06:25AM BLOOD K-4.7 [**2157-8-2**] 03:06AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 [**2157-8-2**] 03:06AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75197**] (Complete) Done [**2157-8-1**] at 11:31:06 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2088-4-2**] Age (years): 69 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG ICD-9 Codes: 440.0, 518.82, 424.1 Test Information Date/Time: [**2157-8-1**] at 11:31 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW4-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.2 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.0 cm Findings LEFT ATRIUM: Mild LA enlargement. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Significant PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE CPB The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Mild-moderate pulmonic regurgitation is seen. POST CPB Normal biventricular systolic function. No changes form pre-CPB study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician RADIOLOGY Final Report CHEST (PA & LAT) [**2157-8-3**] 9:42 AM CHEST (PA & LAT) Reason: evaluate left apical ptx [**Hospital 93**] MEDICAL CONDITION: 69 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate left apical ptx HISTORY: A 69-year-old male status post CABG. Evaluate left apical pneumothorax. COMPARISON: Radiograph [**2157-7-27**]. TWO VIEWS OF THE CHEST: The small left apical pneumothorax is not changed. Bilateral pleural plaques are extensive but not changed. The cardiac and mediastinal contour is normal. The bony thorax is normal. IMPRESSION: Persistent small left apical pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 3900**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: WED [**2157-8-3**] 8:32 PM ?????? [**2152**] CareGroup Brief Hospital Course: Admitted [**8-1**] and underwent cabg x3 with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition on a titrated propofol drip.Extubated later that afternoon and transferred to the floor on POD #1 to begin increasing his activity level. Beta blockade titrated and gently diuresed toward his peroperative weight. Chest tubes and pacing wires removed without incident.Cleared for discharge to home with services on POD #4. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: atenolol 25 mg daily plavix 600 mg (SINGLE DOSE 9/11) ASA 325 mg daily norvasc 5 mg daily MVI daily Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. 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* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary artery disease s/p cabg x3 HTN ^chol. polio Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Call our office with sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 17025**] for 1-2 weeks. See dr. [**Last Name (STitle) 7047**] in [**12-18**] weeks Make an appointment with Dr. [**Last Name (STitle) **] in 4 weeks. Completed by:[**2157-8-30**]

Admission Date: [**2107-3-12**] Discharge Date: [**2107-3-18**] Date of Birth: [**2030-1-25**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old woman status post bilateral nephrectomy and on hemodialysis, status post a DVT with IVC filter placement, who was at [**Hospital3 7**] recuperating from her nephrectomy surgery, and over the past week had developed mild left upper extremity weakness. Workup included a MRI scan at [**Hospital3 9717**] which showed a right subdural hematoma in the right cerebral hemisphere and right frontal subdural hygroma. The patient was transferred to [**Hospital1 188**] for further management. PAST MEDICAL HISTORY: Right nephrectomy in [**2106**], left nephrectomy in [**2093**], status post DVT with SVC filter placement, she is HIT positive, breast cancer, MI in [**2106**], hepatitis A and B. PHYSICAL EXAMINATION ON ADMISSION: Her temperature is 98.1, heart rate is 89, BP is 157/72, respiratory rate is 18, saturation is 96% on room air. Awake, alert, and oriented x 3 with no facial droop. Pupils are equal, round and reactive to light and accommodation. EOMs are full. Cardiovascular with a regular rate and rhythm. Chest is clear to auscultation bilaterally. The abdomen is soft, nontender, and nondistended. Positive bowel sounds. Extremities reveal no edema. Muscle strength is [**4-21**] except for the left upper extremity which is [**3-22**]. HOSPITAL COURSE: The patient was admitted to the ICU for close neurologic observation. The renal service was consulted due to her need for hemodialysis. The patient was evaluated by the neurosurgical service and felt to require bur hole drainage of the subdural hematoma. The patient was seen by Dr. [**Last Name (STitle) 1327**] and prepared for surgery. On [**2107-3-14**] the patient underwent a right frontal parietal craniotomy bur hole drainage of a subdural hematoma without intraoperative complication. Postoperatively, the patient had no complaints of headache. She reported improved dexterity in the left hand. Vital signs were stable, and her strength was [**4-21**] in all muscle groups. She had no drift. Her face was symmetric. Her dressing was clean, dry, and intact. She was transferred to the regular floor on postoperative day 1. Her subdural drain was removed. She had a repeat head CT which showed good evacuation of the subdural. She continued to be followed by the renal service and undergo every other day renal dialysis. She was evaluated by the physical therapy and occupational therapy service and felt to be safe for discharge to home with home PT and OT. Her condition was stable, and a repeat head CT prior to discharge showed a stable condition of the evacuation of her subdural hematoma. DISCHARGE FOLLOWUP: She was discharged on [**2107-3-18**] with followup for staple removal on Monday, [**2-18**], at 10:00 a.m. and followup with Dr. [**First Name (STitle) **] in 1 month for a repeat head CT. MEDICATIONS ON DISCHARGE: 1. Famotidine 20 mg p.o. b.i.d. 2. Percocet 1 to 2 tablets p.o. q.4h. p.r.n. 3. Metronidazole 500 mg p.o. q.12h. (for 5 days - to finish up a course for C. difficile). 4. Dilantin 100 mg p.o. t.i.d. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2107-3-18**] 15:21:00 T: [**2107-3-18**] 16:26:20 Job#: [**Job Number 19846**]

Admission Date: [**2164-1-6**] Discharge Date: [**2164-1-11**] Date of Birth: [**2164-1-6**] Sex: F Service: NB HISTORY: Baby Girl [**Known lastname 3659**] twin #1 was born at 35-6/7 weeks gestation to a 31 year-old gravida III, para I, now III woman with noncontributory past medical history and prenatal screens of O positive, DAT negative, HBSAG negative, RPR nonreactive, rubella immune, GBS negative. Antenatal history: This is a twin gestation with an estimated date of delivery of [**2164-2-4**] who delivered by cesarean section for multiple gestation under spinal anesthesia. Rupture of membranes occurred at delivery yielding amniotic fluid. There was no intrapartum fever or clinical evidence of chorioamnionitis. The infant was vigorous at delivery, orally and nasally bulb suctioned, dried, had Apgars of 8 and 9 at one and five minutes respectively. Was transferred to the regular nursery where she developed grunting respirations at 4 hours of age and was then transferred to the Neonatal Intensive Care Unit for further care. Birth weight of 2140 grams which is 10th to 25th percentile. Length of 43 cm which is 10th to 25th percentile, head circumference of 31.5 cm, which is 25th to 50th percentile. PHYSICAL EXAMINATION ON ADMISSION: Shows preterm infant with examination consistent with gestational age between 35 and 36 weeks gestation, had stable vital signs. Head, eyes, ears, nose and throat: Head anterior fontanelle was soft and flat, nondysmorphic, intact palate. No nasal flaring. Chest: There were no retractions. Mild intermittent grunting respirations, good breath sounds bilaterally. No adventitious sounds. Cardiovascular: Well perfused, normal rate and rhythm. Femoral pulses were normal. Normal S1, S2, no murmur. Abdomen soft, nondistended, no organomegaly, no masses. Bowel sounds active, patent anus. Genitourinary: Normal female genitalia. Central nervous system: Active, alert, respirations. Responsive to stimuli. Tone was appropriate for gestational age and symmetric. Normal suck, root, gag, grasp. Skin normal. Musculoskeletal normal. Straight spine. Hips intact. Intact clavicles. SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: The infant had transitional grunting, flaring and retracting on admission which resolved quickly thereafter. Has remained stable on room air since admission to the Neonatal Intensive Care Unit not requiring any supplemental oxygen. Has had no issues with apnea or bradycardia but does have intermittent brief periods of oxygen saturation drift to the mid 80s and comes back up on her own. 2. CARDIOVASCULAR: The infant has remained hemodynamically stable with no signs of a murmur, normal blood pressure and heart rate. 3. FLUID, ELECTROLYTES AND NUTRITION: Enteral feedings were initiated on the newborn day. No IV fluids were ever initiated. The baby has been mostly p.o. feeding. For the past 48 hours has been all p.o. feeding. Is presently taking 140 ml per kilo per day of breast milk or Enfamil 20 with iron. Occasional p.g. feeds were required in the first couple of days of life. No electrolytes have been measured. 4. GASTROINTESTINAL: The infant has mild hyperbilirubinemia with a peak bilirubin level of 10.9/0.3 on [**2164-1-11**]. She has required no phototherapy thus far. She is recommended to have a repeat bilirubin level drawn tomorrow on [**2164-1-12**]. CBCs and blood cultures were not done on admission so no hematocrit testing was measured. She is pink and well perfused. 5. INFECTIOUS DISEASE: There is no history of sepsis risk factors so CBC and blood cultures were not drawn on admission. She has not been treated with any antibiotics and has shown no signs or symptoms of sepsis. 6. NEUROLOGY: The infant has maintained grossly normal neurologic examination for gestational age. 7. SENSORY: Hearing screen should be done prior to discharge from the hospital to home. It has not been done at this time. 8. PSYCHOSOCIAL: There have been no active psychosocial issues with this family at this time but if there are any psychosocial concerns a [**Hospital1 64489**] social worker can be reached at [**Telephone/Fax (1) 8717**]. CONDITION ON DISCHARGE: Fair. DISCHARGE DISPOSITION: Transfer to [**Hospital6 4620**] Newborn Nursery level 2. Accepting neonatologist will be Dr. [**First Name4 (NamePattern1) 1059**] [**Last Name (NamePattern1) 65550**]. NAME OF PRIMARY CARE PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 55013**], M.D. from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Pediatrics, address is [**Street Address(2) 65551**] in [**Location (un) 1110**], Mass, phone number [**Telephone/Fax (1) 55024**]. CARE RECOMMENDATIONS: Enteral feedings, p.o., p.g. at 140 ml per kilo per day of breast milk or E-20 with iron. MEDICATIONS: The infant is on no medications at this time. CAR SEAT TEST: Car seat testing should be done prior to discharge from the hospital. Has not been done at this time. IMMUNIZATIONS RECEIVED: The infant has received hepatitis B vaccine on [**2164-1-11**]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks gestation. 2) born between 32 and 35 weeks gestation with 2 of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or 3) 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 contact and out of home care- givers. DISCHARGE DIAGNOSES: Prematurity, appropriate for gestational age twin #1. Transitional respiratory distress. Mild hyperbilirubinemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**] Dictated By:[**Doctor Last Name 65552**] MEDQUIST36 D: [**2164-1-11**] 13:35:43 T: [**2164-1-11**] 14:14:58 Job#: [**Job Number 65553**]

Admission Date: [**2166-10-9**] Discharge Date: [**2166-10-29**] Date of Birth: [**2090-4-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x3 (off pump)(Left internal mammary artery -> left anterior descending artery, saphenous vein graft -> obtuse marginal, saphenous vein graft -> posterior descending artery) History of Present Illness: 75 year old male underwent routine stress test that was positive and underwent cardiac catherization [**2166-10-9**] at OSH which showed three vessel coronary artery disease and was transferred for surgical evaluation Past Medical History: Kidney Disease Coronary Artery Disease Gastroesophageal reflux disease benign prostatic hypertrophy Hypertension Elevated Cholesterol Gout Hypothyroid Social History: Married and lives with wife denies tobacco occasional ETOH Family History: non contributory Physical Exam: Admission General: well appearing, no acute distress Vitals: HR 56 SR, B/P 139/56, RR 14, RA sat 100% Wt 83.5kg Neuro: alert and oriented x3 PERRLA, EOMI, grip strengths and plantar flexion equal bilterally CV: RRR, no rub/murmur Resp: lungs clear bilaterally anterior GI: + bowel sounds, soft, nontender, nondistended, no masses Ext: warm, well perfused, no varicosities Pulses: palpable, no carotid bruit Discharge General: well appearing, no acute distress Vitals: Temp 99 HR 70 SR, B/P 125/60, RR 18, RA sat 95% Wt 83.6kg Neuro: alert and oriented x3 PERRLA, EOMI, R=L strength CV: RRR, no rub/murmur/gallop Resp: lungs clear bilaterally anterior and posterior GI: + bowel sounds, soft, nontender, nondistended, no masses Ext: warm, well perfused, pulses palpable - Left big toe warm edematous Inc: Sternal - stable no drainage, no erythema; Left leg endovascular harvest with steristrips no erythema or drainage Pertinent Results: [**2166-10-9**] 09:15PM PT-11.7 PTT-27.8 INR(PT)-1.0 [**2166-10-9**] 09:15PM PLT COUNT-128* [**2166-10-9**] 09:15PM WBC-7.7 RBC-4.52* HGB-13.9* HCT-41.2 MCV-91 MCH-30.7 MCHC-33.6 RDW-14.2 [**2166-10-9**] 09:15PM TSH-2.8 [**2166-10-9**] 09:15PM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [**2166-10-9**] 09:15PM ALT(SGPT)-10 AST(SGOT)-14 ALK PHOS-79 AMYLASE-75 TOT BILI-0.3 [**2166-10-9**] 09:15PM LIPASE-104* [**2166-10-9**] 09:15PM ALBUMIN-3.6 MAGNESIUM-2.0 [**2166-10-9**] 09:15PM GLUCOSE-99 UREA N-40* CREAT-2.3* SODIUM-144 POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-28 ANION GAP-12 [**2166-10-29**] 06:10AM BLOOD WBC-8.4 RBC-3.22* Hgb-9.8* Hct-29.4* MCV-91 MCH-30.3 MCHC-33.2 RDW-13.8 Plt Ct-205 [**2166-10-29**] 06:10AM BLOOD Plt Ct-205 [**2166-10-17**] 12:46PM BLOOD Eos Ct-470* [**2166-10-29**] 06:10AM BLOOD Glucose-96 UreaN-89* Creat-4.7* Na-138 K-4.7 Cl-104 HCO3-23 AnGap-16 [**2166-10-26**] 03:22AM BLOOD Glucose-102 UreaN-86* Creat-5.0* Na-138 K-4.0 Cl-106 HCO3-22 AnGap-14 [**2166-10-24**] 04:00AM BLOOD UreaN-75* Creat-5.3* Na-137 K-4.3 Cl-104 HCO3-23 AnGap-14 [**2166-10-23**] 01:36AM BLOOD Glucose-164* UreaN-64* Creat-4.7* Na-139 K-4.9 Cl-105 HCO3-25 AnGap-14 [**2166-10-22**] 12:00PM BLOOD Glucose-136* UreaN-55* Creat-3.8* Na-143 K-5.0 Cl-112* HCO3-22 AnGap-14 [**2166-10-21**] 11:30AM BLOOD Glucose-164* UreaN-51* Creat-2.7*# Na-144 K-4.9 Cl-115* HCO3-19* AnGap-15 [**2166-10-19**] 04:50AM BLOOD Glucose-82 UreaN-64* Creat-3.8* Na-140 K-5.0 Cl-110* HCO3-20* AnGap-15 [**2166-10-16**] 06:20AM BLOOD Glucose-98 UreaN-57* Creat-2.9* Na-141 K-4.8 Cl-108 HCO3-22 AnGap-16 [**2166-10-12**] 04:45AM BLOOD Glucose-95 UreaN-60* Creat-3.1* Na-140 K-4.7 Cl-107 HCO3-24 AnGap-14 [**2166-10-28**] 06:00AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0 UricAcd-10.0* [**2166-10-17**] 05:35AM BLOOD calTIBC-224* Ferritn-260 TRF-172* [**2166-10-16**] 06:20AM BLOOD PTH-156* [**2166-10-17**] 05:35AM BLOOD C3-124 C4-34 [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Reason: bilat upper extremity vein mapping for future AV fistula [**Hospital 93**] MEDICAL CONDITION: 76 year old man with REASON FOR THIS EXAMINATION: bilat upper extremity vein mapping for future AV fistula VENOUS DUPLEX UPPER EXTREMITY. REASON: Chronic kidney disease in need of placement of fistula. FINDINGS: Duplex evaluation was performed of both upper extremity venous systems. Both subclavian veins are patent and phasic. Both brachial arteries are patent with triphasic waveforms. Both cephalic veins show significant thrombophlebitis, right greater than left without evidence of extension into the deep system. Both basilic veins are patent. On the right, the diameter ranges from 0.30-0.57 cm and on the left 0.22-0.32 cm. IMPRESSION: Patent bilateral subclavian veins and bilateral brachial arteries. Patent bilateral basilic veins with diameters as noted. Thrombophlebitis in both cephalic veins, right greater than left as described above. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ECHO MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 5 mm Hg Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A Ratio: 1.50 INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Complex (mobile) atheroma in the aortic arch. Normal descending aorta diameter. Complex (mobile) atheroma in the descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Suboptimal image quality. The patient appears to be in sinus the patient. Conclusions: 1. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are complex (mobile) atheroma in the aortic arch. There are complex (mobile) atheroma in the descending aorta. 5.The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). 7.There is a trivial/physiologic pericardial effusion. 8. Post revascularization LV and RV systolic function are unchanged. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2166-10-21**] 16: RENAL U.S.; -59 DISTINCT PROCEDURAL SERVIC Reason: duplex to assess for renal artery stenosis//flow [**Hospital 93**] MEDICAL CONDITION: 76 year old man with CRI pre-op CABG REASON FOR THIS EXAMINATION: duplex to assess for renal artery stenosis//flow INDICATIONS: Chronic renal insufficiency. Three coronary artery bypass. Assess artery stenosis. RENAL ULTRASOUND: Comparison is made to [**2166-10-10**]. The study is limited by the patient's breath-holding ability for the Doppler portion. There is a discrepancy in renal size with the right kidney measuring 7.6 cm, and the left measuring 11.8 cm. There is no hydronephrosis or renal mass. Doppler assessment of blood flow to both kidneys was severely limited on the right, but there is a suggestion of a parvus tardus waveform. The peak velocity within the artery was 12.5 cm. The renal vein is patent. The left kidney was better evaluated, and the upstrokes appear more brisk with higher peak velocities. IMPRESSION: Small right kidney with findings most consistent with chronic right renal artery stenosis. MRI/MRA may be performed if there is unresponsive hypertension. CAROTID SERIES COMPLETE [**2166-10-15**] 8:50 AM CAROTID SERIES COMPLETE Reason: bruit [**Hospital 93**] MEDICAL CONDITION: 76 year old man with CAD REASON FOR THIS EXAMINATION: bruit CAROTID STUDY HISTORY: Coronary artery disease and a bruit. FINDINGS: Minimal plaque involving the ICA on the left only. The peak systolic velocities bilaterally are normal as are the ICA to CCA ratios. There is normal antegrade flow involving both vertebral arteries. IMPRESSION: Widely patent common and internal carotid arteries bilaterally. DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**] Approved: WED [**2166-10-22**] 9:00 AM Brief Hospital Course: Mr. [**Known lastname 2026**] was admitted from OSH for cardiac surgery evaluation. In preoperative evaluation he had renal consult that worked him up for increased creatinine. His creatinine continued to be elevated and wa closely monitored. On [**10-21**] he was transferred to the operating room for off pump coronary artery bypass graft surgery, please see operative report for further details. Surgery was uncomplicated and he was brought to the CSRU for invasive monitoring. He was weaned from sedation and and awoke neurologically intact. On posterative day 1 he was extubated without incident. He remained in the CSRU for close hemodynamic monitoring, respiratory management, and renal function. Nephrology continued to follow. He continued to progress physically but with elevated creatinine. He was transferred to [**Hospital Ward Name **] 2 on postoperative day 6. His creatinine remained elevated with adequate urine output, allopurinol was restarted for elevated uric acid. On postoperative day 8 he was ready for discharge home with VNA services with follow up by own Nephrologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Medications on Admission: Nadolol, synthroid, lisinopril, proscar, prilosec, lipitor, ASA, allopurinol, folate Discharge Medications: 1. 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* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. 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* 10. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Outpatient Lab Work Uric Acid level qweekly please call results to Dr [**Last Name (STitle) 68884**] [**Name (STitle) 745**] ([**Telephone/Fax (1) 68885**]) and Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 53192**]) 12. Outpatient Lab Work Lab work: SMA 7 twice weekly and as needed please call results to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 53192**]) and Dr [**Last Name (STitle) 68884**] [**Name (STitle) 745**] ([**Telephone/Fax (1) 68885**]) and Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 11763**]. 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 14. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: s/p Coronary Artery Bypass Graft x3 (off pump) Non oliguric acute tubular necrosis Acute Gout Chronic Kidney Disease Coronary Artery Disease Gastroesophageal reflux disease benign prostatic hypertrophy Hypertension Elevated Cholesterol Discharge Condition: good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 68884**] [**Name (STitle) 745**] in 1 week ([**Telephone/Fax (1) 68885**]) please call for appointment Dr [**Last Name (STitle) 29070**] in [**2-14**] weeks ([**Telephone/Fax (1) 37284**]) please call for appointment Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 53192**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Nephrologist Dr [**Last Name (STitle) **] for follow with lab results for renal function Completed by:[**2166-11-4**]

Admission Date: [**2191-7-13**] Discharge Date: [**2191-7-16**] Date of Birth: [**2125-3-29**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1232**] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 65 y/o male with [**Doctor Last Name **] 6 prostate cancer. He had a 26 core prostate needle biopsy this afternoon with Dr. [**Last Name (STitle) **]. He had rectal bleeding shortly after going home from the clinic this afternoon, and was brought to the ED by ambulance after feeling lightheaded with continuous rectal bleeding. He had a syncopal episode on admission to the ED. He denies nausea, vomiting, fevers, chills, chest pain, dyspnea, hematuria, urinary urgency, frequency. The patient had discontinued his aspirin one week prior to the biopsy as instructed. Past Medical History: HTN Hyperlipidemia Mild COPD/Asthma Colonic polyps Social History: Past tobacco use (quit 3-4 years ago), +EtOH use (approx 4 drinks per day) Family History: Father, mother: [**Name2 (NI) 499**] cancer Physical Exam: VS: Afebrile, HR 65, BP 139/49, R 16, 100%RA NAD, A&Ox3, lying in Trendelenburg RRR, No respiratory distress Abd: Soft, nondistended, nontender GU: No active rectal bleeding on initial exam. On DRE, pressure and surgicel were applied to the prostate, and there was no active bleeding or clots after pressure applied. Ext: No cyanosis/clubbing/edema. Pertinent Results: [**2191-7-15**] 02:41AM BLOOD WBC-8.8 RBC-2.93* Hgb-9.1* Hct-26.6* MCV-91 MCH-31.2 MCHC-34.4 RDW-12.6 Plt Ct-226 [**2191-7-14**] 02:59AM BLOOD PT-15.9* PTT-23.5 INR(PT)-1.4* [**2191-7-14**] 02:59AM BLOOD Glucose-128* UreaN-13 Creat-0.9 Na-139 K-4.0 Cl-108 HCO3-26 AnGap-9 [**2191-7-15**] 02:41AM BLOOD CK-MB-5 cTropnT-<0.01 Brief Hospital Course: On [**2191-7-13**], the patient was admitted to Dr.[**Doctor Last Name **] Urology service/SICU from the ED with rectal bleeding and syncope after prostate needle biopsy. In the ED, surgicel and pressure were applied to the prostate and the acute bleeding stopped. The patient was placed in trendelenburg and serial Hct's were checked. GI consult was requested by the ICU team, and they recommended Vit K for elevated INR 1.5. Cardiac enzymes were negative. On HD 2, the patient had several bloody bowel movements and remained in the ICU for monitoring. Hematocrits were stable at 26-27 without transfusion on HD 2. On HD 3, the patient was seen by general surgery, who performed an anoscope. The anoscopy showed old clot, no active bleeding. Also on HD 3, the patient was transferred to the floor from the ICU in stable condition. Serial Hct's were monitored, which continued to be stable at 24-26. He received peri-operative antibiotic prophylaxis, and he remained afebrile throughout his hospital stay. At discharge, patient denied pain, was tolerating a regular diet, ambulating without assistance, and voiding without difficulty. He denied chest pain, dyspnea, abdominal pain at discharge. He was given explicit instructions to call Dr. [**Doctor Last Name 5752**] office to schedule follow-up appointment. Medications on Admission: Levoxyl 75mcg Fluoxetine 20mg Simvastatin 10mg Levaquin (perioperative) Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Rectal bleeding status post ultrasound guided prostate needle biopsy Discharge Condition: Stable Discharge Instructions: -Call Dr.[**Doctor Last Name **] office ([**Telephone/Fax (1) 80892**]) to schedule follow up appointment. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -If you have fevers > 101.5 F, abdominal pain, nausea or vomitting, bright red blood per rectum, call your doctor or go to the nearest emergency room. Followup Instructions: Call Dr.[**Doctor Last Name **] office ([**Telephone/Fax (1) 80892**]) to schedule follow up appointment. Completed by:[**2191-7-16**]

Admission Date: [**2193-11-21**] Discharge Date: [**2193-11-25**] Date of Birth: [**2145-6-8**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2193-11-21**] Coronary Artery Bypass Graft x 2 (Left internal mammary artery to left anterior descending, Saphenous vein graft to diagonal) History of Present Illness: Mr. [**Known lastname **] is a 48-year-old, with end-stage renal disease, who was recently diagnosed with coronary artery disease of his left anterior descending artery and diagonal artery. Because of his end-stage renal disease, it was deemed appropriate for a coronary bypass. After risks, benefits and alternatives were explained to the patient, he agreed to proceed to surgery. Past Medical History: DM Type I x 30 years HTN S/p L vitrectomy and R vitrectomy (diabetic loss of vision) ESRD on PD (recent baseline 6) Gallstones s/p arthroscopic knee surgery Diveriticulosis Social History: He used to work as a medical assistant at [**Last Name (un) **], but quit in order to avoid infectious exposures, and now works in real estate. He lives with his partner who is HIV+; his partner has recently been sick with cancer and Zoster secondary to HIV. He practices safe sex and is HIV- as of [**5-26**], smokes tobacco (40-50 pack years), drinks EtOH socially, and denies IVDU Family History: His mother has diabetes, as does maternal aunt and uncle. There is also history of gastric cancer in his father's side Physical Exam: Exam: Well developed man in no acute distress Vitals: WT 183# BP 152/96 P 84 bpm reg HEENT: Rt cheek minimal induration, small central ulceration present on most posterior lesion, other closed Lt cheek multiple healing ulcerations Neck: no JVD Lungs: good air movement, no crackles or wheezes Cardiac: RRR, no s3, s4 or murmurs Ext: 1+ edema bilaterally Pertinent Results: [**2193-11-21**] ECHO PRE-CPB: 1. The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A left atrial appendage thrombus cannot be excluded. 2. No thrombus is seen in the right atrial appendage 3. No atrial septal defect is seen by 2D or color Doppler. 4. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. No left ventricular aneurysm is seen. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). 5. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with borderline normal free wall function. 6. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 7. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. The NCC is calcified and nonmobile. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. 8. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified in person of the results. POST-CPB: On infusion of phenylephrine, a-pacing. Preserved biventricular systolic function. LVEF is now 50%. MR remains mild. The aortic contour is normal post decannulation. [**2193-11-24**] 06:50PM BLOOD WBC-12.4* RBC-2.73* Hgb-7.9* Hct-23.3* MCV-85 MCH-28.8 MCHC-33.9 RDW-17.4* Plt Ct-276 [**2193-11-24**] 01:11AM BLOOD WBC-13.4* RBC-2.87* Hgb-8.4* Hct-24.4* MCV-85 MCH-29.2 MCHC-34.4 RDW-17.7* Plt Ct-263 [**2193-11-23**] 06:07AM BLOOD WBC-16.4* RBC-2.74* Hgb-7.9* Hct-23.6* MCV-86 MCH-28.8 MCHC-33.4 RDW-17.4* Plt Ct-279 [**2193-11-21**] 11:00AM BLOOD WBC-6.5 RBC-2.39*# Hgb-6.8*# Hct-20.1*# MCV-84 MCH-28.3 MCHC-33.6 RDW-15.8* Plt Ct-188 [**2193-11-21**] 06:07PM BLOOD PT-14.8* PTT-32.1 INR(PT)-1.3* [**2193-11-21**] 11:00AM BLOOD PT-16.9* PTT-43.5* INR(PT)-1.5* [**2193-11-24**] 06:50PM BLOOD Glucose-59* UreaN-51* Creat-10.2* Na-135 K-4.1 Cl-95* HCO3-27 AnGap-17 [**2193-11-24**] 01:11AM BLOOD Glucose-113* UreaN-46* Creat-10.4* Na-134 K-4.2 Cl-95* HCO3-24 AnGap-19 [**2193-11-23**] 06:07AM BLOOD Glucose-84 UreaN-42* Creat-10.5* Na-137 K-4.6 Cl-98 HCO3-26 AnGap-18 [**2193-11-22**] 04:17AM BLOOD Glucose-72 UreaN-42* Creat-11.2* Na-137 K-4.8 Cl-103 HCO3-22 AnGap-17 [**2193-11-21**] 12:43PM BLOOD UreaN-40* Creat-10.9*# Cl-104 HCO3-23 [**2193-11-24**] 06:50PM BLOOD Mg-1.9 [**2193-11-24**] 01:11AM BLOOD Calcium-8.2* Phos-7.4* Mg-2.0 [**2193-11-23**] 06:07AM BLOOD Calcium-8.4 Phos-7.5* Mg-2.1 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2193-11-21**] for elective surgical management of his coronary artery disease. He was admitted as a same day surgery and taken to the operating room where he underwent coronary artery bypass grafting to two vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for invasive hemodynamic monitoring. Within 24 hours, Mr. [**Known lastname **] had awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. Mr. [**Known lastname **] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He continued his peritoneal dialysis as per usual routine. Some serous and serosangeuenous drainage was noted on POD 4 and he was started on 7 days of prophylactic Keflex. He progressed well and on POD 4 he was stable and was discharged to home. Medications on Admission: Norvasc 10', calcitrol 0.25', phoslo 666", lasix 80", gabapentin 600", B-complex, folic acid, cinacalet 30', lantus, humalog, labetolol 200", asa 81', mvi Discharge Medications: 1. 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* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Please take as long as you take narcotics for pain. Disp:*60 Capsule(s)* Refills:*0* 3. 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* 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*0* 5. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 7 days. Disp:*14 Capsule(s)* Refills:*0* 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2 PMH: -DM Type I x 30 years -HTN -S/p L vitrectomy and R vitrectomy (diabetic loss of vision) -ESRD on PD (recent baseline 6) -Gallstones -s/p arthroscopic knee surgery -Diveriticulosis Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) **] in [**1-20**] weeks Please schedule appointments Completed by:[**2193-11-25**]

Admission Date: [**2114-11-13**] Discharge Date: [**2114-11-16**] Date of Birth: [**2072-6-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: asystolic arrest Major Surgical or Invasive Procedure: screening for organ donation after declared brain dead History of Present Illness: 42 year old female with h/o SDH [**2-26**], EtOH abuse, ?seizure disorder admitted to ICU following asystolic arrest. According to her boyfriend, she was in her USOH until this a.m., when she went for a walk. She came back and went to the bathroom, where she collapsed. Her boyfriend heard her fall; when he found her, he noted jerky motions of her upper ext bilaterally (?duration). He moved her to the bed, where he saw she wasn't breathing/no heart beat. He called EMS and started CPR; ~12 minutes before they arrived. When EMS arrived, she was noted to be apneic, pulseless, cyanotic, and cold. Initial EKG was asystole. She was intubated in the field. She received epinephrine 1 mg IV X 3, atropine 1 mg IV X 2, Narcan 2 mg X 1 -> PEA. Pacing was attempted unsuccessfully. Another atropine 1 mg IV X 1 was given and the pt converted to narrow-complex tachycardia (down time ~ 20 minutes after EMS arrival). She was transported to [**Hospital1 18**] ED where a LSC placed and pt received 950 cc NS, Cefazolin 2 g IV X 1, tetanus shot, and started on dopamine gtt. Foley was placed with drainage of 250 cc of fluid. She is admitted to the MICU for further management. Further history reveals that she had stopped drinking alcohol ~ 3 days ago. Past Medical History: 1) h/o EtOH abuse 2) ?seizure disorder 3) s/p MVA [**2-26**] with resultant right SDH and left subfalcine bleed Social History: Living with boyfriend. History of heavy alcohol abuse, reportedly quit 3 days ago, although he reports that she may have been leaving the house to drink. No other known drug use. Family History: unknown Physical Exam: T 94, HR 132, bp 90/72, resp 26, 100% (AC 500X24 100% FiO2 PEEP 5) Gen: cachectic, middle-aged female, intubated, unresponsive HEENT: anicteric, pale conjunctiva, left pupil 4 mm, right pupil 2 mm, both non-reactive, no corneal reflex noted, intubated, oral mucosa dry, hard collar in place. Cardiac: tachycardic, regular, no M/R/G appreciated Pulmonary: Coarse ronchi throughout. Abd: Hypoactive bowel sounds, soft, mildly distended, liver edge 2 cm below RCM. Ext: No cyanosis, clubbing, or edema noted, cool with dopplerable DP bilaterally. Skin: Abrasions/ecchymosis noted over knees bilaterally and right flank noted. Lines: LSC with oozing at dressing noted Neuro: Asymmetrical, non-reactive pupils as above, no corneal reflex, no gag, no movement of extremities to painful stimuli, toes mute bilaterally. Pertinent Results: Na 130 K 4.3, Cl 88, HCO3 4, BUN 28, Cr 1.3, glc 187 wbc 4.9, Hgb 12.1, HCT 33.5, plt 52 PT 17.3, INR 2.1, PTT 48.4 ABG 7.14/23/381 (on 100% FiO2). CXR: Left SC in place, ETT 2 cm above carina, clear lung fields bilaterally . Head CT w/o contrast: No ICH or midline shift . CT Abd/Chest/Pelvis (wet read): No evidence of trauma. Markedly fatty liver. . CT C-spine: no evidence of fracture or misalignment . EKG: ST @ 121 bpm, nl axis, nl intervals, Q II, III, avF. Brief Hospital Course: Patient was unresponsive on admission s/p cardiac arrest of unclear etiology with estimated down time of 20-35 minutes. Clinical picture and the need for aggressive repletion of electrolytes were most consistent with a starvation/alcoholic ketoacidosis resulting in electrolyte abnormalities which led to cardiac arrhythmia and arrest. The patient had no brain stem function on admission other than initially breathing over the ventilator. She was cooled to 34 degrees celsius for 48 hours and then rewarmed in an attempt to preserve brain function. After the rewarming the patient did not develop any further signs of improving neurologic status and was no longer breathing over the ventilator, she continued to require pressors to maintain adequate blood pressure. After a complete neurologic exam once all electrolytes had been corrected and the patient was normothermic, the patient was declared brain dead on hospital day 3. The patient's brother was the next of [**Doctor First Name **] and he elected to donate her organs. The NEOB then coordinated further work up and evaluation for organ donation. Medications on Admission: unknown Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None Completed by:[**2114-12-26**]

Admission Date: [**2155-10-5**] Discharge Date: [**2155-10-9**] Date of Birth: [**2092-1-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 297**] Chief Complaint: dislodged trach Major Surgical or Invasive Procedure: Bronchoscopy Tracheostomy tube change History of Present Illness: 63 y/o F w/ h/o COPD, trach dependent, DM, HTN who presented to OSH with complaint of trach tube falling out. States she doesn't know how to tighten strings or make it feel better. Respiratory assessed trach. Felt that trach was out further than it should be and can not push it back into place. Attempts to replace tube were unsuccessful. Contact[**Name (NI) **] Dr. [**Last Name (STitle) **] for plan to transfer to [**Hospital1 18**]. Pedi-endotracheal tube in place for airway. . On arrival here, denies chest pain, sob Past Medical History: COPD trach dependent- after abd surgery last year DM HTN OSA Social History: Lives at home with son and his family Family History: n/a Physical Exam: vitals- T 98.0, BP 142/75, HR 95 NSR, RR 20, 95% on 40% FiO2 TM gen- sleepy but arousable, mouths words heent- EOMI. neck- trach in place. pink granulation tissue around trach. no purulent drainage or blood oozing pulm- CTA b/l. no r/r/w cv- RRR. no m/r/g abd- soft, NT/ND ext- venous stasis change b/l LE's, 1+ edema b/l neuro- alert and oriented, follows commands Pertinent Results: [**2155-10-5**] 06:54PM BLOOD WBC-5.7 RBC-3.75* Hgb-11.5* Hct-34.7* MCV-93 MCH-30.8 MCHC-33.3 RDW-15.5 Plt Ct-198 [**2155-10-8**] 07:38AM BLOOD WBC-6.5 RBC-3.88* Hgb-12.0 Hct-35.6* MCV-92 MCH-31.0 MCHC-33.7 RDW-15.7* Plt Ct-206 [**2155-10-8**] 07:38AM BLOOD Plt Ct-206 [**2155-10-5**] 06:54PM BLOOD PT-11.5 PTT-26.0 INR(PT)-1.0 [**2155-10-6**] 04:15AM BLOOD Type-ART Temp-37.1 Rates-14/ Tidal V-490 PEEP-5 FiO2-60 pO2-71* pCO2-72* pH-7.39 calTCO2-45* Base XS-14 Intubat-INTUBATED Brief Hospital Course: Pt was admitted to the Medical ICU and underwent Bronchoscopy on HD#1. She was found to have supraglottic obstruction with granulation tissue on Bronchoscopy. Her tracheostomy was replaced and on HD#2 she no longer required ventilator support. On HD#3 she remained stable with some mild desaturations down to the 70's on no vent support and only 50% trach mask. She was evaluated by otolaryngology / head & neck surgery who felt most of her obstruction was sub-glottic. On HD#4 she was deemed medically stable for D/C home and was sent home with her family. She is to return in [**2-21**] weeks for bronchoscopy with possible T-tube placement. Medications on Admission: prilosec 20mg/day centrum daily levothyroxine 150mcg/day lasix 40mg [**Hospital1 **] metformin 500mg/day diabeta 5mg qam, 2.5mg qpm zoloft 50mg/day metoprolol 25mg [**Hospital1 **] Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. 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:*0* Discharge Disposition: Home Discharge Diagnosis: Dislodged Traceostomy Tube Suprastromal Granulation Tissue Discharge Condition: Good Discharge Instructions: You should follow-up with Interventional Pulmonology in [**2-21**] weeks after the swelling goes down for bronchoscopy. You were admitted to the hospital for a respiratory difficulties from tracheostomy site. You should call your doctor or return to the ER should you experience any of the following: Severe increase in drainage or redness at trach site Severe Increase in pain from trach site Fever > 101 Severe pain Numbness/Tingling/Paralysis Severe Dizziness Nausea/Vomiting Severe Chest Pain/SOB Any other symptoms that worry you. Followup Instructions: You should follow-up with interventional pulmonology in [**2-21**] weeks for bronchoscopy on Friday [**2155-10-24**]. You should come to [**Hospital Ward Name 121**] 8 at 7:30am for an 8:30am procedure. You should remain NPO after midnight the night before your procedure. You should call ([**Telephone/Fax (1) 17398**] should you need to reschedule. Please follow-up with your primary care doctor in [**1-20**] weeks for maintenance of your longterm medical care. Provider: [**Name10 (NameIs) 454**],NINE DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2155-10-24**] 7:30 Provider: [**Name10 (NameIs) **],IP PROC IP PROCEDURES Date/Time:[**2155-10-24**] 8:30 Provider: [**Name10 (NameIs) **],ROOM ONE IP ROOMS Date/Time:[**2155-10-24**] 8:30 Completed by:[**2155-10-14**]

Admission Date: [**2184-11-25**] Discharge Date: [**2184-12-22**] Date of Birth: [**2144-12-16**] Sex: M Service: SURGERY Allergies: Levaquin Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal and back pain, fever Major Surgical or Invasive Procedure: coil embolization x2 for pseudo-aneurysm of right intrahepatic artery History of Present Illness: 39 M with history of MEN I and multiple procedures including parathyroidectomy, unilateral adrenalectomy, partial pancreatectomy and segment III liver resection ([**2184-3-18**]) with recent gastrinoma metastisis to liver presented to [**Hospital1 18**] with fevers to 103 and shoulder/back/abdominal pain. He was in his usual state of health. On [**2184-11-17**] he underwent radiofrequency ablation of his liver lesion. He did well until [**11-25**] when he noted worsening pain and fevres. He presented to [**Hospital3 **] Hospital where he received antibiotics and was transferred to the [**Hospital1 18**] for further care. Past Medical History: 1. Gastrinoma and Zollinger-[**Doctor Last Name 9480**] syndrome 2. MEN 1 syndrome: medical records indicate genetic testing confirmed MEN1 syndrome. Per hx, pt had GERD symptoms in [**2172**], Abd U/S showed rt adrenal mass. - s/p 3 parathyroid surgeries ([**2172**]-[**2176**]) with eventual total parathyroidectomy & reimplant in arm - Unilateral rt adrenalectomy ([**11/2174**]) at MD [**Last Name (Titles) 4223**]: pathology demonstrated 7 x 6.5 x 4 cm pheo, adrenocortical hyperplasia, & mult adrenal cortical adenomas. Pt noted to have nl left adrenal at this time. Pre-op urinary mets were 5000, nl urinary catecholamines. - 80% partial pancreatectomy ([**11/2174**]) at MD [**Last Name (Titles) 4223**]: for masses in body & tail of pancreas; pre-op gastrin level was 895. Path demonstrated islet cell tumors, immunostaining results not available 3. Type 1 DM: dx'd at age 16 (presenting sx fatigue, polyuria); has h/o DKA; complications include nephropathy. 4. CKD stage II (diabetic nephropathy), baseline creatine 1.4-1.6 5. s/p splenectomy ([**11/2174**]): done at same time as adrenalectomy and partial pancreatectomy. 6. Gastritis 7. GERD 8. Completion pancreatectomy, segement 3 liver resection [**2184-3-18**] Social History: He quit smoking in [**2182**]. He admits to occasional marijuana use. He denies alcohol use. Family History: Father with MEN-->presumably type 1 though this is not stated explicitly in records; medical records indicate he had high gastrin level pre-op and high glucagon s/p Whipple procedure. Mother & sibling are healthy. Cousin w/brain tumor, unknown type. Grandfather died of colon cancer. Physical Exam: On admission: VS: Temp 99.3, HR 109, BP 124/77, RR 20, O2 sat 100% on room air Gen: alert and oriented, stable, tired appearing HEENT: No icterus, no LAD CV: RRR Pulm: clear bilaterally Abd: soft, NT, ND, +BS well healed sub-costal scar Ext: left ankle with 1+non-pitting edema, [**3-19**] DP/PT pulses On discharge: VS: Temp 101.1, HR 102, BP 117/80, RR 26, O2 sat 94% on room air Gen: alert and oriented, no acute distress, more energetic HEENT: anicteric sclera, no lymphadenopathy CV: RRR, no murmurs, gallops, rubs Pulm: clear bilaterally Abd: soft, nontender, nondistended, palpable hepatomegaly Ext: 1+ edema bilaterally up to knees, 2+ distal pulses Pertinent Results: Discharge labs: [**2184-12-22**] 04:47AM BLOOD WBC-15.7* RBC-3.29* Hgb-9.0* Hct-29.2* MCV-89 MCH-27.4 MCHC-30.9* RDW-18.5* Plt Ct-863* [**2184-12-22**] 04:47AM BLOOD Glucose-85 UreaN-16 Creat-1.4* Na-141 K-4.0 Cl-103 HCO3-30 AnGap-12 [**2184-12-22**] 04:47AM BLOOD ALT-23 AST-28 AlkPhos-331* TotBili-0.8 [**2184-12-17**] 04:38AM BLOOD Lipase-6 [**2184-12-22**] 04:47AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0 [**2184-12-19**] 05:19AM BLOOD TSH-1.2 CT abdomen/pelvis prior to discharge ([**2184-12-21**]): 1. No interval change to known subcapsular and intraparenchymal hematomas without CT findings to suggest superinfection. No new fluid collections identified. 2. Resolution of small left pleural effusion with probably stable right pleural effusion, which displaced posterior and medial components. Moderate amount of interstitial septal thickening involving the visualized aerated right lower lobe may reflect interstitial pulmonary edema, however, in conjunction with metastatic left lower lobe pulmonary nodules, lymphangitic carcinomatosis cannot be excluded. 3. Stable left adrenal lesions and post-surgical changes without evidence of bowel obstruction. Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] on [**11-25**]. Vancomycin and Zosyn were started. A non-contrast CT abdomen/pelvis was obtained given the patient's renal disease and showed a limited evaluation of the liver parenchyma due to lack of intravenous contrast. Expected post-radiofrequency ablation findings in the right lobe of the liver, a small, nonobstructing left anterior abdominal wall hernia, enlarged, nodular left adrenal gland unchanged since [**2184-1-16**], multiple enlarged mesenteric lymph nodes unchanged since the prior study, prior pancreatectomy, splenectomy, partial gastrectomy, partial hepatectomy and right adrenalectomy. Overnight on hospital day 1 he was febrile to 103.1 with a significant leukocytosis. He was continued on antibiotics and cultures were sent. On [**11-28**] RUQ ultrasound was obtained and demonstrated a 6.4 cm heterogeneously echoic lesion within the right lobe of the liver, likely segment VIII, consistent with prior radiofrequency ablation site, a rounded, 1.3 cm vascular area within the radiofrequency ablation site which is suggestive of a pseudoaneurysm. The pseudoaneurysm appeared to arise from an intrahepatic branch of the right hepatic artery. The portal vein was patent. ID service was consulted and patient was switched to meropenem. On [**11-28**] patient developed worsening abdominal/back pain and became diaphoretic. He was hypotensive with BP 82/70 and relative hypoxia with oxygen saturation of 90 %. He received bolus of NS with good response and was transferred to the ICU for closer monitoring. Patient also had a 4% drop in HCT and was transfused 1 unit of PRBCs without appropriate rise in hematocrit. Central line was placed. 2 more units of PRBCs were administered. Given ultrasound findings, patient was administered bicarb and Mucomyst in preparation for angiography and coil embolization of pseudoaneurysm which he underwent on [**2184-11-29**]. At the time of the procedure, the pseudoaneurysm appeared to be successfully obliterated with coiling. Post procedure patient developed oliguric renal failure with creatinine peaking around 7. Nephrology service was consulted and he was managed conservatively. He did not require dialysis. Renal failure subsequently resolved with a concomitant fall in creatinine and marked increase in urine output. During this time he continued to have a leukocytosis between 25-38,000 and continued to periodically spike temps. A non-contrast CT scan of the abdomen was obtained on [**12-2**] and showed increasing size of hyperdensity in the right liver lobe adjacent to the RF ablation and pseudoaneurism embolization site, likely represents presence of a hematoma. Large subcapsular hematoma, compressing the hepatic parenchyma. Since he continued to spike fevers in presence of leukocytosis, there was concern for superinfected hematoma. However, because of the extent of liver damage and size of hematoma, it was deemed unsafe to tap fluid as this could potentially negate the tamponade effect of the capsule and may result in exsanguination. He was managed conservatively and seemed to be stable. Overnight on [**12-5**] into [**12-6**] patient developed an acute drop in hematocrit with relative hypotension. [**Name2 (NI) **] was transfused 2 units of PRBCs. An urgent RUQ u/s was obtained and showed that the pseudoaneurysm has decreased from [**2184-11-29**], and there is now a small thrombus. The vessel remained patent, however. Given these findings, patient was once again administered bicarbonate and Mucomyst in preparation for angiography. He underwent repeat coil embolization of pseudoaneurysm on [**12-7**]. Once again patient developed oliguric ATN approximately 36 hours post procedure. Although fluid intake was minimized he progressively developed respiratory problems with desaturation when supine. CXR revealed a large right sided pleural effusion. This was tapped and drained on [**12-9**] with successful drainage of 1300 cc of dark, blood-tinged exudative fluid. Initial Gram stain showed 4+ PMNs, but no bacteria and subsequent cultures were negative. ATN subsequently resolved and he started auto-diuresing with improvement in respiratory status. Follow-up U/S on [**12-10**] showed complete obliteration of pseudoaneurysm. His hematocrits were stable. Leukocytosis persisted as did his fevers. Antibiotics were continued. Superinfection of liver hematoma continued to be of high concern but collection was not drained given high risk of the procedure. He was transferred out of the SICU on [**12-14**]. TPN was stopped. Kcals were done showing a daily kcal count of ~1300. Nutritional supplements were given. Meropenum was continued for Klebsiella bacteremia (at referring hospital) and subcapsular hematoma. Klebsiella was pan-sensitive. ID recommended at least 3 weeks of treatment using Ertapenum until [**1-5**]. A picc line was placed on [**12-15**]. [**Last Name (un) **] followed for management of diabetes. He received iv lasix for significant lower extremity edema. On [**12-15**] a non-contrast CT was repeated showing stable large subcapsular and intraparenchymal hematomas, without evidence of active extravasation. Follow chest x-rays revealed a stable right sided pleural effusion. Psychiatry was consulted to evaluate for depressed mood, tearfullness, and problems with sleep. It was felt that he was dysphoric and recommendations included avoidance of ambien. Ativan was recommended prn at HS. Outpatient psychiatry follow up was discussed with the patient who agreed to think about it. On [**12-19**], he continued to spike temperatures of 101 to 101.9. A repeat U/A was negative. Blood and urine cultures are negative to date. The possibility of a feeding tube was discussed but he declined this and agreed to eat more and over the last 3 days of his hospital stay he has steadily increased his po intake. He continues to have low grade fevers. A CT scan obtained on [**2184-12-21**] revealed a stable subcapsular hematoma. He is tolerating a diabetic diet and ambulating regularly. He is discharged home in good condition with VNA to administer IV antibiotics for 2 more weeks. He has appropriate follow up appointments scheduled. Medications on Admission: Lantus 15 qam, humalog SS, protonix 40mg daily, HCTZ 25mg [**Hospital1 **], Creon with meals Discharge Medications: 1. PICC Line Care Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Heparin Flush: dispense # 30 (Thirty) Refills 1 (One) Normal Saline Flush: Dispense #100 (one hundred) Refill 1 (One) box 2. PICC Line Care PICC Line Dressing Kit Change dressing q three days and PRN Dispense # 7 (seven) Refill 1 (One) 3. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a day for 14 doses. Disp:*14 units* Refills:*1* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: [**5-21**] Caps PO QIDWMHS (4 times a day (with meals and at bedtime)). Disp:*540 Cap(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous once a day. Disp:*1 bottle* Refills:*2* 10. Insulin Glargine 100 unit/mL Solution Sig: Three (3) units Subcutaneous at bedtime. 11. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:*1 * Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: MEN I Metastatic gastrinoma Klebsiella bacteremia (at referring hospital) Subcapsular liver hematoma s/p RFA with pseudoaneurysm s/p Pseudoaneurysm coil embolization x 2 Acute renal failure Anemia Discharge Condition: good Discharge Instructions: Please call Dr.[**Name (NI) 670**] office at [**Telephone/Fax (1) 673**] if you experience: - fever >101.5 - chills - persistent nausea or vomiting - dizziness - abdominal pain not relieved by your medication - inability to eat or drink - any other concerns you may have You will have weekly labs drawn by the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 58870**] (cbc, bun, creatinine, ast, alt, alk phos, t.bili). The results should be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in the [**Hospital **] clinic at [**Telephone/Fax (1) 432**]. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-12-31**] 8:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2184-12-31**] 1:10

Admission Date: [**2104-12-4**] Discharge Date: [**2104-12-21**] Date of Birth: [**2049-7-29**] Sex: M Service: MEDICINE Allergies: Penicillin V Potassium Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Cough, Fever Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 74199**] is a 55 yo man with a history of CML day +196 status post donor-matched allogeneic SCT complicated by GHV of gut and skin, cardiomyopathy (TTE [**8-18**] with LVEF > 55%) who presented with fever to 101, fatigue, and chest congestion. Per pt, has experienced dry cough since being discharged on [**8-18**] for sinusitis, that he believes has not acutely worsened. Over the past 2-3 days, he has also experienced worsening dyspena, chest congestion, and fatigue. He noted a fever to 101F yesterday afternoon and presented to the ED. Denies sick contacts, recent travel, sinus tenderness, rhinorrhea, myalgias, arthalgias, new rashes, chest pain. He does note abdominal muscle tenderness [**1-12**] cough. No changes in bowel habits. Past Medical History: # CML: Diagnosed [**7-/2103**], s/p Allogeneic transplant (sister as donor)in [**5-18**]. # Acute GVHD- ([**7-18**]) Maximum grade 1 skin and grade 2 gut. Currently he is grade 0 skin and gut. # Cardiomyopathy. He is being followed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]. # Sweet's syndrome associated with CML diagnosed during admission [**Date range (1) 74200**]. Social History: Lives in [**Location **] Mass in a single family home with his 32 yo son and 33 [**Name2 (NI) **] daughter and her two children ages 1 and 13. He is divorced x 2. Has a new girlfriend [**Name (NI) **] who has been together with for 6 months. Worked full time for a bus company many years, stopped work when he was first diagnosed, but went back full time for the past 6 months. He has also been a volunteer firefighter x23 yrs. Two older sisters, and two younger sisters. [**Name (NI) **] also has 3 younger bothers. His younger sister [**Name (NI) **] is his donor. His older sister [**Name (NI) **] is [**Name8 (MD) **] RN. Brothers are not involved. Patient has recently quit smoking after 35 years. Family History: Grandmother had leukemia Physical Exam: MICU Admission PE: Vitals: Tm 102, Tc 100.3 BP 100/72 HR 121, RR 25, O2 sat 98% 100% aerosolized O2 mask General: Awake, alert, does not appear as tachypneic as noted vitals, mild accessory muscle use, no paradoxical breathing noted. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, slightly dry MM, no lesions noted in OP, no sinus tenderness appreciated Pulmonary: moving fair amount of air bilaterally, coarse breath sounds in both bases with mild coarse crackles, L>R Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Right sided Hickmann in place without surrounding erythema Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact, except for slightly diminished hearing on right -motor: normal bulk throughout. moving all 4 extremities symmetrically, No abnormal movements noted. -cerebellar: No nystagmus, dysarthria, intention or action tremor Pertinent Results: Admission Labs: [**2104-12-4**] 08:00PM WBC-10.2 RBC-3.80* HGB-13.5* HCT-37.9* MCV-100* MCH-35.6* MCHC-35.8* RDW-14.8 [**2104-12-4**] 08:00PM NEUTS-84.8* LYMPHS-7.4* MONOS-6.8 EOS-0.6 BASOS-0.5 [**2104-12-4**] 08:00PM PLT COUNT-275 [**2104-12-4**] 08:00PM ALT(SGPT)-28 AST(SGOT)-28 LD(LDH)-210 ALK PHOS-76 TOT BILI-0.3 [**2104-12-4**] 08:14PM GLUCOSE-73 LACTATE-1.1 NA+-141 K+-3.6 CL--98* TCO2-27 [**2104-12-4**] 08:00PM UREA N-14 CREAT-1.3* [**2104-12-5**] 12:00AM PT-12.5 PTT-31.8 INR(PT)-1.1 [**2104-12-4**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2104-12-4**] 08:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2104-12-4**] 08:00PM URINE HYALINE-[**2-12**]* [**2104-12-4**] 08:00PM IgG-300* CTA [**2104-12-14**] IMPRESSION: 1. Evaluation limited for subsegmental branches, however, no evidence of pulmonary embolism within the main lobar or segmental branches. 2. New consolidation in the left lower lobe concerning for pneumonia. Additional small foci of opacity within the right upper and left upper lobes are concerning for additional foci of inflammation or infection. 3. Unchanged emphysema and chronic airway disease. Brief Hospital Course: Mr. [**Known lastname 74199**] is a 55 year old man with a history of CML status post allogeneic SCT complicated by GVHD of skin/gut on immunosuppression who was admitted with RSV bronchiolitis that was then complicated by hospital acquired pneumonia. . During this admission the following issues were addressed: # Hypoxia: On admission the pt had a positive RSV assay on rapid respiratory viral nasopharyngeal aspirate. The pt did not have evidence of lower lung disease and his chest x-ray on admission did not reveal an infiltrate. The pt also had a CTA of the chest that was negative for PE. The pt was treated with bronchodilators and received a single dose Synagis (15mg/kg) on [**2104-12-5**] with improvement in oxygen saturation. During the admission the pt required multiple transfers to the ICU for hypoxia, and was diagnosed with hospital acquired pneumonia and treated with Cefepime and Vancomycin initially. The pt then developed a diffuse morbilloform eruption that was attributed to Cefepime, and the antibiotic regimen for hospital-acquired pneumonia was changed to Linezolid, Aztreonam, Cipro and Flagyl per infectious disease recommendations. The pt was treated with a total 14-day course and on discharge he was able to breathe comfortably on room air and did not have any oxygen desaturations on ambulation. # CML: During this admission the pt was continued on his home immunosuppressive regimen of prednisone, Cellcept and Neoral. The pt was continued on his outpatient prophylaxis regimen of acyclovir and posaconazole. The pt's most recent inhaled pentamidine was on [**2104-11-25**]. During the admission the pt also received a dose of intravenous immune globulin. Medications on Admission: ACYCLOVIR 400mg q8h CYCLOSPORINE MODIFIED 25mg [**Hospital1 **] POSACONAZOLE 400mg qam and 200mg qpm FOLIC ACID 1 mg daily LORAZEPAM 0.5-1mg q4h prn METOPROLOL SUCCINATE 150mg daily MYCOPHENOLATE MOFETIL 250mg [**Hospital1 **] OMEPRAZOLE 20mg [**Hospital1 **] PREDNISONE 7.5mg daily URSODIOL 300 mg Capsule [**Hospital1 **] ARTIFICIAL TEAR WITH LANOLIN - Ointment - 1 Ointment(s) R eye daily ASCORBIC ACID 500mg daily CALTRATE-600 PLUS VITAMIN D 600 mg-400 unit 2tab daily MAGNESIUM OXIDE 400 mg Tablet [**Hospital1 **] MULTIVITAMIN 1 tab daily TACROLIMUS ELIXIR 0.5/5ml's 5ml's swish and spit tid DEXAMETHASONE 5 mL(s) by mouth Swish and Spit QID Discharge Medications: 1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 2. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. Posaconazole 200 mg/5 mL Suspension Sig: Two (2) PO QAM (once a day (in the morning)). 4. Posaconazole 200 mg/5 mL Suspension Sig: One (1) PO QPM (once a day (in the evening)). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 7. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Dexamethasone 0.5 mg/5 mL Solution Sig: Five (5) ML PO TID PRN: MIX WITH TACROLIMUS SUSPENSION. Disp:*600 ML(s)* Refills:*2* 16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 17. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Saliva Substitution Combo No.2 Solution Sig: One (1) ML Mucous membrane 5X/DAY (5 Times a Day). Disp:*150 ML(s)* Refills:*2* 20. Tacrolimus suspension 0.5mg/5cc swish and spit three times daily as needed for mouth pain. Mix with dexamethasone suspension. 21. Pentamidine 300 mg Recon Soln Sig: One (1) Inhalation once a month. Discharge Disposition: Home with Service Discharge Diagnosis: RSV pneumonia Bacterial pneumonia Discharge Condition: Stable. Discharge Instructions: You were admitted with a viral respiratory infection and with a superimposed bacterial pneumonia. You were treated with immunoglobulin therapy directed against the virus and with intravenous immunoglobulin, as well as a 14-day course of antibiotics. Please call or return to the Emergency Department with fevers, chills, cough, shortness of breath, or other concerns. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in the hematology clinic next week. Please call ([**Telephone/Fax (1) 34375**] tomorrow morning to confirm the day and time of your appointment.

Admission Date: [**2185-6-24**] Discharge Date: [**2185-7-21**] Date of Birth: [**2107-8-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Intubated ([**2185-6-24**]) History of Present Illness: History of Present Illness: 77M history of schizophrenia, neurogenic bladder presenting from NH with ACS with resuscitation at [**Hospital1 2177**] 1 month ptp, brought in by EMS due to hypoxia, concern for PNA at nursing home. The patient is schizophrenic per history and is unable to provide a history of his own. Per discussion with the floor nurse from his nursing home, a CXR was obtained 4 days prior to admission for a cough that was consistent with a pneumonia. He was started on a Z-pack. One day prior to admission, he developed tachypnea and started to desaturated in the the low 80's. EMS were call and he was stat low 90's on a NRB. He was brought in by Ambulance. In the ED, initial VS were T 99, HR 120, BP 104/79, RR 24 satting 92% on NRB. Labs showed WBC of 10.1, HCT of 43, plts 305. LFTs showed AP of 214 otherwise WNL. Coags were WNL. CMP showed hypernatremia of 150, Cl of 112, BUN 33, with rest of BMP in normal range, Lactate was 2.1, and valproate level was 27. ABG was checked and pH was 7.51, pCO2 of 28, pO2 of 72. Given tachypnea and hypoxemia as well as high work of breathing, patient was intubated with fentanyl and midazolam for sedation. Noted was food in oropharynx/larynx per ED resident on intubation. His CXR showed a questionable aspiration pneumonia as well as possible LLL process. CT scan showed bilateral PE and likely pneumonia. He was empricially provided with levofloxacin, metronidazole, and vancomycin. His blood pressure dropped to 70/40 just before transfer to the ICU. After an 3 additional 3L NS SBP increased to 100's. Past Medical History: 1) Osteoarthritis 2) Schizophrenia 3) Tardive dyskinesia 4) Neurogenic bladder indwelling catheter with recurrent UTIs 5) BPH 6) CAD 7) Lumbar pain 8) TURP 9) Dysphagia with large hiatial hernia . Social History: Lives at [**Hospital1 **] 174 [**Location (un) 538**], MA Family History: Patient unable to elucidate. Physical Exam: ADMIT EXAM: Vitals: Temp: 36.8 ??????C, HR: 84, BP: 96/53(68)mmHg, RR: 26 insp/min, SpO2: 97% General: Sedated on vent, NAD, thin HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, 2mm pupils, poorly reactive Neck: supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: limited exam Clear to auscultation bilaterally on anterior exam Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: suprapubic foley Ext: warm, well perfused, 1+ pulses Neuro: moving all extremities DISCHARGE EXAM: AF 97.6/98 100-116/59-80 HR 84-100 RR 18 sat 96% on RA Gen: NAD. Sleeping comfortably HEENT: moist mucosa. Patient with upper airway wheezing. Nasal breather. Appears obstruction in nose. Tongue protruding while sleeping CV: tachycardic, regular rhythm, [**1-25**] holosystolic murmur Lungs: Tachypnic. Upper airway wheezing. CTAB but intermediate aeration Abd: NT, ND, soft Ext: no peripheral edema Skin: no rashes or lesions noted; area around suprapubic cath is c/d/i without erythema or discharge Pertinent Results: IMAGING: CT ANGIO CHEST [**2185-6-24**] - TECHNIQUE: CTA of the chest was performed per department protocol. Oblique sagittal and coronal reformats were available for review along with the axial images. CT OF THE CHEST: There are small pulmonary arterial filling defects in the subsegmental bronchi supplying the lingula (4:71) as well as additional filling defect in the subsegmental right lower lobe bronchi (4:87). An additional area of segmental pulmonary embolus is seen in the apical segment of the right upper lobe (4:33). There is no evidence of right heart strain. Within the right middle and upper lobe there are extensive nodular opacities as well as several more gound glass appearing areas of opacity (4:61 and 4:27). There is extensive atelectasis of the right lower lobe (4.83) with relative [**Name (NI) 71062**] peripheral area within the collapsed lung. No definitive arterial supply with embolus is seen in this area; however in the setting of other emboli and configuration of this finding, it is concerning for infarct. There is no pleural or pericardial effusion. In the left hemithorax, there is a large hiatal hernia with stomach and GE junction above the diaphragm. This causes compressive atelectasis (4:102) on the adjacent lung. The patient is intubated with endotracheal tube terminating approximately 4 cm from the carina. An nasogastric tube is seen in the esophagus but does not reach the GE junction or the stomach. Subdiaphgramatically, gallstones are seen. The aorta and the great vessels appear unremarkable. No suspicious lytic or sclerotic lesions are seen within the bones. IMPRESSION: 1. Right middle and upper lobe nodular opacities as well as several areas of ground-glass opacity consistent with infectious process. 2. Bilateral pulmonary emboli in the segmental and subsegmental levels with no evidence of right heart strain. There is an area of hypoenhancement within the atelctatic right lower lobe along the periphery concerning for infarction. 3. Complete right lower lobe atelectasis. 4. Large diaphgramatic hernia. 5. Cholelithasis. BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND [**2185-6-24**] - Grayscale and Doppler son[**Name (NI) **] of the left common femoral, left superficial femoral, left popliteal vein show normal compressibility, flow and augmentation. Note is made of duplicated left superficial femoral veins. The left calf veins show normal flow. Grayscale, color, and spectral Doppler examination of the right common femoral vein shows normal compressibility and flow. Note is made of duplicated right superficial femoral veins. There is partially occlusive thrombus noted within one of the right proximal superficial femoral veins which is of unclear chronicity. The distal superficial femoral vein, the entire length of the other superficial femoral vein, popliteal vein appear patent. The right posterior tibial veins were patent. The right peroneal veins were not visualized. IMPRESSION: 1. Partially occlusive thrombus noted within one of the two right proximal superficial femoral veins which is of unclear chronicity. Right peroneal veins were not visualized. 2. No DVT in left lower extremity. ECHO [**2185-6-24**] - Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Findings LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality as the patient was difficult to position. Suboptimal image quality - ventilator. Conclusions Technically suboptimal study. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No definate aortic regurfgitation is seen. The mitral leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is an anterior space which most likely represents a very prominent fat pad. IMPRESSION: Very suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Mild mitral regurgitation. CXR [**2185-6-26**] Compared with [**2185-6-25**] at 5:46 a.m., an NG tube is again noted. It overlies the lower chest, but appears to overlie the gastric fundus, which is elevated due to a diaphragmatic herniation, as seen on [**2185-6-24**] CT scan. If clinically indicated, a lateral view could help to confirm this. Again noted is ET tube in satisfactory position above the carina. Prominence of right paratracheal soft tissues is noted, but may be accentuated due to patient rotation. There is focal opacity in the right upper zone and patchy opacity in the right lower zone medially. These findings are better depicted on [**2185-6-24**] CT scan. The lung apices are excluded from the film. Electronic battery pack is noted overlying left iliac crest. CXR [**2185-7-6**] FINDINGS: In comparison with the study of [**7-5**], the orogastric tube has been removed. Other monitoring and support devices remain in place. Persistent opacification at the left base with progressive clearing of opacification at the right base. No vascular congestion. CXR [**7-8**] Portable: IMPRESSION: Increased opacification in left base with some volume loss. CXR [**7-10**] Portable: IMPRESSION: Possible area of loculated fluid with trapped air verses pneumothorax verses atypical appearance of stomach bubble near the left CPA. Follow up upright chest radiograph with the patient swallowing 15 cc of barium just prior to imaging should help rule out these etiologies CXR [**7-11**] PA/Lat: CONCLUSION: There is no significant pneumothorax. ECG [**7-17**]: Sinus rhythm. Borderline low QRS voltage. Possible inferior wall myocardial infarction of indeterminate age. The lateral lead Q waves are likely not representative of a myocardial infarction but rather septal Q waves. Compared to the previous tracing of [**2185-7-8**] the sinus rate has decreased by 20 beats per minute with no other diagnostic change. MICRO/PATH: MRSA SCREEN (Final [**2185-6-26**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2185-6-25**] 2:00 pm BRONCHIAL WASHINGS BRONCHIAL WASH. Blood Culture, Routine (Final [**2185-7-1**]): NO GROWTH. GRAM STAIN (Final [**2185-6-25**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. GRAM STAIN (Final [**2185-6-28**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2185-6-30**]): Commensal Respiratory Flora Absent. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 351-9662P ([**2185-6-24**]). YEAST. RARE GROWTH. GRAM NEGATIVE ROD(S). RARE GROWTH. GRAM STAIN (Final [**2185-7-4**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. Catheter tip Cx [**7-6**]: No growth BCx [**7-9**] and [**7-10**]: No growth Urine Cx ([**7-10**]) URINE CULTURE (Final [**2185-7-12**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ADMIT LABS: [**2185-6-24**] 08:40AM BLOOD WBC-10.1 RBC-4.41*# Hgb-13.6*# Hct-43.0# MCV-97# MCH-30.8 MCHC-31.6# RDW-14.1 Plt Ct-305 [**2185-6-24**] 08:40AM BLOOD Neuts-85.8* Lymphs-9.7* Monos-3.5 Eos-0.8 Baso-0.3 [**2185-6-24**] 08:40AM BLOOD PT-12.3 PTT-29.6 INR(PT)-1.1 [**2185-6-24**] 08:40AM BLOOD Glucose-91 UreaN-33* Creat-0.8 Na-150* K-3.5 Cl-112* HCO3-25 AnGap-17 [**2185-6-24**] 08:40AM BLOOD ALT-22 AST-31 AlkPhos-214* TotBili-0.6 [**2185-6-24**] 05:10PM BLOOD Calcium-7.7* Phos-2.0* Mg-1.8 [**2185-6-24**] 08:40AM BLOOD Albumin-3.4* [**2185-6-24**] 09:34AM BLOOD Type-ART pO2-72* pCO2-28* pH-7.51* calTCO2-23 Base XS-0 RELEVENT LABS: [**2185-6-24**] 05:10PM BLOOD WBC-11.6* RBC-3.43* Hgb-10.8* Hct-33.2* MCV-97 MCH-31.4 MCHC-32.4 RDW-14.3 Plt Ct-288 [**2185-6-25**] 03:11AM BLOOD WBC-12.6* RBC-3.39* Hgb-10.6* Hct-33.0* MCV-97 MCH-31.2 MCHC-32.1 RDW-14.3 Plt Ct-319 [**2185-6-26**] 03:46AM BLOOD WBC-14.4* RBC-3.57* Hgb-11.2* Hct-34.2* MCV-96 MCH-31.3 MCHC-32.6 RDW-14.7 Plt Ct-355 [**2185-6-25**] 03:11AM BLOOD Neuts-81.7* Lymphs-12.0* Monos-3.0 Eos-2.8 Baso-0.5 [**2185-6-25**] 03:11AM BLOOD PTT-58.7* [**2185-6-26**] 03:46AM BLOOD PT-14.2* PTT-88.5* INR(PT)-1.3* [**2185-6-26**] 10:04AM BLOOD PTT-128.0* [**2185-6-24**] 05:10PM BLOOD Glucose-93 UreaN-25* Creat-0.5 Na-149* K-2.8* Cl-119* HCO3-21* AnGap-12 [**2185-6-25**] 03:11AM BLOOD Glucose-100 UreaN-23* Creat-0.5 Na-148* K-3.7 Cl-120* HCO3-19* AnGap-13 [**2185-6-25**] 02:52PM BLOOD Glucose-85 UreaN-20 Creat-0.5 Na-150* K-3.4 Cl-120* HCO3-20* AnGap-13 [**2185-6-26**] 03:46AM BLOOD Glucose-148* UreaN-15 Creat-0.5 Na-144 K-2.8* Cl-115* HCO3-20* AnGap-12 [**2185-6-26**] 03:23PM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-140 K-3.9 Cl-115* HCO3-20* AnGap-9 [**2185-6-24**] 08:40AM BLOOD ALT-22 AST-31 AlkPhos-214* TotBili-0.6 [**2185-6-25**] 03:11AM BLOOD Calcium-7.8* Phos-1.8* Mg-1.9 [**2185-6-25**] 02:52PM BLOOD Calcium-8.0* Phos-2.9 Mg-2.4 [**2185-6-26**] 03:46AM BLOOD Calcium-7.5* Phos-1.7* Mg-2.1 [**2185-6-26**] 03:23PM BLOOD Calcium-7.2* Phos-1.8* Mg-2.0 [**2185-6-24**] 05:50PM BLOOD Type-ART pO2-84* pCO2-27* pH-7.45 calTCO2-19* Base XS--2 [**2185-6-25**] 03:10PM BLOOD Type-ART Temp-37.2 pO2-114* pCO2-27* pH-7.47* calTCO2-20* Base XS--1 Intubat-INTUBATED [**2185-6-25**] 10:16PM BLOOD Type-ART pO2-91 pCO2-23* pH-7.49* calTCO2-18* Base XS--2 [**2185-6-26**] 04:01AM BLOOD Type-ART pO2-96 pCO2-26* pH-7.51* calTCO2-21 Base XS-0 [**2185-6-26**] 03:31PM BLOOD Type-ART Temp-36.8 pO2-85 pCO2-27* pH-7.50* calTCO2-22 Base XS-0 Intubat-INTUBATED [**2185-6-30**] 04:22AM BLOOD WBC-11.2* RBC-3.32* Hgb-10.4* Hct-31.5* MCV-95 MCH-31.4 MCHC-33.1 RDW-14.8 Plt Ct-450* [**2185-7-3**] 04:24AM BLOOD WBC-13.7* RBC-3.62* Hgb-11.3* Hct-34.2* MCV-95 MCH-31.3 MCHC-33.1 RDW-14.6 Plt Ct-615* [**2185-7-5**] 02:42AM BLOOD WBC-8.5 RBC-3.03* Hgb-9.3* Hct-28.9* MCV-96 MCH-30.6 MCHC-32.0 RDW-14.6 Plt Ct-646* [**2185-7-7**] 03:49AM BLOOD WBC-8.6 RBC-2.97* Hgb-9.3* Hct-28.1* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.5 Plt Ct-596* [**2185-7-2**] 03:48AM BLOOD Neuts-62.4 Lymphs-28.4 Monos-6.7 Eos-2.0 Baso-0.6 [**2185-7-4**] 04:06AM BLOOD Neuts-64.0 Lymphs-25.8 Monos-6.5 Eos-2.9 Baso-0.9 [**2185-7-3**] 04:24AM BLOOD PT-25.9* PTT-116.3* INR(PT)-2.5* [**2185-7-4**] 04:06AM BLOOD PT-38.3* PTT-85.2* INR(PT)-3.7* [**2185-7-5**] 02:42AM BLOOD PT-27.3* PTT-42.7* INR(PT)-2.6* [**2185-7-6**] 03:39AM BLOOD PT-31.1* INR(PT)-3.0* [**2185-7-7**] 03:49AM BLOOD PT-50.0* PTT-46.7* INR(PT)-5.0* [**2185-7-6**] 03:39AM BLOOD ALT-11 AST-17 AlkPhos-125 TotBili-0.5 [**2185-7-7**] 03:49AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.0 [**2185-7-3**] 04:24AM BLOOD TSH-8.2* [**2185-7-3**] 04:30PM BLOOD T3-99 Free T4-0.78* [**2185-7-6**] 06:45AM BLOOD Cortsol-24.3* - 05:45AM BLOOD Cortsol-16.8 (STIM TEST) [**2185-7-4**] 04:06AM BLOOD Cortsol-6.0 DISCHARGE LABS: [**2185-7-20**] 06:55AM BLOOD WBC-5.4 RBC-3.25* Hgb-10.3* Hct-30.4* MCV-94 MCH-31.7 MCHC-33.8 RDW-14.2 Plt Ct-263 [**2185-7-20**] 06:55AM BLOOD PT-37.9* PTT-47.8* INR(PT)-3.7* [**2185-7-20**] 06:55AM BLOOD Glucose-87 UreaN-9 Creat-0.9 Na-140 K-3.8 Cl-107 HCO3-25 AnGap-12 [**2185-7-20**] 06:55AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.4 Brief Hospital Course: Mr. [**Known lastname 71063**] is a 77 yo M transferred from MICU [**7-7**] with schizophrenia, neurogenic bladder, without guardianship, and found to have pneumonia and bilateral pulmonary emboli causing hypoxia/hypotension requiring pressors and intubation. He has been relatively stable on the floor while undergoing treatment for UTI. # UTI- Currently has suprapubic catheter in setting of neurogenic bladder and was found to have GNR's 10-100K in urine on [**2185-7-3**]. Species on [**7-3**] was Alcaligenes achromobacter. Patient complained of need to void urine on [**2185-7-11**] several times which was new for him. His suprapubic catheter was changed [**2185-7-13**] by urology. Levofloxacin was started on [**2185-7-11**] per [**2185-7-3**] sensitivities; for total 14 day course (last day is [**7-24**]). # Acute Pulmonary Emboli: Patient previously on Coumadin. [**2185-6-24**] CTA showed bilateral pulmonary emboli in the segmental and subsegmental levels without evidence of right heart strain. There was no clear cause for why he developed a PE. There was an area of hypoenhancement within the atelectatic right lower lobe along the periphery concerning for infarction. Increased coumadin from 1mg po to 2mg po daily on [**2185-7-13**]. Further increased coumadin from 2mg po to 4mg po daily on [**2185-7-16**]. His INR has been difficult to manage, likely in setting of antibiotics, malnutrition, Levothyroxine. On discharge, his Coumadin has just been restarted at 3mg after he has been supratherapeutic for the past 2 days. As an outpatient, he should have his INR followed (check in 48-72hrs). If his INR <2, he should be bridged with Lovenox 60mg q12h due to high risk for thromboembolism. On discharge, he is on room air, slightly tachypneic and tachycardic but has been stable. # Tachycardia/Hypotension: Related to above. Heart rates have been in 80-110's. SBP <80s in the ICU requiring pressors. Likely due to known pulmonary emboli with infection. Patient does not currently have sx of infection, so sepsis is less likely cause. It may be from pain, since patient is relatively unable to communicate. # Schizophrenia- Difficult to evaluate mental status. No evidence of responding to internal stimuli. Baseline over past few months [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] is that he is able to communicate pain/discomfort but does not have capacity. He is mostly lucid but answers questions in mumbles and broken statements. Patient had court date for guardianship on [**2185-7-19**] which was approved. He sometime says inappropriate comments but not frequently. Patient was ambulatory in [**Month (only) 205**] with assistance per previous [**Hospital1 1501**]. We continued his Depakote, Risperdal, and Remeron. # Pneumonia, MRSA: Treated with 8 day course of Vanc/Zosyn for bilateral patchy infiltrate and found to be MRSA positive on bronchial washings. Patient was hypotensive and hypoxic requiring intubation and pressors for 10 days in MICU. Extubated [**2185-7-6**]. [**2185-7-6**] CXR: Persistent opacification at the left base with progressive clearing of right base without vascular congestion. Later CXR cleared, he has finished treatment. # Hypothyroidism: Levothyroxine started this admission for TSH 8.6 in setting of acute septic shock. TSH 7.8 on [**2185-7-9**]. He should continue levothyroxine 25mcg po daily. He will need outpatient follow up of TSH in 1 month [**2185-8-8**] # FEN: IVF prn, replete electrolytes prn, ground solids, if ever needs tube feeds, needs post-pyloric b/c hiatal hernia TRANSITIONAL ISSUES - Continued on Levofloxacin until [**7-24**] - Guardianship obtained during admission. - Will need outpatient psych follow-up - He will need close management of coumadin with goal INR [**12-24**] indefinitely. He should have a bridge with Lovenox 60mg q12 if ever INR<2. Discharge Coumadin dose is 3mg. - please check TSH and free T4 on [**2185-8-8**]. Patient started on levothyroxine [**2185-7-3**] for low Triiodothyronine Thyroxine (T4), Free 0.78* and TSH 8.5. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Divalproex (DELayed Release) 250 mg PO QAM 2. Divalproex (DELayed Release) 375 mg PO QHS 3. Ranitidine (Liquid) 150 mg PO DAILY 4. Acetaminophen 650 mg PO BID 5. Milk of Magnesia 30 mL PO ONCE:PRN constipation 6. Bisacodyl 10 mg PO DAILY:PRN constipation 7. Loperamide 2 mg PO TID:PRN loose stools 8. Lorazepam 0.5 mg PO Q4H:PRN anxiety 9. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Q6 hours wheezing 10. Megestrol Acetate 10 mg PO BID 11. Risperidone 7 mg PO HS 12. Mirtazapine 30 mg PO HS 13. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q6H:PRN pain Monitor for sedation, RR < 8 14. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Divalproex (DELayed Release) 250 mg PO QAM 2. Divalproex (DELayed Release) 375 mg PO QHS 3. Risperidone 7 mg PO HS 4. Acetaminophen 650 mg PO BID 5. Bisacodyl 10 mg PO DAILY:PRN constipation 6. Multivitamins 1 TAB PO DAILY 7. Megestrol Acetate 10 mg PO BID 8. Milk of Magnesia 30 mL PO ONCE:PRN constipation 9. Mirtazapine 30 mg PO HS 10. Ranitidine (Liquid) 150 mg PO DAILY 11. Loperamide 2 mg PO TID:PRN loose stools 12. Lorazepam 0.5 mg PO Q4H:PRN anxiety 13. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q6H:PRN pain Monitor for sedation, RR < 8 14. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Q6 hours wheezing 15. Levothyroxine Sodium 25 mcg PO DAILY avoid taking around time of maalox, tums, simethicone RX *levothyroxine 25 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 16. Levofloxacin 500 mg PO Q24H Duration: 4 Days Please give until [**7-24**] for a total of 14 days RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 17. Warfarin 3 mg PO DAILY16 Goal INR [**12-24**] (bridge with lovenox if INR <2) RX *warfarin 3 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*3 Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Pneumonia, Pulmonary Embolism Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Confused - always. Discharge Instructions: Mr. [**Known lastname 71063**], you were admitted to the [**Hospital1 827**] on [**2185-6-24**] for shortness of breath at your nursing facility. You were found to have pneumonia with MRSA in your lungs in addition to multiple blood clots in your lungs. This required you to be in the intensive care unit on a ventilator for over 1 week and requiring medicine to keep your blood pressure normal. After you had several days of antibiotics for your pneumonia, you were taken off the ventilator. Due to your lung clots, you will need to be on coumadin (a blood thinner) indefinitely. We have continued to change your dose depending on your INR (which needs to be between [**12-24**] to help prevent blood clots). You will be returning to your nursing home. Please follow up with your primary care physician. Followup Instructions: Please follow up with your Primary Care physician at [**Name9 (PRE) **] where you stay.

Admission Date: [**2167-11-5**] Discharge Date: [**2167-11-11**] Date of Birth: [**2119-2-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4891**] Chief Complaint: Lower GI bleed Major Surgical or Invasive Procedure: EGD [**2167-11-5**] Small bowel capsule study Blood Transfusion History of Present Illness: 48 y.o. male with hyperlipidemia and past bleeding duodenal ulcer presenting with dark stools and hematochezia *4 days. He has had four episodes of GI bleeding since earlier this year. In [**2167-5-23**], he had several days of dark stools with some mixed blood; upper and lower endoscopy revealed no active bleed. A similar episode occurred in [**2167-7-23**], when upper/lower endoscopies and capsule study were all negative for active bleeding. More recently, he had dark tarry stools last month, for which he again sought care at [**Hospital 1474**] Hospital. Per patient report, upper endoscopy revealed a bleeding duodenal ulcer that was both clipped and cauterized. Colonoscopy revealed hemorrhoids and a single polyp, that was removed (pathologic diagnosis unknown). The patient does not think any of his upper endoscopies were accompanied by biopsies. He has not been treated for H. pylori infection. Since his procedures in [**Month (only) **] through this past weekend, the patient did not have any recurrences or other GI complications. On Monday [**11-2**], he had recurrent dark, tarry stools. He saw his PCP, [**Name10 (NameIs) 1023**] ordered labs notable for Hct of 37 (per patient report). For the next several days, he continued to have dark tarry stools, but no other significant symptoms. This morning, he awoke at 4:00 am with palpitations and mild dyspnea, and had another bowel movement with dark stools and some blood on the toilet paper. Denies abdominal pain, nausea, vomiting, or BRBPR. He went to the ED at [**Hospital **] Hospital, where he received 800 cc NS and IV famotidine for guaiac positive stool. There, an NG lavage was negative. He was transferred to [**Hospital1 18**] for further evaluation. In [**Hospital1 18**] ED, the patient reported lightheadedness, dizziness, and dyspnea (with movement). Endorsed nausea but denied abdominal pain. His initial VS: 97.7 96 124/73 18 99% RA. Hct 18.5. The patient was given 1 liter NS and IV pantoprazole. A second liter of NS was started. ECG showed sinus tachycardia at 96 bpm. He was seen by GI who recommended obtaining OSH records for prior endoscopic reports, and repeating EGD here. He was cross-matched for two units but no RBC's were transfused, prior to being sent up to MICU. Upon arrival to the MICU, the two units of packed RBCs were ordered and transfusion was initiated. The patient reports feeling mild dyspnea with exertion, but denies abdominal pain, nausea, vomiting, or any more bowel movements of any kind since 4:00 am this morning. Denies recent NSAID use. Past Medical History: -Hx of GI bleeds x 2. Most recent bleed in [**10-2**], found to have duodenal ulcer at [**Hospital 87735**] Hospital, which was clipped vs cauterized -Hyperlipidemia -S/p motorcycle accident [**2162**], with bowel resection, ileostomy and reversal. Social History: Lives at home with wife and children. Remote smoker (quit >20 years ago). Denies illicits or etoh intake. Family History: Mother: MI at age 70. Father: MI at age 64. Three children (two sons and one daughter) are healthy. No known GI disease in the family. Physical Exam: VS: Temp:97.6 BP: 129/71 HR:104 (sinus rhythm) RR:18 O2sat 99% RA GEN: pleasant, comfortable, NAD. Sitting up comfortably in bed. HEENT: Mild conjunctival pallor. PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no carotid bruits, no thyromegaly or thyroid nodules. JVP to 8 cm at 45 degrees. RESP: CTA b/l with good air movement throughout. No wheeze or crackles. CV: RR, S1 and S2 wnl, no m/r/g ABD: Soft, NT/ND. No masses or hepatosplenomegaly. No pulsatile masses. Large eccentric vertical scar over upper abdomen. Assymetric firm areas over upper quadrants "calcifications" per patient. Guaiac positive stool in ED EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters. Single skin tag on right lower back. NEURO: AAOx3. CN II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated Pertinent Results: On admission: [**2167-11-5**] 10:00AM BLOOD WBC-6.0 RBC-2.10* Hgb-6.2* Hct-18.5 NOTIF MCV-88 MCH-29.6 MCHC-33.7 RDW-16.2* Plt Ct-206 [**2167-11-5**] 10:00AM BLOOD Neuts-67.7 Lymphs-28.1 Monos-3.3 Eos-0.6 Baso-0.4 [**2167-11-5**] 10:00AM BLOOD PT-14.9* PTT-27.3 INR(PT)-1.3* [**2167-11-5**] 10:00AM BLOOD Glucose-107* UreaN-19 Creat-0.7 Na-139 K-4.2 Cl-105 HCO3-30 AnGap-8 [**2167-11-5**] 10:00AM BLOOD ALT-22 AST-18 AlkPhos-53 TotBili-0.5 [**2167-11-5**] 10:00AM BLOOD Albumin-3.7 [**2167-11-6**] 01:04AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.9 [**2167-11-7**] 06:31AM BLOOD Lipase-51 [**2167-11-5**] 10:06AM BLOOD Lactate-1.3 [**2167-11-5**] 10:06AM BLOOD Hgb-6.5* calcHCT-20 [**2167-11-5**] 11:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2167-11-5**] 11:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG On discharge: [**2167-11-11**] 05:50AM BLOOD WBC-5.0 RBC-3.31* Hgb-9.4* Hct-28.4* MCV-86 MCH-28.3 MCHC-33.1 RDW-14.7 Plt Ct-265# [**2167-11-11**] 05:50AM BLOOD Glucose-93 UreaN-7 Creat-0.8 Na-142 K-3.7 Cl-106 HCO3-27 AnGap-13 [**2167-11-11**] 05:50AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.2 Blood Culture, Routine (Final [**2167-11-13**]): NO GROWTH. Blood Culture, Routine (Final [**2167-11-13**]): NO GROWTH. URINE CULTURE (Final [**2167-11-9**]): NO GROWTH. [**2167-11-10**] 3:35 pm Blood Culture, Routine (Pending): [**2167-11-10**] 9:20 pm Blood Culture, Routine (Pending): EKG (no prior for comparison): Normal sinus rhythm at 96 bpm. Normal axis and normal intervals. No ischemic ST or T wave changes. Pathology Report DIFFICULT CROSSMATCH AND/OR EVALUATION OF IRREGULAR ANTIBODIES Study Date of [**2167-11-6**] DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname **] had a diagnosis of anti-K antibody at outside hospital which was confirmed at [**Hospital1 18**]. Anti-K antibody is clinically significant and capable of causing hemolytic transfusion reactions. In the future, Mr. [**Known lastname **] should receive K-antigen negative products for all red cell transfusions. Approximately 91% of ABO compatible blood will be K-antigen negative. A wallet card and a letter stating the above will be sent to the patient. EGD [**2167-11-5**]: Small hiatal hernia No bleeding site noted Previous duodenal resection with end to side anastomosis of the distal bulb Otherwise normal EGD to third part of the duodenum Abdominal Xray [**2167-11-7**]: IMPRESSION: 1. Nonspecific bowel gas pattern without evidence of obstruction. Unusual appearance in the upper abdomen with dense material, question heterotopic ossification iatrogenic material. Clinical correlation is requested. If there is no prior imaging through this area, then a CT scan would be recommended for further assessment. 2. Focal bone lesion in the left proximal femur. Dedicated left proximal femur radiographs are recommended for further assessment. CT Abdomen/Pelvis w/contrast [**2167-11-7**]: IMPRESSION: 1. Abnormal ossification involving the anterior abdominal wall communicating with the costochondral junctions of the lower ribs and sternum is in keeping with heterotopic ossification after either surgery or trauma. 2. No evidence of small or large bowel obstruction. 3. Multiple matted small bowel loops abutting the lower anterior abdominal wall suggests adhesions. Chest (PA & LAT) [**2167-11-7**]: The right hemidiaphragm is elevated. Allowing for this, heart size is borderline. The aorta is minimally unfolded and slightly calcified. No CHF, focal infiltrate, or effusion is identified. Small bowel capsule study [**2167-11-10**]: PROCEDURE INFO & FINDINGS: 1. Suture material at the duodenal bulb. 2. Normal small bowel. No active bleeding site or ulcer (s) seen. Brief Hospital Course: 48 y/o M with multiple episodes of GI bleeding over past year, with duodenal ulcers and polyps identified, presenting with guaiac positive stools and significant hematocrit drop over past 72 hrs. 1. GI Bleed: Pt initially presented with melena and was found to have Hct of 18. He was transfused a total of 4 units in the ICU and Hct thereafter remained stable at 27-29. He was seen by the gastroenterology team who an EGD that was unremarkable. The GI team subsequently performed a small bowel capsule study that also did not reveal any site of intra-abdominal bleeding. He was maintained on IV PPI gtt initially at the ICU, then transitioned to IV PPI [**Hospital1 **] on the floor and eventually to po PPI [**Hospital1 **] by the time of discharge. Pt did not complain of further episodes of melena during hospital admission and was monitored on telemetry without any significant events. He was advised to follow-up with his outpatient gastroenterologist on discharge. 2. Fever: Upon transfer from ICU to floor, pt developed fevers peaking at 102. At the onset of his fevers, he complained of abdominal pain, distention, and difficulties passing flatus. Abdominal x-ray was performed that did not show obstruction. Pt was started on IV cipro, flagyl, and vancomycin for possible intra-abdominal infection. A CT abdomen revealed old changes from his prior surgery but no acute intra-abdominal process. A CXR and UA was also negative for any source of infection. Urine culture and two sets of blood cultures were negative. (Of note, two sets of blood cultures were still pending on discharge.) He improved markedly on the IV antibiotics. WBC decreased from 13 at time of fevers to 5 by time of discharge. Fevers, abdominal pain, and obstipation resolved and he was transitioned to po cipro and flagyl. He was told to continue the po antibiotics at home for a total course of 10 days, for empiric coverage of bacterial translocation in the setting of GI bleeding. 3. CT Findings: A CT abdomen was performed to evaluate for intra-abdominal process that could be causing pt's fevers and abdominal pain. The CT was negative for acute processes but revealed several incidental findings that pt confirmed were due to his prior bowel surgery. These included abnormal ossifications of the anterior abdominal wall and multiple matted small bowel loops consistent with adhesions. He was also noted to have a proximal femoral lesion suspicious for fibrous dysplasia which per patient was due to a bone biopsy he had had in the past. He also had an IVC filter with struts extending beyond the lumen of the inferior vena cava. This was discussed with an interventional radiologist who did not feel that this required intervention. 4. Iron Deficiency Anemia: Pt had hx of iron deficiency anemia and was taking daily ferrous sulfate supplements. His ferrous sulfate was temporarily discontinued while he was in the hospital to better distinguish between melena and dark stools and because he complained of constipation. He was discharged back on his home ferrous sulfate with the addition of a stool softener. 5. Hyperlipidemia: No acute issues. He was continued on his home simvastatin. Medications on Admission: -Simvastatin 40 mg PO daily -Protonix 40 mg PO daily -Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 4. 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:*0* 5. iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Melena Fever Secondary: Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at the hospital. You were admitted with dark stools and found to have a very low blood count. You were admitted to the intensive care unit where you received a blood transfusion. Your blood counts rose with the transfusion and you were transferred to the general medicine floor where you complained of abdominal pain and were found to have a fever. An x-ray of the abdomen and a CT scan of the abdomen did not show any acute process. You were started on IV antibiotics for your fever and abdominal pain and improved significantly. You were transitioned to two oral antibiotics that you should continue to take for five more days (until Monday [**2167-11-16**]). For work-up of your dark stools, an EGD was performed that was unremarkable. You also underwent a small bowel capsule study that also did not reveal any significant findings. You should follow-up with your gastroenterologist for continued monitoring of your symptoms. The following changes were made to your medications: 1) Pantoprazole was increased to 40mg twice a day 2) Ciprofloxacin 500mg every 12 hours was started (continue until [**2167-11-16**]) 3) Metronidazole 500mg every 8 hours was started (continue until [**2167-11-16**]) 4) Colace 100mg twice a day was started. This is a stool softener because your iron can cause constipation. Please continue your iron supplements. Followup Instructions: Please call your primary care doctor Dr. [**Last Name (STitle) **] to schedule an appointment with him in the next week. Name: [**Last Name (LF) **],[**First Name3 (LF) **] E. Location: [**Hospital **] [**Hospital **] HEALTH CENTER Address: [**Location (un) 10215**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 10216**] Fax: [**Telephone/Fax (1) 87736**] Please also call your gastroenterologist Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 87737**] to make an appointment with him within 1-2 weeks of discharge. Completed by:[**2167-11-15**]

Admission Date: [**2190-10-13**] Discharge Date: [**2190-10-19**] Date of Birth: [**2104-7-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3298**] Chief Complaint: L knee pain Major Surgical or Invasive Procedure: [**2190-10-13**]: s/p left total knee replacement revision - rotating hinge History of Present Illness: (Per Orthopedic Admission Note) Mr. [**Known lastname **] previously had a total knee replacement performed in [**2174**] by Dr. [**Last Name (STitle) 26181**]. This was revised due to loosening in [**2184**] by Dr. [**Last Name (STitle) 82679**]. He required an allograft prosthetic reconstruction. At that point in time, the allograft fractured following a fall. In addition, the [**Doctor Last Name 3549**] taper between the tibial component and the tibial stem has become disengaged and has been disengaged for several years. Mr. [**Known lastname **] presents with chronic pain and requires a revision. As pt presented for elective surgery other review of systems unremarkable and feeling well. Past Medical History: aortic stenosis coronary artery disease hypertension hyperlipidemia benign prostatic hyperplasia s/p resection of left acoustic neuroma s/p left tibial rodding s/p bilateral total knee replacements revision of left knee bilateral cataract surgery bilateral carpal tunnel release tonsillectomy/adenoidectomy excision of left upper extremity lipoma Social History: retired lives with wife tobacco: quit 40 yrs ago EtOH: 1 drink per month Family History: brother with MI, RHD father suffered MI Physical Exam: On Admission: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm On Discharge: VS: T 99.2, BP 102/56, P 71, RR 18, O2 95% on RA HEENT:OP clear w/o lesions CV: RRR, 3/6 systolic murmur Pulm: Clear to ausculatation bilaterally GI: Soft, NT, ND, Bowel sounds + Extrem: Left leg in immobilizer, dressing C/D/I Neuro: Alert and oriented to person, place, year (intermittently month) appropriate and pleasant with fluent speech Pertinent Results: ==================== LABORATORY RESULTS ==================== On Admission (from ICU) WBC-7.0# RBC-2.83*# Hgb-8.9*# Hct-25.2*# MCV-89 RDW-14.9 Plt Ct-104* PT-13.1 PTT-26.6 INR(PT)-1.1 Glucose-140* UreaN-16 Creat-0.9 Na-142 K-4.0 Cl-109* HCO3-24 On Discharge: WBC-4.7 RBC-3.34* Hgb-10.2* Hct-30.1* MCV-90 RDW-14.2 Plt Ct-183 Glucose-100 UreaN-25* Creat-0.8 Na-140 K-3.7 Cl-108 HCO3-27 Other Important Trends: [**2190-10-14**] 05:43AM CK(CPK)-1137* CK-MB-14* MB Indx-1.2 cTropnT-0.07* [**2190-10-14**] 09:26PM CK(CPK)-1576* CK-MB-34* MB Indx-2.2 cTropnT-0.55* [**2190-10-15**] 03:14AM CK(CPK)-1250* CK-MB-28* MB Indx-2.2 cTropnT-0.72* [**2190-10-15**] 11:23AM CK(CPK)-853* CK-MB-17* MB Indx-2.0 cTropnT-0.76* [**2190-10-15**] 06:58PM CK(CPK)-599* CK-MB-10 MB Indx-1.7 cTropnT-0.86* ============= MICROBIOLOGY ============= Joint Fluid [**2190-10-13**]: GRAM STAIN (Final [**2190-10-13**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2190-10-16**]): NO GROWTH. ACID FAST SMEAR (Final [**2190-10-14**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Blood Cultures [**2190-10-14**] and [**2190-10-15**]: No growth to date Urine Culture [**2190-10-14**]: No growth ============== OTHER STUDIES ============== Knee Radiograph [**2190-10-13**]: IMPRESSION: Intact left total knee revision. No complications. ECG [**2190-10-14**]: Rapid regular tachycardia, rate 110. There is complete right bundle-branch block. Atrial activity is not visible on the current tracing. There is marked ST segment depression in leads V2-V6. Compared to the previous tracing of [**2188-3-25**] the complete left bundle-branch block and the ST segment depressions are new and consisetnt with acute ischemia. ECG [**2190-10-15**]: Sinus tachycardia. The P-R interval is prolonged. Left axis deviation. Right bundle-branch block with left anterior fascicular block. Compared to the previous tracing of [**2190-10-14**] the rate is slower and ST segment depression is no longer present. TTE [**2190-10-15**]: 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 mild regional left ventricular systolic dysfunction with distal inferior hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and (top normal) transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**11-29**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2188-3-24**], a aortic bioprosthesis is now seen. In addition very focal distal inferior hypokinesis is now seen. Head CT [**2190-10-15**]: Impression: 1. Bilateral periventricular hypodensities likely representing chronic ischemic changes. There is a right caudate infarct of undeterminate age. If anacute infarct is suspected, MRI is recommended for further evaluation. 2. Dense opacification of the left maxillary sinus with calcification may represent fungal infection. Unilateral Upper Extremity Ultrasound [**2190-10-16**]: IMPRESSION: No evidence of right upper extremity DVT. Studies Pending at Discharge: Blood Cultures from [**10-14**] and [**10-15**] remained negative at discharge but will be held for a full week each. Brief Hospital Course: This is an 86 yo M with CAD s/p CABG, BPH admitted following left total knee arthroplasty revision which was complicated by significant intra-operative and post-operative blood loss and hypotension. He was initially admitted to the Medical Intensive Care Unit and his hospital course was notable for acute blood loss anemia requiring 12 units pack red blood cells in total as well as cardiac biomarker elevation related to increased demand from anemia, hypotension, and tachycardia. #Revision of left knee arthroplasty/Intra- and Post-Operative Acute Blood Loss Anemia/Hypotension: Patient suffered 1.2L blood loss in the OR and had intraoperative hypotension. He was admitted to the Medical Intensive Care Unit where he was transfused to a hematocrit of >30 which required 12 units in total including in the OR. Following hemodynamic stabilization the patient was transferred to the medical floor where betablockers and diuretics were restarted. He was also started on prophylactic anticoagulation with no signs of active bleeding. #CAD s/p CABG/NSTEMI: Following surgery the patient developed an elevation in his cardiac biomarkers with elevation in TnT but without elevation in CK-MB index. It was felt this was reflective of potential fixed obstruction with increased cardiac demand from hypotension, anemia, tachycardia, and withholding of home beta-blockers. Cardiology was consulted who felt there was no further intervention required. An echocardiogram was obtained which showed only a focal distal inferior hypokinesis which was not felt to represent an acute coronary syndrome as detailed above. EF was preserved. Patient was continued on aspirin, betablocker, and statin when hemodynamically stable. #Chronic diastolic heart failure: Initially beta-blockade and diuretics were held, but these were restarted when the patient became hemodynamically stable and when the patient became mildly volume overloaded following stablization of bleeding. He was restarted on home diuretic therapy with furosemide 40 mg a day with good improvement. #Encephalopathy: Patient developed encephalopathy post-operatively felt to be due to a combination of hypotension, anesthesia, and narcotics for pain control. He failed a speech evaluation in this setting and was made NPO. His encephalopathy cleared prior to discharge and he was cleared by speech and swallow for a ground solid and nectar-thickened liquid diet. #Benign Prostatic Hypertrophy: Terazosin was held in setting of hypotension but restarted prior to discharge. Pt voided after removal of foley catheter without incident. #CODE: FULL #Disposition: Patient was discharged to rehab with Orthopedics and cardiology follow-up. Transitional Issues: -Pt was previously on no limitation of diet and will need further speech and swallow evaluation to be advanced back to full liquid diet without limitations. -Pt will continue physical therapy and knee kept in immobilizer until cleared by orthopedics. Medications on Admission: Metoprolol 25 mg twice a day, simvastatin 40 mg once a day, terazosin 5 mg once a day, aspirin 81 mg once a day, - Held for OR potassium 20 mg once a day, furosemide 40 mg once a day, Zantac 150 mg twice a day. Discharge Medications: 1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 4 weeks. 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 7. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Primary Diagnoses: failed L total knee replacement Post-operative bleeding complicated by acute blood loss anemia Type 2 (demand) non-ST elevation myocardial infarction Secondary Diagnoses: Aortic stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after your left total knee replacement revision. You had a significant amount of blood loss during surgery and required blood transfusions in the Intensive Care Unit. You were noted to have stress on your heart, but did not have a true heart attack. You also had a CT scan of your head which did not show any bleeding, but did show evidence of a possible old stroke. Therefore, it is important that you follow up with your primary care physician and cardiologist once you are discharged from rehab to see if you require any modifications to current medication regimen or if you require any additional testing. You also had a speech and swallowing evaluation prior to discharge to rehab which showed some difficulties with swallowing, likely due to weakness. You were put on thickened liquids and ground foods in order to help prevent aspiration of food into your lungs, which can cause respiratory problems. Please make sure to make follow up appointments with Orthopedics and cardiology. Your rehab will help make a follow up appointment with your PCP after discharge. In addition: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Stitches will be removed at your first f/u appt. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in 2 weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow up appt in two (2) weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker at all times for 6 weeks. Mobilize. FULL EXTENSION AT ALL TIMES. NO ROM. KNEE IMMOBILIZER. No strenuous exercise or heavy lifting until follow up appointment. Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2190-10-28**] at 1 PM With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) 7327**],[**First Name3 (LF) **] R. Specialty: INTERNAL MEDICINE Address: [**Location (un) 7330**], [**Location (un) **],[**Numeric Identifier 7331**] Phone: [**Telephone/Fax (1) 7328**] **Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge.** Name: [**Last Name (LF) **], [**First Name3 (LF) **] Specialty: CARDIOLOGY Location: THE HEART CENTER OF [**Hospital1 **] Address: [**First Name8 (NamePattern2) **] [**Location (un) **], [**Numeric Identifier 7398**] Phone: [**Telephone/Fax (1) 6256**] Appointment: WEDNESDAY [**11-17**] AT 10AM

Admission Date: [**2154-6-1**] Discharge Date: [**2154-6-3**] Date of Birth: [**2118-9-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5608**] Chief Complaint: "Found unresponsive" Major Surgical or Invasive Procedure: None. Pt required 4 point restraints initially given confusion and altered mental status in the setting of alcohol intoxication with opioid and cocaine. History of Present Illness: 35 YO M who was found down unresponsive in the floor of his appartment building. There was a pipe and a bag with him and he had fresh tracemarks in the dorsal area of his hands. EMS were called and brought him to our ER. . In the ER his initial VS were T 96.0 F, HR 100 BPM, BP 89/45 mmHg, RR 16 X', SpO2 100% on RA. He was very somnolent with mild reposne to pain. His pupils were 1 mm and slugish bilateraly, no rub, poor air movement. He received 0.4 mg of narcan with mild response (deep insiprations), but a few minutes later he became "apneic". The ER was unable to document how long he was going without a breath. Narcan doses were repeated up to a total of 2 mg. Pt WBC were 5.8 with 61% PMNs and no bands, HCT of 35 (normocytic normochronic), PLTs 183. His BMP was unremarkable. His alcohol level was 185 and he was negative for ASA, Acetmnphn, Benzo, Barb, Tricyc. His ECG showed . Pt received 1 L NS as fluid resucitation for his low SBPs. Then, he became very agitated and combative and the ER physicians gave him ativan, 5 mg of haldol and droperidol without improvement of his symptoms. He has been tachycardic up to 120s. His VS prior to transfer were: HR 88 BPM, RR 14 X', SpO2 100%, BP 141/86 mmHg. He had a sinlge 18G in his L arm, but I requested a second one (if possible). Past Medical History: Polysubstance abuse: - Heroin (last used 2 weeks ago) - Cocaine every week - Alcohol 2 pints 2-3x per week Tobacco dependance Hepatitis B? Social History: Pt lives with his girlfriend some of the time, has a long history of polysubstance abuse, ETOH and tobacco dependance as described above. He smokes 1 pack per day and has h/o 5 pack-year. He has used IV drugs including heroin, the last time 2 weeks ago. He is originally from [**Male First Name (un) 1056**] Family History: Mother with DM2. [**Name2 (NI) **] family history of stroke, early MI or cancer. Physical Exam: BP 116/60 mmHg, HR 75 BPM, RR 13 X', O2-sat 100% RA GENERAL - confused, agitated alternating with somnolence HEENT - miotic pupils of 1 mm proximately, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, 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 [**6-5**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2154-6-2**] 03:37AM BLOOD WBC-8.4# RBC-4.41* Hgb-11.8* Hct-37.1* MCV-84 MCH-26.7* MCHC-31.7 RDW-14.6 Plt Ct-201 [**2154-6-2**] 03:37AM BLOOD Glucose-78 UreaN-6 Creat-0.9 Na-140 K-3.8 Cl-107 HCO3-23 AnGap-14 [**2154-6-2**] 03:37AM BLOOD CK(CPK)-124 [**2154-6-1**] 05:53PM BLOOD CK(CPK)-202 [**2154-6-1**] 07:35AM BLOOD ALT-8 AST-19 LD(LDH)-152 AlkPhos-59 TotBili-0.3 [**2154-6-2**] 03:37AM BLOOD CK-MB-2 cTropnT-<0.01 [**2154-6-2**] 03:37AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.6 [**2154-6-1**] 01:25AM BLOOD ASA-NEG Ethanol-185* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . CT head [**2154-6-1**]: IMPRESSION: No acute intracranial process. . CXR [**2154-6-1**]: IMPRESSION: Bibasilar subsegmental atelectasis. A small retrocardiac area of consolidation cannot be excluded. Brief Hospital Course: Mr [**Known firstname **] [**Known firstname **] [**Last Name (NamePattern1) 1538**] is a 35 YO M who was found down unresponsive in the floor of his apartment building who comes with alcohol intoxication, cocaine use and opiod use. . #. Alcohol withdrawal - Pt was drinking up to 2 days ago aproximately 2 pints per day. Initially he was very somnolent and required Narcan (see below) and there was concern that he may need to be [**Last Name (LF) 86302**], [**First Name3 (LF) **] was admitted to the ICU. His initial alcohol level was 186. Initially he was tachycardic, hypertensive, combative, diaphoretic and there was concern for alcohol withdrawal and given lack of initial info he was given 10 mg of IV Valium and put on CIWA protocol. Her required a total of 65 mg of IV Valium. He also received multiple Banna bags. He was discharged on a PPI for possible alcohol gastritis that can be stopped if he does not have symptoms; Folate, MVI and Thiamine. . #. Opioid overdose - Pt has tracings in dorsum of hand and positive urine for opioids. Furthermore, responded to narcan in the ER and was admitted for monitoring. Pt reports taking 2 long white tablets of unknown content, but denies any heroin use. He denies any SI, but states he would not care if he died. He did not require any Narcan or intubation in the ICU and slowly woke up within 24 hours after admission. - Hepatitis screening was negative - He reports being negative for HIV, but did not consent for us to test him . #. Cocaine - Pt will get very agitated, diaphoretic, upon admission and he was positive for cocaine. He was placed a 0.1 clonidine patch. . #. Anemia - Pt has normocytic normochromic anemia with normal RDW. This still could be concerning for acute bleeding. His iron panel was compatible with iron deficiency, probably for poor diet +/- minor GIB in the setting of alcohol gastropathy (not scoped). He is being discharged on Iron tablets. He did not require any RBCs. His HCT is 34.2. . #. ECG Changes ?????? Pt with STE in infero-lateral leads, which could be only secondarily to tachycardia. He was rule dout without any elevation in CE. Upon discharge he had Minimal ST segment elevation that are non specific according to cardiology. They could be compatible with minimal pericardial disease, but he did not have any other symptoms. . #. Psych - Pt reports he would not care if he died and over-dosed himself. Furthermore, initially he was very confused, aggresive and in danger to harming himself or others and required 4-point leather restraints as well as chemical restraints with IV haldol. He is currently coherent and wanting detox. According to psyychiatry he is capable of making decission of going to detox program and leaving the hospital. . #. FEN - Tolerating regular diet. Medications on Admission: None. Discharge Medications: 1. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 6. Thiamine HCl 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcohol intoxication Cocaine intoxication Opioid intoxication . Secondary Diagnosis: None. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: He is followed at [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House in [**Location (un) 86**]. Followup Instructions: Please follow up with your primary care within the first week (unless you are at a facility) . We strongly recommend that you go to a detox program.

Admission Date: [**2111-6-9**] Discharge Date: [**2111-7-3**] Date of Birth: [**2050-5-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6565**] Chief Complaint: Transferred for respiratory failure on vent, b/l IJ compression, large supraglottic SCC tumor and urgent XRT to shrink tumor burden Major Surgical or Invasive Procedure: PICC line placement x 3 History of Present Illness: 61 yo M w/ h/o ETOH abuse, smoker, Supraglottic SCC stage [**Doctor First Name 690**], initially admitted on [**5-13**] for G tube placement course c/b respiratory failure, C-diff infection, and psuedomonal PNA. . He initially presented with a sore throat, dysphagia and anorexia who on fiberoptic laryngoscopy found a large supraglottic mass. A biopsy was done and final pathology confirmed poorly differentiated SCC stage [**Doctor First Name 690**]. He was admitted to an OSH on [**2111-5-13**] specifically for a G-tube placement due to this large subglottic mass. His course was c/b ETOH withdrawal requiring benzos prn, then developed PNA with cultures revealing Psedomonas. He subsequently developed respiratory failure and was initially intubated on [**2111-5-16**], extubated on [**2111-5-25**]. However, he had to reintubated by ENT on [**2111-5-28**] with question of difficulty reintubating due to supraglottic mass. The pt underwent tracheostomy on [**2111-6-1**]. . He was initially treated with zosyn for his pseudomonal pna, then switched to Ceftaz; Pseudomonal culture sensitivities returned on [**6-8**] and abx were switched to Cefapime and Gent prior to transfer. . His WBC began to rise from 11-->25-->32 with the development of diarrhea which was C-diff + and initially treated with PO vanco then switched to PO flagyl. . His HCT dropped (28.6 TO 26.9) of unclear etiology and was transfused 2 UPRBC on [**6-1**], hct increased to 33.4. . He started chemotherapy with Carbotaxol x 1 on [**6-4**] and was called out to the medicine service on [**6-5**]. While on the medicine service he became tachypneic and hypoxic with O2 sats 70% and transferred back to the MICU. There are no records of CTA or chest CTs done during this hypoxic event. . He was transferred to [**Hospital1 18**] for further management of b/l IJ clots R>L and possible XRT to shrink tumor burden. Past Medical History: -ETOH abuse and dependence -PTSD -supraglottic SCC dx [**2111-4-28**] via fiberoptic laryngoscopy and bx on [**2111-5-19**] Social History: -Lives with girlfriend, works as custodian in [**Location **] -+TOB 50+ pack year -ETOH: [**1-3**] brandys and bottle of beers daily -Exposure to [**Doctor Last Name 360**] [**Location (un) 2452**] in [**Country 3992**] war Family History: Non contributory Physical Exam: VS: 101.4 BP 152/87 HR 98 RR 21 98% PS 15/5 FiO2 0.5 GEN: Uncomfortable lying in bed c/o neck pain HEENT: diffusely enlarged neck ~30cm, w/significant neck adenopathy, trach in place RESP: good air movement throughout anteriorly, no wheezing CV: Reg Nml S1, S2, no M/R/G ABD: soft ND, +BS, sore throughout, no rebound or guarding, G-tube in place EXT: cachectic LE b/l, warm, 2+DP pulses b/l NEURO: A&O X 1, unable to fully assess CN, did follow simple commands Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2111-6-23**] 04:12AM 12.1* 2.49* 8.6* 24.3* 98 34.5* 35.3* 15.9* 206 [**2111-6-20**] 05:14AM 23.0* 2.61* 8.9* 25.8* 99* 34.1* 34.5 15.5 189 [**2111-6-19**] 04:06AM 28.2* 2.46* 8.5* 24.7* 101* 34.4* 34.2 16.0* 180 [**2111-6-18**] 03:30PM 27.7* 2.61* 9.0* 26.4* 101* 34.4* 34.0 16.0* 177 [**2111-6-18**] 04:41AM 22.2* 2.36* 8.0* 23.8* 101* 34.0* 33.8 15.7* 176 [**2111-6-16**] 07:56PM 27.8*# 3.12* 10.5* 30.6* 98 33.7* 34.3 15.7* 227 [**2111-6-16**] 05:00AM 6.3# 2.87* 9.7* 28.7* 100* 33.8* 33.8 15.1 283 [**2111-6-14**] 05:29AM 0.6*# 2.69* 9.0* 26.4* 98 33.5* 34.1 15.0 339 [**2111-6-13**] 05:29AM 1.6* 2.83* 9.6* 27.9* 99* 34.1* 34.5 14.4 338 [**2111-6-11**] 03:50AM 7.0 2.56* 8.6* 25.6* 100* 33.8* 33.8 14.8 323 [**2111-6-9**] 07:25PM 11.9* 2.82* 9.3* 29.1* 103* 33.2* 32.1 15.3 382 . The pt. was initially admitted with a WBC 11.9, however his WBC continued to drop, as low as 0.6, becoming neutropenic, probably secondary to dose of CarboTaxol received at the [**Location 1268**] VA. He received several doses Neupogen, after which his WBC increased, currently 12.1 on [**2111-6-23**] . RENAL & GLUCOSE Glu UreaN Creat Na K Cl HCO3 AnGap [**2111-6-23**] 04:12AM 118* 13 0.5 132* 4.5 96 31 10 [**2111-6-22**] 04:43PM 129* 13 0.5 130* 4.5 93* 29 13 [**2111-6-21**] 08:32PM 74 12 0.4* 129* 4.8 95* 28 11 [**2111-6-21**] 07:40AM 126* 11 0.3* 126* 4.9 93* 28 10 [**2111-6-20**] 05:14AM 143* 10 0.5 132* 3.9 93* 32 11 . [**2111-6-16**] 05:00AM 105 10 0.3* 138 3.7 98 34* 10 [**2111-6-14**] 05:29AM 151* 8 0.3* 137 3.4 101 32 7* [**2111-6-10**] 03:41AM 126* 7 0.3* 133 4.0 99 26 12 [**2111-6-9**] 07:25PM 97 6 0.4* 136 3.6 101 27 12 . The pt. was initially admitted with Na 136, however he started to trend down as low as 126 . MICROBIOLOGY: . IMAGING: CT head [**2111-6-9**] - No acute intracranial hemorrhage or masses is seen. - Large bilateral posterior cervical triangle masses, likely metastatic, necrotic lymph nodes. . CT chest [**2111-6-9**] - Extensive necrotic lymphadenopathy of the supraclavicular region, with apparent occlusion of both internal jugular and subclavian veins. - Moderate-to-large right pleural effusion and small left pleural effusion, with associated atelectasis involving the entire right lower lobe. - Biapical opacities may reflect radiation treatment if there is such a history. - Ground-glass opacities throughout the remainder of the lungs are nonspecific, possibly reflecting edema or infection. A more focal opacity in the lower right upper lobe suggests pneumonia. - Axillary lymphadenopathy and borderline mediastinal nodes. - Extensive subcutaneous edema. . Chest Xray [**2111-6-9**] - Multifocal opacities consistent with pneumonia. - Bilateral pleural effusions, right greater than left. - Tracheostomy tube in appropriate position. . MRA of neck [**2111-6-12**]: - No evidence of arterial occlusion or invasion identified by large masses in the neck. - There is no evidence of occlusion of the superior vena cava seen. - Both jugular veins are occluded, the left vein is occluded in the upper third, while the right vein is occluded by tumor near the skull base. - Partial visualization of both subclavian veins with findings suspicious for invasion and extension of tumor through the right internal jugular vein to the junction of right subclavian vein. . ECHO [**2111-6-10**] - EF > 55% - Normal study. Preserved biventricular cavity sizes with normal global and regional systolic function. Brief Hospital Course: 61 yo M with large supraglottic SCC here for XRT, s/p trach for resp. failure, now on trach collar. Also with pseudomonal PNA, R pleural effusion, and C-diff infection. . # Supraglottic SCC with potential compression of bilateral IJs on MRI. Pt is s/p 1 dose carboplatin/paclitaxel prior to transfer and was temporarily neutropenic, but now resolved after G-CSF. Heme-onc is following and restarted carboplatin/paclitaxol on [**6-30**] with goal of improving radiotherapy efficacy. He is also s/p 15 doses XRT since arrival in [**Hospital Unit Name 153**], for a total of 16 treatments per Rad-onc. He had an almost immediate reaction consisting of facial swelling and erythema after the 1st dose, which is now resolved. He has had good response to the XRT with significant decrease in size of his neck mass. Pt is receiving supportive care with pain control with Dilaudid & Fentanyl prn though has not required pain control recently. There is a plan for family meeting with heme-onc, rad-onc, and medicine team today or tomorrow. . # Respiratory: Pt is currently satting well on trach collar with FiO2 of 35%. Pt had pseudomonal PNA (s/p 12-day course of meropenem + gentamycin) and large R plueral effusion. Also treated for stenotrophomonas in his sputum (10-day course of bactrim). He was previously on intermittent ventilation for temporary desats thought to be related to worsening of pleural effusion off ventilation. He has not needed ventilation in past 2 weeks. CXR shows large R pleural effusion with some increased organization/consolidation; this has been stable. Effusion is likely due to lymphedema and will most likely reaccumulate if drained. He continues to have secretions that require suctioning despite good cough, though suctioning frequency has greatly decreased. Antibiotics were completed on [**6-28**] however sputum from [**6-28**] contained >25 PMNs and grew 4+ pseudomonas, now resistant to meropenem. No other signs of infection-- afebrile, no leukocytosis, no change in O2 requirement. He did have copious white trach secretions (req suction q1h) at the time but now has greatly decreased. He was started today ([**7-1**]) on cipro for tracheobronchitis. Finally, he receives albuterol/atrovent MDIs through trach. . # RUE DVT, seen on US: - Cont. heparin gtt, bridging to coumadin - continue coumadin 5mg qhs . # Endocrine issues. Hyponatremia/hyperkalemia FeUrea = ~45%. Differential diagnosis: SIADH (pulmonary, SSC,) vs. adrenal insufficiency vs. hypothyroidism (all not very much likely since they have been present for a long time and hyponatremia now new). Random cortisol level relatively high, and now off dex since [**6-15**] --> suggests adrenal insufficiency unlikely. TFTs show elevated TSH, but nl T4, T3 more consistent w/sick euthyroid (free T4 low) which is likely to have been present chronically and not the primary source of hyponatremia, further more not strikingly hypothyroid to cause hyponatremia. Most likely diagnosis is therefore iatrogenic due to IV meds and diuresis without adequate Na replacement. Decision was made to give patinent a 1 week break from XRT, as took heavy toll on patient, especially w/ ICU setting. Pt is scheduled for follow up next week with Dr. [**Last Name (STitle) 3929**] to revisit if continued XRT should be pursued. Meeting must be attended with patient's brother. . # Goals of care: Social work and [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] from palliative care are involved in this case with the family, discussing long-term plans and goals. Pt's baseline mental status is unclear; however, he occasionally has more lucid intervals and appears dissatisfied with being in hospital, stating "get me out of here." At the same time, he expresses wishes to continue radiation/chemo for disease palliation. He also appears to have a depressed affect. Psych has been consulted to determine competency and address depression. . # HTN: BP well-controlled on metoprolol 12.5 [**Hospital1 **]. At home, he is on metoprolol 25 TID. . # Anemia: This is likely due to myelosuppression from prior chemo as his retic count was 0 on admission. HCT currently stable/increasing. He has not required PRBC transfusions at [**Hospital1 18**]. . # C-Diff colitis: Pt is on Flagyl po until 2 weeks after completion of other antibiotics ([**6-26**]). He is on C-Diff precautions. . # MS changes: He is oriented to name and date. This is likely delirium. He is on low-dose Haldol prn agitation, avoiding BZDs as possible. He is also on supplemental thiamine, Folate & MVI for ETOH history. Needed to be maintained on restraints while in ICU, has been 1:1 on the floors w/o further aggitation. . # CODE: DNR Medications on Admission: -Acetaminophen 650mg q4hr prn -Albuterol Neb Q6HR -Albuterol inh Neb q2hr prn -Aspirin 81 mg daily per G-tube -Cefepime 1gm -enoxaparin 70mg [**Hospital1 **] -Fentanyl patch 25mcg q3d -folic acid 1mg daily -gentamicin 80mg daily -ipratropium neb q6hr -lorazepam 1 q4hr prn anxiety -Metoprolol 25mg TID -MVI -Nicotine transdermal 14mg/24hr patch qdaily -omeprazole 20mg NG daily -psyllium powder, oral 1 teaspoonful PO TID -Thiamine tab 100mg daily -vancomycin oral solution 250mg PO q6hr -dexamethasone 8mg [**Hospital1 **] through [**6-6**] Discharge Medications: 1. Metronidazole 500 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO TID (3 times a day) as needed for c-diff. 2. Thiamine HCl 100 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 160 mg/5 mL Solution [**Month/Day (4) **]: Four (4) ml PO Q4H (every 4 hours) as needed for pain, fever. 5. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (4) **]: Two (2) Puff Inhalation Q6H (every 6 hours). 6. Lidocaine HCl 1 % Solution [**Month/Day (4) **]: One (1) ML Injection Q1H (every hour) as needed for cough. 7. Senna 8.8 mg/5 mL Syrup [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a day) as needed. 8. Metoprolol Tartrate 25 mg Tablet [**Month/Day (4) **]: 0.5 Tablet PO BID (2 times a day). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation Q6H (every 6 hours). 11. Morphine 2 mg/mL Syringe [**Last Name (STitle) **]: [**12-2**] Injection ONCE (Once) as needed. 12. Haloperidol Lactate 5 mg/mL Solution [**Month/Day (2) **]: [**12-2**] Injection Q4H (every 4 hours) as needed for agitation/insomnia. 13. Ciprofloxacin 400 mg/40 mL Solution [**Month/Day (2) **]: One (1) Intravenous Q12H (every 12 hours). 14. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: One (1) Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Discharge Diagnosis: supraglottic SCC respiratory failure pneumonia RUE DVT pleural effusion c.diff infection Discharge Condition: Stable Discharge Instructions: You are being transfere back to the VA [**Hospital 1268**] hospital after being transfered from that facility in order to receive radiation treatment for you cancer of the tongue. The initial round of treatment showed a successful response, and the choice of whether to receive additonal treatment will be deceided in a future follow up next week. Your hospitalization has been complicated by respiratory distress due to both obstruction of your airway due to your cancer and pneumonia. You had an airway created surgically, and we are currently treating your pneumonia. You are now being transfered back to the VA, but if you decide to continue radiation treatment, you will be transported back here daily for radiation. Followup Instructions: Please follow up w/ Dr. [**Last Name (STitle) 3929**] ([**Telephone/Fax (1) 8082**] on [**7-8**] at 4pm Fennard Basement, must attend with brother. **** Brother is calling to reschedule, follow up on new appointment. [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]

Admission Date: [**2191-3-3**] Discharge Date: [**2191-3-15**] Date of Birth: [**2110-2-5**] Sex: F Service: SURGERY Allergies: Simvastatin / Rosuvastatin Attending:[**First Name3 (LF) 1234**] Chief Complaint: Bilateral disabling claudication. Major Surgical or Invasive Procedure: [**2191-3-3**]: 1. Bilateral extensive iliofemoral endarterectomy with bovine pericardial patch angioplasty. 2. Bilateral common iliac stent grafts 7-37 I cast extension of the stent graft in the left common iliac artery of [**6-26**]. 3. Right exterior iliac stent complete SE 780 and extension into the common femoral artery with a 7 x 40 complete SE on the right. On the left side, an [**7-/2159**] complete SE stent. [**2191-3-10**]: Sigmoidoscopy History of Present Illness: The patient is an elderly female with longstanding claudication that has gotten worse over the last 2 years to the point where she could barely walk and started to develop pain in the back of her heel on the left. Can barely walk to the bathroom. After clearance by Cardiology and Pulmonology and understanding the risks and benefits, we decided to electively proceed to surgery. Past Medical History: PMHx: 1. Chronic atrial fibrillation 2. Hypertension 3. Hypercholesterolemia 4. Aortic regurgitation (mild AR echo [**10-11**]) 5. 3.1-cm infrarenal abdominal aortic aneurysm, stable since [**2186**], but requires annual followup. 6. Cholelithiasis. 7. Emphysema. 8. Colonic diverticulosis. 9. Stable small left paraovarian cyst, over 3 years. 10.Peripheral Arterial Disease. Social History: - originally from [**Country 4754**], widowed (husband died of a heart attack in [**2167**]). She used to run figures at an insurance company, but now is retired and lives off of her husbands pension. She says she lives alone and is independent with all of her ADL. She has a 30-pack year smoking history and not currently smoking, occasionally drinks wine. Physical Exam: Alert and oriented x 3 VS:BP128/50 HR 87 atrial fibrillation Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: Left DP dop ,PT dop Right DP dop ,PT dop Feet warm, well perfused. No open areas Groin incisions: slightly red but no warmth and drainage. Pertinent Results: [**2191-3-15**] 07:25AM BLOOD WBC-8.4 RBC-3.15* Hgb-8.9* Hct-27.7* MCV-88 MCH-28.2 MCHC-32.1 RDW-14.7 Plt Ct-344 [**2191-3-15**] 07:25AM BLOOD Glucose-79 UreaN-16 Creat-1.3* Na-135 K-4.0 Cl-104 HCO3-21* AnGap-14 [**2191-3-15**] 07:25AM BLOOD Calcium-7.8* Phos-1.7* Mg-1.8 [**2191-3-14**] 07:10AM BLOOD PT-29.1* PTT-48.7* INR(PT)-2.8* [**2191-3-3**] 02:52PM BLOOD Glucose-142* UreaN-40* Creat-2.4* Na-133 K-4.5 Cl-106 HCO3-18* AnGap-14 Brief Hospital Course: The patient was brought to the operating room on [**2191-3-3**] and underwent bilateral ileofemoral endarterectomies with patch angioplasty and bilateral iliac stents. The procedure was without complications. She was closely monitored in the PACU and then transferred to the ICU for ongoing gas exchange issues related to baseline emphysema and diastolic heart failure. She was transferred to the floor for further monitoring on POD #2 in stable condition. We continue to monitor her breathing pattern and gas exchange diuresing her with lasix to maintain a negative fluid balance to treat her acute on chronic diastolic CHF exacerbation post surgery. Her diet was gradually advanced. She worked with physical therapy who recommended rehab. On POD # 7 she had an episode of hypotensive causing ischemic colitis which was treated with fluid/albumin. By POD #9 her abdominal pain resolved and she started to tolerate on a regular diet. She was discharged to rehab on POD # 13 in stable condition. Follow-up has been arranged with Dr. [**Last Name (STitle) **] in one week. 1.Peripheral Arterial Disease sp bilateral ileofemoral endarterectomies with patch angioplasty and bilateral iliac stents on [**2191-3-3**] for disabling claudication. Dopplerable LE pulses. Groin incisions are clean, slightly red and should be covered with DSD until removal at followup appointment next week. 2.Diastolic Congestive Heart Failure She had acute exacerbation of her chronic congestive heart failure after her procedure which we closely monitored and treated with lasix as needed. She is on her home dose of lasix 40mg daily. Her PREOP WEIGHT is 77.1 kg. TODAY'S WEIGHT is 85.7 kg. We have been unable to diurese secondary to hypotension and ischemic colitis. 3.Ischemic Colitis On POD #7 she had an episode of hypotension to the 70's after lasix administration. At that time, our goal was 1 liter negative a day. Shortly after this episode, she had vomitting with diarrhea with LUQ abdominal pain. Her lactate level was 3.1 and her wbc rose to 23.3 from 7.6 earlier in the day. She was aggressively resusitate her with fluid and albumin. An Abd CT did not show any overt mesenteric ischemia. Flexible sigmoidoscopy, to evaluate mucosa, was negative for ischemia. Cdiff was also negative. She was started on vanco/cipro/flagyl. She had continued improvement with return of her WBC to normal and resumption of a regular diet by POD #9. 4.Hypertension BP now 120's/80. WE HAVE NOT RESTARTED HER HOME ANTIHYPERTENSIVES/CARDIAC MEDS of amlodipine 5mg, diltiazem HCl XR 360mg or moexipril 15mg secondary to relative hypotension (90s systolic) in the setting of presumed bowel ischemia. Please contine to monitor and restart medications as tolerated. 5.Chronic Kidney Disease Admission Cr. 2.4. Today's Cr is 1.3, likely related to holding diuresis and ACE. 6.Emphysema 02 sats are 94% on 2L which is her baseline at home. 7.Atrial Fibrillation HR 80s. Coumadin restarted post procedure. INR 2.8 today. We have held coumadin for the last several days. Medications on Admission: albuterol sulfate 90 mcg'; amlodipine 5'; atorvastatin 80'; calcitriol 0.25' M-W-F; cilostazol 100'; diltiazem HCl XR 360'; fluticasone-salmeterol 250 mcg-50 mcg''; furosemide 40'; moexipril 15'; tiotropium bromide 18 mcg'; warfarin 3'; ascorbic acid 1,000'; aspirin 81'; calcium carbonate 250'; hexavitamin Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for astma. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. warfarin 1mg tonight. Discharge Disposition: Home Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Bilateral disabling claudication, Acute on chronic diastolic CHF Emphysema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Division of Vascular and Endovascular Surgery Discharge Instructions What to expect when you go leave the hospital : 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**1-7**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Department: VASCULAR SURGERY When: TUESDAY [**2191-3-22**] at 10:00 AM With: [**Hospital 21926**] CLINIC [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2191-3-15**]

Admission Date: [**2181-1-2**] Discharge Date: [**2181-1-8**] Service: CARD [**Last Name (un) **] The patient was admitted on [**2181-1-2**] for same admission for a CABG. HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old female who for the past six months has had increasing angina when walking requiring her to reduce her activity level. She use to walk one mile before the onset of this pain. The pain is relieved with rest. She had no previous Nitroglycerin use. PREOPERATIVE DATA: Preoperative showed an ejection fraction of 60%, 90% LAD occlusion, left circumflex 90% occlusion, 95% RCA occlusion. PAST MEDICAL HISTORY / PAST SURGICAL HISTORY: 1. ....................surgery in [**2133**]. 2. Hypertension. 3. Diabetes Type II with retinopathy, diabetes times 25 years. 4. Status post some type of laser surgery times two. MEDICATIONS: 1. Vasotec 10 milligrams q day. 2. Aspirin 81 milligrams q day. 3. Glucophage 850 milligrams tid. 4. Amaryl 10 milligrams [**Hospital1 **]. 5. Atenolol 25 milligrams q day. 6. Nitroglycerin tablet prn as needed. 7. Caltrate 1200 milligrams q day. 8. Vitamin E 400 international units q day. FAMILY HISTORY: Significant for a sister who died of an MI at 65. She is a retired nurse. She lives alone in an apartment with daughter who lives next door. PHYSICAL EXAMINATION: On admission was unremarkable. She had no wheezing, no shortness of breath, no crackles. She had no evidence of peripheral vascular disease. She was alert and oriented. She had completely intact neurological function. She had 5/5 strength. LABORATORY DATA: EKG revealed normal sinus rhythm at 60 beats per minute with a Q wave in lead III. HOSPITAL COURSE: The patient was taken to the operating room on [**2181-1-2**] with a CABG times three with a LIMA to LAD to OM plus PDA graft and a atrial pacing wire. The patient tolerated the procedure well and was transferred to the Intensive Care Unit. Inside the Intensive Care Unit her extubation was postponed due to a slight hypertensive episode and a slight descend to the AD with tachypnea and diaphoresis. The patient recovered well from this. On postoperative day two she was extubated. Labs were all within normal limits. Electrolytes were repleted prn. On [**2181-1-5**] postoperative day three from her CABG she was doing well. On [**2181-1-6**] the patient was transferred to the floor. Physical Therapy and rehab screening were obtained. Foley and CVL were discontinued as were chest tubes. Wires were taken out. On [**2181-1-7**] postoperative day five the patient was doing well, advanced her diet. On postoperative day six which was [**2181-1-8**] the patient is doing well. Her physical exam reveals the patient is in no acute distress. Her sternal wound is intact and non-discharging. Her harvest sites reveal no signs of infection or erythema. The patient somewhere around level II to III and requires rehab to recover full function and strength. DISCHARGE STATUS: The patient is going to be discharged to rehab today in good condition. DISCHARGE MEDICATIONS: 1. Aspirin 325 milligrams q day. 2. KCL 20 milliequivalents po bid. 3. Lasix 20 milligrams po bid times one week. 4. Colace 100 milligrams po bid. 5. Ranitidine 150 milligrams po bid. 6. Regular insulin on a sliding scale. 7. Glucophage 850 milligrams tid. 8. Captopril 12.5 milligrams q HS. 9. Amaryl 10 milligrams [**Hospital1 **]. 10. Lopressor 75 milligrams po bid. 11. Caltrate 1200 milligrams q day. 12. Vitamin E 400 international units q day. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient is to follow up with Dr. [**Last Name (Prefixes) **] in four weeks as well as her PCP. DISCHARGE CONDITION: Upon discharge she is in good condition with no acute cardiovascular issues. Her bypass grafts are functioning well. DISCHARGE DISPOSITION: To rehab. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2181-1-8**] 09:57 T: [**2181-1-8**] 10:01 JOB#: [**Job Number **]

Admission Date: [**2118-10-19**] Discharge Date: [**2118-10-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2751**] Chief Complaint: S/p fall. Major Surgical or Invasive Procedure: EGD - black sloughening mucosa with bleeding on contact suggesting ischemic esophagitis. History of Present Illness: This is an 89 yo woman with mechanical fall. She slipped in her sock, hit her left shoulder on a towel rack, then landed on her right knee, with right knee and hip pain. In the ED was very orthostatic->SBP to 68/35, HR unknown, and this was asymptomatic. She has had multiple falls over the past week, sounding mechanical in nature but she is hazy on the details. She notes pain at her left shoulder and right knee. She has no other complaints. She denies fevers, chills, nausea, vomitting, abdominal pain, melena, brbpr, chest pain, cough, sob, dysuria, hematuria, rash. She does acknowledge constipation, last BM [**10-17**]. In the ED VS: 97.9 88 102/60 18 99% RA. She was given 2L NS, tylenol and ibuprofen. She was guaiac negative in the ED. ROS: 10 point review of systems negative except as noted above. Past Medical History: h/o frequent falls macrocytic anemia, previously with iron deficiency, refused endoscopic evaluation hypothyroidism peripheral vascular disease hyperlipidemia GERD PMR h/o GIB on NSAIDS COPD macular degeneration h/o CVA leg pain: RLS vs. fibromyalgia [**6-11**] ? bipolar d/o fibromyalgia aortic aneurysm (5-6 cm) Social History: Lives in [**Hospital3 **], ambulates with walker. She smoke for 15 years remotely, but denies past/current etoh, illicit drug use. Family History: Per OMR: Father with history of CAD, sister with [**Name2 (NI) 499**] cancer in her 70s. Physical Exam: VS: T 97.8 HR 86 BP 98/60 RR 20 Sat 96% RA Gen: Elderly woman in NAD Eye: extra-occular movements intact, pupils equal round, reactive to light, sclera anicteric, not injected, no exudates ENT: mucus membranes moist, no ulcerations or exudates Neck: no thyromegally, JVD: flat, well healed scars over anterior neck Cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: Soft, non tender, non distended, no heptosplenomegally, bowel sounds present Extremities: A&O x1, No cyanosis, clubbing, edema, joint swelling; right thumb with with nail thickening Neurological: CN II-XII intact, normal attention, speech fluent Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, pleasant Hematologic: no cervical or supraclavicular LAD Pertinent Results: Admission labs: wbc 5.7/hct 29.6/plt 168-->7.1/hct 26.8/plt 160 (no ivf in between, hct baseline 30-32) bmp: 136/5.0/102/24/40/1.0/140 coags: ptt 26.4, inr 1.0 UA: Tr protein, otherwise negative. [**2118-10-19**]: right knee film right hip films left shoulder film cxr all done, not yet read ECG [**2118-10-18**]: NSR (88), nl axis and intervals, QW III, across precordium (III new since prior, but prior from [**2101**]), no acute ST-T changes. Brief Hospital Course: MICU course: This is an 89 yo woman with mechanical fall found to be orthostatic and anemic. 1. Ischemic esophagitis: Patient was transferred to the [**Hospital Unit Name 153**] for hematemesis that began while she was on the floor. She was seen by GI right after arriving to [**Hospital Unit Name 153**] and underwent EGD which showed evidence of ischemic esophagitis (see EGD report). Patient was put on IV PPI [**Hospital1 **] and sucrafate QID, HOB elevated. She required a total of 5u pRBC, and her hematocrit stabilized for 2 days prior to transfer back to the floor. She had no more episode of hematemesis since arriving to [**Hospital Unit Name 153**], and was started on clear liquids on [**10-21**]. Per GI, her diet was advanced to soft on [**10-24**] and then to full on day of discharge. She tolerated this without difficulty. She should not receive any NSAID medications. HCT prior to d/c was 33. 2. Fall: Sounds mechanical in nature but given profound orthostasis in ED (asymptomic) this may possibly be contributing. Also, given her subsequent hematemesis and baseline anemia, bleeding likely contributing. Physical therapy was re-consulted following transfer out of the ICU. Blood pressures were stable on the floor but she will need further PT rehab. 3. Orthostasis: unclear what degree related to anemia/bleeding, dehydration, medication effect (amitriptyline, trazadone both can cause orthostasis) or autonomic dysfunction. Trazodone was discontinued and Amitriptyline was decreased to 50mg. 4. Anemia: Likely secondary to chronic GI bleeding. Pt has refused colonoscopy in the recent past; family remains hesitant to pursue further testing at this time. Hct remained stable following transfer out of the ICU and was >34 on [**10-24**]. It is recommended this be repeated in [**2-4**] weeks time. 5. Peripheral vascular disease: Aspirin was stopped in the setting of her hematemesis; she was continued on pentoxifylline. 6. A TSH was sent while in the ICU. It was elevated at 11. It is recommended this be repeat tested in [**2-4**] weeks at her PCPs office. 7. Hypokalemia. This was repleted several times and she was discharged on daily KCL 10Meq. Medications on Admission: iron 325mg daily colace 100mg [**Hospital1 **] MOM prn suppositories prn amitriptyline 100mg QHS trazadone 50mg-100mg QHS prn insomnia-->pt states not taking this pentoxifylline SR 400mg [**Hospital1 **] advil pm qhs aspirin 81mg daily terbinafine 250mg daily for nail fungus, started [**2118-10-8**] vitamin C 500mg daily multivitamin daily ocuvit daily caclium 500mg + vitamin D 2 tabs daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as needed for Ishemic esophagitis with bleeding. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily): do not take at same time as calcium tablets. Disp:*30 Tablet(s)* Refills:*0* 10. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Acetaminophen 500 mg Capsule Sig: One (1) Tablet PO Q 8H (Every 8 Hours) as needed for pain. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Do not take NSAIDs (e.g. ibuprofen, diclofenac, ketorolac or related medications) 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab Discharge Diagnosis: Upper GI Bleed Ischemic esophagitis H/o NSAID gastritis Elevated TSH Discharge Condition: Improved Discharge Instructions: You were hospitalized for bleeding in the esophagus. You were found to have low blood pressure on admission to the hospital, which undoubtedly caused you to have the fall at home, and which led to changes in perfusion to the esophagus causing it to bleed. You were given a total of 5 units of red blood cells to replace the blood you lost. You were found to have an elevated TSH which may indicate you have an underactive thyroid gland. Tests of this sort during hospitalization can be inaccurate, and so I recommend that you have this test repeated within the next 1 to 2 weeks. You should have your blood count and potassium checked then, too. You should not take NSAID medications. Your potassium level was running low in the hospital and so you were begun on a daily replacement postassium tablet. Followup Instructions: Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2118-12-19**] 1:30 I recommend you call Dr. [**Last Name (STitle) **] to have another appointment made for 1 to 2 weeks from now to review the events of this hospitalization and to follow-up on repeat blood tests. If you are at rehab during this time, then CBC, potassium, and TSH, Free T4 should be drawn at that facility and results should be called into Dr.[**Name (NI) 96157**] office for review and further instruction.

Admission Date: [**2183-6-10**] Discharge Date: [**2183-6-19**] Date of Birth: [**2122-10-12**] Sex: F Service: ORTHOPAEDICS Allergies: morphine / OxyContin / Bacitracin / Betadine / adhesive tape Attending:[**First Name3 (LF) 3190**] Chief Complaint: Scoliosis and stenosis Major Surgical or Invasive Procedure: Anterior and posterior fusion T11-L5 for scoliosis History of Present Illness: 60 year old female with back pain secondary to scoliosis and stenosis, who presents for operative intervention. Past Medical History: Scoliosis HLD HTN Laminectomy Breast biopsy Hysterectomy Social History: Lives at home. Denies any smoking, alcohol or illicit drug use. Family History: Non-contributory. Physical Exam: Alert and oriented x 3 Calm and cooperative HEENT: Normocephalic, atraumatic, Extraocular muscles intact, supple Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Skin: Warm and dry, No rash Neuro: sensation grossly intact Psych: Normal mood, Normal mentation Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Ext: Good strength in upper and lower extremities Pertinent Results: [**2183-6-18**] 09:10PM BLOOD WBC-8.0 RBC-3.25* Hgb-10.2* Hct-29.2* MCV-90 MCH-31.4 MCHC-35.0 RDW-14.1 Plt Ct-434 [**2183-6-18**] 07:05AM BLOOD WBC-6.7 RBC-3.21* Hgb-9.8* Hct-28.3* MCV-88 MCH-30.4 MCHC-34.5 RDW-14.1 Plt Ct-342# [**2183-6-17**] 02:35AM BLOOD WBC-5.6 RBC-2.85* Hgb-8.9* Hct-25.1* MCV-88 MCH-31.2 MCHC-35.4* RDW-13.9 Plt Ct-203 [**2183-6-16**] 12:48AM BLOOD WBC-5.9 RBC-2.55* Hgb-8.0* Hct-22.8* MCV-89 MCH-31.2 MCHC-34.9 RDW-14.3 Plt Ct-185 [**2183-6-15**] 01:00AM BLOOD WBC-6.2 RBC-2.95* Hgb-9.4* Hct-26.5* MCV-90 MCH-31.8 MCHC-35.5* RDW-14.8 Plt Ct-157 [**2183-6-13**] 01:12PM BLOOD PT-13.6* PTT-24.4 INR(PT)-1.2* [**2183-6-13**] 01:12PM BLOOD Fibrino-678* [**2183-6-19**] 05:35AM BLOOD Glucose-132* UreaN-6 Creat-0.5 Na-132* K-3.8 Cl-95* HCO3-25 AnGap-16 [**2183-6-18**] 09:10PM BLOOD Glucose-128* UreaN-6 Creat-0.4 Na-134 K-3.5 Cl-95* HCO3-27 AnGap-16 [**2183-6-17**] 02:35AM BLOOD Glucose-106* UreaN-7 Creat-0.5 Na-135 K-3.5 Cl-97 HCO3-29 AnGap-13 [**2183-6-16**] 12:48AM BLOOD Glucose-141* UreaN-9 Creat-0.6 Na-135 K-3.3 Cl-100 HCO3-27 AnGap-11 Brief Hospital Course: 60 year old female with scoliosis and stenosis presented for circumfrential fusion. On [**2183-6-13**] she underwent an Anterior fusion T11-L5 with chest tube and Posterior on T11-L5 chest tube removed. The patient received multiple units of Cell [**Doctor Last Name **] in addition to fresh frozen plasma and platelets, as well as approximately 5 units of packed red blood cells. She was transferred intubated and sedated to the SICU after surgery. An epidural was placed for pain control once the patient was extubated. On [**6-18**] the patient produced 2 liters of urine in 2 hours. Sent serum lytes and urine lytes. Vitals were stable, blood pressure acceptable. Most likely cause was diuresis from OR fluid load and HCTZ was resumed. The patients labs and vitals were monitored throughout her hospitalization and remained stable. Physical therapy evaluated the patient and she is stable for discharge today. Medications on Admission: Acetamenophen Amlodipine Diovan Fenofibrate Hydrochlorothiazide Klonopin Arimidex Discharge Medications: 1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. anastrozole 1 mg Tablet Sig: One (1) Tablet PO Daily (). Disp:*60 Tablet(s)* Refills:*2* 4. clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at bedtime)) as needed for insomnia. Disp:*60 Tablet(s)* Refills:*0* 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 8. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 11. magnesium citrate Solution Sig: One (1) 300 ML PO ONCE (Once) for 1 doses. Disp:*1 300 ML(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Clipper Home Discharge Diagnosis: Scoliosis/ spinal stenosis Discharge Condition: Awake and alert/ ambulating short distances/ incisions healing well with no signs of infection Discharge Instructions: Ambulate as tolerated in TLSO brace. [**Month (only) 116**] be OOB without brace for bathroom privileges Physical Therapy: Ambulate as tolerated/ use TLSO brace when walking/ [**Month (only) **] go to bathroom without brace Activity: Pneumatic boots Activity: Pneumatic boots Treatments Frequency: Incisions healing well /inflammatrion along anterior incision healing well Followup Instructions: 10 days in office

Admission Date: [**2130-9-14**] Discharge Date: [**2130-9-18**] Date of Birth: Sex: F Service: The patient expired on [**2130-9-18**]. HISTORY OF PRESENT ILLNESS: This is a 56 year old white female who was transferred to the [**Hospital1 190**] from the [**Hospital3 8834**] earlier in morning of admission when she was talking on the telephone with her son and suddenly complained of a severe headache and fell to the ground. She did experience loss of consciousness and there were reported seizures lasting approximately five minutes during that time with reported decorticate posturing. EMS was called and arrived at the scene and transported the patient returned to consciousness and was following commands with no apparent neurologic deficit. A CT scan showed subarachnoid hemorrhage with diffuse bleeding in all cisterns. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus. MEDICATIONS ON ADMISSION: 1. Zestril. 2. Glyburide. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On physical examination, she was awake and oriented times three but somnolent with blood pressure 150/80, respiratory rate 12, heart rate 110 beats per minute and she was afebrile. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements were full. The tongue was midline. There was no facial asymmetry. Shoulder shrug was positive. Extremity strength was [**5-27**] in all muscle groups bilateral left and right. Sensory was intact to light touch grossly and reflexes were symmetric bilaterally. HOSPITAL COURSE: Due to the clinical findings, the patient was admitted with the diagnosis of subarachnoid hemorrhage and was considered neurologically stable at that time. A lengthy discussion between family and Dr. [**Last Name (STitle) 1132**] ensued at which time the family agreed to go forward with diagnostic angiography and further treatment and the patient therefore had diagnostic angiogram and was subsequently taken to the operating room later on [**2130-9-14**], where under a general endotracheal anesthetic, a right craniotomy and clipping of an anterior communicating artery aneurysm was performed by Dr. [**Last Name (STitle) 1132**]. A ventricular drain was placed at the beginning of the procedure, and the patient was returned to the Neurosurgical Intensive Care Unit for postoperative recovery. The patient was initially noted to be doing well, awakened from the surgery, was opening eyes to voice and following commands on the first postoperative day. By the second postoperative day, the patient was awake, alert and oriented to person and time and following two step commands with grip and strength 5/5 bilaterally. The patient's neurologic condition remained stable until early on [**2130-9-18**], the patient was noted to have become somnolent and less responsive. Again, after discussion with the family, decision was made to take the patient back for angiographic study and possible treatment if vasospasm was seen. The patient was taken to the angiogram suite on the afternoon of [**2130-9-18**], where a diagnostic angiogram was performed and vasospasm was noted and Papaverine was administered. However, there was a small amount of extravasation of the angiographic dye noted during the procedure and shortly thereafter the patient's systolic blood pressure rose markedly as well as intracranial pressures rising to 160 millimeter of water. The procedure was immediately halted and the patient was taken to the Neurosurgical Intensive Care Unit after replacement of the ventricular drain was done and successfully placed. Upon lengthy discussion with the family including the husband and son, the family expressed a wish that no further heroic or supportive measures be considered other than comfort measures and due to the family wishes and in concert with the clinical condition, the decision was made to place the patient on comfort measures only status at approximately 9:00 p.m. on [**2130-9-18**], and the patient subsequently was found to have fixed and dilated pupils with no heart or respiratory activity and the patient was pronounced dead at 10:40 p.m. on [**2130-9-18**]. The immediate cause of death was respiratory failure secondary to subarachnoid hemorrhage. The family was informed of the expiration of the patient. They declined autopsy and expressed their gratitude for the care which the patient had received. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Name8 (MD) 5474**] MEDQUIST36 D: [**2131-4-5**] 10:30 T: [**2131-4-8**] 12:30 JOB#: [**Job Number 15329**]

Admission Date: [**2120-6-16**] Discharge Date: [**2120-7-1**] Date of Birth: [**2065-9-5**] Sex: M Service: MEDICINE Allergies: Diphenhydramine Attending:[**First Name3 (LF) 1973**] Chief Complaint: etoh withdrawal, vocal cord mass or selling Major Surgical or Invasive Procedure: bronchoscopy intubation tracheostomy PICC History of Present Illness: 54 year old Male with a PMH of HTN and etoh abuse who presented to [**Hospital3 **] on [**6-13**] in etoh withdrawal, reporting tachycardia, cough, and chest pain. He drinks 1 quart of vodka several days a week and last drink was around [**6-12**] or [**6-13**]. He ruled out with 2 sets of negative cardiac enzymes and a non-ischemic ekg, and was evaluated by cardiology. CXR neg for acute process. His chest pain was felt likely due to bronchitis. During the hospitalization he continued to exhibit withdrawal symptoms so was started on CIWA. He required 20mg IV lorazepam during the initial 6 hours of withdrawal and had respiratory distress, cyanosis, and stridor. During intubation he was noted to have a vocal cord polypoid mass and is thus being transferred to [**Hospital1 18**] for further evaluation. Over the past 24 hours he has required 12mg IV lorazepam. He is also on levofloxacin for unclear reason. VS prior to transfer were 100.7, 87, 120/72, 31, 95%. Upon arrival to the [**Hospital1 18**] MICU, patient is intubated, on propofol, and mildly agitated. Vent settings are: AC, TV 500, RR 16, PEEP 5, FiO2 40%. He failed multiple weaning attempts and ultimately underwent tracheostomy. After tracheostomy he was discovered to have a pulmonary embolism on [**6-21**]. Subsequent laryngoscopy showed severe laryngeal edema. Past Medical History: - OSA s/p removal of adenoids and uvula - ? COPD - Hepatitis C - ETOH abuse - Nicotine abuse - Anxiety Social History: Was sober for 7 years but relapsed 5 years ago and has been drinking a quart of vodka several times per week. Desires to quit and has been through 20 rehabs. Smoked for over 30 years but recently cut down to 1 pack per week. Lives with girlfriend. Family History: No history of head and neck cancer Physical Exam: ADMISSION EXAM: Vitals: 97.2, 106/67, 88, 27, 98% on vent General: Intubated, agitated but calm after a bolus of versed HEENT: Sclera anicteric, pupils pinpoint but equal and reactive. ET tube and OG tubes in place. Neck: Very thick neck, unable to assess JVP. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly. Well healed scar over LLQ. GU: + foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Moving all four extremities. Lines/tubes: Left subclavian, OG tube, ET tube Pertinent Results: IMAGING: [**2120-6-21**] CTA Chest IMPRESSION: 1. Acute thromboembolus in the right upper lobar artery and several main segmental branches of the middle lobar artery. There are findings suggestive of pulmonary hypertension, but no lung infarction or right heart strain. 2. Stable bilateral small pleural effusions and stable atelectasis. No evidence of acute infectious process. . [**2120-6-20**] ECHO The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. No late contrast is seen in the left heart (suggesting absence of intrapulmonary shunting). Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No evidence of intracardiac or cardiopulmonary shunt. Normal left ventricular cavity size and wall thickness with preserved global and regional left ventricular systolic function. Mildly dilated right ventricle. Mildly dilated aortic root and ascending aorta. Normal pulmonary artery systolic pressure. [**2120-6-29**] 10:38AM BLOOD WBC-10.3 RBC-3.60* Hgb-11.2* Hct-33.3* MCV-93 MCH-31.0 MCHC-33.5 RDW-14.0 Plt Ct-435 [**2120-6-26**] 05:31AM BLOOD WBC-6.7 RBC-3.48* Hgb-10.5* Hct-32.2* MCV-93 MCH-30.2 MCHC-32.6 RDW-13.8 Plt Ct-332 [**2120-6-21**] 03:57AM BLOOD WBC-7.9# RBC-3.18* Hgb-9.8* Hct-30.3* MCV-95 MCH-30.9 MCHC-32.5 RDW-13.7 Plt Ct-275 [**2120-6-16**] 09:52PM BLOOD WBC-11.1* RBC-3.76* Hgb-11.7* Hct-36.2* MCV-96 MCH-31.2 MCHC-32.5 RDW-14.7 Plt Ct-227 [**2120-6-16**] 09:52PM BLOOD Neuts-77.0* Lymphs-14.6* Monos-4.6 Eos-3.2 Baso-0.5 [**2120-6-27**] 02:18AM BLOOD PT-12.4 PTT-37.8* INR(PT)-1.1 [**2120-6-19**] 02:18AM BLOOD PT-11.2 PTT-28.7 INR(PT)-1.0 [**2120-6-29**] 10:38AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-141 K-3.6 Cl-104 HCO3-28 AnGap-13 [**2120-6-24**] 09:40PM BLOOD Glucose-117* UreaN-14 Creat-0.6 Na-140 K-4.0 Cl-102 HCO3-31 AnGap-11 [**2120-6-18**] 03:01AM BLOOD Glucose-82 UreaN-15 Creat-0.8 Na-141 K-3.8 Cl-109* HCO3-28 AnGap-8 [**2120-6-16**] 09:52PM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-142 K-4.2 Cl-107 HCO3-30 AnGap-9 [**2120-6-28**] 07:35AM BLOOD ALT-47* AST-33 LD(LDH)-252* CK(CPK)-86 AlkPhos-55 TotBili-0.6 DirBili-0.3 IndBili-0.3 [**2120-6-19**] 02:18AM BLOOD ALT-53* AST-62* LD(LDH)-185 CK(CPK)-752* AlkPhos-44 TotBili-0.8 [**2120-6-20**] 04:02AM BLOOD Lipase-11 [**2120-6-16**] 09:52PM BLOOD CK-MB-3 cTropnT-<0.01 [**2120-6-29**] 10:38AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.9 [**2120-6-28**] 07:35AM BLOOD Albumin-3.9 Calcium-9.0 Phos-2.5* Mg-2.0 [**2120-6-19**] 02:18AM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.2 Mg-2.1 [**2120-6-16**] 09:52PM BLOOD Calcium-8.5 Phos-4.3 Mg-2.2 [**2120-6-22**] 05:02AM BLOOD Triglyc-109 [**2120-6-20**] 04:02AM BLOOD Triglyc-78 [**2120-6-25**] 05:50AM BLOOD Vanco-4.0* [**2120-6-23**] 05:51AM BLOOD Vanco-32.5* [**2120-6-21**] 03:57AM BLOOD Vanco-9.6* [**2120-6-26**] 02:59PM BLOOD Type-ART pO2-88 pCO2-49* pH-7.43 calTCO2-34* Base XS-6 [**2120-6-26**] 05:45AM BLOOD Type-ART pO2-107* pCO2-54* pH-7.41 calTCO2-35* Base XS-7 [**2120-6-23**] 08:43PM BLOOD Type-ART pO2-125* pCO2-44 pH-7.48* calTCO2-34* Base XS-9 [**2120-6-21**] 09:15PM BLOOD Type-ART Temp-36.9 Rates-24/ Tidal V-440 PEEP-12 FiO2-60 pO2-71* pCO2-49* pH-7.45 calTCO2-35* Base XS-8 Intubat-INTUBATED Vent-CONTROLLED [**2120-6-16**] 11:54PM BLOOD Type-ART Temp-37.2 Rates-16/5 Tidal V-600 PEEP-5 FiO2-100 pO2-205* pCO2-66* pH-7.29* calTCO2-33* Base XS-3 AADO2-442 REQ O2-76 -ASSIST/CON Intubat-INTUBATED [**2120-6-23**] 06:10AM BLOOD freeCa-1.14 [**2120-6-20**] 05:04AM BLOOD freeCa-1.10* [**2120-6-19**] 02:32AM BLOOD freeCa-1.19 [**2120-6-18**] 03:11AM BLOOD freeCa-1.14 Brief Hospital Course: 54M with a h/o etoh abuse who presented to an OSH on [**6-13**] for chest pain, felt likely secondary to bronchitis. Hospital course complicated by etoh withdrawal. Patient reportedly developed stridor. ENT evaluated patient with CT scan and felt he may have had a mass around the cords. He was sent to [**Hospital1 **] for further evaluation. ACTIVE ISSUES: # Respiratory failure/Hypoxemia/Laryngeal Edema: Patient was intubated at OSH for respiratory distress. On tubated there was a polypoid lesion on his vocal cords and he was sent to [**Hospital1 18**] for evaluation. Here, ENT performed direct laryngoscopy which revealed edematous cords. He was given a short course of steroids. Extubation was attempted however resulted in recurrent respiratory distress requiring reintubation. ENT felt that he has [**Last Name (un) 50614**] edema which will resolve in a few weeks. He underwent tracheostomy placement. ***PATIENT WILL REQUIRE DOWN-SIZING OF TRACH DURING WEEK OF [**7-8**] PER IP RECOMMENDATIONS.*** He was also need follow up with Dr. [**Last Name (STitle) **] in ENT. # Ventilator Associated Pneumonia: Patient was treated with 7 days of antibiotics while in patient. He remained afebrile. # Pulmonary Embolism: While intubated, patient was difficult to ventilate. A CT was performed which revealed multiple PEs. He was started on lovenox. After all procedures are completed, he should transition to Coumadin for at least a 6 month course unless the mass is found to be a solid tumor, in which case there is some evidence to use LMWH for solid tumors over coumadin. # Alcohol Dependence, withdrawal: Given thiamine, folic acid, multivitamin. Ciwa scale was maintained while in the ICU # Clostridium difficile Colitis: dx made on [**2120-6-28**]. Was started for 10 day course of PO Flagyl and will be completed on [**2120-7-8**]. # Anxiety: Patient started on clonazepam for anxiety. Will likely need to wean this prior to discharge from facility. Transitions of care: - will need outpatient speech and swallow appointment to discuss advancing his diet once ENT has cleared him. - will need trach changed out during week of [**7-8**] Medications on Admission: Home Medications: Girlfriend unable to recall Transfer Medications: 1. pantoprazole 40mg daily 2. acetaminophen 650mg Q6h prn 3. heparin 5000units SC Q8h 4. artificial tears 5. chlorhexidine 15ml TID 6. propofol 100ml IV Q4h 7. vecuronium 8mg Q6h IV prn 8. lorazepam Q2h IV prn CIWA 9. levofloxacin 100ml IV Q24h 10. guaifenesin 200mg Q4h prn 11. nitroglycerin 0.4mg SL prn Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Clonazepam 1 mg PO BID hold for rr < 10 and somnolence 3. FoLIC Acid 1 mg PO DAILY 4. Pantoprazole 20 mg PO Q24H 5. Mirtazapine 7.5 mg PO HS hold for rr < 10 and somnolence 6. Thiamine 100 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Miconazole Powder 2% 1 Appl TP TID:PRN rash apply to affected area 9. Enoxaparin Sodium 110 mg SC Q12H 10. Clonazepam 0.5 mg PO QHS:PRN anxiety/insomnia 11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days D1 = [**2120-6-28**]. 12. Albuterol-Ipratropium [**1-8**] PUFF IH Q6H:PRN sob/wheeze Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**] ([**Hospital3 1122**] Center) Discharge Diagnosis: Primary: ETOH intoxication airway edema and possible airway mass/lesion ventilator associated pneumonia pulmonary embolus clostridium difficile oliguria Secondary: GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the hospital for alcoholic detoxification and respiratory distress due to airway compromise from swollen vocal cords. It is not exactly clear why there was swelling around your vocal cords but a tracheostomy was needed to protect your airway and you will need to see the ENT doctor when you leave the hospital to assess further plans to manage these issues. After you see the ENT doctor, you should following up with a speech/swallow therapist to discuss advancing your diet. While in the hospital, you developed a clot in your lungs which you will need to been on blood thinning medications for. You also have an infection of your colon for which you will need to take a course of antibiotics. Please be sure to complete this course of antibiotics. Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. Please followup with your primary care physician [**Name Initial (PRE) 176**] [**7-16**] days regarding the course of this hospitalization. Followup Instructions: Department: OTOLARYNGOLOGY-AUDIOLOGY When: THURSDAY [**2120-7-4**] at 9:45 AM With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2120-7-2**]

Admission Date: [**2142-7-28**] Discharge Date: [**2142-8-11**] Date of Birth: [**2084-9-3**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 3(LIMA-LAD,SVG-RI,SVG-OM) [**2142-8-6**] Aorto-left leg arteriogram ,balloon angioplasty proximal peroneal artery [**2142-7-31**] History of Present Illness: This 57 year old male wastransferred from [**Hospital3 1280**] after cardiac catherization revealed double vessel disease. He initially presented there on [**7-22**] with a nonhealing infection of a left toe. During his hospitalization he underwent amputation of the left middle toe on [**2142-7-25**]. He developed two episodes of new rest chest pain with EKG changes of transient ST elevations in AVR, V1, V2. Chest pain resolved on its own and enzymes were negative. These episodes occurred on [**7-22**] and [**7-25**], with no chest pain in the past 3 days. Cardiac catheterization was performed on[**7-27**] and he was transferred to [**Hospital1 18**] today for cardiac surgical evaluation. Past Medical History: Paroxysmal Atrial Fibrillation Diabetes Mellitus on insulin pump Congestive heart failure Dyslipidemia Peripheral Vascular Disease h/o Cellulitis History of C. diff colitis Hypothroidism Hypertension Right below knee amputation [**5-7**] Left middle toe amputation [**2142-7-25**] Cataract surgeries multiple vascular surgical procedures Social History: Race:Caucasian Last Dental Exam: Several years ago - poor denition Lives with: Widowed, lives with dtr and granddaughter Occupation: Retired x 7 years Tobacco: None ETOH:None Family History: noncontributory Physical Exam: admission: Pulse:AF 69 Resp:13 O2 sat:100% RA B/P Right:145/66 Left: Height:5'9" Weight:170# General: Skin: Dry [] intact [] Multiple pinpoint lesions LLE HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Right BKA, Left 3rd toe wound packed, tissue pink, no purulent drainage Neuro: Grossly intact xPulses: Femoral Right:2+ Left:2+ DP Right:NA Left:0 PT [**Name (NI) 167**]:NA Left:0 Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [**2142-7-30**] Vein mapping: Patent left greater and short saphenous vein with diameters amenable for bypass conduit [**2142-7-30**] Carotid U/S: Right ICA <40% stenosis. Left ICA <40% stenosis. [**2142-8-6**] Echo: PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral annular calcification as well as calcification of both subvalvular apparati. There is non-flow restricting chordal [**Male First Name (un) **] but no valvular [**Male First Name (un) **]. Trivial mitral regurgitation is seen. There is a very small pericardial effusion. POSTBYPASS: The patient is A-paced and is on a phenylephrine infusion. Left ventricular function remains normal. Mild aortic regurgitation persists. Trivial mitral regurgitation persists. Aortic contours are normal. [**2142-8-10**] 04:30AM BLOOD WBC-8.9 RBC-2.92* Hgb-8.7* Hct-26.2* MCV-90 MCH-29.8 MCHC-33.1 RDW-15.7* Plt Ct-259 [**2142-7-28**] 04:50PM BLOOD WBC-7.9 RBC-3.41* Hgb-10.0* Hct-29.4* MCV-86 MCH-29.3 MCHC-34.0 RDW-13.6 Plt Ct-358 [**2142-8-10**] 04:30AM BLOOD Glucose-162* UreaN-28* Creat-1.7* Na-135 K-4.1 Cl-104 HCO3-24 AnGap-11 [**2142-7-28**] 04:50PM BLOOD Glucose-408* UreaN-26* Creat-1.5* Na-131* K-5.2* Cl-98 HCO3-25 AnGap-13 Brief Hospital Course: He received medical management while undergoing extensive pre-operative work-up, including lab work, carotid ultrasound, vein mapping and a vascular surgical consult. On [**7-31**] he was brought to Operating Room by vascular surgery for serial arteriogram of the left lower extremity and balloon angioplasty of the proximal peroneal artery. Please see operative note for details. Following the case he was transferred back to floor for further medical care. On [**8-6**] he was brought to the Operating Room where he underwent coronary artery bypass graft x 3 was undertaken. Please see operative report for surgical details. He tolerated the procedure well and was extubated easily. The wound vac remained on the left toe amputation site. He was begun on beta blockers and then Cardizem was initiated after Amiodarone failed to control his atrial fibrillation. He converted to sinus rhythm and Coumadin was resumed for the paroxysmal fibrillation and his peripheral vascular disease. He was below his properative weight at discharge but there remained a moderate asmount of right stump edema which precluded the prosthesis from fitting. A stump shrinker was therfor utilized. The toe amputaion site was clean with a wound vac in place. he will be followed by his vascular surgeon Dr.[**Last Name (STitle) **] after discharge. He was stable and ready for discharge to rehabilitaion on POD 5. medicationsd were as listed as was follow up. Medications on Admission: Avapro 300 mg daily Diltiazem 180 q PM IV Vanco 1 gm daily Florastor 250 [**Hospital1 **] Levothyroxine 50 daily Metoprolol 100 TID ASA 325 daily Crestor 5 daily Novolog pump Coumadin 5 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML Injection PRN (as needed) as needed for line flush. 13. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours). 14. Metoclopramide 5 mg/mL Solution Sig: Two (2) ml Injection Q6H (every 6 hours) as needed for gastroparesis. 15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 16. Insulin Pump Reservoir 3 mL Misc Sig: as directed- self administered Miscellaneous continuous: self administration. 17. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: INR [**1-31**] goal. 18. Outpatient Lab Work INR [**8-12**] then M-W-F for 2 weeks then prn Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary artery bypass graft x Past medical history: Paroxysmal Atrial Fibrillation Diabetes Mellitus on insulin pump Congestive heart failure Dyslipidemia Peripheral Vascular Disease Cellulitis History of C diff 1 year ago Hypothroidism Hypertension Past Surgical History: Right BKA [**5-7**] Left middle toe amputation [**2142-7-25**] Cataract surgeries > 30 surgeries on bilateral LE d/t PVD - vascular surgeon is Dr. [**Last Name (STitle) **] Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet and Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. Wound Vac left toe Edema right stump Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] at [**Hospital3 1280**] in 2 weeks([**Telephone/Fax (1) 6256**]) office will call with appointment Please call to schedule appointments with: Primary Care: Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 20261**]in [**12-30**] weeks Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31888**] in [**12-30**] weeks Vascular Surgery: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? for paroxysmal atrial fibrillation/peripheral vascular disease Goal INR 2-2.5 First draw day after discharge Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directedby [**Hospital1 **] staff Completed by:[**2142-8-11**]

Admission Date: [**2111-12-17**] Discharge Date: [**2112-1-21**] Date of Birth: [**2052-7-24**] Sex: F Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 2145**] Chief Complaint: increased work of breathing Major Surgical or Invasive Procedure: - Intubation/ventilation - Tunneled HD catheter placement - Central line History of Present Illness: The patient is a 59y/o WW w/ a PMH significant for DM1 (c/b CRF, neuropathy, and retinopathy), morbid obesity, and HTN who was recently hospitalized for an episode of ARF [**1-14**] ATN. This occurred in the setting of a osteomyelitis [**1-14**] an ankle fx. She was sent back to her Rehab center following this admission and there she developed dyspnea and anuria. Her Cr rose to 4.8 and she had a leukocytosis at 16. She was admitted and noted to have troponins in the 3 and was seen to have a NSTEMI but was not anticoagulated [**1-14**] the feeling that her presentation represented a subacute event. She required a NRB during her early admission that was quickly weaned but, considering her fluid overload, renal was consulted and decided to proceed to HD. During this time, she also was noted to have a UTI that was initially treated w/ levo/flagyl (b/c of a presumed aspiration PNA at this time as well) but this was later changed to linezolid when it grew VRE. On the floor, she had an episode of unresponsiveness for which a code blue was called. She was initially pulseless but returned to NSR w/ CPR. She was intubated during this code during which she was also noted to have a 12b run of VT. . During MICU stay, pt's vent settings were weaned quickly. She received very little sedation and was comfortable on the vent. She was maintained on the vent for the first two days in the MICU for her tunneled HD catheter placement and for initiation of HD. Her line was placed on MICU day #2 in IR without complications. HD was done the same day through the line and 1kg was removed. Pt tolerated HD well. ON MICU day #2, she was changed to PS 5/5 and a RSBI on MICU day #3 was 28. She was extubated on MICU day #3 and maintained her O2 sats in high 90s. An insulin gtt was briefly started for high blood sugars but this was titrated off. A c. diff infection was treated w/ flagyl. . On ROS today, the patient complains of "labored breathing" but denies any CP, abdominal pain, N/V, HA, weakness, paresthesias, visual changes, or palpatations. Past Medical History: s/p laser, neuropathy manifestation, diabetic nephropathy. crf 1.7 1 year ago. pcr [**12-15**]. prot. for 5 years. [ACEI cough, high K on [**Last Name (un) **]] - Hyperlipidemia, NOS - Obesity - Anemia of Other Chronic Illness - on procrit for 2 years. on q 3 wk. large dose. only on procrit once every 3 weeks now, small dose. - Hypothyroidism primary - Hypertension, essential NOS: - Hyperparathyroidism (secondary) now on hectorol at hospital. - CVA - [**2111**]5, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30210**]. of the Left Internal Cap. Social History: Married and lives with her husband. 2 children, retired school teachers. No tob, no EtOH. Family History: Father died of Colon Cancer Physical Exam: PE: 96.2, 133/36, 75, 100% 40%FM Gen: Obese woman lying in bed in NAD, foley and rectal tube in place HEENT: EOMI, PERRLA, MMM, O/P clear Lungs: Diffusely rhonchi Cardiac: Difficult to hear w/ coarse breath sounds but Abdomen: Obese, S/NT/ND, +BS, - HSM appreciated Extremities: 2+ LE edema bilaterally w/ trace UE edema as well Skin: no rashes. L heel wrapped Neuro: CN and strenght exam limited by lack of cooperation by patient, AAO x3 Pertinent Results: Admission Labs: [**2111-12-17**] 05:32PM BLOOD WBC-15.1* RBC-3.67* Hgb-10.2* Hct-31.5* MCV-86 MCH-27.8 MCHC-32.4 RDW-16.5* Plt Ct-283 [**2111-12-17**] 05:32PM BLOOD Neuts-92.1* Bands-0 Lymphs-3.7* Monos-2.0 Eos-2.0 Baso-0.2 [**2111-12-19**] 06:30AM BLOOD Neuts-86.3* Bands-0 Lymphs-7.5* Monos-2.2 Eos-3.7 Baso-0.3 [**2111-12-17**] 05:32PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Stipple-OCCASIONAL [**2111-12-17**] 05:32PM BLOOD Plt Smr-NORMAL Plt Ct-283 [**2111-12-30**] 06:33PM BLOOD ESR-115* [**2111-12-17**] 09:58PM BLOOD CK(CPK)-9140* [**2111-12-29**] 05:46PM BLOOD Lipase-10 [**2111-12-17**] 09:58PM BLOOD CK-MB-118* MB Indx-1.3 cTropnT-2.86* [**2111-12-17**] 05:32PM BLOOD Calcium-8.4 Phos-6.9* Mg-2.0 [**2111-12-30**] 06:33PM BLOOD VitB12-600 Folate-10.5 [**2111-12-30**] 06:33PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE [**2112-1-9**] 03:45AM BLOOD TSH-6.7* [**2111-12-31**] 02:08PM BLOOD Cortsol-27.1* [**2111-12-31**] 02:08PM BLOOD Cortsol-38.2* [**2111-12-31**] 04:20PM BLOOD Cortsol-41.8* [**2111-12-20**] 04:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2111-12-30**] 06:33PM BLOOD CRP-216.0* [**2111-12-30**] 06:33PM BLOOD PEP-NO SPECIFI [**2112-1-1**] 12:26AM BLOOD Vanco-13.4* [**2111-12-22**] 05:04PM BLOOD HCV Ab-NEGATIVE [**2111-12-17**] 04:05PM BLOOD Glucose-180* Lactate-2.0 Na-138 K-6.4* Cl-104 calHCO3-22 [**2111-12-17**] 05:32PM BLOOD Glucose-206* K-5.4* [**2111-12-17**] 04:05PM BLOOD pH-7.19* Comment-GREEN TOP [**2111-12-17**] 07:24PM BLOOD Type-ART Temp-38.3 Rates-/14 pO2-113* pCO2-41 pH-7.31* calHCO3-22 Base XS--5 Intubat-NOT INTUBA Comment-ROOM AIR -CXR [**12-30**] - Lretrocardiac, R base, R upper lobe above minor fissure opacities suggestive of atelectasis but could be aspiration. -EKG: at time of event unchanged, sinus tach -Abd XR - [**12-29**] - Non-diagnostic bowel gas pattern. No evidence of small bowel obstruction. -TTE [**2111-12-18**]: mild sym LVH. LV size normal. EF >55% with no obvious wall motion abnormality (due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded). Mild pulm artery systolic HTN. . EMG: Complex, abnormal study. There is electrophysiologic evidence for a severe, ongoing, proximal myopathy with denervating features (as can be seen in inflammatory myopathy, critical illness myopathy or toxic myopathy). In addition, there is evidence for a severe, chronic, sensorimotor, generalized polyneuropathy with both axonal and demyelinating features, as can be seen in diabetics, although other causes of neuropathy cannot be excluded . Micro - [**12-17**] Urine - VRE, yeast (resolved) [**12-21**] Stool + for C diff (resolved) [**12-24**] Urine - yeast (resolved) . MRI: 1. There is moderate cerebral and cerebellar atrophy. 2. There are areas of abnormal signal intensity in the brain parenchyma, the distribution of which suggests ischemic lesions including old lacunes in the thalami, probable small, old brainstem infarcts, and a probable old infarct in the right internal capsule. Given the patient's age, demyelinating disease is a consideration but the [**Doctor Last Name 352**] matter lesions are unusual. 3. There is good flow in the distal internal carotid arteries, the distal vertebral arteries and the basilar artery. The major branches of the cerebral arteries are normal.There is no evidence of a significant stenosis. Brief Hospital Course: 59F multiple ICU admissions for problem[**Name (NI) 115**] respiratory function including repiratory arrest requiring intubation who was most recently transferred back to the MICU on [**1-3**] with increased secretions and decreased functional respiratory reserve, concerning for neurologic induced weakness. She had been transferred out of the MICU 2 days prior ([**1-1**]) and while on the floor was noted to have marked increased purulent sputum on suctioning as well as increased residuals in her NG tube concerning for obstruction. Furthermore, while on the floor she was continuing work-up for her subacute weakness which included an MRI showing no cervical cord compression. Her other medical problems include DM type 1 (c/b CRF, neuropathy, and retinopathy), osteomyelitis s/p fracture, morbid obesity, HTN, CRF. She was originally admitted for this admission from rehab w/ volume overloaded and in renal failure. This early part of the hospitalization was also c/b NSTEMI which was medically managed, as well as a UTI (VRE), which was treated. . During her first MICU stay ([**12-21**]), pt's vent settings were weaned. She had a tunnelled HD line placed and dialysis was initiated. Also the patient was found to have Cdiff and started on flagyl. She was transferred to the floor on [**2111-12-23**]. . On the floor the patient had persistent hypoxia at times requiring a non rebreather. This was thought to potentially be due to vol overload vs muscular weakness. The patient has seemed to improve with HD. Of note on [**2111-12-28**] the patient was having abdominal pain with tube feeds and had 1 episode of coffee ground emesis in NGT suction. This cleared quickly and did not recur. Hct has remained stable. Other ongoing problems include ulcers on both feet, followed by Wound Care. A sacral decubitus ulcer developed and was treated by Wound Care. . Pt had an episode of hypotension to the 80's, hypoxia to the 70's, and unresponsiveness on [**12-30**] prompting code blue & transfer back to MICU. Anesthesia required an oral airway and bag mask ventilation transiently but the patient quickly regained consciousness spontaneously. Her BP normalized 120's and she was satting in the high 90's on NRB mask. EKG was unchanged and ABG during the episode was 7.44/36/223. In MICU she was started on Zosyn for pneumonia, was transferred to the floor on [**1-1**] after stabilization. . Weakness: Pt has had subacute (over wks) progression of profound muscular weakness and CKs were as high as 9000s (w/low CK-MB). CKs resolved spontaneously. An LP was done and was normal with negative culture. Methylmalonic acid from the CSF was normal and IgG was nondiagnostic. Her NIFs were followed and approximately -40. An EMG was done and c/w critical illness myopathy and DM neuropathy. An MRI was done which showed nothing specific. Pt never on steroids during this admission. DiffDx also includes rheumatologic cause such as polymyositis. Muscle Bx ([**1-8**]) c/w ICU myopathy as well as more chronic changes, but special stains are still pending. Neuro plans for outpt follow up. During course, a GJ tube was placed and tube feeds begun because of concern for pt's ability to swallow [**1-14**] weakness (NOTE: fasteners will need to be removed [**2112-1-24**] similar to sutures per Radiology who placed GJ tube). At time of discharge, patient lifting L arm > R, minimal movement of legs (none against gravity). . Hypotension: She had several episodes of hypotension in the ICU which initially resolved with fluids. No evidence of sepsis. On [**1-10**], pt's BP was persistently in the 90s/30s with MAPs in the 50s that didn't respond to 500cc bolus so she was started on low-dose Levophed. Renal evaluated the patient, and felt that the hypotension seemed to occur post-dialysis, and recommended a trial of mitodrine. She was started on this medication and was titrated Levophed to off [**1-13**]; BP was stable afterwards. Prior to discharge, patient restarted on beta blocker tx, particularly in light of recent NSTEMI, once BP was stable. BB should be held on AM of dialysis. . Diabetes: Patient with poorly controlled DM. Was transiently on insulin drip during 1st MICU stay and then transitioned to Lantus 50U [**Hospital1 **]. On [**1-9**], pt noted to have a blood sugar of 11 so Lantus discontinued and [**Last Name (un) **] consulted. Now stable and titrating up Lantus doses, with SS insulin as needed. Glucoses ranging in high 100s-low 200s of late (110-261). . C. diff colitis: Treated with flagyl, repeat toxin testing negative. . Respiratory compromise: likely due to increased secretions from tracheobronchitis. Pt was requiring sunctioning every [**12-14**] hours. She was continued on Zosyn x 10 days, last dose 1/28. Glycoperolate nebs were started to help with secretions but stopped as they may have been thickening the secretions. Weakness may have a component of her respiratory compromise. Continues to be stable on NC with clear lung exam & CXR. A CTA was performed which was negative for PE; did reveal some mild hilar lymphadenopathy. . CAD: h/o severe CAD, and ?NSTEMI (peak CK 9000s but peak MB only 173 so may be more noncardiac skeletal muscle) in early [**Month (only) 404**]. Cardiology followed peripherally and would consider cardiac cath in future. Started on ASA, now added beta blocker. Intolerant of ACE-I and [**Last Name (un) **] by hx. . Acute on Chronic Renal Failure: Patient now with ESRD on HD likely from diabetes. Cont renagel, phoslo. Renal following. Pt will require dialysis while in Rehab. . FEN: On Tube Feeds via G-J tube. NOTE: fasteners will need to be removed [**2112-1-24**] similar to sutures per Radiology who placed GJ tube. . PPX: On PPI, Heparin sub Q. . Medications on Admission: Insulin Glargine 40 U hs Bowel reg. Renagel 1600 qac Bethanechol 10 tid Metoprolol XL 150 Insulin (Lispro) SS Prozac 40 ASA 81 Simvastatin 80 Synthroid 100 Plavix 75 MVI Bowel Reg: senna, colace, mineral oil, dulcolax Ciprofloxacin 500 daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 10. Aloe Vesta 2-n-1 Skin Cond 3 % Lotion Sig: One (1) Topical qday () as needed for to periwound tissue. 11. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 16. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 19. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 21. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for pain. 22. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours) as needed. 23. Insulin Glargine 100 unit/mL Solution Sig: 68 Units Subcutaneous at lunch. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: - Critical illness myopathy - Respiratory arrest/hypotension - Congestive heart failure - Renal failure on HD - Urinary Tract Infection (VRE, treated, neg cx [**2112-1-1**]) - C diff colitis (treated, negative toxin) - Diabetes mellitus, triopathy [Intolerant of ACE (cough) and [**Last Name (un) **] (hyperkalemia)] - Non-ST-Elevation Myocardial Infarction - Hyperlipidemia - Obesity - Anemia chronic disease on procrit - Hypothyroidism - Hypertension - Secondary hyperparathyroidism - CVA [**7-16**] left internal capsule Discharge Condition: Fair Discharge Instructions: - Take the medications as prescribed. - You will be working with Physical Therapy while at Rehab. You will follow up with Neurology regarding your muscle weakness and the results of the special biopsy muscle stains as scheduled below. - Call a doctor, return to ED for: * fever * chest pain * shortness of breath * other concerns. Followup Instructions: 1. NEUROLOGY: Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 1038**], M.D. Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2112-4-14**] 9:30 2. With your primary care doctor, call to schedule an appointment for a convenient time. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

Unit No: [**Numeric Identifier 64018**] Admission Date: [**2193-7-12**] Discharge Date: [**2193-7-23**] Date of Birth: [**2193-7-12**] Sex: F Service: Neonatology HISTORY: Baby Girl [**Known lastname **] is a 1375 gram product of 29 [**4-6**] week gestation born to a 24 year-old gravida III, para 0, now I mother. Prenatal screen: A positive, antibody negative, Rubella immune. Remainder, RPR and GBS unknown. Mother initially presented early on the morning of delivery to [**Hospital3 **] in preterm labor. Betamethasone given and magnesium sulfate started. [**Hospital 37544**] transfer to [**Hospital1 346**] for further management. At [**Hospital3 **] continued progressive unstoppable preterm labor despite magnesium sulfate. Magnesium stopped and epidural placed for maternal anesthesia. Perinatal sepsis risk factors include preterm delivery and unknown GBS status. Otherwise no maternal fever, prolonged rupture of membranes or fetal tachycardia. Mother given initial antibiotics for unknown GBS status approximately 10 hours prior to delivery. Infant delivered by vaginal delivery. Obstetrics service noted placental abruption. Infant with spontaneous cry though weak and only intermittent. Routine drying, suctioning and stimulation. Positive blow-by O2. Responded well but with early respiratory distress requiring facial CPAP. Apgars of 7 and 8 were assigned. PHYSICAL EXAMINATION: On admission birth weight 1375, 50th percentile, length 45 cm, 50th to 75th percentile, head circumference 28 cm, 50th percentile. Nondysmorphic. Positive molding. Overriding sutures. Anterior fontanelle open and flat. Red reflex x2. Ears normal set. Intact palate and clavicles. Neck supple without masses. Lungs poor bilateral aeration. Positive grunting, retractions and flaring. Regular rate and rhythm. No murmur. 2+ femoral pulses. Centrally pale, perfused. Abdomen soft, minimal bowel sounds, no hepatosplenomegaly. Genitourinary: Normal preterm female, patent anus, nos acral dimples. Neurologic: Normal and symmetric tone. Strength: Weak suck but good grasp. Plantar reflexes and symmetric Moro. HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname **] was admitted to the Neonatal Intensive Care Unit with respiratory distress. Decision made to intubate infant. Received one dose of surfactant and weaned to CPAP at 24 hours of age. She remained on CPAP for a total of 24 hours and was extubated to room air. She has been stable in room air through the remainder of her hospital course. She was empirically started on caffeine citrate for apnea and bradycardia of prematurity. She is currently receiving 7 mg per kilogram per day. CARDIOVASCULAR: No issues. FLUID AND ELECTROLYTE: Birth weight was 1375. Discharge weight is 1245 gms. She was initially started on 80 cc per kilo per day of D10W. Enteral feedings were initiated on day of life #2. She is currently receiving 160 cc per kilo per day of breast milk 26 calorie through PG feeds, tolerating well. GASTROINTESTINAL: Peak bilirubin was on day of life #2 of 7.9/0.4. She was treated with phototherapy and her most recent bilirubin is 5.9/0.2 ([**2193-7-22**]). HEMATOLOGY: Hematocrit on admission is 47.5. She has not required any blood transfusions. INFECTIOUS DISEASE: A CBC and blood culture were obtained on admission. CBC was benign and blood culture remained negative at 48 hours at which time ampicillin and gentamicin were discontinued. NEUROLOGIC: In light of maternal abruption urine toxicology screen was sent and it was negative. She has otherwise been appropriate for gestational age. SENSORY: Hearing screening has not been performed but will need to be done prior to discharge. Ophthalmologic examination has not been done. It should be done at 32 weeks corrected gestational age. PSYCHOSOCIAL: Parents have been appropriate and involved in infant's care. DISCHARGE DISPOSITION: Is to [**Hospital3 **] special care nursery. Name of primary pediatrician is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45724**]. Telephone #[**Telephone/Fax (1) 37501**]. CARE RECOMMENDATIONS: Continue 150 cc per kilo per day of breast milk 26 calorie, advancing calorie density as needed to support weight gain. Medications: Continue caffeine citrate of 7 mg per kilo per day as needed. Care seat positioning screening has not been. State Newborn Screens have been sent per protocol and have been within normal limits. Infant received hepatitis B vaccine on [**2193-7-12**]. Also received hepatitis immune globulin on [**2193-7-12**] for unknown maternal hepatitis status. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1) born at less than 32 weeks. 2) Born between 32 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, or 3) With 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 care-givers. DISCHARGE DIAGNOSES: 1. Premature infant born at 29 [**4-6**] week gestation. 2. Respiratory distress syndrome 3. Rule out sepsis with antibiotics. 4. Hyperbilirubinemia. 5. Apnea and bradycardia of prematurity. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Last Name (NamePattern1) 64019**] MEDQUIST36 D: [**2193-7-21**] 20:44:12 T: [**2193-7-21**] 21:40:06 Job#: [**Job Number 45713**]

Admission Date: [**2121-9-8**] Discharge Date: [**2121-10-1**] Date of Birth: [**2047-1-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2763**] Chief Complaint: transfer from osh c severe sepsis Major Surgical or Invasive Procedure: -Intubation -Central venous line placement -Arterial line placement History of Present Illness: This is a 74 y.o. male with history of adrenal insufficiency, hypothyroidism, paranoid schizophrenia, and DM II presenting with sepsis of unclear etiology. On the day prior to admission the patient's family reports he had decreased PO intake as well as congestion symptoms. Last night his family noted that he was a little weak and put him to bed. Although he did not complain of any fevers his family noted that he was extremely cold to the touch and gave him several blankets and heating blankets to help him stay warm. The next day they noted that he was awake but was not verbal. Given this he was taken to [**Location (un) **] ED. At [**Location (un) **] he was noted to be very hypotensive to 40s-50s. He was given Solumedrol 125mng x 1, he was also noted to be bradycardic to 40s and received Atropine. Azithromycin, Zosyn were initiated and a HeadCT was performed which was negative. He was also intubated and started on Dopamine, Levophed and Neo. . In the [**Name (NI) **], pt was given 2gm of Vancomycin and 750mg of Levofloxacin. He was also given stress dose steroids of Hydrocortisone 100mg IV x 1, PEEP was increased to 10 and pt was set on ARDSnet protocol. He also received a total of 8L of NS. His labs were notable for leukopenia, thrombocytopenia 116, creatinine 3.7, BUN 93. Troponin was noted to be 0.06 with a CK of 1836 and CK-MB that was pending. Urine and serum tox were negative. ABG obtained after intubation noted to be pH 7.28, pCO2, 43, O2 60, HCO3 21 on PEEP of 5 that was increased to 10. . Review of systems: unable to obtain ROS [**1-20**] intubation Past Medical History: Paranoid Schizophrenia (unable to care for self at baseline) HTN DM II COPD h.o. PNA requiring hospitalization nephrectomy mild CRI Social History: Pt lives with family at home. Per PCP family is not able to care for pt adequately and home is in disrepair and has been investigated by department of health with consideration for condemning the property Family History: noncontributory Physical Exam: General: Elderly Caucasian Male intubated in NARD. Psych: Localizes to pain, opens eyes to verbal stimuli HEENT: Sclera anicteric, MMM Neck: difficult to eval JVP given IJ Lungs: Crackles noted diffusely on anterior exam with diminished crackles over left lung field. CV: Borderline bradycardic (50), S1 + S2, no murmurs, rubs, gallops Abdomen: no grimacing noted on abdominal palpation, non-distended, obese, + bowel sounds present, no rebound tenderness or guarding Left Groin: Hematoma noted from femoral line placement, appears better [**Name8 (MD) **] RN from ED after warm compress Ext: 2+ edema noted in all extremities. Pertinent Results: LABS ON ADMISSION: [**2121-9-8**] 06:50PM BLOOD WBC-2.6* RBC-3.77* Hgb-11.2* Hct-35.7* MCV-95 MCH-29.7 MCHC-31.4 RDW-17.1* Plt Ct-116* [**2121-9-8**] 06:50PM BLOOD Neuts-37* Bands-29* Lymphs-27 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-2* [**2121-9-8**] 06:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Burr-OCCASIONAL [**2121-9-8**] 06:50PM BLOOD PT-12.8 PTT-32.7 INR(PT)-1.1 [**2121-9-8**] 06:50PM BLOOD Fibrino-623* [**2121-9-8**] 06:50PM BLOOD Glucose-332* UreaN-93* Creat-3.7* Na-145 K-4.8 Cl-107 HCO3-22 AnGap-21* [**2121-9-8**] 06:50PM BLOOD ALT-74* AST-109* CK(CPK)-1836* AlkPhos-59 TotBili-0.2 [**2121-9-8**] 06:50PM BLOOD CK-MB-230* MB Indx-12.5* [**2121-9-8**] 06:50PM BLOOD Calcium-8.3* Phos-4.5 Mg-2.3 FROM OSH: blood culture 2/4 bottles growing 2 species of coag neg staph urine cx growing >100,000 VRE sensitive to ampicillin, daptomycin and linezolid GRAM STAIN (Final [**2121-9-10**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. YEAST. MODERATE GROWTH. ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/M _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | AMPICILLIN/SULBACTAM-- =>32 R CEFEPIME-------------- 32 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I IMIPENEM-------------- 2 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R URINE CULTURE (Final [**2121-9-11**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LINEZOLID------------- 2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R Brief Hospital Course: This is a 74 y.o. Male with h.o. hypothyroidism p/w septic shock, NSTEMI, hypothermia with suspected pulmonary versus urine source. ##. Septic Shock: Pt noted to be in septic shock on admission to the ED on multiple pressors. Per family pt has a history of PNA versus aspiration PNA, hospitalized three times over the past year and also had dirty UA and ?pna on cxr from ed. Pt was initially started on zosyn, cipro and vancomycin for broad coverage in this frequently hospitalized pt in addition to pressors and xygris given pt's high apache score. Stress dose steroids were also started as pt was on dexamethasone as outpt per his med list. Influenza antigen and legionella antigen were sent and were negative. Pressors able to be weaned and antibiotics switched to linezolid for VRE in urine and meropenem for acinetobacter in sputum. Antibiotic course was completed on [**9-26**]. ##. Respiratory Failure: Pt arrived intubated in ventilatory failure believed to be [**1-20**] pna versus ards from urosepsis. This was complicated by fluid overload in the setting of volume repletion. Pt's infections were treated and pt was diuresed aggressively with resolution of pulmonary edema at time of discharge. Tracheostomy tube placed on [**9-26**]. Secretions continued to be a problem so t-tube kept in place. # [**Last Name (un) **]: baseline Cr of 1.8-2, which slowly rose to 4.6. Etiology was believed to be ATN secondary to hypotension in setting of septic shock. Renal functions improved with creatinines trending towards baseline (baseline is 1.8-2.0, at time of discharge was 2.3). Home lasix, glyburide, flomax, lubripristone, fenofexadine, verapamil held. ##. NSTEMI: Pt showed no ischemic EKG changes in the ED but cardiac enzymes were noted to be positive with a CK of 1836, CKMB 230, CKMBI 12.5, troponin 0.06. TWI in I, avL, q in Lead III, small R-wave and aVF inferiorly. Pt ruled in, likely ischemic from his prolonged episode of hypotension. Aspirin was initially held as pt had been started on xygris, but asa was restarted once xygris course completed. In future could consider adding ace inhibitor as renal function resolves. Did not start beta blocker given episodes of bradycardia. ##. Bradycardia: Pt noted to be bradycardic, requiring atropine in the field for HR in the 40s. Bradycardia initially thought to likely be due to his hypothermia. However, had additional episodes of sinus bradycardia periodically, particularly in the evening. Improved during hospital course, with patient maintaining normal sinus rhythm with regular rate at time of discharge. # Anemia: pt??????s hematocrit trended down throughout first few days of admission. Likely [**1-20**] aggressive fluid hydration. Pt does also have h/o peptic ulcers, and was on xygris which increases risk of GIB, however, stool and NG aspirate both guiac negative, there was no evidence for RP bleed or intracranial bleed. Pt was maintained on PPI and active type and screen maintained. Pt was transfused one unit on [**9-14**] and his hematocrit did bump appropriately. Anemia thought to be secondary to renal failure. Was not actively bleeding and HCT was stable at time of discharge. #. Hypothyroidism: continued on home levothyroxine . #Schizophrenia: Intially held clozaril and perphenazine while intubated and sedated. Pt was then started on linezolid so clozaril and perphenazine were held for concern for seratonin syndrome. Linezolid course was completed on [**9-26**]. Clozaril should be held another 2 weeks, at least, and could be restarted on [**10-10**] as long as patient is not sedated. Can be continued on perphenazine per home dose. . #COPD: continue atrovent and albuterol prn, usually on nebs but switched to inh while intubated. . #? adrenal insufficiency: on dexamethasone 2mg at home, hydrocortisone was initially started at stress doses and then weaned down and eventually transitioned back to dexamethasone. Pt can follow up c his PCP regarding whether he will need to continue dexamethasone (this diagnosis is very recent and did not seem definite based on OSH records). . # DM: Pt with known DM type 2. Initially placed on insulin drip as it was felt that his skin was likely too edematous to get good absorption of sc insulin (target range for gtt was 150-200). After diuresis pt was placed on sc insulin. # SW: SW consulted for regarding safety of pt's living situation. They felt that placement at home would not be a good idea and should go to rehab and be further evaluated for placement at time of discharge from rehab. # Prophylaxis: Subcutaneous heparin , bowel reg # Code: FULL PCP Dr [**Last Name (STitle) 84660**] [**Telephone/Fax (1) 24017**] Medications on Admission: per pt list: lasix 40 [**Hospital1 **] levothyroxine 50 mcg daily glyburide 2.5 daily amitiza 24 mcg (lubiprostone) flomax 0.4 mg fexofenadine verapamil 120 perphenazine 4 clozaril 200 (recent dc summary says 100??) asa 81 centrum "Cenna plus?" dexamethasone 2mg atrovent nebs albuterol nebs Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Perphenazine 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 6. Levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Dexamethasone 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 9. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 11. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation QID (4 times a day). 12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: 1) Uro/pneumo sepsis 2) Ventilator acquired pneumonia 3) S/p tracheostomy and PEG tube placement Discharge Condition: Stable for discharge to rehab. Good saturation on 60% FiO2 via T-tube. Discharge Instructions: You were admitted to the ICU because you had a severe infection in your urine and in your lungs that caused your blood pressure to fall. While in the ICU, we treated you for this by giving you fluids and giving you antibiotics (linezolid and meropenem) for these infections, of which you completed the course. Because you had trouble breathing, we started you on a breathing machine. Over the course of several days, your infection began to clear, your fevers improved, and your blood pressure returned to normal. You were also getting better at breathing so we took you off the ventilator and put in a tracheostomy, which allows us to give you oxygen safely. When you go to rehab, they will assess you daily to see when your tracheostomy can be safely removed or whether your PEG tube can come out once you can safely take food by mouth. . The following medication changes were made: (1) Because of renal failure, we stopped your lasix. As your renal failure begins to clear, this can be restarted. (2) We stopped your glyburide because of your renal failure. (3) We stopped your home dose of flomax because of your renal failure. (4) We stopped your verapamil b/c of your renal failure. (5) we Stopped your clozaril, because in combination with the linezolid, this can cause your white blood cell count to drop. You can restart clozaril on [**10-10**]. (6) You should continue to take perphenazine 4 mg [**Hospital1 **] as at home; this can also be given PRN for agitation. (7) You should start lansoprazole which protects your stomach from getting irritated. Followup Instructions: 1) Monday, [**2121-10-27**] you should follow up with Pulmonary with Dr [**Last Name (STitle) 2168**]. His office is located on the [**Location (un) **] in the [**Hospital Ward Name 23**] building. (2) Please follow up with renal on Tues [**2123-11-11**] AM with Dr [**Last Name (STitle) **]. This is located in the [**Hospital Ward Name 23**] building on the [**Location (un) **]. (2) You should follow up with your primary care physician and your outpatient psychiatrist within 1 month of discharge. You will need to have these appointments scheduled. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2121-10-1**]

Admission Date: [**2197-1-6**] Discharge Date: [**2197-1-13**] Date of Birth: [**2145-2-12**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2197-1-8**] Urgent coronary artery bypass grafting x2 left internal mammary artery to left anterior descending coronary artery and reversed saphenous vein single graft from the aorta to the posterior descending coronary artery. Endoscopic left greater saphenous vein harvesting. History of Present Illness: 51 year old male has a history of coronary artery disease and had an angioplasty and stent in 9/[**2185**]. He also has a history of hypercholesteremia and had exertional chest pain for the past 4-5 days which resolved with rest. He presented to his PCP [**12-29**] and was referred to Dr. [**Last Name (STitle) **]. He had a cardiac cath at LGH yesterday which revealed: LAD: 80-90%, RCA: dom., 70% [**Last Name (un) 2435**]., and a LVEF of 55%. He was transferred [**Hospital1 18**] for surgical evaluation. Past Medical History: hypercholesteremia CAD-s/p PTCA and stent to LAD in [**9-/2185**], s/p cardiac cath [**5-/2190**] h/o postoperative seizures after SDH s/p R subdural hematoma with evacuation [**1-2**] Social History: Lives with: Wife and daughter Occupation: auto mechanic Cigarettes: Smoked yes last cigarette 25 yrs ago Hx: 10 pk yr ETOH: [**3-7**] drinks/week Family History: Father MI < 55 [x] 2 brothers with CABG in their 40's. Physical Exam: Pulse:97 Resp: 18 O2 sat: 97% on 2 liters NC B/P Right: 111/63 Left: Height: 5'3" Weight: 184 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _no____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2197-1-10**] 08:44AM BLOOD WBC-8.3 RBC-3.95* Hgb-12.7* Hct-34.8* MCV-88 MCH-32.1* MCHC-36.4* RDW-12.8 Plt Ct-141* [**2197-1-9**] 09:25PM BLOOD WBC-7.7 RBC-4.07* Hgb-12.4* Hct-35.8* MCV-88 MCH-30.4 MCHC-34.6 RDW-12.9 Plt Ct-132* [**2197-1-9**] 01:43AM BLOOD WBC-7.5 RBC-4.14* Hgb-12.6* Hct-36.2* MCV-87 MCH-30.5 MCHC-34.9 RDW-12.8 Plt Ct-145* [**2197-1-10**] 08:44AM BLOOD Glucose-127* UreaN-18 Creat-0.9 Na-133 K-4.1 Cl-97 HCO3-29 AnGap-11 [**2197-1-9**] 09:25PM BLOOD Glucose-136* UreaN-14 Creat-1.0 Na-134 K-4.4 Cl-100 HCO3-27 AnGap-11 [**2197-1-9**] 01:43AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-136 K-4.3 Cl-103 HCO3-25 AnGap-12 [**2197-1-8**] 12:56PM BLOOD UreaN-10 Creat-0.8 Na-137 K-4.0 Cl-107 HCO3-26 AnGap-8 [**2197-1-11**] 01:00PM BLOOD WBC-8.2 RBC-3.84* Hgb-11.8* Hct-34.4* MCV-90 MCH-30.8 MCHC-34.4 RDW-12.6 Plt Ct-139* [**2197-1-12**] 06:30AM BLOOD UreaN-21* Creat-0.8 Na-135 K-4.3 Cl-99 TTE [**2197-1-8**] Pre Bypass: The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch and the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post Bypass: Patient is A paced on phenylepherine infusion. Preserved Biventricular function. LVEF 55%. Aortic contours intact. Remaining exam is unchanged. Cardiology Report ECG Study Date of [**2197-1-8**] 2:38:02 PM Sinus rhythm. Inferior T wave inversions in leads III and aVF, possibly non-specific, although cannot exclude inferior non-Q wave myocardial infarction. Compared to the previous tracing of [**2197-1-7**] there is no interval change. Intervals Axes Rate PR QRS QT/QTc P QRS T 92 154 88 [**Telephone/Fax (2) 92045**] -19 Brief Hospital Course: Transferred in for surgical evaluation on [**1-6**] and was stable overnight until the next day when he started to have chest pain. Intravenous nitro and heparin were instituted, but they had to be titrated up for recurrent chest pain. It was felt that the he should proceed with coronary revascularization on [**1-8**] due to recalcitrant chest pain on maximal medical therapy. He was brought to the operating room on [**1-8**] where the patient underwent urgent coronary artery bypass grafting. See operative report for further details. Overall the he tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. In the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. On post operative day one he was started on betablockers for heart rate and lasix for diuresis, both were adjusted over the next few days. His pain medication was adjusted for improved pain control with good response. He was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The he was evaluated by the physical therapy service for assistance with strength and mobility. He continued to require intravenous diuresis for volume overload and remained until post operative day five when he was ambulating on room air with oxygen saturations 92-96 %, He was discharged home with services in good condition with appropriate follow up instructions and to continue on oral lasix, plan for follow up wound check thrusday [**1-19**]. Medications on Admission: SL NTG PRN Atenolol 50 mg PO daily Simvistatin 40 mg PO qhs Imdur 30 mg PO daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 3. 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:*1* 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 9. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 2 weeks. Disp:*14 Capsule, Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Coronary artery disease s/p cabg Unstable angina Hypercholesteremia postoperative seizures after Subdural hematoma Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace bilateral lower extremities Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments [**Hospital **] medical building [**Apartment Address(1) **] A cardiac surgery office Wound Check [**Telephone/Fax (1) 170**] on [**2197-1-19**] 10:15 Surgeon: Dr. [**Last Name (STitle) 914**] [**Name (STitle) 766**] [**Telephone/Fax (1) 170**] on [**2197-2-20**] 1:15 Cardiologist:Dr. [**Last Name (STitle) **] [**2-7**] at 12:00pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 32668**] in [**5-3**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2197-1-13**]

Admission Date: [**2146-9-9**] Discharge Date: [**2146-9-19**] Date of Birth: [**2079-1-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Dyspnea, dysphagia Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Mrs. [**Known lastname **] is a 67 yo female with PMH significant for hypertension, type II diabetes and hypercholesterolemia presenting with 3 weeks of worsening shortness of breath and one week of difficulty swallowing, sent over from PCP's office to ED for worsening dyspnea. In regards to the shortness of breath, she notes that she has had increasing dyspnea on exertion, getting winded going from bed to the bathroom, resolving with rest. She notes that she has had difficulty breathing at other times but never this bad. She denies shortness of breath at rest. She describes the shortness of breath as the feeling that she cannot get enough air in. She also notes her legs have been increasingly swollen over the past three weeks. She has [**1-19**] pillow orthopnea ("I sleep sitting up"), also with paroxysmal nocturnal dyspnea. She denies chest pain, palpitations, nausea, vomiting, dizziness and lightheadness, nocturia. In terms of the dysphagia, she notes feeling difficulty swallowing solids since coming back from a trip on the 10th of the month. She describes this as "just cannot get food down from my mouth." She denies pain and cannot localize where food feels stuck. She has been eating soups, juice, tea for the past several weeks and feels this has irritated her stomach, causing some RLQ pain. She denies regurgitation, halitosis, or GERD. . In the ED, initial vs were: T96.8 P106 BP109/64 R18 98%O2 sat. Patient was given 20mg lasix x1, 3 baby aspirin (patient took one at home), 4000 unit heparin bolus, heparin gtt @ 1000 units per hour for ? NSTEMI. . On the floor, vitals were T95.5 P106 BP 110/72 RR18 99% on O2 sat, FSG 348. She was resting comfortably on the floor . Review of sytems: (+) cough, shortness of breath, edema, PND, [**1-19**] pillow orthopnea, dysphagia (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. Type II diabetes-diagnosed in [**2134**], HgA1c in [**4-26**] was 6.3%, checks blood sugars one time a day 2. Hypertension-diagnosed in [**2128**] 3. Hypercholesterolemia 4. S/p cataract surgeries, OS [**2141**] and OD [**2143**] Social History: Patient is retired since [**2139**] from Met Life. She lives in a senior center in [**Location (un) 686**] and has a vibrant social life. She enjoys walking, shopping, doing senior center activities. She has been divorced for many years. Currently not sexually active. Admits to drinking beer ([**11-19**] a week) and has a 10 pack-year smoking history (she quit 25 years ago). Denies illicit drug use. Says she enjoys walking (10,000 steps on pedometer) and recently bough a bicycle. One son, 43yo, in good health, with 6 children, lives in [**State 531**]. She reports she has been on the "fat burning" diet for the past year--vegetables, fruits, etc. Family History: Mother and father both passed away from MIs at age 85. She is one of 8 children. Siblings history notable for asthma, diabetes. 1 sister with breast cancer, 1 brother with coronary artery disease. Physical Exam: T95.5 P106 BP 110/72 RR24 99% on O2 sat weight - 92.85 kgs General: Alert, oriented, pleasant obese woman, appears younger than stated age, no apparent distress HEENT: Sclera anicteric, PERRLA, EOM intact, peripheral field cuts in superior fields bilaterally, MMM, oropharynx clear Neck: supple, JVP elevated to 10cm H2O, no LAD Lungs: crackles at the bases bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, obese abdomen, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses bilaterally, 2+ pitting edema bilaterally to knees Skin: no rash on exposed surfaces Neuro: CNII-XII intact, alert and oriented x 3 Motor: 5/5 strength UE and LE bilaterally Sensation: intact to light touch in UE and LE DTR: 2+ patellar, biceps tendon reflexes Coordination: intact finger to nose Gait: not assessed ----- ON DISCHARGE ----- weight: 85.4 kgs Gen: alert, lying flat in bed at 30 degrees, NAD HEENT: supple, no carotid bruits noted, JVD to 5cm with pt at 30 degrees CV: RRR, tachy, no M/R/G RESP: creackles [**11-21**] Left > right. [**Month (only) **] BS. ABD: soft, NT, pos bs EXTR: [**11-19**]+ pitting edema to knees NEURO: A/O Pulses: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Skin: intact Pertinent Results: Admission labs: [**2146-9-9**] 10:20AM BLOOD WBC-7.3 RBC-4.43 Hgb-11.9* Hct-36.0 MCV-81* MCH-26.9* MCHC-33.1 RDW-16.5* Plt Ct-308 [**2146-9-9**] 10:20AM BLOOD Neuts-71.7* Lymphs-23.2 Monos-4.5 Eos-0.3 Baso-0.2 [**2146-9-9**] 05:10PM BLOOD PT-14.7* PTT-121.6* INR(PT)-1.3* [**2146-9-9**] 10:20AM BLOOD Glucose-361* UreaN-24* Creat-1.4* Na-129* K-4.8 Cl-94* HCO3-22 AnGap-18 [**2146-9-9**] 10:20AM BLOOD CK-MB-NotDone proBNP-9783* . Cardiac enzymes: [**2146-9-9**] 10:20AM BLOOD CK(CPK)-78 [**2146-9-9**] 10:20AM BLOOD cTropnT-0.24* [**2146-9-9**] 03:15PM BLOOD CK(CPK)-64 [**2146-9-9**] 03:15PM BLOOD CK-MB-NotDone cTropnT-0.27* [**2146-9-10**] 02:20AM BLOOD CK(CPK)-94 [**2146-9-10**] 02:20AM BLOOD CK-MB-NotDone cTropnT-0.22* [**2146-9-10**] 09:40AM BLOOD CK-MB-7 cTropnT-0.27* [**2146-9-10**] 09:40AM BLOOD ALT-124* AST-50* CK(CPK)-110 AlkPhos-48 TotBili-PND . CXR [**9-9**]: Bibasilar opacities concerning for consolidation with likely underlying right greater than left bilateral pleural effusions. LHC/RHC [**9-13**]: 1. Selective coronary angiography of this right dominant system revealed diffuse 2 vessel obstructive coronary artery disease. THe LMCA had a 50% ostial stenosis. The LAD had diffuse calcified disease with a mid subtotal occlusion. The LCX had no significant stenoses. The RCA was occluded in the mid portion, with the distal vessel filling via collaterals from the LAD. 2. Resting hemodynamics demonstrated elevated right sided filling pressures with a RVEDP of 24 mm Hg. Pulmonary artery pressures were elvated at 65/35 mm Hg. The wedge pressure was markedly elevated at a mean of 43 mm Hg. Calculated ardiac output and index were low at 3.8 L/min and 2 L/min/m2, respectively, using an assumed oxygen consumption of 125 ml O2/min/m2. The SVR was increased at 1432 dyne s/cm5. 3. Unsuccessful attempt to cross the mid LAD occlusion with a 1.5 x 9 balloon. . FINAL DIAGNOSIS: 1. 2 vessel obstructive coronary artery disease. 2. Markedly elevated right sided and wedge pressures, consistent with severe heart failure. 3. Unsuccessful PCI attempt of the mid-LAD. . TTE [**9-12**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis with relative preservation of the basal inferolateral and lateral walls (LVEF = 20-25 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([**11-19**]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Severe biventricular systolic dysfunction c/w multivessel CAD or other diffuse process. Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. No pericardial effusion. . CAROTID DOPPLER [**9-16**]: Impression: Right ICA stenosis <40%. Left ICA stenosis <40%. . BLE ULTRASOUND [**9-10**]: IMPRESSION: No DVT in either lower extremities. . CXR [**9-14**]: IMPRESSION: Overall unchanged appearance of bilateral pleural effusions and pulmonary vascular congestion. Brief Hospital Course: # Cardiomyopathy: ?Tachycardia/AT mediated vs. ETOH related with CHF exacerbation: Upon arrival to the floor, the patient was consistently dyspneic with as little exertion as ambulating from her bed to the bathroom. She was mildly tachypneic, but oxygen saturation was stable, and there was low index of suspicion for pulmonary embolism. Furthermore, she had already been empirically placed on heparin for concern over her elevated cardiac biomarkers. With more aggressive diuresis, the patient's shortness of breath and peripheral edema improved dramatically. She underwent left and right heart catheterization. Heart cath showed diffuse 3VD with no intervenable targets. Mid LAD near total occlusion was too tight to thread balloon through. She was seen by CT-surgery (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]) who felt that she had poor targets for surgical revascularization, and should be treated medically. Patient was admitted to CCU for further diuresis. She responded well to IV lasix boluses and did not require pressor support for adequate diuresis. Oxygen requirements were quickly weaned down to zero and the patient was transferred to the floor. She continued to diuresis well, ultimately requiring lasix IV + metolazone PO to continue diuresis. On discharge the patient had mild rales in the lung bases bilaterally. She was transitioned to PO lasix, BB, ACEI. She was noted to have frequent episodes of rapid atrial tachycardia, sometimes lasting hours, while on the floor. She will be seen by Dr. [**Last Name (STitle) **] as an outpatient to determine whether she would benefit from AT ablation (if potentially causing tachy-mediated myopathy) . Patient may eventually require ICD placement given EF 20-25%. Unclear if her cardiomyopathy is [**12-20**] ischemia (unlikely given no prior infarcts) vs. tachy-mediated as above, or ETOH (prior history of substantial ETOH abuse many years ago), in which case under SCD-HEFT criteria the patient should have NYHA II/III symptoms in order to merit ICD placement. Repeat echo in 3 mos. and follow up as outpatient to reassess sx to see if ICD placement is warranted. . # CAD: The patient's cardiac enzymes featured elevated troponins and normal CK/MB's. Her EKG did not have any new ischemic changes, but had signs consistent with prior MI. Given the patient's female gender, diabetes, and evidence of prior MI with no history of chest pain, there was concern that the patient could have potentially suffered an NSTEMI. For this reason and given the patient's high TIMI score, she was started on a heparin gtt. TTE demonstrated global hypokinesis and a left ventricular ejection fraction of 20-30%. LHC/RHC revealed no evidence of acute MI but did show severe diffuse 3VD. No intervention was possible. CT Surgery was consulted but felt that as the patient had no appropriate sites for touchdown, CABG was not warranted. Patient will be continued on maximal medical therapy. - statin, ASA, BB, ACEI . # Dysphagia: The patient complained of having food stuck high in her throat. This only applied to solid foods, as liquids were able to go down fine. The patient was ordered to undergo barium swallowing study after her cardiopulmonary status improved. The barium study revealed passive swallowing with no mechanical obstruction and normal motility. . # [**Last Name (un) **]: The patient's admission labs featured a BUN/creatinine of 24/1.4. Her baseline as of [**2146-4-18**] was 12/0.9. The [**Last Name (un) **] was believed to be secondary to decreased effective circulating volume and diuresis. With further diuresis, the patient's renal function stabilized. . # Hyponatremia: The patient had hypervolemic hyponatremia on arrival, with initial serum sodium of 129. Low Na poor prognostic sign in CHF. Sodium somewhat improved during course of admission. D/c Na was 130. . # Hypertension: Upon admission, the patient's blood pressure was stable in the high 90s-low 100's overnight. Diuresis was initiated in the ED, but the patient received a small fluid bolus for tachycardia. Her ACE inhibitor and beta blocker were initially held, both for preventing worsening [**Last Name (un) **] and to allow the blood pressure to stay high enough to provide adequate diuresis. Ultimately BB + ACEI were started to control BP before discharge. . # Diabetes mellitus: The patient's oral hypoglycemics were initially held, and she was started on a humalog sliding scale. Fingerstick blood sugars were high from 180-250, and patient was started on a basal dose of insulin glargine 10 units qhs. HbA1c 7.9% during hospitalization. This will be controlled by the [**Name6 (MD) 228**] primary MD, Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 16258**]. Medications on Admission: actos 30 mg tab once daily furosemide 20 mg once daily (per PCP, [**Name10 (NameIs) **] takes this only sometimes) torsemide (dose unknown); per patient, she takes this once/month lotrel (amlodipine-benazepril) 5mg-40mg capsule once daily metformin 1000 mg QAM, 500 QPM ASA 81mg Discharge Medications: 1. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Acute on chronic Systolic congestive heart failure Hypertension Diabetes Mellitus Atrial Tachycardia Discharge Condition: weight 85.4 kg Rhythm, atrial tachycardia Discharge Instructions: You had an exacerbation of congestive heart failure, that means your heart is not pumping well and the fluid backed up behind the heart leading to trouble breathing and swelling in your legs. You will need to take all of your medicines every day, follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] to prevent this from happening again. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if your weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liters or about 8 cups of fluid. . Medication changes: 1. STOP taking Actos, Lotrel and Metformin 2. Start gluburide, a diabetes medicine that is better for your heart 3. Start taking Furosemide (Lasix) every day to prevent fluid buildup 4. Start Metoprolol: a medicine to slow your heart rate 5. Start taking a full 325mg aspirin every day 6. Start taking simvastatin, a medicine to lower your cholesterol 7. Start taking Lisinopril, a medicine to lower your blood pressure and help your heart work better. 8. Start taking Omeprazole, a medicine to reduce indigestion Please call Dr. [**Last Name (STitle) **] if you have trouble lying flat to sleep, if your legs start to swell again or if you get short of breath with walking. Call Dr. [**Last Name (STitle) 16258**] if you have any fevers, increasing cough, a racing pulse or any other concerning symptoms. ***Please speak to Dr. [**Last Name (STitle) **] about a cardiac rehabilitation program. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2146-9-20**] 1:20 . Primary Care: [**Last Name (LF) **],[**First Name3 (LF) 11595**] R. Phone: [**Telephone/Fax (1) 19196**] Date/Time: [**9-27**] at 1:30pm. . Cardiology: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 62**] [**Hospital Ward Name 23**] clinical Center, [**Location (un) 436**]. [**Hospital Ward Name 516**], [**Hospital1 18**]. Date/Time: [**11-2**] at 9:20pm. Office will call you with an earlier appt. . Diabetes: Dr. [**Last Name (STitle) 83286**], MD [**2146-9-20**] 1:30pm [**Last Name (un) 3911**], [**Location (un) 17879**] Phone: [**Telephone/Fax (1) 2378**] . Electrophysiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: Wednesday [**12-21**] at 11:00am. [**Hospital Ward Name 23**] clinical Center, [**Location (un) 436**]. [**Hospital Ward Name 516**], [**Hospital1 18**]. Office will call you with an earlier appt. Completed by:[**2146-9-19**]

Admission Date: [**2190-6-3**] Discharge Date: [**2190-6-7**] Date of Birth: [**2126-9-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9180**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catherization with stenting to right coronary artery History of Present Illness: This is a 63 year-old male with history of type 2 diabetes mellitus and ESRD on hemodialysis who was admitted to the CCU after an NSTEMI. He had intially presented to [**Hospital 1474**] Hospital emergency department with 4 to 6 hours of crushing chest pain and shortness of breath that occurred while he was watching television. He rated the pain [**9-16**] and reports that it did not radiate. The pain was accompanied by diaphoresis, nausea, vomiting, and severe shortness of breath. He called EMS for further assistance. He received 3 sublinqual nitroglycerin and IV lasix with relief of the pain. On arrival to [**Last Name (LF) 1474**], [**First Name3 (LF) **] EKG showed ST depressions in the anterolateral leads with inverted T waves. A chest x-ray was notable for pulmonary edema. He had elevated cardiac enzymes. He received plavix and heparin and was transfered to the [**Hospital1 18**]. He underwent cardiac catherization that reveal 3 vessel disease. A stent was placed in the right coronary. He was transfered to the CCU. with the goal of CABG with LIMA-LAD and SVG-diagnol. On arrival to the CCU, he was chest pain free. Past Medical History: 1. Type 2 Diabetes 2. End stage renal disease on hemodialysis 3 times per week. He does make some urine. 3. Chronic obstructive pulmonary disease. 4. Hypertension 5. Status post stroke Social History: He is separated from his wife. [**Name (NI) **] has not worked for the past three years but used to be employed as a salesman. He has an 80 pack year tobacco history and smokes 2.5 packs per day. He had six bloody [**Doctor First Name **] on the day prior to admission but reports that he does not normally drink alcohol. He denies IV drug use. Family History: He is unsure of what diseases run in his family. He reports that his parents had "all the big diseases." His brother had an aneurysm. He reports that his sister has inner ear troubles. Physical Exam: Vitals: Temperature:100.3 Pulse:92 Blood Pressure:110/69 Respiratory Rate:17 Oxygen Saturation:95% 2L nasal cannula General: Tired appearing man resting in bed. Alert and oriented in no acute distress. HEENT: Pupils equal and reactive, extraoccular movements intact, anicteric sclera, mildly dry mucous membranes, poor denition. Cardiac: Regular rate and rhythm, S1 S2, without murmurs, rubs, or gallops. Bilateral carotid bruits. No jugular venous distension. Pulmonary: Mild expiratory wheezes anteriorly and laterally. Abdomen: Soft, normoactive bowel sounds, mild right upper quadrant tenderness without rebound orguarding. Extremities: No cyanosis or edema, feet cool bilaterally, 1+ dorsalis pedis pulses bilaterally, sheath in place in right groin. Neuro: Alert and oriented. Pertinent Results: Hematology: WBC-12.6 Hgb-11.7 Hct-34.2 Plt Ct-196 . Chemistries: Na-137 K-4.2 Cl-94* HCO3-28 UreaN-26 Creat-4.5 Glucose-141 . Coagulation: PT-26.5 PTT-67.3 INR(PT)-2.7 . Liver Function: ALT-23 AST-155 AlkPhos-63 Amylase-96 TotBili-0.5 Albumin-4.0 . Lipid Panel: Triglyc-206 HDL-69 CHOL/HD-2.5 LDLcalc-65 . Diabetes: %HbA1c-6.1 . VitB12-312 . Phenytoin-1.7 . Urinalysis with 500 protein and 100 glucose otherwise dipstick negative. . EKG: 1. On admission to [**Hospital1 1474**]: sinus tachycardia at 113, STE V1, STD in I, II, III, aVF, V3-V6, TWI II, III, aVF, V4-V6 (new) 2. At [**Hospital1 18**]: Normal sinus at 94, nl axis, STE in V1, V2, STD I, II, V3-V6, TWI V3-V6, LVH 3. Post procedure: Normal sinus at 85, nl axis, STE V1, V2, V3, STD I, V4-V6, TWI V4-V6, LVH . Liver Ultrasound: Normal Study. . Cardiac Catherization: Right dominant circulation. The LMCA was short and heavily calcified with a distal taper. The LAD had a proximal eccentric 80% lesion and the distal vessel had a tubular 70% lesion. Numerous diagonal arteries were without critical lesions. The left circumflex was a non-dominant vessel with heavy calcifications. Only a ramus was seen and it was occluded proximally. The RCA was a dominant vessel with a proximal 99% lesion. The abdominal aorta was found to have moderate diffuse disease with iliac aneurysmal dilation and poor distal flow to the CFA. The RCA was stented with a 3.0 x 18 Cypher. The final residual was 0% with normal flow. . Echocardiogram: EF of 40-45% with moderate global left ventricular hypokinesis. Brief Hospital Course: This is a 63 year-old male admitted with NSTEMI. . 1) NSTEMI: He was admitted with an NSTEMI. Cardiac catherization revealed three vessel disease. He had a stent placed in his right coronary. A post-catherization echocardiogram showed mildly dilated left atrium, mild global hypokinesis, and an ejection fraction of 40-45%. The initial plan was to undergo CABG to address is left circumflex and left anterior descending disease. During the pre-operative work-up, he was found to have totally occluded bilateral internal carotid arteries. Therefore, he was deemed to not be a surgical candidate. He was medically managed with aspirin, high dose statin, beta-blocker, ACE-inhibitor, and Plavix. His cardiac enzymes trended down and he had no further chest pain. He was discharged with cardiology follow-up. . 2) End stage renal disease: He was maintained on his regular Tuesday, Thursday, Saturday dialysis. He received epoetin with dialysis and was maintained on Nephrocaps and phosphate binders. His dialysis flow sheets during this admission were faxed to his outpatient dialysis center. He was discharged to continue his regular dialysis. . 3) Status post CVA: The details of his CVA are unknown. He was supposedly on dilantin, but his level was subtherapeutic. He was maintained on his outpatient dilantin while in house. He was maintained on aspirin and Plavix for secondary prophylaxis. . 4) COPD: He had no active issues. He was maintained on albuterol and Atrovent inhalers. . 5) Elevated LFT's: His elevated LFTs were thought to be secondary to alcohol intake or Statin use. A right upper quadrant ultrasound was normal, and his LFTs remained stable throughout the admission. He will need his LFTs followed as an outpatient. . 6) Diabetes: He was not taking any medications at home for his diabetes. His A1c on admission was 6.1. His sugars remained under good control with minimal coverage with an insulin sliding scale. His blood sugars and A1c should be monitored as an outpatient. . 7) FEN: He was maintained on a renal, cardiac, and diabetic diet. He was maintained on phosphate binders. . 8) Code: Full. . 9) Dispo: On the day after his catherization, he wanted to leave AMA. At the time, he was delirious and could demonstrate that he understood the gravity of his medical condition. Psychiatry evaluated him and felt that he did not have the capacity to leave AMA. He subsequently cleared his delirium. His son was involved and wanted to take the patient home with him. The patient was discharged in the care of his son who would help monitor his medications and follow-up appointments. Psychiatry also recommended behavioral neurology follow-up as well and neuropsychiatry testing. Medications on Admission: 1. Paxil 20 mg daily 2. Lopressor 50 mg [**Hospital1 **] 3. Plavix 300 mg x1 4. Protonix 5. Dilantin 400 daily 6. Nephrocaps 1 tab daily 7. Prandin 1 mg QAC 8. Lipitor 40 mg daily 9. Gemfibrozil 600 mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 5. 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* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) dose Injection ASDIR (AS DIRECTED). 8. Phenytoin 100 mg/4 mL Suspension Sig: One (1) tab PO DAILY (Daily). Disp:*30 tab* Refills:*2* 9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*60 Capsule(s)* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: NSTEMI DM 2 s/p CVA Discharge Condition: Stable. He was chest pain free with stable respiratory status. Discharge Instructions: Please seek medical attention immediately if you experience chest pain, arm pain, jaw pain, shortness of breath, nausea, vomiting, sweating, dizziness, abdominal pain, or fevers/chills. Please take all medications as prescribed. You MUST continue to take aspirin and plavix. If you stop these medications, you are at very high risk of a serious heart attack or even death. Please attend all follow-up appointments. Your dilanytin level was very low at the time of discharge and it was not clear that you were taking this medication at home. You need to have a follow up dilantin level when you see your primary care physician. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 39008**] on [**6-22**] at 1:30PM. Please follow-up with Dr. [**First Name (STitle) **] (cardiologist) on [**6-21**] at 12:45 PM in [**Hospital Ward Name 23**] 7th. Please follow-up with behavioral neurology on [**6-10**] at 1:30 PM located in [**Hospital Ward Name 860**] [**Location (un) **]: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**] Date/Time:[**2190-6-10**] 1:30 Completed by:[**2190-6-8**]

Admission Date: [**2142-6-27**] Discharge Date: [**2142-7-7**] Date of Birth: [**2096-2-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3853**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 46 yo female with PMH significant for asthma (diagnosed 7 years ago at which time she required intubation) who presented to her PCP with [**Name Initial (PRE) **] few day history of progressively worsening cough, HA and shortness of breath. The patient was in her normal state of health until the evening prior to presentation when she developed viral like symptoms with rhinorrhea, cough productive of thin yellow sputum and frontal HA. Symptoms became acutely worse the day of presentation despite went to her PCP where she was noted to be tachypneic with bilateral wheezes. Of note the patient ran out of her home albuterol and a few days ago and flovent approximately 1 month ago. She was given nebulizer treatments x 2 with no improvement prompting her PCP to send her into the emergency department. . In terms of her asthma the patient was diagnosed 7 years ago when she had an acute exacerbation requiring intubation. Since that time she has been hospitalized a several occasions most recently a few months ago. She is on albuterol PRN at home which she has been requiring more frequently (though as above she ran out of this medication recently). She was previously on flovent but stopped this medication approximately 1 month ago due to insurance issues. . In the ED, initial VS were: 97.7 102 174/102 22 99% RA. Initial peak flow 350. She was given nebulizers x 3 the started on scheduled nebs q 1 hr nebulizer treatments in addition to prednisone 60 and IV magnesium. Oxygen saturations remained stable in the high 90s. Patient continued to have significant wheezing requiring hourly nebs. Peak flow trended downward to 250 and she was admitted to the MICU for further treatment. . On arrival to the MICU, patient's VS were 98.4 104 112/99 99% RA. She noted continued wheezing but and chest pain with cough but denied recent fever, chills, abdominal pain, dysuria, visual changes, or dizziness. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Asthma - Nml PFT's in [**2135**], but previously intubated for severe asthma - Hypertension - HSV II - Depression - Bacterial Vaginosis Social History: Lives with 5 year old daughter is independent -EtoH: social -Smoking: denies -Ilicits: denies Family History: Patient reports history of HTN in her mother and her sister in addition to DM in a sister. Physical Exam: ADMISSION EXAM Vitals: 98.4 104 112/99 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Diffuse wheezes throughout Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . Discharge PE VS HR-90-100's, satting wnl on RA, BP wnl General: AAOX3, NAD HEENT: sinuses not TTP, CN 2-12 grossly intact, left side of neck TTP from C-5 to occipital protuberance CV: RRR, no RMG Lungs: clear anteriorly, posterior lung fields have end expiratory rhonchi/wheeze mostly in lower lung fields Abdomen: NTND, active BS X4, no HSM Pertinent Results: ADMISSION LABS [**2142-6-27**] 12:59PM BLOOD WBC-6.4 RBC-4.60 Hgb-13.8 Hct-39.7 MCV-86 MCH-29.9 MCHC-34.6 RDW-13.4 Plt Ct-203 [**2142-6-27**] 12:59PM BLOOD Neuts-72.0* Lymphs-16.4* Monos-4.1 Eos-7.0* Baso-0.6 [**2142-6-27**] 12:59PM BLOOD Glucose-112* UreaN-8 Creat-0.8 Na-139 K-3.1* Cl-106 HCO3-24 AnGap-12 [**2142-6-27**] 07:00PM BLOOD Calcium-8.5 Phos-2.8 Mg-2.7* [**2142-6-27**] 01:00PM BLOOD Lactate-1.2 URINE STUDIES [**2142-6-27**] 02:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 [**2142-6-27**] 02:30PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2142-6-27**] 02:30PM URINE RBC-5* WBC-6* Bacteri-NONE Yeast-NONE Epi-6 NonsqEp-<1 [**2142-6-27**] 02:30PM URINE UCG-NEGATIVE MICROBIOLOGY [**2142-6-27**] URINE URINE CULTURE-PENDING INPATIENT [**2142-6-27**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2142-6-27**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] STUDIES CXR-IMPRESSION: Similar band-like opacity suggesting minor atelectasis or scarring in the right lower lung with no definite acute disease. . H-CT [**2142-7-3**] IMPRESSION: Mild effacement of the basal cisterns and crowding of the foramen magnum is concerning for increased intracranial pressure. Mild cerebral edema cannot be excluded. Further evaluation with MRI could be helpful, if clinically indicated. . [**2142-7-3**] sinus CT IMPRESSION: Relatively mild mucosal changes in the paranasal sinuses without evidence of osseous remodeling to suggest chronic sinusitis. No evidence of acute sinusitis. . MRI/MRV brain [**2142-7-3**] IMPRESSION: 1. Normal MRI/MRV of the head, specifically without evidence of acute hypertensive encephalopathy, sinus vein thrombosis, infarct, or mass. 2. Low lying cerebellar tonsils and small syrinx in the proximal cervical cord that should be further assessed by MR [**Name13 (STitle) 2853**]. . MRI C/T/L spine [**2142-7-9**] IMPRESSION: 1. Mildly low-lying cerebellar tonsils without posterior fossa abnormality or crowding at the level of the foramen magnum. 2. Small syrinx at the C1/C2 level without evidence of associated lesion. 3. Otherwise, normal appearance of the cervical and thoracic cord, conus and cauda equina. 4. Mild degenerative changes of the lumbar spine as detailed above. . EKG [**2142-7-5**] Sinus rhythm. Leftward axis. Otherwise, normal tracing. Compared to the previous tracing of [**2142-7-3**] no change. . [**2142-7-5**] CXR IMPRESSION: New peripheral left lower lobe opacity, concerning for developing pneumonia. Brief Hospital Course: 46 yo female with a hx of asthma requiring intubation in the past who presents with wheezing and shortness of breath c/w an asthma exacerbation in the setting of a probable viral infection, medication non complaince course c/b pneumonia and headaches found to have a chiari malformation and cervical syrinx # Acute exacerbation of asthma Presentation was felt to be most consistent with an exacerbation of the patients known asthma secondary to environmental factors, URI and medication non compliance. Initially, there was no e/o PNA on CXR (see below). CP mildly concerning for ACS though normal EKG and TnI is reassuring. Pt does not have risk factors for PE. As above she initially required q 1 hr albuterol treatment in the ED. She was started on oral prednisone and given a one time dose of IV magnesium. She was admitted to the ICU given need for frequent treatments and history of requiring intubation. Respiratory status improved and nebulizer treatments were spaced to albuterol every 4 hours and ipratropium every 6 hours. She was additionally restarted on her home Flovent. She was transferred to the floor where her symptoms persisted. Pulmonary was consulted and they advised to add Singulair and briefly placed her on IV steroids. Her symptoms slowly improved and her peak flow improved to around 350 (reported baseline is 500). The Pulmonary team recommended a cost effective regimen including Symbicort, Spiriva and Singulair, given the patient social situation. The pharmacy was called and it was estimated that this regimen would cost about $13 dollars a month. They also recommended tapering the patients prednisone down to 20 mg until follow up with them on [**7-23**]. In addition, the patient will be set up with outpatient Allergy follow up for possible RAST testing. Smoking cessation was strongly advised. The patient left the floor multiple times, according to the nursing staff, for reasons unknown. . # Hospital acquired pneumonia Throughout the patients course she complained of a cough which was initially attributed to her asthma exacerbation. Two CXR's were checked on [**6-27**] and [**7-2**] and both were negative for an acute process. During that time the patient didn't have a fever or leukocytosis. Due to a slow recovery, a 3rd was checked on [**7-5**] and she was found to have a LLL opacity. Given that the patient had been hospitalized, she was initially started on broad spectrum coverage with zosyn. Her cough and symptoms continued to improve and as a result her coverage was narrowed to Augmentin. She remained afebrile and her WBC was stable. She will be discharged to home with 9 additional days of Augmentin to complete her course. . # subacute headaches/neck pain likely due to Chiari malformation The patient initially presented with mild headaches and then on [**2142-7-3**] she reported the "worst headache of her life" with decreased visual acuity, floaters and left upper extremity paresthesias in the setting of poorly controlled BP's in the SBP 170-150 range. As a result, a H-CT was obtained which showed a effacement of the basal cisterns and a question of cerebral edema. Neurology team was consulted and they recommended a MRI/MRV to rule out venous sinus thrombosis. These studies were done and they were without evidence of acute hypertensive encephalopathy, sinus vein thrombosis, infarct, or mass. They did show a low lying cerebellar tonsils and small syrinx in the proximal cervical cord. The Neurosurgery service was then involved and recommended MRI of the spinal cord for further evaluation which showed a small syrinx at C1/C2 and mildly low lying cerebellar tonsils. The Neurosurgery service felt that her signs and symptoms of left sided neck pain and headaches were due to her syrinx and Chiari malformation and the patient was strongly encouraged to follow up in the clinic. She was treated in house symptomatically and her headache and floaters resolved. Her only remaining symptoms toward the end of her hospitalization was left posterior neck pain/stiffness which was reproducible on exam. She was given lidocaine patches and was encouraged to use non-narcotics analgesics given her constipation. Her blood pressure was also controlled. . # HTN, poorly controlled The patient had been on blood pressure medications in the past and it appears they had been stopped for economic reasons. She was re-started on Norvasc in house to try and achieve better BP control, BB were not used due to her asthma. HCTZ was then added and her SBP were between 130-140. Further titration of her blood pressure regimen should be done as an outpatient. . # Constipation The patient was started on an aggressive bowel regimen. She had a bowel movement with the assistance of enemas and multiple medications . # Chest pain- most likely [**2-8**] to coughing. EKG was not concerning for ACS. The patient had TnI negative X3 while in house. Patient was given Tessalon pearles and Guaifenesin for cough as well as Guaifenesin with codeine to allow for better sleep at night. . # Sinus Tachycardia Likely due to anxiety about discharge and albuterol treatment throughout her course. This improved as nebulizer treatments were spaced. . # Complex social issues The patient requested social work support several times during her stay. She reported housing issues in addition to difficulty obtaining medications. SW provided her with as much support as possible and made SW support in her PCP's practice aware of these issues. In addition, they called the patients pharmacy to be sure she could get her medications with her current insurance. The pharmacy indicated that she could and the floor team faxed her prescriptions to the pharmacy. The patient indicated she did not have any medications at home, as a result I refilled all her medications. I also continually stressed the importance of good outpatient follow up. . TRANSITIONAL ISSUES - Patient should have outpatient Pulmonary follow-up ([**2-9**] weeks), Allergy (2-3 weeks), Neurosurgery (2-3 weeks) and PCP (1-2 weeks) follow up . Medications on Admission: Albuterol Sulfate 2.5 mg/3 mL (0.083 %) Neb Solution 1 ampule po q 6 h prn Ambien 10 mg Tab 1 Tablet(s) by mouth hs as needed for sleep Flonase 50 mcg/Actuation Nasal Spray 2 sp each nostril once a day Flovent HFA 220 mcg/Actuation Aerosol Inhaler 2 pffs twice a day ibuprofen 600 mg Tab 1 Tablet(s) by mouth three times a day as needed with food lorazepam 0.5 mg Tab 1 Tablet(s) by mouth twice a day as needed for anxiety Discharge Medications: 1. nebulizers Misc Sig: One (1) nebulizer Miscellaneous use as directed. Disp:*1 nebulizer* Refills:*1* 2. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. Disp:*QS for 1 month * Refills:*0* 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*QS for 1 month Cap(s)* Refills:*0* 4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please take 40 mg PO QD for one additonal day and then take 20 mg po QD until follow up with pulmonary. Disp:*QS for 1 month supply Tablet(s)* Refills:*0* 6. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:*18 Tablet(s)* Refills:*0* 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*QS for 1 month * Refills:*0* 8. Combivent 18-103 mcg/actuation Aerosol Sig: 1-2 puffs Inhalation every 6-8 hours as needed for shortness of breath or wheezing. Disp:*QS for 1 month * Refills:*0* 9. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 10. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for headache, pain. Disp:*25 Tablet(s)* Refills:*0* 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): please do not take more then 4 g of tylenol. Disp:*60 Tablet(s)* Refills:*0* 13. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. Disp:*60 Tablet(s)* Refills:*0* 14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: left sided neck pain. Disp:*QS for 1 month Adhesive Patch, Medicated(s)* Refills:*0* 15. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-8**] Sprays Nasal QID (4 times a day). Disp:*QS for 1 month * Refills:*2* 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 17. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:*QS for 1 month Powder in Packet(s)* Refills:*0* 18. Flonase 50 mcg/actuation Spray, Suspension Sig: Two (2) each nostril Nasal twice a day. Disp:*QS for 1 month * Refills:*0* 19. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for allergy symptoms. Disp:*QS for 1 month Tablet(s)* Refills:*0* 20. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Disp:*20 Tablet(s)* Refills:*0* 21. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Disp:*15 Tablet(s)* Refills:*0* 22. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for neck stiffness. Disp:*30 Tablet(s)* Refills:*0* 23. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 24. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO HS (at bedtime) as needed for cough. Disp:*QS for 1 week supply ML(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation Chiari Malformation and small cervical syrinx Hospital acquired pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 69**] with a severe asthma attack. You initially were cared for in the Intensive Care Unit so that you could receive frequent nebulizer treatments before you could be transferred to the floor. You improved with both nebulizer treatments and steroids, which you will continue for about 2 weeks. You were also placed on antibiotics for a small pneumonia. You will discharged home on antibiotics. You also devloped a severe headache and were evalauted by both the Neurology team and the Neurosurgery team. Imaging of your brain showed that you have a malformation that is likely causing your headaches. You should follow up with the Neurosurgeons as an outpatient for this. Please also follow up with your PCP [**Last Name (NamePattern4) **] [**1-8**] weeks. . Medications changes: 1) symbicort 2 puffs twice a day 2) tiotropium 1 cap inhaled daily 3) monteleukast 10 mg daily 4) prednisone 40 mg for one day then 20 mg daily until follow up with Pulmonary physicians 5) amoxicillin/clavulonate 1 tab twice a day 6) combivent 1-2 puffs Q6-8H prn wheezing 7) albuterol nebulizers prn wheezing-if you feels your heart racing please do not take as frequently 8) amlodipine 7.5 daily 9) hydrochlorothiazine 12.5 daily 10) tylenol 1000 mg Q8H, scheduled for pain 11) ibuprofen 600 mg Q6H prn moderate pain 12) oxycodone 5 mg Q6-8H prn severe pain 13) lidocaine patch QD prn for neck stiffness 14) docusate 100 twice a day for constipation 15) miralax 17 g QD prn constipation 16) bisacodyl prn constipation 17) sodium chloride nasal spray 2 sprays four times a day 18) fexofenadine 80 twice a day prn for allergic symptoms 19) cyclobenzaprine 10 Q8H prn muscle spasm 20) codein-guafenesin syrup prn cough at night Followup Instructions: Department: DIV OF ALLERGY AND INFLAM When: TUESDAY [**2142-7-10**] at 9:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9703**], RNC [**Telephone/Fax (1) 9316**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**] Campus: OFF CAMPUS Best Parking: Parking on Site Department: [**Hospital1 7975**] INTERNAL MEDICINE When: THURSDAY [**2142-7-12**] at 3:45 PM With: [**First Name11 (Name Pattern1) 2801**] [**Last Name (NamePattern4) 14773**], NP [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: NEUROSURGERY When: TUESDAY [**2142-7-17**] at 9:15 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: PULMONARY FUNCTION LAB When: MONDAY [**2142-7-23**] at 9:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2142-7-23**] at 10:00 AM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2111-2-18**] Discharge Date: [**2111-3-18**] Date of Birth: [**2037-11-1**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8850**] Chief Complaint: Mental status changes. Major Surgical or Invasive Procedure: Brain biopsy [**2111-2-23**] Central line placement [**2111-2-28**] Portacath placement [**2111-3-12**] G-tube placement [**2111-3-12**] History of Present Illness: This is a 73 year old female with history of alcohol abuse, cirrhosis, bipolar disorder, and hypothyroidism, who was transferred to [**Hospital1 18**] with mental status change, aphasia, left sided weakness and facial droop, and encephalopathy. She was found at outside hospital to have multiple brain lesions with mass effect on CT scan. Here an MRI of the head showed multiple, likely metastatic lesions of the brain. CT abd showed suspicious low attenuation lesion in dome of liver. CT head repeat showed multiple enhancing lesions including the largest in the right frontal lobe measuring 15 mm, most consistent with metastatic disease. Unchanged cerebral edema in the right frontal lobe with associated mass effect upon right lateral ventricle, and no interval development of hemorrhage or hydrocephalus. The patient underwent bipsy on 2/209 which has confirmed CNS lymphoma. Overnight ([**2111-3-3**]) the patient was transferred to the [**Hospital Unit Name 153**] after triggering for hypoxia, for closer observation given O2 sats in the 80's to low 90's while on a non re-breather venti mask. On CXR on [**2111-3-3**] the patient was found to have new collapse of the RML and RLL, in addition to enlarging pleural effusions compared to prior AP films. On repeat imaging, the RML and RLL collapse had resolved and the patient's oxygenation status improved. It is possible that the patient's hypoxia and RML/RLL collapse were due to her expanding pleural effusion or to a mucous plug. Given her improved clinical status, she was transferred back to the OMED floor. Past Medical History: - Bipolar disorder - Anxiety - Hypothyroidism - Chronic ETOH use - Left distal radial fracture in [**2110-8-22**], chronic back pain, recent fall with chin laceration and facial contusion, recent hospital admission for failure to thrive. Social History: Smokes 1 pack of cigarettes per day. There is a history of about half pint vodka per day but has stopped. She has home health aid for care for her 5 days/week. Family History: Non-contributory. Physical Exam: VITAL SIGNS: T 95.4 F, BP 94/48, HR 59, RR 20, O2sat 99% on RA. GENERAL: NAD. Oriented x3. SKIN: Full turgor. HEENT: NCAT. Sclera anicteric. Left sided facial droop improved. Thrush. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. CARDIOVASCULAR: regular, normal S1, S2. PULMONARY: No chest wall deformities. Respirations were unlabored, decreased breath sounds at bases. Crackles on right base. ABDOMEN: Soft, non-tender, slightly-distended. g-tube site clean, dry, intact. EXTREMITIES: No clubbing or cyanosis. Radial and DP pulses 2+ NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is 50. She is awake, alert, and oriented to person and hospital only. She cannot name this place or the date, season, or year. There is no right-left confusion but she cannot show me her thumb. She has psychomotor slowing. Her language apears fluent with good comprehension. Cranial Nerve Examination: Her pupils are equal and reactive to light, 3 mm to 2 mm bilaterally. Extraocular movements appears full; there is saccadic intrusion. She blinks to threat in the right, but not the left, visual field. She has a left facial droop. Corneal reflexes are intact bilaterally. Her hearing is grossly intact. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius appear strong. Motor Examination: She moves the left side less well than the right. Her muscle strengths are, in general, [**5-26**] on the right and 4+/5 on the left. Her muscle tone is normal. Her reflexes are 3+ bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is notable for grimace to pinch applied to all 4 extremities. Coordination examination does not reveal gross appendicular dysmetria. She cannot walk. Pertinent Results: Labs on admission: [**2111-2-18**] 09:35PM AMMONIA-11* [**2111-2-18**] 06:50PM URINE HOURS-RANDOM [**2111-2-18**] 06:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2111-2-18**] 06:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050 [**2111-2-18**] 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2111-2-18**] 06:08PM LACTATE-1.0 [**2111-2-18**] 06:00PM GLUCOSE-128* UREA N-19 CREAT-0.8 SODIUM-141 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [**2111-2-18**] 06:00PM estGFR-Using this [**2111-2-18**] 06:00PM ALT(SGPT)-6 AST(SGOT)-12 LD(LDH)-142 CK(CPK)-30 ALK PHOS-80 TOT BILI-0.3 [**2111-2-18**] 06:00PM CK-MB-2 cTropnT-<0.01 [**2111-2-18**] 06:00PM TSH-0.88 [**2111-2-18**] 06:00PM T3-62* FREE T4-1.2 [**2111-2-18**] 06:00PM PHENYTOIN-9.3* VALPROATE-41* [**2111-2-18**] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2111-2-18**] 06:00PM WBC-7.5 RBC-3.57* HGB-12.4 HCT-35.8* MCV-100* MCH-34.9* MCHC-34.8 RDW-12.7 [**2111-2-18**] 06:00PM NEUTS-84.3* LYMPHS-10.3* MONOS-3.6 EOS-1.3 BASOS-0.4 [**2111-2-18**] 06:00PM PLT COUNT-432 [**2111-2-18**] 06:00PM PT-14.2* PTT-28.7 INR(PT)-1.2* Labs on discharge: [**2111-3-18**] 12:00AM BLOOD WBC-3.4* RBC-2.72* Hgb-9.3* Hct-27.2* MCV-100* MCH-34.1* MCHC-34.1 RDW-14.1 Plt Ct-368 [**2111-3-18**] 12:00AM BLOOD Glucose-100 UreaN-21* Creat-0.3* Na-132* K-4.1 Cl-101 HCO3-26 AnGap-9 [**2111-3-17**] 12:00AM BLOOD ALT-37 AST-17 LD(LDH)-146 AlkPhos-60 TotBili-0.3 [**2111-3-18**] 12:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0 Tissue pathology [**2111-2-23**]: A) "-5": Gliotic brain tissue. "-4": Smear - Gliotic brain tissue. B) "-3": Gliotic brain tissue with scattered atypical round cells. "-2": Smear - Gliotic brain possibly with some necrosis. C) "-1": Gliotic brain tumor with reactive astrocytes, endothelial proliferation, and infiltration by atypical cells. "TP": Smear - Gliotic brain with atypical cells - could be met or infiltrating neoplasm. D) "+1": Gliotic brain tissue endothelial proliferation, a minute focus of necrosis, and infiltration by lymphoid cells. "+2": Smear - Gliotic brain tissue. focus of possible necrosis and heterogeneous round cell infiltrate. Favor lymphoma but would also consider inflammatory process, or metastatic neoplasm. E) "+3": High grade non-Hodgkin lymphoma, in keeping with a primary diffuse large B-cell lymphoma of the CNS, see note. "+4": Smear - Gliotic brain tissue. with heterogeneous small round cell infiltrate. Favor lymphoproliferative but would also consider inflammatory process, or other metastatic neoplasm. F) "+5":High grade non-Hodgkin lymphoma, in keeping with a primary diffuse large B-cell lymphoma of the CNS, see note. G) "Right brain lesion": Minute fragment of atypical glial cells, inflammatory cells and necrosis. The diagnostic lesion is best seen in Specimens E and F, although it is likely that there is some infiltration by lymphoma in B, C and D. Hematopathology note: (E), (F): High grade non-Hodgkin lymphoma, in keeping with a primary diffuse large B-cell lymphoma of the CNS, see note. Note: Sections E and F show similar features. There is a diffuse dense infiltrate of atypical mononuclear cells comprised of predominantly large cells, within finely dispersed chromatin and multiple small nucleoli. There are focal areas of necrosis/apoptosis, frequent mitosis as well as perivascular cuffing noted (see slide F). Reticulin stain highlights multiple vessel walls. By immunohistochemistry performed on blocks E and F, the large atypical cells are diffusely immuno reactive for leucocyte common antigen LCA (CD45) as well as pan B cell marker, CD20, and co-express bcl-6 and MUM-1. They do not aberrantly express CD10 or TdT. By MIB-1 staining, the proliferative fraction among the neoplastic cells is nearly 100%. CD3 highlights few admixed T cells. EBV encoded RNA in situ hybridization stain for [**Doctor Last Name 3271**] [**Doctor Last Name **] virus is negative. Overall, the findings are of a high grade B-cell non-Hodgkin lymphoma in keeping with a primary diffuse large B cell lymphatic of the CNS. CT head [**2111-2-18**]: Multiple enhancing cerebral lesions, with vasogenic edema surrounding the largest of these in the right frontal lobe. Findings are concerning for metastatic disease. MRI head [**2111-2-20**]: Multiple enhancing masses suggesting most likely malignant neoplasm, metastatic or primary. Diffuse white matter infiltration and cortical infiltration raises the possibility of either glial infiltration, or swelling related to recent seizure activity. ECHO [**2111-3-2**]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The anterior mitral valve leaflet is mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mitral leaflet thickening with mild mitral regurgitation. Video swallow [**2111-3-13**]: Moderate oropharyngeal dysphagia, including aspiration of thin liquid. The patient is at significant risk for aspiration of other consistency if eating too quickly. Patient should repeat bedside swallow evaluation in one to two weeks. The swallowing pattern correlates to a dysphagia outcome severity scale (DOSS) rating of 3, moderate dysphagia. Please refer to the speech therapist's note for full evaluation and recommendation. Brief Hospital Course: This is a 73 year old female with history of alcohol abuse, cirrhosis, bipolar disorder, and hypothyroidism, who was transferred to [**Hospital1 18**] with mental status change, aphasia, left sided weakness and facial droop, and encephalopathy. She was found at outside hospital to have multiple brain lesions with mass effect on CT scan. Here an MRI of the head showed multiple, likely metastatic lesions of the brain. CT abd showed suspicious low attenuation lesion in dome of liver. CT head repeat showed multiple enhancing lesions including the largest in the right frontal lobe measuring 15 mm, most consistent with metastatic disease. Unchanged cerebral edema in the right frontal lobe with associated mass effect upon right lateral ventricle, and no interval development of hemorrhage or hydrocephalus. The patient underwent biopsy on [**2111-2-23**] which has confirmed CNS lymphoma. Overnight ([**2111-3-3**]) the patient was transferred to the [**Hospital Unit Name 153**] after triggering for hypoxia, for closer observation given O2 sats in the 80's to low 90's while on a non re-breather venti mask. On CXR on [**2111-3-3**] the patient was found to have new collapse of the RML and RLL, in addition to enlarging pleural effusions compared to prior AP films. She was diuresed and started on vanc/unasyn on [**2111-3-4**] for aspiration. On [**2111-3-4**], on repeat imaging, the RML and RLL collapse had resolved and the patient's oxygenation status improved. It is possible that the patient's hypoxia and RML/RLL collapse were due to her expanding pleural effusion or to a mucous plug. Given her improved clinical status, she was transferred back to the OMED floor. The patient received a G-tube and PORT placement on [**2111-3-12**]. She also received her second round of Methotrexate chemotherapy after these procedures and Methotrexate levels followed until clear. Her renal function remained normal throughout this treatment. At the time of discharge, she is alert and oriented x 3 with increasing function of her left upper and lower extremities to 4/5 strength. She will be returning in two-weeks for her next methotrexate treatment. Medications on Admission: 1. Synthroid 88 mcg daily 2. depakote 250mg daily 3. Ativan prn 4. lasix 20mg daily 5. folate 1mg daily 6. KCl 40meq daily 7. Vit B1 100mg daily 8. Colace 100mg [**Hospital1 **] 9. Prilosec 20mg [**Hospital1 **] 10. MOM prn 11. Dulcolax prn Discharge Medications: 1. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day: Give by g-tube. Tablet(s) 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DVT prophylaxis. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: give by g-tube. 4. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection ASDIR (AS DIRECTED). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) g PO DAILY (Daily) as needed. 12. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 16. Famotidine 20 mg IV Q12H 17. LeVETiracetam 1000 mg IV BID 18. Lorazepam 0.5-2 mg IV Q4H:PRN for sz > 3 min or 3 per hour 19. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 20. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 21. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center Discharge Diagnosis: Central Nervous System Lymphoma. Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted for altered mental status and weakness and were found to have a lymphoma in your brain. This was treated with neurosurgery and two rounds of chemotherapy (methotrexate). You are scheduled to return in two weeks for your next round of chemotherapy (see appointment below). In the meantime, you will continue your physical therapy and rehabilitation. Please see you medication list for details. You are on dexamethasone, a steroid which helps with swelling in the brain. Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: You will be contact[**Name (NI) **] for follow up in two weeks for your next Methotrexate treatment. Please call [**Telephone/Fax (1) 1844**] for exact appointment and directions. Completed by:[**2111-3-26**]

Admission Date: [**2119-4-26**] Discharge Date: [**2119-4-28**] Date of Birth: [**2050-3-25**] Sex: F Service: NEUROSURGERY HISTORY: The patient underwent right occipital craniotomy for resection of tumor without interoperative complications. The patient was monitored in the Surgical Intensive Care Unit. Preoperatively the patient had bilateral left hemianopsia. PAST MEDICAL HISTORY: The patient has a past medical history of status post lung carcinoma with lung resection in 7/99, status post chemotherapy and XRT; hypercholesterolemia; gastroesophageal reflux disease. ALLERGIES: No known drug allergies. MEDICATIONS: Multivitamin, ASA 325 mg p.o. q. day. PHYSICAL EXAMINATION: On physical examination, she was afebrile. Blood pressure was 134/80, heart rate 80, respiratory rate 16, saturations 97% on room air. HEENT examination revealed no icterus. The neck was supple. The lungs were clear to auscultation. Cardiac examination revealed regular rate and rhythm. The abdomen was benign. Neurologically, the patient was awake, alert, and oriented times two following commands. Speech was fluent. Pupils equal, round, and reactive to light. Extraocular movements were full. There was no nystagmus. There was decreased right red point discrimination on the left. Hearing was intact. Motor strength was [**4-8**] in all muscle groups. There was no drift. There was negative Romberg. Sensory examination was intact to light touch and pinprick. HOSPITAL COURSE: On [**2119-4-26**], the patient underwent right occipital craniotomy for resection of tumor. There were no interoperative complications. Postoperatively, vital signs were stable. The patient was monitored in the Surgical Intensive Care Unit. Her vital signs remained stable. She was neurologically intact. Her dressing was clean, dry, and intact. She was transferred to the regular floor. She had an MRI scan which showed good resection of tumor. She was transferred to the regular floor on postoperative day #1. She was out of bed and ambulating, tolerating a regular diet, Foley catheter was discontinued, and the patient was voiding spontaneously. She was discharged to home on [**2119-4-28**]. She will return to CC-7 in seven to ten days to have staples removed. She will follow up in the Brain [**Hospital 341**] Clinic on [**2119-5-7**]. DISCHARGE MEDICATIONS: Percocet 1-2 tablets p.o. q. 4 hours p.r.n., Decadron from which she will be weaned 8 mg q. 6 hours to 2 mg b.i.d. and stay at 2 mg b.i.d., Zantac 150 mg p.o. b.i.d. DISCHARGE STATUS: Vital signs were stable. The patient was afebrile and neurologically intact at the time of discharge. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2119-4-28**] 08:49 T: [**2119-4-30**] 11:42 JOB#: [**Job Number 26473**]

Admission Date: [**2163-2-22**] Discharge Date: [**2163-2-27**] Date of Birth: [**2086-12-13**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Percocet / Lipitor / Zocor Attending:[**First Name3 (LF) 2291**] Chief Complaint: fatigue, anorexia, worsening lung lesions from imaging Major Surgical or Invasive Procedure: Bronchoscopy with biopsy and BAL Pigtail catheter placement to treat iatrogenic pneumothorax History of Present Illness: 76 year old female with h/o hypothyoidism, HTN/HLP, AAA repair in past with notable known lung adenoCA and new RLL lung mass which has enlarged in size over the last 4 months, being followed by Dr. [**Last Name (STitle) **] in oncology, who presented to Dr.[**Name (NI) 3371**] clinic today for follow-up of recent multiple ground glass opacities and recent biopsy of RL lung with c/o progressive night sweats, anorexia, weakness. Pt is being admitted directly from oncology clinic for further evaluation and inability to care for herself at home secondary to weakness. Notable results from recent biopsy revealed new squamous cell CA (different than prior adenoCA). . Regarding the patient's symptoms - noted last seen by Dr. [**Last Name (STitle) **] 3wks prior - with progressive symptoms of fatigue, wt loss (10 lb past 6 mo), NS, decreasing BP with PCP down titrating BP meds recently. Overall symptoms had started [**4-10**] mo ago with rhinorrea, dry cough, ear pain all without fevers - tx with several courses of azithromycin/levofloxacin. In addition with progressive fatigue - pt with further difficulty ambulating 50m more due to gen decreased strength, no focal symptoms, does have mild DOE without SOB at rest, productive cough/hemopytosis. Pt with general mild mid-lower back pain without any current CP complaints presently. Pt denies any current ear pain, HA, or sinus complaints. Note patient has not taken any of her home medication yet today at time of evaluation. . ROS: Denies skin changes, changes in urination or bowels, otherwise 10-point ROS is negative except as detailed above. Past Medical History: Onc PHMx: . 1. Stage I adenocarcinoma of the lung, 1.5 cm in [**2154**] (stage IA). Did not receive adjuvant therapy. Tumor harbors had a KRAS mutation and was EGFR wild-type. 2. Multiple pulmonary ground glass opacities with indolent growth pattern (unclear etiology, thought to be possible adenocarcinomas) since [**2154**]. 3. Stage I (T1c, N0, M0), ER/PR positive, HER-2/neu positive breast cancer of the left breast in [**2148**]. 4. Possible early stage squamous cell carcinoma of the lung diagnosed on [**2163-2-11**] (growing right lower lobe lesion). . TREATMENTS: 1. Status post adjuvant hormone therapy (tamoxifen) from [**2148**] to [**2150**] for her stage I breast cancer. 2. Status post right lower lobe wedge resection in [**2155-1-27**]. 3. Status post erlotinib 150 mg/day from [**4-2**] to [**2156-4-22**] (intolerant to medication due to grade [**2-6**] rash). . PMHx: . - hypothyroidism - osteoporosis - HTN - HLD - hiatal hernia and GERD - AAA s/p repair [**2132**], then [**2134**] with concurrent b/l fem-[**Doctor Last Name **] bypasses with complicated post-op course - h/o peritonitis [**2134**] - h/o SBO [**1-6**] abdominal adhesions in [**2132**] - s/p cholecystectomy [**2138**] - depression [**2153**] - Lung adenocarcinoma stage 1, s/p RLL wedge resection [**2154**], no adjuvant tx, multiple pulm ground glass opacities with very indolent growth pattern ? bronchioloalveolar carcinoma since [**2154**], s/p erlotinib - Stage 1 ER/PR+, HER2/neu + breast ca of left breast in [**2148**], s/p tamoxifen - cervical myelopathy Social History: Prior smoker. Approximately 50 pack-years. Quit in [**2140**]. Lives with husband. Married. [**Name2 (NI) **] 2 children. She is currently retired but previously worked in payroll. Family History: She has a daughter who was diagnosed with breast cancer at the age of 38. The daughter is a thoracic nurse [**First Name (Titles) **] [**Name (NI) 3372**]. Daughter has undergone genetic testing and is BRCA1 and 2 negative. There is no family history of ovarian cancer. Her father died at the age of 53 of pancreatic cancer. There is a strong family history of coronary artery disease and cerebrovascular disease. Physical Exam: VITAL SIGNS: . 98.1 150/60 69 16 100% RA Wt: 112.2 lb . GENERAL: NAD, Lying in bed. AA0 x 3. SKIN: No new rashes. HEENT: No lesions. Anicteric sclerae. Oropharynx is clear. No palor or jaundice. NECK: Supple, No LAD. CHEST: no crackles, mild end exp wheezing in R fields, otherwise clear. CARDIAC: Regular rate and rhythm. [**12-10**] hsm, no r/g ABDOMEN: Soft, nontender, and nondistended, noted old scars, BS+. EXTREMITIES: No edema. Pulses symmetric. PHYSCH: Normal affect. NEURO: Non-focal motor exam, motor strength 5+ in upper and lower extremities, sensory exam symmetric. Pertinent Results: MR HEAD W & W/O CONTRAST Study Date of [**2163-2-23**] IMPRESSION: Stable MRI examination of the brain with no evidence of leptomeningeal disease. [**2163-2-25**] - bronchoscopy report Impression: 76 year old woman with history of squamous cell carcinoma of the lung now with new lung mass, underwent flexible bronchoscopy with transbronchial biopsies under fluoroscopy, and bronchoalveolar lavage, also endobronchial ultrasound with transbronchial needle aspiration. Transbronchial biopsies taken from the right middle lobe lateral segment, and right upper lobe anterior segment. BAL taken from right upper lobe anterior segment. TBNA taken from station 7. Patient tolerated the procedure well, with no complications. Recommendations: Follow up with Dr [**Last Name (STitle) 3373**] on [**3-3**] Follow up cytology and pathology [**2163-2-22**] 02:25PM BLOOD WBC-13.0* RBC-3.12* Hgb-9.2* Hct-28.0* MCV-90 MCH-29.4 MCHC-32.8 RDW-12.5 Plt Ct-402 [**2163-2-23**] 06:00AM BLOOD WBC-13.7* RBC-3.14* Hgb-9.2* Hct-28.4* MCV-90 MCH-29.2 MCHC-32.3 RDW-12.6 Plt Ct-430 [**2163-2-23**] 06:00AM BLOOD Neuts-69.3 Lymphs-12.6* Monos-6.6 Eos-10.9* Baso-0.6 [**2163-2-24**] 11:15AM BLOOD PT-12.9* PTT-26.6 INR(PT)-1.2* [**2163-2-22**] 02:25PM BLOOD ESR-107* Gran Ct-[**Numeric Identifier 3374**]* [**2163-2-22**] 02:25PM BLOOD UreaN-16 Creat-0.8 Na-126* K-5.0 Cl-94* HCO3-20* AnGap-17 [**2163-2-23**] 06:00AM BLOOD Glucose-106* UreaN-11 Creat-0.9 Na-132* K-4.3 Cl-101 HCO3-20* AnGap-15 [**2163-2-24**] 06:06AM BLOOD Glucose-105* UreaN-11 Creat-0.9 Na-133 K-4.5 Cl-102 HCO3-21* AnGap-15 [**2163-2-22**] 02:25PM BLOOD ALT-12 AST-17 AlkPhos-82 TotBili-0.3 [**2163-2-22**] 02:25PM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.3 Mg-2.0 [**2163-2-22**] 02:25PM BLOOD RheuFac-10 [**2163-2-23**] 11:00AM BLOOD B-GLUCAN-negative [**2163-2-23**] 11:00AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Negative URINE CULTURE (Final [**2163-2-23**]): <10,000 organisms/ml. ____________________________________ PENDING: Pathology Tissue: RIGHT MIDDLE LOBE MASS Cytology TBNA EBUS 7 Cytology BRONCHIAL WASHINGS [**2163-2-22**] BLOOD CULTURE, Routine-PENDING [**Last Name (LF) 831**],[**First Name3 (LF) **] [**2163-2-22**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY [**2163-2-25**] 2:30 pm BRONCHOALVEOLAR LAVAGE RIGHT UPPER LOBE BAL. GRAM STAIN (Preliminary): 1+ PMN's, no organisms. RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora ACID FAST SMEAR (Preliminary): negative direct AFB smear, concentrated smear pending ACID FAST CULTURE (Preliminary): pending FUNGAL CULTURE (Preliminary): pending . Urine studies: [**2163-2-22**] 03:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2163-2-22**] 03:10PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [**2163-2-22**] 10:54PM URINE Hours-RANDOM Creat-47 Na-80 K-17 Cl-75 [**2163-2-22**] 10:54PM URINE Osmolal-350 Brief Hospital Course: 76 year old female with h/o hypothyoidism, HTN/HLP, AAA repair in past, known prior stage I lung adenoCA (pt of Dr. [**Last Name (STitle) **] s/p limited resection 04' with now new RLL lung mass along with multiple ground glass opacities with new RLL lesion biopsied showing new squamous cell CA, was admitted for evaluation of recent progressive sx of night sweats, anorexia, weakness with decreased ability to care for self. . . # Anorexia, Fatigue, nightsweats, mild DOE # Eosinophilia Given the subacute nature of her presentation and climbing eosinophilia, there was concern for the possibility of fungal lung infection. Interventional Pulmonary was consulted, and pt underwent flexible bronchoscopy with biopsies and BAL for micro. She tolerated the procedure well, but had a pneumothorax following the procedure. A follow up repeat CXR was obtained, which showed an increase in the size of the pneumothorax, and therefore Interventional Pulmonary placed a pigtail catheter to treat. Her pneumothorax remained stable with the chest tube in place, and the chest tube was removed on the day of discharge. She will follow up with Dr. [**Last Name (STitle) **] as an outpatient for the results from the bronchoscopy. Her serum galactomannan and beta-glucan are negative. All her culture data is negative to date, but final results are still pending. . # Lung CA - prior slow progressive adenoCA with now noted new, more aggressive squammous cell CA. After d/w Dr. [**Last Name (STitle) **], he was concerned about possible leptomeningeal spread of malignancy given her constellation of symptoms, and he requested MRI head. MRI head was performed, which did not show any e/o malignancy, and specifically did not show any leptomeningeal disease. She will follow up as an outpatient for further evaluation and management of her malignancy, and follow up of pending bronch biopsies. . # Hyponatremia/SIADH Pt was noted to have hyponatremia on presentation, with sodium 126. Urine studies were obtained, and confirmed the hyponatremia was consistent with SIADH. She was placed on 1200 cc fluid restriction, and her sodium subsequently improved. She was discharged with recommendations for ongoing fluid restriction of 1500cc. She should have her sodium rechecked at her next clinical appointment. . # Hypothyroidism - continued home dose synthroid in-house. . # HLP - continued home dose lovastatin . # HTN - continued home BP regimen (metoprolol, enalpril, amlodipine). . FEN: regular diet, nutrition consult Proph: heparin Disp: discharged to home Medications on Admission: ALPRAZOLAM - 0.5 mg Tablet - [**12-6**] Tablet(s) by mouth qhs prn AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth qam (NO LONGER TAKING PER PT) AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 Tablet(s) by mouth at bedtime BENZONATATE - 200 mg Capsule - 1 Capsule(s) by mouth q 8hr as needed for cough (NOT NEEDING AS OFTEN) ENALAPRIL MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day FLUTICASONE - 50 mcg Spray, Suspension - 1 spray(s) nasally once a day each nostril (NOT NEEDING PER PT) LEVOTHYROXINE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 88 mcg Tablet - 1 Tablet(s) by mouth once a day LOVASTATIN - 40 mg Tablet - 2 Tablet(s) by mouth once a day METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day, [**12-6**] tab in evening SERTRALINE [ZOLOFT] - 100 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day COENZYME Q10 [CO Q-10] - (OTC) - Dosage uncertain DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100 mg Capsule - 2 Capsule(s) by mouth once daily SALMON OIL-OMEGA-3 FATTY ACIDS [FISH OIL] - (OTC) - 500 mg-100 mg Capsule - 1 Capsule(s) by mouth daily --------------- --------------- --------------- Discharge Medications: 1. alprazolam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 2. amlodipine 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 3. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed for cough. 4. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lovastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day. 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily): restart on [**3-2**]. 11. coenzyme Q10 Oral 12. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 13. salmon oil-omega-3 fatty acids 500-100 mg Capsule Sig: One (1) Capsule PO once a day. 14. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO at bedtime. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1* 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: # Anorexia, Fatigue, nightsweats, mild DOE # Eosinophilia # Concern for possible pulmonary fungal disease # Lung cancer # Hyponatremia/SIADH # Pneumothorax s/p bronchoscopy with BAL/Biopsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized for evaluation of your progressive symptoms of night sweats, poor appetite, fatigue, and weakness. There is concern for possible fungal infection in your lungs, and you underwent bronchoscopy for biopsies and labs to further evaluate. The results from these tests are still pending, and you will need to follow up with Dr. [**Last Name (STitle) **] for these results and next steps. . You also had an MRI of your head, which did not show any evidence of cancer. . You were found to have a pneumothorax following your bronchoscopy procedure, and a catheter was placed to treat this. The pneumothorax was stable, and the catheter was removed. . You were also found to have low sodium levels, likely due to a syndrome known as SIADH. Your sodium levels have corrected with fluid restriction. We recommend you continue with fluid restriction of 1500ml/day. . You had your AM amlodipine STOPPED on this admission, as you reported that you had been having low BP's as an outpt, and that you had stopped taking your AM amlopdipine. Your blood pressure has been in good range during this hospitalization. We recommend you continue to HOLD your AM amlodipine. . Please follow-up with your physicians as instructed below. . Please take your medications as prescribed below. . Followup Instructions: Department: [**Hospital **] MEDICAL GROUP Specialty: Primary Care When: FRIDAY [**2163-3-4**] at 1 PM With: DR. [**First Name8 (NamePattern2) 132**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, PHD Specialty: Hematology/Oncology Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**0-0-**] We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in the next 9-15 days. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call [**0-0-**].

Admission Date: [**2104-4-12**] Discharge Date: [**2104-4-15**] Date of Birth: [**2029-8-6**] Sex: F Service: Medical Intensive Care Unit CHIEF COMPLAINT: Pustular discharge from implantable cardioverter-defibrillator pocket. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old female with a past medical history significant for coronary artery disease status post three-vessel coronary artery bypass graft surgery x 2, aortic stenosis status post aortic valve replacement, type 2 diabetes mellitus, and hypertension with a prolonged complicated recent hospital course at [**Hospital1 1444**] from [**1-30**] to [**2104-3-26**]. The patient was transferred from an outside hospital on [**2104-1-30**] with new onset atrial fibrillation with rapid ventricular rate and non-ST elevation myocardial infarction for cardiac catheterization. On cardiac catheterization the patient was noted to have left main and two-vessel disease with elevated pulmonary capillary wedge pressure and severe pulmonary hypertension. On [**2-5**], the patient underwent redo coronary artery bypass grafting with left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to the diagonal, and saphenous vein graft to the posterior descending coronary artery. The patient's postoperative course was complicated by hypotension requiring pressors, failure to extubate, atrial fibrillation with rapid ventricular rate with failure to cardiovert, and acutely worsening congestive heart failure with a decreased ejection fraction of less than 20% (prior to coronary artery bypass grafting the patient's ejection fraction was 50%). The patient returned for relook cardiac catheterization with noted acute graft closure and underwent percutaneous transluminal coronary angioplasty and stenting of the left internal mammary artery to the left anterior descending coronary artery, and saphenous vein graft to the diagonal. Post cardiac catheterization the patient developed acute renal failure with volume overload requiring CVVH, worsening heart failure requiring intra-aortic balloon pump complicated by rectus sheath hematoma, and ventricular fibrillation arrest requiring amiodarone and lidocaine. The patient again failed to extubate on multiple occasions and a tracheostomy was placed on [**3-2**]. The patient also underwent PEG tube placement on [**3-4**] and PICC line placement on [**3-7**]. An implantable cardioverter-defibrillator was placed on [**3-11**] with dual pacer (the delay in implantable cardioverter-defibrillator placement was secondary to multiple infections throughout the hospitalization including yeast graft harvest site, wound infection, Enterobacter bacteremia, C. difficile colitis, and yeast cystitis). Two days post ICD placement, the patient developed greater than 70 episodes of ventricular fibrillation/ventricular tachycardia. A repeat echocardiogram demonstrated a thrombus on the aortic valve anterior leaflet. The patient was started on TPA for a total of 24 hours with significant improvement in her aortic valve gradient. However, the patient subsequently developed an ICD pocket hematoma requiring operating room evacuation on [**3-17**]. The patient was eventually discharged to rehabilitation on [**2104-3-26**]. Since discharge the patient has remained hemodynamically stable without further episodes of ventricular fibrillation and the patient has been undergoing a progressive weaning trial from the ventilator with signs of success. The patient has also remained afebrile, however two days prior to the current admission, the patient was noted to have significant erythema around the ICD pocket site. Twenty-four hours later the patient was noted to have blood and pus draining spontaneously from the site and the patient was transferred to [**Hospital1 69**] for ICD removal. The patient received one dose of vancomycin the morning of admission while at rehabilitation. The patient denied fever, chills, abdominal pain, shortness of breath, chest pain as well as diarrhea. Of note, the patient has been off diuretics since [**4-7**] for prerenal azotemia. PAST MEDICAL HISTORY: 1. Atrial fibrillation with rapid ventricular rate (on amiodarone). 2. Hypertension. 3. Hypercholesterolemia. 4. Peripheral vascular disease. 5. Status post right bilateral carotid endarterectomy (left, [**2102-7-26**]; right [**2101-9-20**]). 6. Type 2 diabetes mellitus. 7. Coronary artery disease with three-vessel disease status post coronary artery bypass grafting in [**2092**] and redo coronary artery bypass grafting on [**2104-2-5**]. Repeat catheterization on [**2104-2-9**] with percutaneous transluminal coronary angioplasty and stenting to the LIMA-LAD-SVG-diagonal. 8. Congestive heart failure with biventricular failure. Echocardiogram in [**2104-2-16**] had an ejection fraction of less than 20%, severely depressed left ventricular systolic function, severe global right ventricular free wall hypokinesis, 2+ mitral regurgitation, 2+ tricuspid regurgitation, and bileaflet aortic valve without aortic regurgitation and normal gradient. 9. History of ventricular fibrillation arrest between [**2-18**] and [**3-13**] status post ICD placement with dual pacer [**3-11**]. 10. Prosthetic aortic valve thrombosis status post TPA thrombolysis complicated by ICD hematoma requiring operating room evacuation. 11. Failure to wean from the respiratory ventilator status post coronary artery bypass graft, status post tracheostomy on [**3-2**], vent dependent. 12. History of depression. 13. Status post PEG tube. 14. Status post right rectus sheath hematoma evacuation. 15. Aortic stenosis status post aortic valve replacement (St. [**Male First Name (un) 923**]) in [**2092**] on Coumadin. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Amiodarone 400 mg p.o. q.d. 2. Synthroid 25 mg p.o. q.d. 3. Glipizide 10 mg p.o. b.i.d. 4. Reglan 10 mg per PEG tube t.i.d. 5. Coumadin 3 mg per PEG tube q.h.s. 6. Insulin sliding scale. 7. Oxycodone. 8. Lansoprazole 30 mg per PEG tube q. day. 9. Aldactone 25 mg per PEG tube q. day (held since [**4-7**]). 10. Lasix 80 mg per PEG tube b.i.d. (held since [**4-7**]). 11. Zaroxolyn 5 mg per PEG tube q. day (held since [**4-4**]). 12. Aspirin 325 mg p.o. q. day. 13. Vitamin C 500 mg p.o. q.d. 14. Multivitamins one q. day. 15. Zinc 270 mg p.o. q.d. 16. Albuterol metered dose inhaler q. 4 hours p.r.n. SOCIAL HISTORY: The patient is a widow with a 15-pack-year tobacco history (he quit greater than 15 years ago), with no history of alcohol excess. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature 97.4, heart rate 72, blood pressure 103/34, respiratory rate 17, oxygen saturation 97% on CPAP pressure support of 15, PEEP of 5 and FIO2 of 50%. General: The patient is a nontoxic appearing elderly female in no acute distress. HEENT: Normocephalic, atraumatic, pupils were equal, round, and reactive to light and accommodation, extraocular movements intact bilaterally, dry mucous membranes, no thrush, edentulous. Neck: Supple, no lymphadenopathy, tracheostomy in place. Cardiovascular: Regular rate and rhythm with normal S1 and S2 with a 3/6 systolic ejection murmur at the left upper sternal border radiating to the neck. Lungs: Clear to auscultation bilaterally anteriorly with no rhonchi, and well-healed midline sternal incision. ICD site dressing clean, dry and intact. Abdomen: Soft, normal active bowel sounds, nontender, nondistended, no hepatosplenomegaly, PEG tube in place, clean, dry and intact. Extremities: No cyanosis, clubbing or edema, warm and well perfused, with 1+ dorsalis pedis and posterior tibial pulses bilaterally, left lower extremity thigh wound at the graft incision packed with occlusive dressing and no purulent drainage. Neurologic: Nonfocal. LABORATORY DATA: Complete blood count with a white blood cell count of 10.7, hematocrit 27.9, platelet count 315. Chem-7 with a sodium of 131, potassium 3.8, chloride 93, bicarbonate 28, BUN 70, creatinine 1.2, and glucose 455 (status post two amps of D50 for a glucose of 33). White blood cell differential 91% polys, 0% bands, 5% lymphocytes. Chest x-ray on admission showed no evidence of pneumothorax, ICD leads in good position, bilateral lower lobe atelectasis with small bilateral pleural effusions. EKG on admission was normal sinus rhythm at 90 with left bundle branch block, left axis, Q waves in leads 2, 3 and aVF with poor R wave progression (unchanged compared with [**2104-2-16**]). Microbiology of note during the hospitalization with swab cultures from the ICD pocket from admission on [**4-12**] with 3+ Gram positive cocci in pairs and clusters, culture positive for Staphylococcus aureus (sensitivities pending). Blood culture and urine culture from admission were without growth. HOSPITAL COURSE: In the Emergency Department, the electrophysiology, CT surgery and infectious disease services were consulted. Per electrophysiology and CT surgery recommendations, the patient was taken to the operating room for ICD box removal. Because the patient's admission INR was 2.7, only the ICD box was removed; the pacer/defibrillator leads were capped and left in place for future removal. An intraoperative transesophageal echocardiogram demonstrated an ejection fraction of less than 20% with 2% mitral regurgitation and tricuspid regurgitation and no evidence of valvular vegetation. The patient was admitted to the intensive care unit given her ventilator dependence. REMAINDER OF HOSPITAL COURSE BY SYSTEMS: 1. Infectious disease: The patient's initial OR swab of the ICD site demonstrated 3+ Gram positive cocci in pairs and chains and Staphylococcus aureus on culture. The Staphylococcus aureus sensitivities are still pending at the time of dictation. The patient continued on vancomycin dosed by level less than 15 per infectious disease recommendations, and is currently on day four of vancomycin. The patient has remained afebrile throughout the hospital course and blood cultures remain no growth to date. The patient will continue on vancomycin for a total of a 14-day course. A PICC line was placed on [**4-15**] for delivery of intravenous antibiotics. 2. Cardiovascular: The patient was monitored on telemetry post ICD removal with frequent premature ventricular contractions and no evidence of recurrent ventricular fibrillation or ventricular tachycardia. The patient remained rate controlled in the 70s on amiodarone. The patient was restarted on low-dose aspirin, statin (with lipids: total cholesterol 221, LDL 147, HDL 45, and triglycerides 113), and low-dose enalapril for known coronary artery disease (A low-dose beta blocker was not started during the hospitalization secondary to congestive heart failure exacerbation. However, it is the team's recommendation to start a low-dose beta blocker for known coronary artery disease with better control of the patient's volume status). The patient remained anticoagulated for aortic valve replacement. The patient's Coumadin was held during the hospitalization with the initiation of heparin at an INR of less than 2.5. On hospital day number three, with an INR of 2.2 and four units of fresh frozen plasma, the patient's ICD leads were removed by electrophysiology without complications. Echocardiogram during the procedure and repeat echocardiogram several hours later was without evidence of pericardial effusion. However, the patient's aortic valve gradient was noted to be somewhat elevated at 52. Given the patient's reversal of anticoagulation, there was concern for recurrent aortic valve thrombus. Of note, no thrombus was noted on echocardiogram. Repeat echocardiogram demonstrated a decreased gradient of 43. The electrophysiology service plans to replace the patient's ICD in the near future after completion of antibiotics for infection. The patient's echocardiogram demonstrated persistent biventricular failure with an ejection fraction of less than 20%, 2+ MR, and 2+ TR. On hospital day three (off diuretics for a total of five days), the patient developed pulmonary edema as seen on chest x-ray with coincidental decreased oxygen saturations. The patient's diuretics (Lasix, Zaroxolyn and Aldactone) were restarted with a slow but steady response. Despite the slow response, the patient's oxygen saturations were improved and remained stable in the mid-90s. 3. Pulmonary: The patient continued on the ventilator at her prior vent settings of pressure support 15, PEEP 5, and FIO2 of 40% with adequate oxygenation and ventilation. 4. Endocrine: On admission, the patient developed refractory hypoglycemia presumably secondary to recent dose of glipizide in the setting of decreased PEG tube intake with nausea and vomiting. The patient received D10 per IV and D25 per PEG tube with maintenance of normoglycemia. The patient's blood glucose normalized after approximately 24 hours off dextrose supplements. The patient's glipizide was held during the hospitalization and the patient was covered with sliding scale insulin. The patient's glipizide was restarted on discharge. The patient continues on Synthroid for hypothyroidism secondary to amiodarone. The patient's T4 was within normal limits and the Synthroid was continued on her prior outpatient dose (the patient's TSH was elevated, however it is an unreliable measure of thyroid function in the setting of acute illness). 5. Fluids, electrolytes and nutrition: The patient was intolerant of tube feeds early in the hospital course secondary to persistent nausea and vomiting, despite Reglan and Zofran. On hospital day number three the patient's tube feeds were restarted at 10 cc an hour and advanced slowly without further nausea and vomiting. The patient was started on ProMod with fiber with a goal of 40 cc per hour. 6. Hematology: The patient's admission hematocrit was low at 27 (down from her prior baseline hematocrit of 29-31). The patient received one unit of packed red blood cells on hospital day one with an appropriate bump in her hematocrit. The patient's hematocrit remained stable throughout the hospitalization until hospital day four ([**4-15**]) when the patient's hematocrit dropped to 26.6 from 29.3. The etiology of the drop was unclear with the exception of possible blood loss during the ICD lead removal on [**4-14**]. Of note, the patient also had recent history of guaiac positive stools. During the hospitalization the patient remained guaiac negative. The patient is to require one unit transfusion of packed red blood cells. The [**Hospital 228**] rehabilitation has agreed to transfuse the one unit on transfer, post discharge from [**Hospital1 69**]. The patient underwent PICC line placement on [**4-15**] prior to discharge. CONDITION ON DISCHARGE: Stable, with adequate oxygenation and ventilation, hemodynamically stable. DISCHARGE DIAGNOSES: 1. ICD pocket infection with Staphylococcus aureus (sensitivities pending). 2. Coronary artery disease status post three-vessel coronary artery bypass grafting x 2. 3. Congestive heart failure with an ejection fraction of less than 20%. 4. History of ventricular fibrillation status post ICD placement. 5. Hypothyroidism secondary to amiodarone. 6. Status post bilateral carotid endarterectomy. 7. Type 2 diabetes mellitus. 8. Peripheral vascular disease. 9. Hypercholesterolemia. 10. Hypertension. 11. Atrial fibrillation with rapid ventricular rate. 12. Status post aortic valve replacement for aortic stenosis. 13. Status post tracheostomy for failure to wean post coronary artery bypass grafting. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg p.o. q.d. 2. Synthroid 25 mg p.o. q.d. per PEG tube. 3. Coumadin 5 mg p.o. q.h.s. per PEG tube (dosed for INR 2.5 to 3.5). 4. Reglan 10 mg per PEG tube t.i.d. 5. Lansoprazole 30 mg per PEG tube q. day. 6. Aspirin 81 mg p.o. per PEG tube q. day. 7. Enalapril 2.5 mg per PEG tube b.i.d. 8. Lipitor 10 mg per PEG tube q. day. 9. Lasix 100 mg IV b.i.d. (follow volume status). 10. Aldactone 25 mg p.o. q.d. per PEG tube. 11. Zaroxolyn 5 mg per PEG tube b.i.d. (to be given 30 minutes prior to Lasix dose). 12. Vitamin C 500 mg per PEG tube q. day. 13. Multivitamins 1 per PEG tube q. day. 14. Zinc 270 mg per PEG tube q. day. 15. Regular Insulin sliding scale with q.i.d. fingerstick glucose. 16. Glipizide 10 mg per PEG tube q. day. 17. Albuterol metered dose inhaler q. 4 hours p.r.n. 18. Colace 100 mg p.o. b.i.d. 19. Dulcolax 10 mg p.o./p.r. q. day p.r.n. constipation. 20. Vancomycin 1 gram IV to be dosed by level less than 15 to complete a 14-day course. DISCHARGE INSTRUCTIONS: The patient is to be discharged to rehabilitation where she has been for the prior two weeks. The patient will require dressing changes both for the ICD wound infection and the left thigh graft site wound infection. Recommendation per CT surgery was wet-to-dry dressing changes t.i.d. (nonocclusive dressings). Of note the patient underwent debridement of the left thigh graft wound infection by CT surgery on the day of discharge. The patient will continue with her prior weaning trials per the rehabilitation doctor. The patient has been started back on Coumadin and will continue on Coumadin for an INR of 2.5 to 3.5. In the meantime the patient will be dosed on Lovenox to maintain anticoagulation. The patient will require one unit transfusion of packed red blood cells on arrival to rehabilitation for an hematocrit of 26.6 on [**4-15**]. The patient will need further work-up for her down-trending hematocrit if this persists. The patient is to continue on a 14-day course of vancomycin dosed by level of less than 15. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Name8 (MD) 4935**] MEDQUIST36 D: [**2104-4-15**] 13:33 T: [**2104-4-15**] 14:10 JOB#: [**Job Number 31608**]

Admission Date: [**2124-4-6**] Discharge Date: [**2124-4-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonscopy History of Present Illness: 86yo M with h/o gastric ulcers admitted with BRBPR. pt with hx of gastric ulcers here with rectal bleeding starting today. Had 6 total episodes today. No chest pain, SOB, lightheadedness, dizziness. In the ED, initial vs were: T98.2 HR75 BP:129/70 RR:16 O2Sat:100RA. Gross blood on rectal exam. Underwent NG lavage which came back bilious with no blood or clots. Was going to be admitted to the floor, however, when he got up to use the bedside commode he had a large (1L) bloody BM. He then got up off the commode, felt weak and syncopized onto the bed(did not hit his head) and was transiently not breathing and pulseless. Responded within seconds and was then A&Ox3. GI team saw him afterward in ED but did not feel comfortable sending patient for tagged RBC scan in setting of slightly unstable vital signs. Patient received 2 units uncrossmatched pRBCS in ED and another 2units crossed matched cells on arrival to MICU. General Surgery was consulted. VS prior to transfer to MICU: BP 87/65 HR 65 O2Sat100% NRB. On the floor, patient is feeling comfortable. No abdominal or chest pain. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies cough or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, constipation, abdominal pain. Past Medical History: CKI (baseline creatinines over last year 1.1-1.3) Gastric Ulcers s/p billroth procedure GERD Hypothyroidism Celiac Disease Social History: The patient has never smoked tobacco. He does not drink any alcohol. He has never done any drugs. He is sexually active with his wife. [**Name (NI) **] originally from [**Country 2560**], usually lives with his wife, but his wife is back in [**Country 2560**] right now for another couple of weeks. His nephew was shot in the abdomen in [**Country 2560**], so his wife went back to [**Country 2560**] to be with him. Patient denies any history of smoking. He currently has a couple of jobs, including selling Spanish newspaper on the street. Lives [**First Name4 (NamePattern1) 41140**] [**Last Name (NamePattern1) **]. In [**Country 2560**], he used to be a politician. Moved here about 10 years ago. Family History: His mother had lung cancer. His brother had leukemia, and another brother had [**Name (NI) 2481**] disease. Physical Exam: Vitals: BP:128/75 P:75 R: 18 O2: 100 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2124-4-6**] 08:23PM HCT-35.8* [**2124-4-6**] 06:25PM CK(CPK)-83 [**2124-4-6**] 06:25PM CK-MB-NotDone cTropnT-<0.01 [**2124-4-6**] 06:25PM HCT-39.8* [**2124-4-6**] 02:11PM POTASSIUM-5.3* [**2124-4-6**] 02:11PM CK(CPK)-82 [**2124-4-6**] 02:11PM CK-MB-NotDone cTropnT-<0.01 [**2124-4-6**] 02:11PM WBC-10.0 RBC-4.69 HGB-12.9* HCT-39.2* MCV-84 MCH-27.5 MCHC-32.9 RDW-16.0* [**2124-4-6**] 02:11PM PLT COUNT-221 [**2124-4-6**] 11:50AM HGB-12.7* calcHCT-38 [**2124-4-6**] 10:15AM GLUCOSE-158* UREA N-28* CREAT-1.3* SODIUM-141 POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-30 ANION GAP-15 [**2124-4-6**] 10:15AM WBC-9.6 RBC-4.51* HGB-12.5* HCT-37.9* MCV-84 MCH-27.7 MCHC-33.0 RDW-15.9* [**2124-4-6**] 10:15AM NEUTS-69.8 LYMPHS-19.5 MONOS-5.1 EOS-4.8* BASOS-0.6 [**2124-4-6**] 10:15AM PLT COUNT-282 [**2124-4-6**] 10:15AM PT-11.2 PTT-26.0 INR(PT)-0.9 EKG: New LBBB from prior on [**2123-12-12**] and also new from ED EKG. colonoscopy: Polyps and diverticulosis. Will need repeat colonoscopy in the future to remove polyps. No intervention. Brief Hospital Course: Mr. [**Known lastname 41141**] is an 86 y.o. Spanish speaking male with history of PUD s/p Billroth II and celiac disease, admitted on [**2124-4-6**] to MICU for BRBPR, s/p colonoscopy revealing diverticulosis. # Lower GI Bleed: Patient had a h/o gastric ulcers so initially it was thought that he could have a very brisk UGIB, but with negative NG lavage and rectal blood on exam, lower GI bleed felt more probable. He received 4 units pRBCs, was prepped overnight and then underwent colonoscopy which revealed diverticulosis and several polyps but no active bleeding. The polyps were not removed given recent bleed and the patient will need another colonoscopy for removal as an outpatient. Hcts remained stable and he was called out to the floor for observation. He passed two more clots of old blood per rectum while on the floor, then had no further bleeding for more than 24 hours. Patient was discharged home but told to return if he had any further bleeding or if he developed lightheadedness. He was told to schedule a followup appointment with his PCP for as soon as possible on Monday morning. Because of his history of PUD, he was re-started on omeprazole 20mg daily; he states he does not have any gastritis or reflux symptoms but will discuss whether or not this medication is needed with his PCP. # Hyperkalemia: Patient has had this in the past in the setting of ARF; on admission, his creatinine was slightly elevated which likely contributed to hyperkalemia. There were no associated EKG changes and the K trended down through the course of his ICU stay. # Acute Renal Failure: His baseline creatinine 1.1-1.3 over the last 2 years and on admission his creatinine was high-normal for him at 1.3. This was thought likely [**1-4**] pre-renal azotemia. His medications were renally dosed and the creatinine trended down during the course of his ICU stay after transfusion. # Left Bundle Branch Block: Patient did not have a history of LBBB including on an EKG 5 months prior to admission. As he had a syncopal event in the ED, which was thought likely vasovagal in setting of BRBPR, cardiac enzymes were cycled to rule out cardiac event. Enzymes remained negative. EKG remained unchanged although on telemetry patient noted to have intermittent LBBB. It was thought likely this LBBB was related to age-related degeneration of the cardiac conduction system and less likely ACS so no further workup was pursued. Repeat EKG showed persistent LBBB, not rate related. Patient would benefit from Echocardiogram as an outpatient. # Communication: Patient and Wife [**Doctor Last Name 2048**], currently in [**Country 2560**]): [**Telephone/Fax (5) 41142**] [**Telephone/Fax (3) 41143**] # Code: Full (discussed with patient) Medications on Admission: None Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Diverticular bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 41141**], You were admitted with bleeding in your GI tract. We performed a CAT scan of your abdomen and a colonoscopy, and found that you have a condition called "diverticulosis". Your bleeding stopped on its own, and you now have a condition called "anemia" (low blood counts from bleeding), which will impove with time as your body recovers. You should eat a high fiber diet (at least 25-30g per day) to avoid further progression of divertiulosis. High fiber can be found in whole wheat products, fruits and vegetables. We also discovered that your blood sugar levels are slightly elevated, which indicates that you may have a condition called "diabetes". It is very important that you see Dr. [**Last Name (STitle) **] for follow up to have this treated. No changes have been made to your medications, but it appears that you have previously been prescribed Omeprazole for reflux, which you may continue to take if you would like. We will give you a prescription which you may fill. Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within 2 weeks to have your blood counts monitored. We have also made you an appointment to see Dr. [**Last Name (STitle) **] in gastroenterology (see below) [**First Name9 (NamePattern2) 7289**] [**Known lastname 41141**], Ud fue [**Hospital 41144**] [**Hospital **] hospital porque estaba [**Hospital 41145**] [**Doctor First Name **] colon. Nos parace de [**Location 41146**] [**Location **] tiene Diverticulosis [**Doctor First Name **] colon. Le observabamos, y ahora no [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 41145**]. Ahora tiene anemia, [**Last Name (NamePattern1) **] dice [**Last Name (NamePattern1) **] el nivel de sus [**First Name9 (NamePattern2) 41147**] [**Doctor Last Name **] [**Female First Name (un) **] baja, [**Last Name (un) **] va a mejorar en unas meses. Debe Ud comer una dieta con mucha fibra [**Last Name (un) **] prevenir empeoramiento de [**Doctor First Name **] diverticulosis. Se puede encontrar fibra en vegetales y comida de [**Last Name (un) 41148**]. El nivel de azucar en [**Doctor First Name **] sangre estaba [**First Name9 (NamePattern2) 41149**] [**Last Name (un) 33761**] este hospitalizacion, y es posible [**Last Name (un) **] tenga diabetes. Hay [**Last Name (un) **] seguir con [**Doctor First Name **] doctor [**First Name (Titles) **] [**Last Name (Titles) 41150**]. No hemos cambiado sus medicamentos, [**Last Name (un) **] nos parece [**Last Name (un) **] estaba tomando Omeprazole en el pasado [**Last Name (un) **] acidez, y puede Ud continuar [**Female First Name (un) **] medicine si quiere. Vamos a darle una receta [**Female First Name (un) **] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 41151**]. Por favor, [**Last Name (un) **] una cita con [**Doctor First Name **] doctor [**First Name (Titles) 41152**] [**Last Name (Titles) **] 2 semanas [**Last Name (Titles) **] chequear [**Doctor First Name **] hematocrito ([**First Name9 (NamePattern2) 41147**] [**Doctor Last Name **]) y mantenga [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**First Name9 (NamePattern2) **] [**Last Name (un) **] hemos hecho con el doctor [**First Name (Titles) **] [**Last Name (Titles) 41153**] (Dr. [**Last Name (STitle) **]. Mucho gusto, y suerte con todo! Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2124-5-11**] 1:15 Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] and make an appointment within 1-2 weeks

Admission Date: [**2123-11-15**] Discharge Date: [**2123-11-18**] Date of Birth: [**2076-12-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: rigid bronchoscopy with cautery ([**2123-11-15**]) History of Present Illness: Mr. [**Name13 (STitle) 9261**] is a 46 year-old man with a history of morbid obesity, obstructive sleep apnea, and depression who presented to an outside hospital yesterday with massive hematemesis. He was in his usual state of health until yesterday morning when he suddenly began coughing up large volumes of liquid bright red blood and one large, solid clot of blood. This persisted for approximately 45 minutes before resolving spotaneously while he was in the ambulance in transit to [**Hospital 8**] Hospital. At the outside hospital, his hematocrit was reportedly 38.7 and an NG lavage was positive. His hemoptysis then recurred (approx [**1-11**] hours after initial event) and he was transferred here for emergent bronchoscopy. He was intubated in the ED in preparation for bronchoscopy. On presentation here, his hematocrit was noted to be 34.8 and a CXR showed clear lungs. . ROS: Denies fevers, chills, change in weight/appetite, dysuria, N/V/D, hematuria, hematochezia, melena, headaches, visual changes. Past Medical History: - depression: reports recent worsening with intermittent passive SI and some preliminary plan formation; denies HI; denies any AH/VH in the past but does report some paranoid delusions - obstructive sleep apnea: on CPAP at home - morbid obesity: has worsened over past year - lymphedema - psoriasis Social History: Has not left his house in >1 year due to depression and now worsening obesity; lives with his sister. Formerly smoked 1 ppd up until 3 yrs ago. Was a binge drinker in his 20s, but no longer drinks. Distant marijuana and intranasal cocaine use. Denies IVDU. Family History: Father with 2 [**Name2 (NI) **] in his 50s but still living in his 70s currently. Mother with schizophrenia. Physical Exam: T 100.4 BP 107/75 HR 94 RR 20 Sat 99% on ra Weight: 550 lbs Height: 6'2" Gen: morbidly obese, no acute distress, breathing comfortably HEENT: no icterus, OP clear, MMM Neck: no carotid bruits, no cervical/clavicular lymphadenopathy, unable to assess JVP due to neck size Chest: diffuse faint expiratory ronchi, no wheezes/rales CV: regular rate/rhythm, distant HS, no murmurs heard Abd: morbidly obese, nontender, nondistended, normal BS, unable to palpate liver/spleen edge due to obesity Extr: massive firm ruggated hyperpigmented edema in both legs, 2+ pitting edema in both feet with 1+ bilateral DP pulses Skin: numerous scattered patches of scaling plaques on arms, torso, back Neuro: A&O x3, CN 2-12 intact Pertinent Results: [**2123-11-15**] 04:45PM WBC-11.7* RBC-3.94* HGB-12.6* HCT-34.8* MCV-89 MCH-31.9 MCHC-36.1* RDW-14.7 [**2123-11-15**] 04:45PM NEUTS-90.5* LYMPHS-6.9* MONOS-2.0 EOS-0.5 BASOS-0.2 [**2123-11-15**] 04:45PM cTropnT-<0.01 [**2123-11-15**] 04:45PM GLUCOSE-157* UREA N-18 CREAT-0.8 SODIUM-140 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 Brief Hospital Course: He underwent an emergent rigid bronchoscopy upon admission to the ED which showed a large amount of fresh blood. He was found to have a LLL medial wall arterial "[**Last Name (un) 70229**]" gushing fresh blood, which was cauterized. He also had a large cast of clot/tissue/tumor in the LLL which was removed and sent for pathology. He was sent to the SICU post-procedure where he remained hemodynamically stable and was extubated without difficulty. He was sent to the medicine floor team at this point where he remained hemodynamically stable with no evidence of recurrent bleeding. Because of his morbid obesity, he could not undergo any further imaging (CT, MRI, etc) to evaluate for potential causes of his massive hemoptysis. The tissue sent from his bronchoscopy returned as clot only, and cytology on the bronchial brushings was negative. He was arranged to have follow up with interventional pulmonology for a repeat bronchscopy in [**4-15**] weeks. For his sleep apnea, he was continued on nightly BiPAP per his home regimen. His sister brought in his BiPAP machine fromhome (since he didn't tolerate the hospital's machine) and it accidentally fell and broke while in-house. He was set up to have a new machine delivered to his home immediately after discharge. Due to this bleeding and lack of documented CAD, his aspirin was held while in-house and he was advised to continue holding it, unless directed otherwise by his PCP. For his depression, he was started on Effexor 225mg daily (he had previously been on this dose before running out and never refilled his prescriptions). A social work consult saw the patient and referred him to the Disabled Persons Protection Commission and gave him the phone number for [**Hospital3 40709**] Commission homemaker services for assistance due to his morbid obesity. He was set up with PCP follow up for the day after discharge since he hadn't seen his PCP in over [**Name Initial (PRE) **] year. Medications on Admission: aspirin 81mg daily Lubriderm prn Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:*90 Capsule, Sust. Release 24HR(s)* Refills:*3* 2. Calcipotriene 0.005 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*3* 3. Triamcinolone Acetonide 0.025 % Ointment Sig: One (1) appl Topical twice a day: apply thin layer to affected areas twice daily. Disp:*1 tube* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: massive hemoptysis Secondary diagnosis: obesity, obstructive sleep apnea, depression, psoriasis Discharge Condition: stable Discharge Instructions: You were admitted to the hospital after coughing up large amounts of blood. You emergently underwent a bronchoscopy which showed an artery pumping blood into one of your major airways. This blood vessel was cauterized and the bleeding stopped. You had a breathing tube placed down your throat to protect your airway during this event. You were taken off the breathing tube without difficulty and remained stable when transferred to the floor. We do not yet have an explanation for why you had this large episode of bleeding, so you need to follow up with our pulmonologists (as scheduled below) for a repeat bronchoscopy. Please attend all follow-up appointments as scheduled. Please take all medications as prescribed. If you experience chest pain, shortness of breath, high fevers, loss of consciousness, coughing up of blood, or any other concerning symptoms, you need to seek medical attention. Followup Instructions: Primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1355**] ([**Hospital 8**] Hospital): Friday [**2123-11-19**] at 11:15 am; [**Telephone/Fax (1) 45347**] Pulmonology for repeat bronchoscopy (Dr. [**Last Name (STitle) **]: [**2123-12-20**]; arrive at 7:30 am to [**Hospital Ward Name 121**] 8 Day Care Unit; you cannot have any food or drink (except for medications) after midnight the evening before the procedure. You should not take aspirin for the five days prior to the procedure because it thins the blood. Provider: [**Name10 (NameIs) 454**],NINE DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2123-12-20**] 7:30 Provider: [**Name10 (NameIs) **],IP PROC IP PROCEDURES Date/Time:[**2123-12-20**] 8:30

Admission Date: [**2102-1-20**] Discharge Date: [**2102-1-25**] Date of Birth: [**2027-9-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: weakness, shortness of breath Major Surgical or Invasive Procedure: None (Note: patient had right sided chest tube removed that had been placed at outside hospital) History of Present Illness: In summary, Mr. [**Known lastname **] is a 74 year old male with past medical history significant for COPD on home O2, HTN, paroxysmal atrial fibrillation, (not on coumadin; compliance issues), diastolic CHF, and OA who presented initially to OSH at [**Hospital1 18**] [**Location (un) 620**] on [**1-14**] with worse shortness of breath from baseline, poor PO intake. Notable leukocytosis to 22k range and concern for underlying PNA. Additional imaging with chest CT revealed loculated right pleural effusion with pleural thickening suggestive of an empyema as well as smaller left sided effusion. Zosyn was initiated on [**1-20**] and chest tube was placed at OSH with failure to obtain any pleural fluid. Outside hospital labs were significant for leukocytosis 22.2 ([**1-19**]: 10.7); HCT 43; Na: 135; Co2: 32.7; Creatinine 1.7 (prior 0.9); U tox negative. . He was transferred to [**Hospital1 18**] [**Location (un) 86**] SICU for additional thoracics evaluation for potential VATS/pigtail placement vs. decortication but thoracics team did not feel imaging or clinical picture suggestive of true empyema and feels this is a chronic effusion that does not need to be drained. SICU vitals on arrival to [**Hospital1 18**] [**Location (un) 86**] on [**1-20**] were: HR 93, BP 107/55, RR 24 and O2 sat 97% 3L. Thoracic service had chest tube removed [**1-21**], this morning. Per SICU team, patient's leukocytosis felt to be secondary to possible PNA vs. UTI given that recent urine studies growing coag negative staph. Patient was started on Vanco/Zosyn at [**Location (un) 620**] which was continued here over past day. . In addition, at OSH patient went into afib with RVR to 120s and was managed on a combination of digoxin and diltiazem gtt prior to transitioning back to oral beta blocker therapy with fair resolution and HR control (HRs 70-80s). . Also developed ARF over last week as his creatinine on admission to [**Hospital1 **] [**Location (un) 620**] was 0.8 on [**1-14**] and now up to low 2 range. He had exposure to contrast for CT imaging studies and he was also given lasix for question of CHF exacerbation at OSH which may have been contributing factors. Lasix held here since admission. . Lower extremity doppler done here after transfer for mild LE edema and picked up a right LE DVT with thrombus within the right superficial femoral vein and within the right popliteal vein. At time of transfer now patient has yet to be started on anticoagulation for DVT. . Lastly, patient also complained of some vague abdominal pains and per reports he had question of obstruction at OSH so KUB performed with with nonspecific bowel gas pattern. Here in SICU patient has had healthy bowel sounds but mild LLQ tenderness. No BM since transferred at 10pm last night, no nausea, no vomiting. Of note, history of diverticulosis. . At time of transfer to general medicine service on [**1-21**] patient appeared to be in no apparent distress but seems confused which is near typical baseline per family. Vitals signs at time of transfer: T98.3, BP 110/67, HR 89, RR 16 and 02 Saturation 97% 3L. . Review of systems: Patient unable to cooperate so ROS limited. Denies fever, chills, night sweats, recent weight loss or gain. Denies headaches. Past Medical History: Past Medical/Surgical History: -Asthma -Hypertension -COPD on home oxygen -history of atrial fibrillation -osteoarthritis -seborrheic dermatitis -diverticulosis -RT inguinal hernia -cataract surgery Social History: Social History: Patient states he was living with his son prior to recent hospitalization. Smoking hx of 1PPD x 30 years (quit age 50). Distant ETOH use and per prior OMR notes also history of heroin abuse in the past but quit >20 years ago. Confused at baseline per family. . Family History: Non contributory Physical Exam: Physical Exam at transfer to medicine: Vitals: T98.3, BP 110/67, HR 89, RR 16 and 02 Saturation 97% 3L. General: Alert and oriented x2, mildly agitated, no acute distress HEENT: Sclera anicteric, MMM, PERRL, + Arcus senilis, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bilateral basilar crackles (Right >Left). No wheezes. No dullness to percussion. Prior CT site appears c/d/i with no bleeding, covered with dressing. CV: irregular rhythm noted, normal S1 + S2, no murmurs, rubs, gallops or clicks noted Abdomen: soft and obese, ventral hernia (mild), mild TTP over left abdomen but no rebound, non-distended, bowel sounds present, no guarding, no organomegaly Ext: Warm and increased erythema below mid calf bilaterally, 2+ pulses, [**1-29**]+ edema over RLE, no clubbing, cyanosis Access: 22g PIV and groin/femoral CVL in place Pertinent Results: ADMISSION LABS: [**2102-1-20**] 09:20PM GLUCOSE-151* UREA N-25* CREAT-2.1* SODIUM-134 POTASSIUM-3.9 CHLORIDE-89* TOTAL CO2-33* ANION GAP-16 [**2102-1-20**] 09:20PM ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-85 TOT BILI-1.8* [**2102-1-20**] 09:20PM CALCIUM-8.3* PHOSPHATE-3.4 MAGNESIUM-1.9 [**2102-1-20**] 09:20PM WBC-18.9* RBC-4.88 HGB-14.9 HCT-44.0 MCV-90 MCH-30.5 MCHC-33.8 RDW-15.0, PLT COUNT-336 [**2102-1-20**] 09:20PM PT-15.6* PTT-38.9* INR(PT)-1.4* . Interval significant labs: [**2102-1-18**] TSH 2.2 [**2102-1-24**] INR 2.3 [**2102-1-24**] vanco trough 34.7 . Discharge labs: [**2102-1-25**] GLUCOSE-85 UREA N-7 CREAT-0.9 SODIUM-136 POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-33* ANION [**2102-1-25**] CALCIUM-7.6 PHOSPHATE-2.4 MAGNESIUM-1.7 [**2102-1-25**] WBC-8.5 HCT-36.9 (stable x2 days) PLT COUNT-380 [**2102-1-25**] INR 5.1 [**2102-1-25**] Vanco trough 19.8 . URINE STUDIES: [**2102-1-20**] 09:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.033 [**2102-1-20**] 09:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2102-1-20**] 09:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-[**4-1**] . IMAGING: . [**1-22**] CXR: The examination is compared to [**2102-1-21**]. In the interval, the patient has received a right-sided PICC line. The tip of the line projects over the lower SVC. There is no evidence of complications, notably no pneumothorax. Otherwise, the radiograph is unchanged. [**1-21**] CXR - FINDINGS: As compared to the previous radiograph, the right-sided chest tube has been removed. Minimal right pleural thickening, minimal left pleural effusion. No evidence of pneumothorax. . [**1-20**] CXR - FINDINGS: Small lung volumes. Borderline size of the cardiac silhouette, small left pleural effusion, small platelike right atelectasis. On the right, the patient has a chest tube. The sidehole of the tube is outside the pleural cavity and projects over the soft tissues. There is no evidence of pneumothorax. . [**1-20**] RLE Ultrasound: Thrombus within the right superficial femoral vein, with total occlusion seen in the mid portion and partial occlusion seen in the proximal portion. The distal portion is patent. Patent right common femoral vein, which contains a catheter. Small isolated nonocclusive thrombus within the right popliteal vein. Non-compressible thrombus demonstrated in at least one right deep calf vein. No DVT detected within the left lower extremity. The left peroneal veins were not assessed as the patient refused further evaluation. 6. 3.0 x 2.1 x 2.7 cm right groin hematoma, without internal flow. . OUTSIDE HOSPITAL IMAGES: [**1-19**]: Chest CT: MDCT of the chest was done with intravenous infusion of 100 cc Omnipaque 300. Sagittal and coronal reformatted images were obtained. There is a moderate posterior right pleural effusion. Suggestion of thickening and enhancement of the surrounding pleural surfaces. There is minimal swelling of the overlying soft tissue as well. There is a minimal posterior left pleural effusion. There is anterior pericardial thickening or a small loculated anterior pericardial effusion. Streaky pulmonary parenchymal densities bilaterally, consistent with subsegmental atelectasis and/or scarring. There is scattered atherosclerotic calcification. The heart and mediastinal structures are otherwise unremarkable. No lymphadenopathy is identified. There is no significant chest wall abnormality. IMPRESSION: POSTERIOR RIGHT PLEURAL EFFUSION. EVIDENCE FOR SURROUNDING PLEURAL THICKENING AND ENHANCEMENT SUGGESTS THE POSSIBILITY OF EMPYEMA; VERY SMALL POSTERIOR LEFT PLEURAL EFFUSION. MINIMAL PERICARDIAL THICKENING OR LOCULATED PERICARDIAL EFFUSION. . TTE OSH: Ejection fraction is 55%. He has mild aortic stenosis, normal tricuspid valve, normal pulmonary valve, no pulmonary hypertension. Overall findings of his echocardiogram similar to one from [**2099**]. . [**1-15**] OSH: RLE ULtrasound: NONCOMPRESSIBILITY OF THE RIGHT SUPERFICIAL FEMORAL TO POPLITEAL VEIN BUT WITH NORMAL COLOR FLOW ON DOPPLER STUDIES. AUGMENTATION STUDIES OF THESE SEGMENTS WERE NOT PERFORMED. FINDINGS ARE SUGGESTIVE OF CHRONIC DVT. NO DVT WAS SEEN IN THE OTHER LEG, THE LEFT LOWER EXTREMITY . CARDIAC: EKG on [**1-18**]: afib with RVR in low 100s range . MICROBIOLOGY: [**1-20**] Blood cx - pending [**1-20**] Urine cx - no growth . OSH Urine studies [**1-16**]--> Urine tox was positive for opiates, positive for trace blood, trace ketones, no white blood count. Micro urine: Coag-negative staph, 25-50, organisms per mL. Blood culture is negative. Brief Hospital Course: In summary, Mr. [**Known lastname **] is a 74 year old male with longstanding COPD on home O2, dCHF, atrial fibrillation, admission for PNA/dyspnea now s/p chest tube placement (then removal) for questionable empyema who continues to recuperate on IV antibiotics without any additional thoracic procedures. Please see below for more detailed hospitalization summary: . #Shortness of breath /effusions, healthcare associated PNA: Mr. [**Known lastname **] has longstanding COPD at baseline and requires home O2 2.5L nasal cannula. He arrived to OSH with notable dyspnea worse from typical baseline. This was initially attributed to possible diastolic CHF exacerbation in setting of poorly controlled atrial fibrillation. He was given generous amounts of IV lasix at [**Hospital1 18**] [**Location (un) 620**] but continued to have some worse shortness of breath. CXR showed bilateral effusions. However, review of older images shows these are chronic, fairly stable effusions and seem a less likely cause for acute worsened dyspnea. Given elevated WBC to peak 22k, recent malaise, poor PO intake and shortness of breath there was clinical suspicion for underlying PNA with worse local inflammatory/irritation and COPD flare up as patient with very poor pulmonary reserve. The differential also includes possible underlying malignancy given his declining state x months, prominent smoking history and and note of pleural thickening on recent CT chest. In terms of CHF, recent BNP in 1000s range, h/o mainly diastolic CHF with EF 55% on TTE just days ago. After concern for possible underlying complicated loculated effusion with CT chest questioning empyema, patient underwent right sided chest tube placement at outside hospital but no pleural fluid able to be collected. He was then transferred to [**Hospital1 18**] [**Location (un) 86**] Surgical ICU service with urgent thoracic surgery consult. Thoracic surgery team felt patient had very minimal effusions on imaging and did not feel CT chest imaging constituted a true empyema picture. Thus, thoracic surgery felt a repeat attempt at thoracentesis or any other invasive procedures like IR guided pigtail drain placement or VATS/decortication would only be of minimal or no benefit given very small amount of pleural fluid which was felt to be chronic as patient has had similar fluid at lung bases in previous imaging. Chest tube was removed in SICU and patient transferred to medical service where he was continued on plan for 8 days continued broad coverage for hospital acquired PNA with IV Vancomycin and Zosyn. Blood cultures with no growth. Also continued patient on PRN nebulizers, Advair inhaler, Spiriva, chest physical therapy routine and he was eventually weaned down to usual home 2L O2 nasal cannula. At time of discharge he had no fevers, WBCs in normal range, and no complaints of cough or shortness of breath. . #Leukocytosis: Trend with initial rise from [**1-14**] admission and then resolved after 2-3 days of being on IV Vancomycin/Zosyn therapy. WBC trend 10-> 22-> 19-->10--> 8 prior to discharge. Remained afebrile after his transfer to medicine service on [**1-21**]. Most probable source was underlying PNA. Although there was some initial concern for UTI as his urine grew out coag negative staphylococcus (25-50 only) at OSH. However, a repeat urinalysis and urine culture collected [**1-20**] showed no significant evidence for any UTI. Moreover, patient had no complaints of dysuria, urgency, or frequency. He had some mild tenderness over his abdominal midline and left side but he stated this was chronic and due to history of ventral hernia. He had no concerning abdominal cramps, nausea or emesis prior to discharge. He did have a few loose stools which were felt to be a side effect of his antibiotics. As above, plan is to continue broad IV Abx with Zosyn/Vancomycin for HAP up until [**1-27**] for full 8 day course. . #Right LE DVT: Mild edema was noted on the right lower extremity. Imaging with ultrasound demonstrated a mixed picture of possible mixture of both some newer/older thrombi. Patient very immobile at baseline which increases his risk. He was started on weight based IV heparin gtt with close PTT monitoring and started on daily oral Coumadin with plan for at least 3 months of therapy. His heparin was stopped on [**1-24**] when his INR rose to 2.3 (on 4mg of coumadin) on the evening of [**1-24**] he got 2mg of coumadin. His INR the morning of discharge was 5.1 (goal INR [**3-2**]) and his coumadin is being held. His INR should be followed daily and coumadin restarted at 1 mg once his INR is <3. He will need 3 months of coumadin treatment for his DVT. He should discuss with his PCP whether he needs to stay on coumadin longer for his A fib. He has no significant GI bleeding in past but he is a slight fall risk at this time which makes longer term anticoagulation decision making more challenging as risks/benefits need to be discussed further. . #Atrial fibrillation: Currently rate controlled with HRs 80s-low 100s range. At home had been on PO diltiazem regimen and needed placement on dilt drip, digoxin, and additional metoprolol while at [**Hospital1 18**] [**Location (un) 620**]. He was transitioned to once daily Toprol XL 150 mg the morning of discharge. ******He did have one episode of emesis and a single dose of metoprolol tartrate 25mg was given as it is unclear whether he vomited his AM [**Name (NI) 8864**] dose.********* His metoprolol dose will likely need to be further uptitrated for tighter HR control. He had a CHADS score of 3 and a concomitant diagnosis of RLE DVT and is on coumadin (currently with supratherapeutic INR as above). His worsing a fib could have been due to hypovolemia volume shifts vs. infection as outlined above. He was ruled out for acute cardiac syndromes with biomarkers at OSH. Digoxin was stopped early on in his admission and no additional diltiazem was used as he did very well on metoprolol po TID which was transitioned to toprol XL as above . #ARF: Baseline is near 0.9-1.0 range and peaked up to Cr 2.1 range on [**1-20**]. His creatinine was 0.9 on the day pf discharge. Causes include recent contrast exposure with CT studies, pre-renal causes in setting of OSH lasix dosing. FeUrea <35% and urine electrolyte profile favored pre-renal causes. Renal dysfunction from antibiotics/AIN was also considered but he only had a very scant amount of eosinophils in urine making this less probable. Vancomycin was renally dosed and troughs monitored. His vanco trough was 34.7 on [**1-24**] and 19.8 on [**1-25**]. His vancomycin dosing was decreased to 1 gram q24 hrs and a dose was given the morning of [**1-25**]. Gentle IVFs given to patient and his Lasix was held for several days and his creatinine improved back to his baseline. . #Hypertension, benign: Well controlled and normotensive during hospital course. Continued on beta blocker as above with no need to add other agents. His home diltiazem was discontinued. . #COPD, chronic: At baseline on home oxygen at 2.5L by time of discharge. Currently has O2 saturations in the mid 90s range and has no complaints of worse wheeze or shortness of breath. His cough has now resolved. As above, continued home Advair and tiatropium inhaler medications, gave nebulizers PRN, chest physical therapy and treated PNA with broad antibiotics. . #Chronic diastolic CHF: History of noted diastolic CHF. Recent notes [**First Name8 (NamePattern2) **] [**Location (un) 620**] with last TTE EF%55, mild aortic stenosis, normal tricuspid valve, normal pulmonary valve, no pulmonary hypertension. TTE findings similar to that from [**2099**]. Initially appears intravascularly hypovolemic to euvolemic on exam with no JVP despite mild overloaded picture on CXR. Very minimal LE edema (R>L ; DVT RLE). Continued patient on strict I/O checks, Na restriction diet. Held lasix briefly while ARF resolved and restarted home Lasix 20mg daily (restarted on [**1-24**]). . # Code Status: full code; confirmed with patient . #. HCP is daughter [**Name (NI) 16883**] [**Name (NI) **] cell: [**Telephone/Fax (1) 88245**], home [**Telephone/Fax (1) 88246**] Medications on Admission: . Medications at Home : -Albuterol INH prn -Advair 200/50 [**Hospital1 **] -Diltiazem 120 [**Hospital1 **] -Spiriva 18mcg daily INH -Lasix 20 mg daily . Medications at Transfer from SICU: -Potassium Chloride IV Sliding Scale -Piperacillin-Tazobactam 2.25 g IV Q6H -Digoxin 0.125 mg PO/NG EVERY OTHER DAY -OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain -Magnesium Sulfate IV Sliding Scale -Vancomycin 1000 mg IV Q 12H -Metoprolol Tartrate 50 mg PO/NG TID -Metoprolol Tartrate 2.5 mg IV Q6H:PRN tachycardia -Tiotropium Bromide 1 CAP IH DAILY -Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] -Heparin 5000 UNIT SC TID -Aspirin 325 mg PO/NG DAILY -Ondansetron 4 mg IV Q8H:PRN nausea -Bisacodyl 10 mg PO DAILY -Mirtazapine 15 mg PO/NG HS . Allergies: NKDA . Discharge Medications: 1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain, arthralgias for 1 weeks: hold for sedation or RR<12 and re-eval if still needs in 2 wks. Tablet(s) 3. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 2 days: TO END ON [**2102-1-27**]. 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-29**] Inhalation AS NEEDED as needed for shortness of breath or wheezing. 7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Vancomycin Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24 hrs. Got dose morning of [**1-25**] (prior has supratherapuetic level). Next dose due 10 am on [**1-26**]. Last dose due [**1-27**]. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 16. INR, potaasium, calcium, mag, phos check daily. INR 5.1 on [**2102-1-25**]. Goal [**3-2**] until on stable regimen after antibiotics are completed. 17. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 3 months: PLEASE START ONCE INR <3, WAS 5.1 at DISCHARGE and then monitor daily given pt on antibiotics. goal INR [**3-2**]. Re-evaluate if pt should continue after 3 months for his A fib. Currently on for both DVT and A fib. 18. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: -Pneumonia -Atrial fibrillation -Right lower extremity Deep Vein Thrombosis -Acute Renal Failure Discharge Condition: Mental Status: Oriented to self, knew he was at hospital but not which one, knew date and month but not year. Does not appear confused. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. HCP is daughter [**Name (NI) 16883**] [**Name (NI) **] cell: [**Telephone/Fax (1) 88245**], home: [**Telephone/Fax (1) 88246**] Discharge Instructions: It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted to outside hospital with shortness of breath, poor appetite, and fatigue. You were then transferred from [**Hospital1 18**] [**Location (un) 620**] after imaging of your chest with plain x-rays and chest CT revealed concern for possible complicated pneumonia and worse pleural effusions or fluid on the lungs. You had a chest tube at outside hospital to attempt to drain this fluid but because it was a very small amount it was unable to be successfully drained. . You were sent to [**Hospital1 18**] [**Location (un) 86**] for additional management of a suspected complicated pneumonia and for further evaluation with the thoracic surgical team. The thoracic surgery specialists did not feel you needed any further procedures or surgeries. Your pneumonia was managed with IV antibiotics, increased supplemental oxygen and nebulizer treatments to help with shortness of breath. You had no additional fevers and your breathing was back to your usual baseline on 2.5L oxygen via nasal cannula by time of discharge. Please continue the remainder of your antibiotics as prescribed while your pneumonia continues to resolve. You will need a repeat chest x-ray with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in about 4-6 weeks time. . You also had recurrence of your known abnormal heart rhythm called atrial fibrillation. Your rapid heart rate was eventually controlled on higher doses of metoprolol which should be continued as an outpatient. The medical team diagnosed you with acute kidney injury as well which was attributed to dehydration and effects from a diuretic medication (for your diastolic congestive heart failure treatment) called Lasix. After getting gentle IV fluids and holding your lasix for several days your kidney function returned to [**Location 213**]. . After notice of right lower extremity swelling you had an ultrasound study which revealed a blood clot in your leg called a deep vein thrombosis (DVT). Therefore you were started on blood thinning medications called heparin (IV given) and Coumadin. You will need to continue your outpatient Coumadin therapy for at least 3 months, perhaps longer. Total length of therapy needs to be discussed with Dr. [**First Name (STitle) **], your PCP. . Please see below for all of your outpatient follow-up appointment instructions. . MEDICATION CHANGES/INSTRUCTIONS: The following new medications were started: 1. Coumadin daily therapy for your right lower leg blood clot and atrial fibrillation (prevents strokes). INR level needs lab monitoring closely on this medicine (INR goal [**3-2**]) 2. Toprol XL 150mg daily for heart rate control 3. IV Vancomycin and IV Zosyn until [**1-27**]. 4. oxycodone 2.5mg q8hrs as needed for low back pain 5. bisacodyl, senna, and colace as needed for constipation 6. Mirtazepine 15mg before bed for appetite stimulation and improved mood effects 7. Aspirin 325mg daily 8. Zofran 4mg as needed for nausea The following medications were discontinued: -diltiazem The following medications were continued at their previous dose: 1. Lasix 20mg PO daily 2. albuterol inhaler as needed for shortness of breath or wheeze 3. Advair inhaler twice a day 4. Spiriva inhaler daily Followup Instructions: Please make a follow-up appointment with Dr. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **] at #[**Telephone/Fax (1) 16171**] after you are discharged from rehab Completed by:[**2102-1-25**]

Admission Date: [**2200-1-23**] [**Month/Day/Year **] Date: [**2200-2-8**] Date of Birth: [**2149-10-17**] Sex: F Service: [**Year (4 digits) 662**] Allergies: Penicillins / Ampicillin / Motrin / Bactrim / Lithium / Doxycycline Attending:[**First Name3 (LF) 5755**] Chief Complaint: Shortness of Breath, Hemoptysis Major Surgical or Invasive Procedure: None History of Present Illness: 50 female with h/o COPD on 4L home 02, idopathic cardiomyopathy, CRI and bipolar d/o who presented to the ED today with acute onset SOB, which started this am, hemoptysis, chronic mucopurulent cough and tachycardia. THe hemoptysis was about "the bottom of a cup" and is present every time she coughs something up. At baseline she has a greenish sputum, that is unchanged from prior. She denies any CP, other than her usual CP. She reports fevers several days prior for two days. She had one episode of vomiting yesterday, when she brought up food contents, but denies any hematemesis. She denies headaches, abd pain, nausea, diarrhea, melena, dysuria. She has occ orthopnea and sleeps on 3 pillows. She has stable atypical CP, unchanged from prior. She reports a "40lb weight loss over 40 days". she reports her granddaughter was recently sick with "pneumonia". . In the ED the pt was satting 88% on her home 4L. She received combivent, prednisone 60 and azithromycin in ED. An ABG was done and showed 7.34/60/106 which is close to the patient's baseline. The pt was also found to be in acute renal failure and a CT was not advisable. A VQ scan was ordered and the pt was started on a Heparin gtt. 1L NS was given. Past Medical History: - COPD: on home O2 at 4 L PFTs [**8-31**]: FEV1 0.61 (30%), FVC 1.66 (60%), FEV1/FVC 37 (48%), h/o intubation x 2, h/o steroid tapers [**3-30**] x per year - atypical CP - DM2 - HgbA1c 5.8% on [**2198-11-12**] - h/o small pulomonary microemboli - finished coumadin x 6 months - CRI (baseline 1.5) - Bipolar d/o - HTN - no BB due to copd - CHF - EF 35-40% with impaired LV relaxation - DI- nephrogenic - chronic anemia Social History: Patient lives with her daughter She smoked [**5-1**] PPD x 20 yrs and quit one year ago Denies drug use Family History: Father- MI at 41, died at 72 Son -died at 31 of MI Mother- DM and multiple other medical problems, died at 73 of stroke Brother-prostate Ca Physical Exam: VS 99.1 BP 117/67 HR 84 20 94%4L Gen: well appearing female in NAD HEENT: NC, AT, anicteric sclera, dry mm Neck: no LAD, JVP flat Cardio: tachycardic, distant heart sounds, nl S1 S2, no m/r/g audible Pulm: expiratory rhonchi bilaterally, R >L Abd: soft, NT, ND, + BS, possible midline hernia Ext: 2+ DP pulses, no lower ext edema Neuro: PERRLA, moving all extremities, initially oriented to place, person and day (not to year), President of the USA: [**Doctor Last Name **]. Sluggish speech dosing off. Pertinent Results: [**2200-1-23**] 08:15PM WBC-15.1*# RBC-3.45* HGB-9.8* HCT-30.2* MCV-88 MCH-28.4 MCHC-32.3 RDW-15.8* [**2200-1-23**] 08:15PM NEUTS-75.5* LYMPHS-16.2* MONOS-5.5 EOS-2.0 BASOS-0.7 [**2200-1-23**] 08:15PM PLT COUNT-286 [**2200-1-23**] 08:15PM CK(CPK)-535* [**2200-1-23**] 08:15PM CK-MB-5 cTropnT-<0.01 [**2200-1-23**] 08:15PM GLUCOSE-207* UREA N-28* CREAT-3.1*# SODIUM-144 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-30 ANION GAP-17 [**2200-1-23**] 08:35PM LACTATE-1.8 . GRAM STAIN (Final [**2200-1-24**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2200-1-26**]): MODERATE GROWTH OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Final [**2200-1-31**]): NO LEGIONELLA ISOLATED. . BLOOD CX [**2200-1-23**]: NO GROWTH URINE CX [**2200-1-24**]: < 10K ORGANISMS URINE LEGIONELLA ANTIGEN: NEGATIVE SPUTUM CYTOLOGY: NONDIAGNOSTIC . EKG: Sinus arrhythmia with atrial and ventricular premature beats. Compared to the previous tracing of [**2199-5-29**] baseline artifact is not seen and rhythm change is new. . Echo The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Transmitral Doppler imaging is consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2198-4-20**], the left ventricular function has normalized. . CHEST, ONE VIEW: Comparison with [**2199-5-31**], [**2199-5-29**]. Cardiac, mediastinal, and hilar contours are unchanged; right heart border obscuration again seen, as seen on previous examinations. Again identified is severe apical emphysema. This may accentuate the appearance of lower lobe vascular crowding. Linear atelectasis identified at the left lung base. No pleural effusion. No pneumothorax. Osseous structures appear unchanged. IMPRESSION: Similar appearance of severe apical emphysema and lower lobe vascular crowding, without significant change since [**2199-5-27**] examinations. . CHEST, PA AND LATERAL: The marked upper lobe bullous emphysema is unchanged. This accentuates the appearance of lower lobe vascular crowding. There is no focal consolidation. No pleural effusions are present. The cardiac size, mediastinal and hilar contours are unremarkable. IMPRESSION: Biapical bullous emphysema without pneumonia. Brief Hospital Course: # COPD exacerbation: Patient was treated with IV steroids, azithromycin, and [**Year (4 digits) 1988**] nebs with improvement back to her baseline. She was discharged home on a slow prednisone [**Year (4 digits) 15123**]. She is on continuous oxygen at home at baseline. . # Hemoptysis: Given patient reported no risk factors for PE and had no lower extremity swelling on exam, work-up for PE was deferred. Patient improved quickly to her baseline with treatment of her COPD flare and her hemoptysis resolved. Patient denies any history of weight loss, but CT chest without contrast (given poor renal function) could be considered to further investigate for evidence of malignancy. . # Acute renal failure: Patient's creatinine returned to her baseline off her ACE and with supportive IVF. She was discharged off her ACEI, given her potassium has been running high. She will follow-up with her primary care doctor to discuss restarting this medication if her creatinine and potassium remain stable. # Type 2 diabetes: Patient's sugars were difficult to control while patient was on steroids. [**Last Name (un) **] was consulted and recommended starting NPH, in addition to increasing the patient's home glipizide. The patient received teaching with a glucometer and was able to check her sugars confidently prior to [**Last Name (un) **]. She was given a schedule to wean her NPH as her steroid dose is decreased and she will have close follow-up at [**Last Name (un) **]. . # Somnolence/Pysch: Patient was noted to be intermittently somnolent. The concern in the ICU was for C02 retention; however, repeat ABGs were no different from her baseline. Patient's neuroleptics were held with improvement in sx. She remains on Depakote; risperidal held; and seroquel reduced to 50 mg po qhs. . # CHF: Repeat Echo actually demonstrated improvement in EF to normal. Blood pressure well controlled on her home diltiazem, in addition to newly started nifedipine in the setting of elevated bp's off her ACEI. . # EPS: During her hospitalization noted to be intermittently jittery. Initial concern was ?myoclonic jerks. Repeat ABGs without change in C02. Seen by Neuro/Psych who felt etiology likely secondary to EPS and steroids. Changes to neuroleptics as described above. . # Sinus tachycardia: On the floor, patient had rare bursts of a SVT which appears to be sinus tachycardia. Cardiology was consulted for telemetry and 12 ld concerning for possible afib/flutter but felt this was consistent with sinus tachycardia with background noise from her tremor. . # Bipolar disorder: Patient's psychiatric medications were adjusted, as above. Her mood remained stable on steroids, without evidence of mania. She denies any insomnia. . # Hyperkalemia: Patient had an episode of hyperkalemia while off her ACEI. Renal was consulted. FEK 23%, thus low suspicion for hyporeninemic hypoaldosterone state. CK was normal so no evidence of rhabdo. Renal suspects hyperK due to dietary noncompliance. Patient was put on a renal diet and received nutrition counseling on continuing on this diet at home. Her potassium remained stable and will be rechecked as an outpatient. Medications on Admission: ADVAIR DISKUS 250-50 mcg/Dose--1 puff inh twice a day ALBUTEROL NEBS/IH Q4-6H DILTIAZEM HCL 360mg QD DIVALPROEX SODIUM 250MG QAM/500 QPM GLIPIZIDE 5 mg QD IPRATROPIUM BROMIDE IH/NEB Q6h IRON 325 mg QD LIPITOR 20 mg QD LISINOPRIL 40MG QD MULTIVITAMIN QD RISPERIDONE 1MG QAM, 3MG QHS SEROQUEL 150mg QHS TIOTROPIUM BROMIDE 18 mcg QD TRAZODONE HCL 50MG QHS . [**Last Name (un) **] Medications: 1. Outpatient [**Last Name (un) **] Work Please draw sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, calcium, and phosphorus on [**2200-2-11**]. Please notify Dr. [**First Name (STitle) 17137**] [**Name (STitle) **] of results: Phone [**Telephone/Fax (1) 250**]. 2. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Fifteen (15) units Subcutaneous qam for 3 days: on [**2200-2-11**]. Disp:*3 prefilled syringes* Refills:*0* 3. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Thirty (30) units Subcutaneous qam for 2 days: on [**1-14**]. Disp:*2 prefilled syringes* Refills:*0* 4. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Seven (7) units Subcutaneous qam for 3 days: on [**2200-2-14**]. Disp:*3 prefilled syringes* Refills:*0* 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*1 inhaler* Refills:*2* 6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation twice a day. Disp:*1 inhaler* Refills:*2* 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing: PLEASE USE YOUR SPACER WITH YOUR INHALER. Disp:*1 INHALER* Refills:*2* 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEBULIZER TREATMENT Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*20 VIALS* Refills:*2* 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). Disp:*30 Capsule(s)* Refills:*0* 11. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). Disp:*60 Capsule(s)* Refills:*0* 12. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 8 days. Disp:*8 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 13. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 17. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*60 Tablet(s)* Refills:*0* 18. Prednisone 5 mg Tablet Sig: 1-4 Tablets PO once a day for 8 days. Disp:*17 Tablet(s)* Refills:*0* 19. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1) Tab,Sust Rel Osmotic Push 24HR PO once a day. Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*0* [**Date range (3) **] Disposition: Home With Service Facility: [**Hospital 119**] Homecare [**Hospital **] Diagnosis: COPD exacerbation hyperkalemia chronic renal insufficiency type 2 diabetes, poorly controlled with complications bipolar disorder sinus tachycardia [**Hospital **] Condition: good: breathing at baseline, blood sugars well controlled, electrolytes stable [**Hospital **] Instructions: Please call your doctor or go to the emergency room if you experience worsening shortness of breath, temperature > 101, worsening cough, chest pain, heart racing, or other concerning symptoms. Please have labs drawn on [**Hospital 3816**] to check your electrolytes. Please follow the special kidney diet (low potassium, low phosphorus) you were provided. Please take your blood sugar before every meal and at bedtime. Record these numbers on a piece of paper and bring this with you to your [**Last Name (un) **] appointment. If you ever feel shaky, sweaty, or weak check your blood sugar. If it is < 70, drink some juice and recheck it in 30 minutes. If it is still < 70 call 911. If it improves to > 70, do not take any more insulin, regardless of your prescribed dose. If you are ever vomiting or otherwise unable to eat, do not take any insulin that day. Followup Instructions: Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], nurse [**Last Name (NamePattern1) 3639**] [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **] Diabetes Center on [**2200-2-13**] at 12:30 PM to discuss management of your diabetes. Please bring your glucometer to this appointment. Phone: ([**Telephone/Fax (1) 17484**] Location: One [**Last Name (un) **] Place, [**Location (un) 86**], [**Numeric Identifier 718**] Please follow-up with nurse [**First Name8 (NamePattern2) 3639**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who works with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**], [**2200-2-11**] at 12:40 PM to assess how your breathing is doing. Phone: [**Telephone/Fax (1) 250**]. Location: [**Hospital6 733**], [**Location (un) **], [**Hospital Ward Name 23**] 6, Central Suite Please follow-up with your primary care doctor, Dr. [**First Name (STitle) **], on [**2200-3-3**] at 2 PM for routine care. Phone: [**Telephone/Fax (1) 250**]. Location: [**Hospital6 733**], [**Location (un) **], [**Hospital Ward Name 23**] 6, North Suite Please follow-up with your psychiatrist, Dr. [**Last Name (STitle) **], on [**2-12**], [**2200**] at 10:00 AM. Phone: ([**Telephone/Fax (1) 24780**]

Admission Date: [**2197-12-17**] Discharge Date: [**2197-12-29**] Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 1148**] Chief Complaint: CC:[**CC Contact Info 60684**] Major Surgical or Invasive Procedure: central line placement History of Present Illness: Ms. [**Known lastname **] is a 85 yo female with PMH of CAD s/p CABG, CHF who was in USOH until 1 week ago when she started experiencing cough and sob. She states that over the course of the week she experienced progressing shortness of breath and chills. She states that on the day PTA, she lost her balance and fell and lay there as she was unable to make it to the phone for about 6 hours. Her daughter found her. The next day, her daughter found her to be febrile to 103 and brought her to [**Location (un) 20026**] Hospital. . Initially, on admission to NWH, she was febrile but normotensive. CXR revealed both PNA and fluid overload. BNP 1099. LENI's of her lower extremities were performed due to complaint of calf pain with ambulation; both extremities negative for DVT. She was given Lasix 40 mg IV, and her BP dropped to 60's and she was started on dopamine. She also was treated with Vancomycin, ceftriaxone, and azithromycin. She was placed on NRB for her oxygentation and heparin gtt in the setting of elevated troponins (TropI to 0.9) and transferred to [**Hospital1 18**] for further care. . On arrival to the [**Hospital1 18**] ER, she had a head CT and CXR and started on CPAP prior to her transfer to the MICU. At this time, she reported that her shortness of breath was improving. She denied chest pain, and ROS revealed only one loose BM per day for the past 1 week. . In the MICU, she required mask ventilatory support and Levophed for BP support. A right subclavian CVL and left A-line were placed. Levophed was quickly titrated off, and she was transferred to the general medicine service on 4L NC for further care. Past Medical History: 1. Coronary Artery Disease s/p Coronary Artery Bypass Graft on [**3-5**] 2. Post-op Atrial Fibrillation requiring electrical cardioversion 3. CHF 4. Osteoarthritis 5. Carpal tunnel syndrome 6. Shingles right arm [**2191**] . PSH: s/p pacemaker placement s/p Left knee replacement in [**2192**] s/p Thyroidectomy [**2169**] s/p Cholecystectomy [**2163**] s/p Hysterectomy [**2192**] for ?uterine cancer Social History: She has two children, and currently resides with daughter. She quit smoking 40 yrs ago, previously smoked 1 ppd for 20 years. She admits to occasional EtOH, denies illicit drug use. She ambulates without assistance at baseline. Family History: Father died of MI at age 69. Physical Exam: VS: T 96.9, 132/62, HR 66, RR 20, SpO2 94% on 4L GEn: Elderly obese WF female reclining in bed, pleasant, HOH, NAD. HEENT: moist mucous membranes, clear OP CHEST: bilateral expiratory wheezes, Exp>Insp CVR: rrr, nl s1, s2; no JVD ABdomen: soft, obese, nontender, nondistended Ext: trace edema bilaterally, chronic venous insufficiency changes. Neuro: A&O x 3, moves all ext, 5/5 strength upper and lower ext. Mentating at baseline, per daughter. Pertinent Results: EKG - nsr, left axis, rbbb with lafb, no sig changes compared to previous. . [**12-17**] - CXR: Mild cardiomegaly. Increased opacities in bilateral lower lobes, especially on the right with effusion and atelectasis. Increased vascular markings in upper lobes. These findings can be explained worsening CHF, however, there is a possibility of right lower lobe pneumonia. . Head CT - Chronic small vessel ischemia. No evidence of hemorrhage. . [**12-18**] Echo: 1. The left atrium is moderately dilated. The left atrium is elongated. The right atrium is markedly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3.The right ventricular cavity is markedly dilated. There is focal hypokinesis of the apical free wall of the right ventricle. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. 4.The ascending aorta is moderately dilated. 5.The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. 7.Moderate to severe [3+] tricuspid regurgitation is seen. 8.There is moderate pulmonary artery systolic hypertension. 9.There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. . CXR [**2197-12-20**]: 1. Marked worsening of pulmonary edema. 2. Worsening of bibasilar consolidation, which may be due to an infectious process or aspiration. . TTE [**2197-12-22**]: There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is moderately dilated. There is mild global right ventricular free wall hypokinesis. There is abnormal septal motion/position. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2197-12-18**], the degree of tricuspid regurgitation and pulmonary hypertension are less. The RV is still dilated and hypokinetic. . CXR [**2197-12-23**] Persistent pulmonary edema. Bilateral pleural effusions. The slight interval increase in the left-sided pleural effusion may be attributable to differences in patient positioning. . CXR [**2197-12-27**] Compared with [**2197-12-23**], the posterior left pleural effusion appears grossly unchanged. No significant increase is seen involving the much smaller right pleural effusion. The right lower lobe atelectasis/infiltrate is grossly unchanged. Brief Hospital Course: 85 year old woman with h/o CHF, CAD s/p CABG admitted with pneumonia & CHF exacerbation. . 1. Pneumonia: Likely community acquired PNA. She has been treated with azithromycin, vancomycin, and ceftriaxone; vancomycin d/c'd after 7 days as patient is low-risk for nosocomial MRSA pneumonia. Gram stain and sputum cultures unrevealing. Influenza DFA negative. She completed a 10d of Cef/Azithro. She required supplement O2 at discharge to maintain SpO2>92% (she was down to 1.5L). This should continue to be titrated down. After completing her treatment, she remained afebrile. . 2. CHF: Patient with known h/o CHF. Echo performed during this hospital course show RV dysfunction and dilation (see ECHO reports). Abnormal septal motion/position was felt to be consistent with RV pressure/volume overload. This pulm HTN was not new as she had previously PA HTN from prior to CABG in [**2196**] and in [**6-/2197**] - per ECHO done by her primary cardiologist. LVEF normal. It is possible that cause of RV failure is acute pulmonary disease; however, the differential diagnosis includes PE vs. ischemic disease. She had positive trops, but only mildly elevated without EKG changes and thus was felt to be demand related. At [**Hospital1 18**], our goal for her was for a negative fluid balance, particularly in the setting of worsened pulmonary edema on most recent CXR. After coming off pressors and transfer to floor, the patient was aggressively diuresed with 40mg [**Hospital1 **] IV of lasix. We diuresed her with a goal of -2L per day. She still required oxygen upon discharge, but with continued diuresis, this should be able to be weaned down. She was discharged on Lasix 80mg PO BID; Once she is euvolemic and no longer requiring oxygen, she should be switched back to her home dose of Lasix 40mg po daily. She should have repeat electrolytes on [**1-1**] to ensure her kidney function is stable. She should follow up with her cardiologist in the next 1-2 weeks and have a repeat echocardiogram at that time once she is euvolemic. Initially held BB & [**Last Name (un) **] in the setting of hypotension and ?sepsis. These were restarted before discharge. Continued amiodarone per prior regimen. Weight on discharge was 236lb. She was maintained on a low sodium diet. . 3. CAD: Patient with known h/o CAD, s/p CABG. Patient presented with troponin leak (peaking at 0.15) but asymptomatic with no associated EKG changes. She was on a heparin gtt at outside hospital but this was discontinued once enzymes downward trending. Troponin leak was likely secondary to demand ischemia in the setting of pneumonia. Continued ASA, Zetia, Lipitor and BB. . 4. Acute renal failure: Cr elevated to 2.3 on admission (baseline 1.1) with pre-renal etiology (FeNa <1%). Creatinine did continue to increase with diuresis, and on discharge was 1.4. It is likely indicative of appropriate diuresis with relative hypovolemic state, necessary in this patient to keep her dry and prevent pulmonary edema. . 5. Atrial fibrillation: Rate controlled with beta blocker and amiodarone. In sinue rhythm during this hospitalization. Not clear as to why the patient is not anticoagulated as she was anticoagulated in the past. This should be readressed with her cardiologist. . 6. Pulmonary effusion: R sided effusion; ultrasound shows little layering of the fluid. Followed by XRays. Relatively stable on discharge. . 7. Hypothyroidism: continue levothyroxine. . 8. Code Status: Full code. . 9. Communication with daughter [**Name (NI) **] ([**Telephone/Fax (1) 60685**]. PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**Hospital1 **]. . 10. Dispo: To extended care facility in good condition, on 1.5L of O2 by NC. Medications on Admission: 1. Synthroid 200mcg 2. Lipitor 40 3. Zetia 10 4. Prilosec 40 5. Toprol XL 25 mg daily 6. Lasix 40 daily 7. Amdiodarone 200 mg daily 8. ASA 81 mg daily 9. Avapro 300 mg daily Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 5399**] Nursing Home - [**Hospital1 **] Discharge Diagnosis: PRIMARY: Pneumonia Acute renal failure CHF exacerbation . SECONDARY: CAD Discharge Condition: Stable Discharge Instructions: You were admitted with pneumonia and a CHF exacerbation. You should weigh yourself daily, and call your doctor if you gain more than three pounds in one day. Please call your primary care doctor if you become short of breath, have chest pain, abdominal pain, nausea, vomiting, fever >101, chills, increase in swelling in your lower legs. . You should have a repeat electrolyte panel on [**Last Name (LF) 766**], [**1-1**], to ensure that your kidney function is doing well. . You should continue to have your supplemental oxygen weaned off. . Once you are off oxygen you should be switched back to your home dose of lasix, which is 40mg po daily. Followup Instructions: You have an appointment to follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], on Thursday, [**1-4**] @ 1:45. You can reach his office at [**Telephone/Fax (1) 26303**]. . You should make an appointment to follow up with your cardiologist, Dr. [**Last Name (STitle) **] within the next two weeks. You can reach his office at: ([**Telephone/Fax (1) 42003**]. You will need a repeat echocardiogram at that time.

Admission Date: [**2129-4-21**] Discharge Date: [**2129-4-27**] Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with a history of nephrolithiasis and a question of leiomyosarcoma, transferred from [**Hospital3 1196**] for suspected urosepsis, positive troponin leak in the setting of new atrial fibrillation with a rapid ventricular response, status post cystoscopy with stent placement for obstructing stone with pus. He presented to [**Hospital3 1196**] with suspected urinary tract infection based on a urinalysis and was given Levaquin after [**Hospital3 **] and blood cultures were drawn and then transferred to [**Hospital1 69**] for further management. Here, he reported fevers, chills, nausea and vomiting times two days. He complained of some mild dysuria times two days without frequency and had one episode of nonbloody emesis and bile. He had normal bowel movements. He last had a urinary tract infection about seven months ago, history requiring intervention, possible cysto. The patient was admitted initially to the Medicine Service, but on the morning of [**4-21**] complained of fatigue and mild nausea without abdominal pain or back pain. He was sleepy and forgetful at times. A CT scan was done to rule out stone obstruction basically showed large right renal cyst, mild hydronephrosis with periureteral stranding. Overnight events on [**4-21**] were notable for atrial fibrillation with a rapid ventricular response to 176. He was given Lopressor 5 mg intravenously times three. Dinamap showed blood pressure peaked at 140 there, with blood pressure low of 85/58 and then up to 140s. He spiked and was cultured, and a dose of vancomycin was given. Blood cultures then came back with gram-negative rods in the blood. He had emesis times two on [**4-21**], and a small bowel movement on [**4-21**]. In the afternoon of [**4-22**], he was brought to the operating room for a cystoscopy, a right JJ stent (6 cm X 26 cm) was placed. Pus was drained from behind the obstructing stone. The patient currently denies any chest pain, shortness of breath, nausea, vomiting, and abdominal pain. He only complains of thirst. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diverticulitis. 3. Nephrolithiasis; treated by Dr. [**Last Name (STitle) 41116**] at [**Hospital3 1196**]. 4. Right groin leiomyosarcoma had caused obstruction in the past; surgery at [**Hospital6 1708**] with orchiectomy, treated by Dr. [**Last Name (STitle) **]. 5. Chronic renal insufficiency with a baseline creatinine of 1.2. 6. Right renal complex calcified cyst last measured at 12 cm X 9 cm (as of [**2128-7-25**]). ALLERGIES: PENICILLIN causes hives. MEDICATIONS ON ADMISSION: Medications at home included Vasotec and Hytrin. MEDICATIONS ON TRANSFER: Medications upon transfer from the floor to the Intensive Care Unit included droperidol, Dulcolax, Colace, Fleets, lactulose, intravenous fluids, Tylenol, Ambien, aspirin, and Levaquin. SOCIAL HISTORY: He is a retired psychiatrist. Son [**Doctor First Name **] and daughter ([**Name (NI) **]). Occasional alcohol use. He quit tobacco 40 years ago. PHYSICAL EXAMINATION ON PRESENTATION: In general, the patient was sleep but easily arousable, supine, height of 5 feet 11 inches, weight of 250 pounds, temperature of 99, pulse of 105, blood pressure of 138/56, oxygen saturation of 96% on 2 liters nasal cannula. Head, eyes, ears, nose, and throat examination revealed extraocular muscles were intact. Normocephalic and atraumatic. Cardiovascular examination revealed irregularly irregular. Normal first heart sound and second heart sound. No murmurs. Pulmonary examination anterolaterally revealed clear to auscultation. The abdomen revealed normal active bowel sounds but diminished overall, distended, and nontender. Groin with a well-healed inguinal scar, nontender. Extremity examination revealed no edema. Neurologic examination revealed alert and oriented times three, appropriate, moved all extremities. Rectal was guaiac-negative/brown. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data on [**4-22**] revealed sodium of 141, potassium of 3.8, chloride of 108, bicarbonate of 21, blood urea nitrogen of 40, creatinine of 1.8, blood glucose of 105. Creatine kinase was 111, troponin was 18.3, CK/MB of 26, CK/MB index was 23.4. Magnesium of 1.7. Arterial blood gas revealed 7.49/33/93/26. Lactate was 3.8. Blood cultures revealed gram-negative rods, lactose fermenter not specified. [**Month (only) **] culture revealed pan-sensitive Escherichia coli, gram-negative rods, lactose fermenter not speciated. RADIOLOGY/IMAGING: KUB revealed nonspecific bowel gas pattern with a few prominent gas-filled small bowel loops, but no evidence of high-grade obstruction. CT of the abdomen on [**4-21**] revealed a 8-mm obstructing stone in the distal third of the right ureter producing mild hydronephrosis, several other calcifications were noted in the bilateral peripapillary regions, two 12-cm right renal cysts with peripheral calcification was only partially evaluated on the noncontrast examination. Due to the patient's renal failure, a renal magnetic resonance imaging was recommended to exclude a more complex renal mass when clinically indicated. Cholelithiasis without obstruction or cholecystitis. Slight splenomegaly. Linear soft tissue stranding in the right inguinal region of uncertain etiology of significance; please correlate with physical examination and surgical history to exclude an acute inflammatory process. Apparent regions of focal bone loss in L3 vertebral body and right femoral neck were likely degenerative. Pathologic lesions could not be entirely excluded. Electrocardiogram revealed atrial fibrillation with a rapid ventricular response of 160, with ST depressions in the anterior leads of 2 mm to 3 mm. IMPRESSION: This is a 78-year-old man with urosepsis, atrial fibrillation with a rapid ventricular response, and positive cardiac enzymes. HOSPITAL COURSE: 1. INFECTIOUS DISEASE/UROLOGY: The Urology Service followed the patient while in the hospital, status post stent placement with return of pus. The stent was kept in place to be removed several weeks after discharge when the patient was more stable. Only one stone was removed. The patient had evidence of more stones. He was monitored for further signs or symptoms of obstruction. The patient was continued on intravenous Levaquin with the consideration of adding gentamicin if his creatinine tolerated this. Vancomycin was discontinued. Escherichia coli in the [**Month (only) **] culture at the outside hospital was pan-sensitive. The patient was continued on aggressive intravenous fluids. Intravenous fluids were discontinued because of evidence of congestive heart failure, and the patient was encouraged to take p.o. hydration. Cultures taken at [**Hospital1 69**] were negative to date including blood cultures and [**Hospital1 **] cultures. Levofloxacin was changed from intravenous to p.o. on [**2129-4-24**]. The patient experienced some incontinence, and his Pyridium was changed from p.r.n. to a standing dose. Per the Urology team, he was also discharged on Urised two tablets p.o. q.i.d. times 10 days for his incontinence. Levofloxacin was to be continued for a total of 14 days. 2. CARDIOVASCULAR: Atrial fibrillation with a rapid ventricular rate. The patient was given doses of Lopressor on the floor; a total of 50 mg intravenously. In the Intensive Care Unit, the patient was continued on Lopressor for rate control. He was anticoagulated with heparin, and the plan was to get an echocardiogram on the patient to rule out thrombus. His atrial fibrillation was thought to be triggered by his septic state. The patient's troponin and creatine kinase leak/rise was thought to be ischemia related to sepsis and atrial fibrillation. The patient had no known cardiac history. The patient was anticoagulated with heparin, continued on beta blocker, and continued on aspirin. Creatine kinases and troponins were followed and trended down. The patient remained hemodynamically stable, although with some evidence of congestive heart failure on examination. The patient responded well to diuresis with Lasix. Electrocardiogram which showed ST depressions was repeated with resolution of the ST depressions. The patient was started on captopril 12.5 mg p.o. t.i.d. on [**4-23**]. Coumadin was also started that day for atrial fibrillation with a plan to follow up with Cardiology as an outpatient. On [**4-25**], the patient reverted back to sinus rhythm and was well rate controlled with beta blocker. On further consideration, Coumadin was not started, and he was continued on a heparin drip. The patient remained in sinus rhythm for the remainder of his hospital stay. A cardiac echocardiogram was suboptimal secondary to poor echocardiogram windows showing mild symmetric left ventricular hypertrophy, ejection fraction of greater than 55%, 2+ mitral regurgitation, and mild pulmonary hypertension. He heparin drip was discontinued, but he was continued on his Lopressor and captopril. An outpatient exercise tolerance test will be considered. 3. RENAL: The patient with chronic renal insufficiency with a baseline creatinine of 1.2. This may be secondary to hypertension versus old obstruction. It should not increase in the setting of unilateral obstruction alone, but with sepsis and volume depletion this was not unexpected. He was continued on aggressive hydration; although, this was stopped briefly because of signs and symptoms of congestive heart failure. His [**Month (only) **] output was followed as was his creatinine. Medications were renally dosed for a calculated creatinine clearance of 50 cc per minute. The right renal mass seen on CT scan was thought to be chronic, per his primary care physician. [**Name10 (NameIs) **] electrolytes and FENa were suggestive of prerenal azotemia in the setting of decreased oral intake secondary to nausea, vomiting, and abdominal pain with kidney stone. The patient was to have followup of renal cyst as an outpatient with magnetic resonance imaging or CT with contrast. His renal function improved by the time of discharge with a blood urea nitrogen of 37 and a creatinine of 1.3; almost at his baseline. 4. HEMATOLOGY: The patient with anemia. Guaiac-negative; unknown baseline. Monitored closely on heparin. Coagulations were followed closely on heparin. A decrease in hematocrit may have been secondary to dilution from hydration. On [**4-23**], the patient had a large liquid stool which was occult-blood positive, but his hematocrit remained stable, and he did not require any transfusions. He was continued on Protonix. 5. ONCOLOGY: Leiomyosarcoma without a history of metastatic disease. A head CT in the past was negative for metastatic lesions; though bony lesions were concerning on CT scan. The patient will need further workup of his L3 vertebral body right femoral neck bony lesions. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home. MEDICATIONS ON DISCHARGE: 1. Urised two tablets p.o. q.i.d. p.r.n. 2. Aspirin 325 mg p.o. q.d. 3. Protonix 40 mg p.o. q.d. 4. Lopressor 100 mg p.o. t.i.d. 5. Vasotec (previous home dose). 6. Hytrin (previous home dose). 7. Levofloxacin 500 mg p.o. q.d. (times 12 days). DISCHARGE DIAGNOSES: 1. Right ureteral stone complicated by urosepsis. 2. Paroxysmal atrial fibrillation; troponin leak. 3. Hypertension. 4. History of diverticulitis. 5. History of leiomyosarcoma; removed several months ago. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 10146**] Dictated By:[**Last Name (NamePattern1) 7069**] MEDQUIST36 D: [**2129-7-30**] 18:27 T: [**2129-8-2**] 08:47 JOB#: [**Job Number 41117**]

Admission Date: [**2108-12-5**] Discharge Date: [**2108-12-17**] Date of Birth: [**2043-6-16**] Sex: M Service: MEDICINE Allergies: Cozaar / Nitroglycerin / Primidone / Zestril Attending:[**First Name3 (LF) 4765**] Chief Complaint: gangrenous left heel and right heel/great toe ischemia Major Surgical or Invasive Procedure: 1.Ultrasound-guided imaging for vascular access;contralateral second-order catheter placement with bilateralextremity runoff & abdominal aortogram. ([**2108-12-6**]) 2.Right lower extremity bypass graft with nonreversed saphenous vein graft. ([**2108-12-10**]) 3.Left femoral to posterior tibial artery bypass with in situ saphenous vein graft. ([**2108-12-12**]) History of Present Illness: HPI: 65 M h/o CAD s/p MI in [**2085**], CHF (EF ~20%), DM2, ESRD on HD (? h/o [**Year (4 digits) 2091**] with urosepsis, on since [**10-18**]), admitted [**12-6**] for bilateral foot gangrene s/p b/l femoral bypass on [**12-11**] (right leg) and [**2107-12-13**] (left leg) transferred from vascular service for syncope in setting of V fib. . Patient admitted on [**12-6**] after noted to have gangrenous changes of both heels while at rehab. Underwent bypass sx w/o complication. On [**2108-12-13**] pt was finishing ultrafiltration ~1pm (renal note dated early), when he was noted to have a syncopal event for ~10seconds, with telemetry suggestive of VT/VF. He regained consciousness. Per pt, he had no further syncopal episodes. CODE BLUE called ~13:15 for a syncopal event. Pt was hemodynamically stable upon arrival, alert, oriented, breathing without difficulty. EP was called, and per EP interogation of ICD initially felt to have AF with intermittent conversion to NSR, then VT with attempt to ATP unsucessfull resulting in VF which was shocked x 1. . Of note, the prior evening, patient developed hypotension with sys bp in 60's of unknown etiology and was started on phenylephrine gtt with improvement in BP. Per surgical service, this was in the setting of slow VT, though it is unclear whether slow VT was the sole cause of hypotension (ddx includes sepsis, bleeding, adrenal insufficiency POD#1). He was being treated with cipro/flagyl/vanco empirically. . Patient had been in and out of the hospital since end of [**Month (only) 359**] with recent admissions at OSH for CHF exacerbation, UTI and syncopal episode [**10-18**] [**1-12**] afib with RVR. Discharged to rehab. Noted to be in V-tach at rehab during syncopal episode in 3rd week of [**Month (only) **]. per pt, CPR was administered and he was defibrillated. However, upon reevaluation of rhythm by his cardiologist, thought to be in afib with aberrancy. No history of syncope prior to [**10-18**]. At that time, amiodarone was increased and patient was again discharged to rehab. He was also started on hemodialysis for unclear reasons (?allergic reaction to [**Last Name (un) **]). . On review of symptoms, positive hx of L LE DVT (~[**2104**]). Denies any prior history of stroke, TIA pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Currently w pain in b/l legs with movement. No dysuria. Does report vomiting, approx [**3-16**] episodes post op. Approx 3 episodes today. Denies nausea. Passing flatus, no abdominal pain. Last BM 2 days prior. . *** Cardiac review of systems is notable for absence of chest pain, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Sleeps on 2 pillows. Chronic nonproductive cough for 3 years. Past Medical History: PMH: ESRD/HD, HTN, CHF (preop EF 20%, 2+ MR),s/p AICD placement, CAD s/p MI [**2085**], hypercholestereolemia, gout,IDDM, diabetic neuropathy Social History: Social history is significant for the absence of current tobacco use. Patient is married, lives with wife. Lives in [**Location 11269**]. Able to complete ADLS without difficulty. Retired, in charge of construction and engineering in [**Location (un) 511**] division of [**Company **]. Quit ETOH in [**2100**]. Prior that would drink 6pack of 16oz beer/day + [**12-12**] hard alcohol/day for 15 years. No hospitalization for ETOH, NO hx of DTs. Family History: There is no family history of premature coronary artery disease or sudden death. . Pertinent Results: [**2108-12-5**] 06:26PM GLUCOSE-109* UREA N-26* CREAT-3.5* SODIUM-142 POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-30 ANION GAP-13 [**2108-12-5**] 06:26PM estGFR-Using this [**2108-12-5**] 06:26PM ALT(SGPT)-17 AST(SGOT)-19 ALK PHOS-174* TOT BILI-0.5 [**2108-12-5**] 06:26PM calTIBC-107* FERRITIN-303 TRF-82* [**2108-12-5**] 06:26PM CALCIUM-8.1* PHOSPHATE-2.2* MAGNESIUM-1.7 IRON-36* CHOLEST-75 [**2108-12-5**] 06:26PM %HbA1c-5.4 [**2108-12-5**] 06:26PM TRIGLYCER-97 HDL CHOL-38 CHOL/HDL-2.0 LDL(CALC)-18 [**2108-12-5**] 06:26PM WBC-6.9 RBC-3.96* HGB-13.0* HCT-40.0 MCV-101* MCH-32.9* MCHC-32.6 RDW-18.6* [**2108-12-5**] 06:26PM PLT COUNT-260 [**2108-12-5**] 06:26PM PT-20.2* PTT-29.0 INR(PT)-1.9* Brief Hospital Course: . ASSESSMENT AND PLAN . 65 M with MMP including CAD s/p MI, CHF(EF 20% s/p BiV/AICD), atrial fibrillation on coumadin, Type II DM, ESRD on HD, admitted for gangrenous heels [**1-12**] PVD s/p femoral bypass with course complicated by syncopal episode and V-fibrillation s/p AICD cardioversion. . # Bilateral femoral bypass: Underwent surgery on [**12-11**] and [**12-12**] for right and left femoral bypass. Procedure was uncomplicated with good distal pulses post procedure. . # Hypotension: Patient became hypotensive requiring pressors. Initially started on neosynephrine drip. Following day patient had syncopal episode secondary to Ventricular tachycardia and Code Blue was called. Given low SVR, normal PA diastolic, borderline leukocytosis and two possible infectious sources including BL gangrene and a mass on the RA lead of his AICD, hypotension was felt to be due to sepsis. Although he initially had a low cardiac index, this was thought to be consistent with CHF with EF of 20%, and unlikley to be due to cardiogenic shock. Attempted to wean neosynephrine, but MAPS dropped down to the 55 range. He did not respond to a 1L fluid bolus so a levophed drip was started to provide pressor support with some inotropy. Patient continued to require pressure support for the remainder of his course in the intesnive care unit. Pancultures were sent and antibiotic coverage was advanced to vancomycin and zosyn. However patient minimally improved. . . # CAD/Ischemia: Hx of MI. No evidence of ischemic changes on ECG. mild trop leak likely [**1-12**] renal failure, as CK and MB flat. Continued ASA. ACE and beta blocker held in setting of hypotension. Cardiac enzymes were cycled to rule out ischemic source of troponic leak. However cardiac enzymes remained flat. . # Rhythm: Hx of atrial fibrillation on coumadin since [**2105**]. Recent admission to OSH for syncopal episodes thought to be [**1-12**] atrial fibrillation with RVR. Being followed by EP during this admission for episodes of asymptomatic slow V-tach and afib, plan had been to cardiovert AFIB, and then ablate slow monomorphic VT, however patient later developed polymorphic VT. The patient had multiple episodes of wide complex tachycardiat. Trend has been that he converts from a paced rhythm, to atrial fibrillation, and then degenerates into either polymorphic or monomorphic ventricular tachycardia. Shocked once by ICD and three times externally overnight on [**12-15**], and given 2g of magnesium. EP was consulted, recommending to d/c amiodarone given polymorphic VT in the setting of a prolonged QT interval 450-500, start lidocaine gtt and aggressive repletion of electrolytes. Patient was started on mexilitine. However later due to altered mental status was unable to take oral medications. Patient became increasingly unstable with persistent ventricular tachycardia/fibrillation unresponsive to defibrillation by his AICD or externally. As team was unable to convert rhythm, prognosis was poor, he was unstable and requiring increasing pressure support and patient was in distress from persistent shocks, team had discussion with health care proxy and decision was made to change goals of care to comfort measures only. Pressors were discontinued and patient expired soon afterward. . # Pump: EF 20%, s/p ?biV AICD in [**2105**]. No evidence of frank pulmonary edema, hypotensive requiring pressors with CI 1.8->2.1, likely secondary to class III heart failure with EF of 20%. Therefore CHF regimen held. . # Valves: no evidence of valvular disease on ECHO. . # Thrombus on ICD wire: Reviewed echocardiogram with Dr. [**First Name (STitle) **], and the mass is consistent in nature to infection v. inflammatory. Recommending a TEE for further evaluation. However patient was increasingly unstable and unable to tolerate TEE. . # PVD: s/p bilateral bypass surgery. Extremities were cool, but well perfused, with scant blood oozing from L LE thigh wound, though otherwise groin sites were clean/dry/intact. Continued to be followed by vascular surgery throughout course. . # ESRD: etiology of [**Name (NI) 2091**] unclear(started HD [**10-18**]), s/p ultrafiltration [**2108-12-13**], ?stopped prematurely secondary to syncope and hypotension. Started on CVVH as respiratory status began to decline day prior to expiration. . # DM: insulin dependent, x 12 years. FS QID, continued on ISS. . # hyperlipidemia: - continue statin . . # gout - no sx currently, will follow. - cont allopurinol qod. Medications on Admission: coumadin 1mgm q48hrs ca++ 1000mg"' renagel 1600"' isordil10mg' lactulose 30cc' protonix 40mg' allopurinol 100mg' amidarone 200mg' mvt,hydralazine 50"" omeprazol 20mg' zocor 20mg' lopressor xl 100mg' NPH5u qpm 10u qam HISS ac/hs Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: Ventricular tachycardia; Peripheral vascular disease s/p bypass; septic shock; End stage renal disease Secondary: Congestive heart failure Discharge Condition: Expired

Admission Date: [**2153-1-20**] Discharge Date: [**2153-2-19**] Date of Birth: [**2084-11-24**] Sex: M Service: NEUROSURGERY Allergies: Heparin Agents / Motrin Attending:[**First Name3 (LF) 1835**] Chief Complaint: shoulder pain Major Surgical or Invasive Procedure: S/P ACD S/P POSTERIOR CERVICAL RECONSTRUCTION History of Present Illness: 68 M PMH thyroid ca with mets to bone and liver, history of intrathecal narcotics requirement, who p/w increased pain. The pain is located in the L shoulder scapular to humoral region, with no obvious radation, and was [**2156-9-14**] in severity. He also describes other chronic pains, including leg and some chest pain with heavy coughing, but these have been stable. He was seen by Dr. [**Last Name (STitle) 19**] on [**1-16**], where he was also noted to have some L sided weakness, and was sent for an MRI to evaluate for metastatic disease, which as noted below showed no new changes. He was attempting to increase his decadron as indicated by Dr. [**Last Name (STitle) 19**], when he couldn't handle the pain this AM, and came to the ED. He has also described some diffuse paresthesias of both fingertips, although primarily on the L--no apparent pattern. Otherwise, he denies focal weakness, numbness, incontinence of stool or urine, urinary retention, HA, as well as any F/C/NS, LH, appetite changes, SOB, N/V, or abdominal pain. He has a chronic cough [**3-9**] radiation, and also noted poor fluid intake over the past few days, although no apparent reason. He requires a walker to ambulate, but notes no change over the past few days. . In the ED, given dilaudid 4mg IV x 2, with pain that was not completely revolved, but "tolerable." Past Medical History: Thyroid ca s/p thyroidectomy [**2147**], with mets to bone and liver -s/p implanted epidural narcotics on prior admission; hx of infected Port-A-Cath system S/p carboplatin [**1-9**] S/p cyperknife to T1 [**7-10**] Clear cell ca of L kidney s/p L nephrectomy [**6-6**] S/p appy Social History: History of smoking cigarettes, 1 pack-per-day, for 10 years--stopped in [**2126**]. Occasional alcohol, 1-2 drinks per week. He does not use any illicit drugs. Family History: His mother died of tuberculosis at age 36 in [**2085**]. His father died at age 73 from coronary artery disease. His brother died of smoking-related lung cancer. His sister and his children are healthy. Physical Exam: Vitals: T 98.8 BP 150/91 HR 93 R 20 Sat 97% RA * PE: G: NAD, WN, WD HEENT: Clear OP, MMM Neck: Supple, No LAD, No JVD Lungs: BS BL, No W/R/C Cardiac: RR, NL rate. NL S1S2. No murmurs Abd: Soft, NT, ND. NL BS. No HSM. Ext: No edema. 2+ DP pulses BL. Neuro: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. Strength UE [**6-9**] R, 4/5 L throughout--no pattern and pt denies pain limiting, [**6-9**] BL LE. 2+ reflexes, equal BL. Ungoing toes BL. Past-pointing on L UE, NL on R. Pertinent Results: MR [**Name13 (STitle) 2853**] [**2153-1-17**]: There is no change from [**2152-2-12**]. There is metastatic disease at C7-T1 and T2 with collapse of T1 and resultant kyphosis. There is stable epidural disease. There have been posterior laminectomies and there is no spinal cord compression, although there is probably some myelomalacia and atrophy at the level of the surgery, unchanged. * L Shoulder/humerus Plain film: Read pending; no obvious fracture, ? metastatic involvement. . CXR [**1-22**]: Patchy opacities most prominent in the right lower lobe, worrisome for pneumonia. . CT spine [**1-23**]: Progression of the lytic osseous and epidural metastases, with progressed malalignment. Fracture through the T2 pedicle screws bilaterally . CTA [**1-23**]: 1) Right lower and right middle lobe air space consolidation consistent with pneumonia. There appears to be narrowing of the bronchus intermedius. 2) Left lower lobe atelectasis and patchy multifocal bilateral generalized foci of air space disease most likely reflecting consolidations though metastases are not excluded. 3) Progression of osseous vertebral and hepatic metastasis. 4) No evidence of PE. 5) Possible cervical instability. . Bone scan [**1-23**]: 1) No abnormal uptake in the left upper extremity. 2) Uptakecorresponding to known metastases in the sternum, cervical spine as above. The new uptake in the left 11th and 12th rib ends likely post-traumatic. Brief Hospital Course: 68M thyroid ca to bone + liver p/w increased pain L shoulder/ humerus. Pt was admitted to the Medicine service and treated for the following problems: . # pneumonia: Patient had altered MS and low grade fevers [**1-22**] and CXR performed which suggested pna. Started on levo/flagyl with concern for aspiration. [**1-23**], patient had new hypoxia and hemoptysis. Hematocrit has remained stable. CTA negative for PE but did confirm significant pneumonia. No fevers since starting levo/flagyl. . #L shoulder/humerus pain: Evaluated by radiation oncology who felt that risks of radiation in setting of multiple prior episodes was quite high especially given instability. Neurosurgery consulted for cervical spine. His pain was initially difficult to control, but was ultimately dramatically improved when he was changed to a dilaudid PCA--he did not have relief from fentanyl patch, likely b/c of soft tissue wasting and future efforts at long acting medications should be PO. . #thyroid ca, metastatic disease: progressive in spine and likely contributing to current complaints. Levothyroxine was continued. consider neupogen. Will d/w attending Oncologist . # thrush: The patient was admitted with thrush which was succesfully treated with nystatin S&S. Neurosurgery team asked to eval this pt on [**2153-1-23**] and was transferred to our service for spinal deformity which was noted on upper level of images (CT chest) to r/o PE. CT of cervical thoracic spine was obtained and results of T1 collapse noted. Pts family, at that time wanted to continue care with prior Neurosurgeon/Dr. [**Last Name (STitle) 1327**]. This was communicated to this neurosurgery team. Some short time later the family wished against transfer out to Dr.[**Name (NI) 1334**] care and decided that they would want surgery to correct spinal deformity/kyphosis here. The pt was placed in [**Last Name (un) 20482**] Halo traction at 30lbs of traction. This was in attempt to reduce kyphotic deformity for pre-operative optimization. A CT scan of the spine was obtained in traction and good reduction of the deformity was noted. The pt was then medically optimized and pre-op'd and taken to the OR on [**2153-2-8**] for C7 T1 T2 corpectomies/ anterior approach. There was a lot of bleeding during the initial anterior approach / the case lasting approximately 7 hours. It was decided that the pt would remain intubated and return to the OR on the 5th (the next day for continuation of the case. The second portion of the case was completed that day (the 5th). Thoracic surgery assisted because of mediastinal mass / we needed sternotomy to control bleeding and complete ant. approach. The total EBL was 7.5 liters with the pt being given 22 units of PRBC's. He had a chest tube placed on the left side intraoperatively. This was removed on approx 1/7/7. Postoperatively he was started on Fondiparinox on [**2-13**] as he is HIT positive. On [**2153-2-14**] he had a peg tube place. His postoperative head CT and spine CT's were stable. His neurological status postoperatively was stable. All extremeties are antigravity and his mentation is intact. His course complicated by intermittent low HCT's for which he was transfused. Temps as high as 102.+ for which he was started on Zosyn. On [**2153-2-16**] his left upper extremity was noted to be swollen and son[**Name (NI) **] noted LUE DVT. On the 14th, the halo ring that was initially placed for use of cervical traction and for potential halo vest placement was removed. He remains in a cervical collar and had been OOB to chair. The patient required prolonged ventilation he had difficulty clearing his secretions. His family was offered a trach but they felt the patient had a difficult post operative course and was suffering they did not want to the patient to under go further procedures. The patient had made his wishes clear to his family not to be dependent or on a ventilator for a prolonged period. After a long discussion with the family and Dr [**Last Name (STitle) **] they decided to extubate the patient and see if he could tolerate being extubated, he quickly passed away in a few minutes with his family at his side. Medications on Admission: gabapentin 300/300/900, hydromorphone 4-8 mg Q8H PRN, tizanidine 2mg t.i.d., fentanyl patch 75 mcg per hour every three days, lidoderm patch 50, 3 patches a day lorazepam 0.5mg Q4-6H PRN levothyroxine 0.125 qd protonix 40 qd folic acid decadron 2mg [**Hospital1 **] (incr to 4mg in AM today) Discharge Medications: N/A Discharge Disposition: Extended Care Discharge Diagnosis: cervical spine harware failure s/p cervical spine stabilization metestatic disease Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2153-2-19**]

Admission Date: [**2106-10-4**] Discharge Date: [**2106-10-9**] Date of Birth: [**2049-8-24**] Sex: M Service: MEDICINE Allergies: Morphine / Hydromorphone / Nitroglycerin / Reglan Attending:[**First Name3 (LF) 3984**] Chief Complaint: nausea, vomiting and diarrhea - transfer from [**Hospital3 3583**] Major Surgical or Invasive Procedure: Transesophageal echocardiography Electrical cardioversion History of Present Illness: 57 year old male with pmhx significant for CAD s/p CABG and LAD stent, porcine tricuspid valve, complete heart block s/p pacemaker, hypertension, GERD, biliary stricture s/p CCY and MVA [**2071**] s/p multiple abdominal surgeries including partial liver resection who is transferred from [**Hospital3 3583**] with nausea, vomiting and diarrhea for further GI evaluation. . Patient initially presented to [**Hospital3 3583**] on [**2106-10-3**] with right-sided rib pain, nausea, vomiting (x 1 day) and loose stools (4-5 per day x 1 month, non-bloody). He was found to have a total bilirubin of 1.9, ast 71 and alt of 76; also with elevated white blood cell count of 18.6. Patient had an abdominal CT scan on admission which showed fluid in the colon consistent with enteritis vs colitis. He was started on iv ciprofloxacin and metronidazole. Stool was negative for C.difficile. GI (Dr. [**Last Name (STitle) **] was consulted, reviewed the CT scan with radiology - stable dilation of the CBD compared to [**2102**] and [**2101**] with dilation all the way to the ampulla and no intraluminal abnormality/stone seen; also with stable segmental intrahepatic dilation that appears to be related to previous liver surgery. Dr. [**Last Name (STitle) **] was concerned for biliary obstruction however patient unable to have MRCP due to pacemaker. Per patient's request was transferred to [**Hospital1 18**] for further evaluation. Of note total bilirubin decreased to 1.1 but ALT increased from 76 to 102. . Regarding patient's right-sided rib pain - described as constant, starts under right axilla and radiates to right shoulder and right upper quadrant, worse with inspiration. No recent falls. An x-ray was done at [**Hospital3 3583**] which showed healing fractures of the right 8th and 9th ribs (patient had presented to the [**Hospital1 18**] ED on [**2106-7-26**] after falling out of a broken chair and elbow pushing into right chest wall - pa/lat cxr at the time did not reveal any rib fractures; rib pain had resided two weeks ago). Given patient's significant cardiac history he was monitored on telemetry at [**Hospital3 3583**] without any significant events and ruled out for AMI with 4 sets of negative troponins. CTA of chest was done which was negative for pulmonary embolism (had a positive d-dimer). . Currently patient continues to have right-sided rib pain with inspiration that is [**10-4**] at maximum. Denies any chest pain or sob. Endorses several episodes of palpitations over the past week. Currently denies any abdominal pain. Endorses nausea and dry heaves. No po intake since hospitalization and no further bowel movements. . ROS: - Constitutional: No fevers, chills, sweats, + 2 lbs weight loss, decreased appetite with early satiety x 1 month - HEENT: no changes in vision or hearing, no rhinorrhea, nasal congestion, sore throat, + chronic headaches - Respiratory: no cough, shortness of breath, dyspnea on exertion - Cardiac: + palpitations (several episodes in past week), orthopnea, PND - GI: no BRBPR, melena - GU: no dysuria, hematuria, urgency, frequncey - Hematologic/lymphatic: no bleeding, bruising or lymphadenopathy - MSK: no arthralgias or myalgias - Neuro: no weakness, numbness, seizures, difficulty speaking, changes in memory. - Skin: no rash or pruritis - Psychiatry: no depression or suicidal ideation All other systems negative Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: a)CABG: [**7-/2095**] with SVG to PDA b)PERCUTANEOUS CORONARY INTERVENTIONS: - [**2097**]: Cypher placed in the mid LAD - [**2098**]: PTCA with stent to proximal LAD - [**2101**]: angiograph w/o stenting - [**2104-12-14**]: DES to proximal LAD overlapping with prior stent and POBA to D1 c)PACING/ICD: CHB after CABG, s/p dual chamber pacemaker 3. OTHER PAST MEDICAL HISTORY: - tricuspid valve replacement, porcine [**7-/2095**] - s/p pericardial window - Hypertension - Hypercholesterolemia - MVA [**2071**], 3 month ICU stay at [**Hospital1 2025**] with multiple abdominal surgeries including splenectomy, partial liver resection, partial gastrectomy, and left diaphragm rupture and repair. - GERD - Anxiety - History of migraines - BPH Social History: married with three children, independent not currently working, on disability no current tobacco (distant past hx) no alcohol or illicits Family History: Father - AMI age 40 with hx of rheumatic fever Mother - hypertension [**Name2 (NI) **] known fhx of cancer or diabetes Physical Exam: 97 84P 20RR 116/60 98%RA Appearance: alert, pale appearing, dry heaving Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mm very dry, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 1+ dp/pt bilaterally Pulm: decreased bs at bases Abd: multiple old surgical scars, soft, nt, nd, +bs Msk: tenderness right side over ribs 8 and 9; 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] Pertinent Results: OSH Labs [**2106-10-3**]: labs from admission note, awaiting labs to be faxed from [**Hospital3 3583**] wbc 18.6 -> 16 hct 44 plts 212 . 135 103 20 ------------< 3.8 25 0.9 . ast/alt 71/76 t bili 1.9 alk phos 57 albumin 4.4 lipase 27 amylase 38 . c.diff toxin/antigen negative [**Hospital1 18**] Labs: Cardiac enzymes: [**2106-10-4**] 09:00PM BLOOD CK-MB-2 cTropnT-<0.01 [**2106-10-6**] 01:35PM BLOOD CK-MB-2 cTropnT-<0.01 [**2106-10-7**] 05:45AM BLOOD CK(CPK)-28* Labs on discharge: [**2106-10-9**] 06:20AM BLOOD WBC-6.0 RBC-4.49* Hgb-14.5 Hct-42.1 MCV-94 MCH-32.3* MCHC-34.4 RDW-13.0 Plt Ct-256 [**2106-10-9**] 06:20AM BLOOD PT-14.1* PTT-26.6 INR(PT)-1.2* [**2106-10-9**] 06:20AM BLOOD Glucose-109* UreaN-19 Creat-0.8 Na-138 K-4.0 Cl-108 HCO3-24 AnGap-10 [**2106-10-5**] 07:10AM BLOOD ALT-102* AST-41* AlkPhos-68 TotBili-0.7 [**2106-10-9**] 06:20AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1 [**2106-10-6**] 01:35PM BLOOD TSH-1.4 Microbiology: [**2106-10-4**]: urine cx no growth [**2106-10-4**]: blood cx x 2: no growth to date [**2106-10-6**]: stool studies NO ENTERIC GRAM NEGATIVE RODS, SALMONELLA, SHIGELLA, CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2106-10-6**]): negative OSH Images: [**2106-10-3**] CT abdomen with contrast: cbd 12mm, mild intrahepatic ductal dilatation in anterior segment of right lobe unchanged from [**2102**]; fluid throughout the colon consistent with enteritis or colitis [**2106-10-3**] CTA: no evidence of pulmonary emboli; mild cardiomegaly with right atrial enlargement increased compared with [**2103**] [**Hospital1 18**] Images: [**2106-10-4**] EKG: 77 NSR, nl axis, mix of native beats with RBB morphology and ventricular pacing with LBB morphology [**2106-10-6**] EKG: HR 150s SVT vs aflutter with 2:1 block with RBB morphology [**2106-10-6**] EKG: atrial fibrillation with ventricular sensed QRS/ LBBB at 112 Abdominal U/S: 10/11:11 The liver shows no focal or textural abnormalities. The patient is status post cholecystectomy. The common duct is not dilated. There is no intrahepatic ductal dilatation. Both right and left kidneys are normal without hydronephrosis or stones. The pancreas is unremarkable. The patient is status post splenectomy. The aorta is of normal caliber throughout. The visualized portions of the inferior vena cava appear normal. No free fluid. IMPRESSION: Normal abdominal ultrasound. No intra or extrahepatic ductal dilatation. Echo: [**2106-10-8**] Mild spontaneous echo contrast is seen in the body of the left atrium and the descending aorta. No thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50%). There is borderline free wall hypokinesis of the right ventricle. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: No thrombus identified. Mildly depressed biventricular function. Brief Hospital Course: 57 year old male with pmhx significant for CAD s/p CABG and LAD stent, porcine tricuspid valve, complete heart block s/p pacemaker, hypertension, GERD, biliary stricture s/p CCY and MVA [**2071**] s/p multiple abdominal surgeries including partial liver resection who was transferred from [**Hospital3 3583**] with nausea, vomiting and diarrhea from likely infectious colitis. Hospital course was complicated by the development of symptomatic atrial fibrillation/ atrial flutter requiring TEE cardioversion. 1. presumed colitis: Patient transferred from OSH with nausea/ vomiting/ diarrhea from likely infectious colitis. CT scan at OSH was compatible with diagnosis of acute colitis vs enteritis, although patient's complaint of diarrhea appears to be more chronic and may warrant further outpatient evaluation. Abdominal ultrasound, stool studies were negative including repeat cdiff toxin although cdiff pcr was still pending at the time of discharge. Symptoms improved with conservative management of initial bowel rest followed by BRAT diet, demerol for pain control (given multiple analgesic allergies) and cipro/flagyl. He was discharged to complete an 8 day course of antiobiotics to end on [**2106-10-9**]. Clostridium difficile pcr will need to be followed as an outpatient. 2. atrial fibrillation/ atrial flutter: complained of symptomatic palpitations with dyspnea x 1 month prior to admission. On further investigation, patient was found to have intermittent afib/ flutter with HR up to 160s resulting in dyspnea and anxiety although otherwise hemodynamically stable. He was transferred to the ICU for further evaluation. Etiology of arrhythmia was unclear: CTA negative for PE at OSH, TSH within normal limitis, ruled out for cardiac ischemia although echo showed biventricular dysfunction. Electrophysiology was consulted to interrogate pacemaker and found that mode switch off device was tracking atrial flutter with resultant ventricular rate of 120-130 bpm. Pacer was readjusted with immediate releif of symptoms of palpitations and 'impending sense of doom.' However, remained in a-fib wih occasional bursts of tachycardia, despite increased b-blocker dosing, so Cariology recommended cardioversion. He subsequently had an elective TEE guided cardioversion and was started on dabigatran [**Hospital1 **] for anticoagulation. He was able to ambulate around the ICU with stable heart rate and no significant symptoms. He was discharged home with increased metoprolol dose of 75mg [**Hospital1 **], dabigatran [**Hospital1 **] and was placed on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor x 2 weeks to assess for significant remaining arrhythmias. He will follow up with Dr. [**Last Name (STitle) **] to discuss further treatment and evaluation. 3. R.sided rib pain: osh film with healing 8th and 9th rib fractures - no new trauma, ? healing from injury in [**2106-7-26**] and if so unclear why pain improved and is now worsening; PE ruled out by negative CTA; no evidence of PNA; ROMI negative at OSH and at [**Hospital1 18**], making ischemia unlikely. Pain was managed conservatively with demerol and lidocaine patch prn with resolution of symptoms through hospital course. 4. Leukocytosis: likely due to infectious colitis as further infectious evaluation negative including blood, urine and stool cultures. Downtrended throughout hospital course and was normal at the time of discharge. 5. CAD/HTN: As above, no signs of active ischemia per EKG and serial cardiac enzymes. Maintained on home plavix and statin with addition of ASA 81mg. Bblocker was uptitrated for AV nodal blockade. 6. Anxiety: patient complained of significant anxiety relating to palpitations through hospital course which was managed by ativan prn. Transitions of care: # afib/ flutter s/p d/c cardioversion: - KOH monitor x 2 weeks - dabigatran [**Hospital1 **] for anticoagulation until cardiology follow up - bblocker uptitration - follow up with Dr. [**Last Name (STitle) **] # colitis: - complete antibiotic course - f/u cdiff pcr Medications on Admission: Outpatient medications (per osh admission h and p): plavix 75mg daily ativan 1mg po prn metoprolol xl 50mg daily zantac 150mg [**Hospital1 **] crestor 40mg daily . Medications on transfer: crestor 40mg qhs florastor 250mg po tid plavix 75mg po qam toprol xl 50mg qam ciprofloxacin 400mg iv q12h (started [**2106-10-3**]) metonidzaole 500mg iv q8h (started [**2106-10-3**]) ativan 1mg po daily prn demerol 50mg iv q6h prn motrin 600mg q6h prn roxicodone 5mg q4h prn tylenol 650mg q6h prn zofran 4mg iv q6h prn d5ns 100cc/hr Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 3. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*1* 4. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 9. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain for 7 days. Discharge Disposition: Home Discharge Diagnosis: Primary: Supraventricular tachycardia Colitis Chest wall pain Secondary: Coronary artery disease Gastroesophageal reflux disease Dyslipidemia Hypertension Pacemaker Porcine tricuspid valve Anxiety Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname 1352**], You were transferred to the intensive care unit at [**Hospital1 18**] for fast heart rates that required pacemaker adjustments and an electrical cardioversion. Your heart rate was intermittently fast afterwards, and your metoprolol dose was increased. Your abdominal symptoms improved while taking antibiotics for your colitis. . We have made the following adjustments to your medications: -CONTINUE CIPROFLOXACIN 500 mg every 12 hours, through the end of [**10-9**] (tomorrow) -CONTINUE METRONIDAZOLE 500 mg every 8 hours, through end of [**10-9**] (tomorrow) -START DABIGATRAN 150 mg by mouth every morning and evening. This is a new blood thinner that may make you more likely to bleed. Please see below for warning signs of increased bleeding. Please continue taking this through your appointment with Dr. [**Last Name (STitle) **] (see below for information on how to schedule this appointment). -INCREASE METOPROLOL TARTRATE to 75 mg by mouth, every 12 hours. Please continue taking this regimen until your follow up with Dr. [**Last Name (STitle) **]. At that point, you may be able to switch to a once-daily pill. It is important to continue taking this every 12 hours to maintain your heart rate at a good level. -You can continue to take ACETAMINOPHEN AS NEEDED for pain. Please do not exceed the dosage as recommended on your discharge medication list. . It has a pleasure caring for you. Followup Instructions: You should follow up with the electrophysiologist Dr [**Last Name (STitle) **] [**Name (STitle) **] within one month. Please call his office to schedule an appointment. [**Hospital1 18**] Cardiology [**Street Address(2) 31630**], [**Hospital Ward Name 23**] 7 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 62**] Fax: [**Telephone/Fax (1) 31631**] . Please also call Dr. [**Last Name (STitle) **] if you have any questions or concerns after your discharge. You can call him even on the weekends, when he should have coverage if he is not in the office. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Admission Date: [**2172-9-29**] Discharge Date: [**2172-10-2**] Date of Birth: [**2114-3-3**] Sex: F Service: TRAUMA [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient presented after a moderate speed motor vehicle crash on the [**Location (un) 26358**] around 30 miles per hour. She was the restrained driver. There was no air bag in the car. Partially recalls events. No definite loss of consciousness. The patient was walking at the scene with assistance. Initially she complained of chest pain where the seat belt was. On presentation her vital signs were temperature of 98.8, heart rate 88, blood pressure 107/66, sats 99% on 2 liters nasal cannula, respiratory rate 18. PAST MEDICAL HISTORY: Hypertension. Fibromyalgia. Status post C5-C6 discectomy after previous motor vehicle crash with small bowel repair. Status post hysterectomy. Bilateral mammoplasty. MEDICATIONS ON ADMISSION: Fentanyl 25 mcg patch every 72 hours, aspirin, Prilosec 20 q.day, Prozac 60 q.day, nortriptyline 50 q.h.s., Klonopin 1.5 mg q.h.s. ALLERGIES: Penicillin causes hives. PHYSICAL EXAMINATION: On presentation she was alert, awake and oriented. Pupils were equal and reactive to light. There was a small right subconjunctival hemorrhage. No ptosis. Vision was intact. Trachea was midline. Heart was regular rate and rhythm. Chest had moderate ecchymosis and hematoma forming on her right breast and right flank. She had lacerations with muscle involvement to her chin, right upper eyelid and above her nose. Abdomen was soft. There was significant ecchymosis along the lower abdomen from a seat belt injury. No rebound, no guarding. Guaiac was negative, good rectal tone. She had abrasions to both knees. Strength was [**6-6**] in all extremities. Sensation slightly decreased at the fourth and fifth left fingers. Cranial nerves were intact. Toes downward bilaterally. LABORATORY DATA: On admission hematocrit was 33.9. BUN and creatinine were 18 and 0.8, sodium 140, K 4.3. PT/PTT 12.1 and 25.1, INR 0.9. EKG was within normal limits. Chest x-ray showed no fracture, no pneumothorax. Lateral C-spine was clear to C-5. Pelvis no fracture. CT head no bleed. CT neck no fracture. CT chest showed a large right breast hematoma. CT pelvis abdomen no free fluid or traumatic event. ASSESSMENT: This is a 58 year old woman status post motor vehicle crash with a large right breast hematoma. Studies otherwise negative except for a significant amount of bleeding into her breast which was increasing in size as well as subconjunctival hemorrhage and the facial lacerations. HOSPITAL COURSE: She was admitted to the SICU for hemodynamic monitoring and had serial hematocrits, serial abdominal exams. She received IV fluids, pneumoboots and Protonix. The patient also reported that she was on the way back from the dentist where she was supposed to start erythromycin for a tooth abscess, so we put her on clindamycin 600 q.eight. On her admission hospital day her C-spine was attempted to be cleared given that she had CT scan of her neck which did not show any fracture or dislocation. However, on palpation of the bones of the cervical vertebrae she had tenderness, therefore, the collar was kept on and neurosurgery was consulted. In the SICU she basically had an uneventful course. However, her hematocrit did continue to decrease slightly and the patient had a transfusion of two units given for hematocrit less than 25, approximately 23.4. Facial lacerations were sutured in the emergency department and continued to be treated with bacitracin. She was on fentanyl patch and Neurontin for pain medications which she tolerated. The patient was found to also have a left fourth finger distal phalanx fracture without displacement and plastic surgery was consulted for her hand. They put her in a splint and gave her followup instructions. The patient was transferred to the floor with stable hematocrit. Physical therapy saw her and she was able to ambulate without difficulty, without assistance. C-collar was in place. Neurosurgery gave their final recommendations. DISPOSITION: To home. CONDITION ON DISCHARGE: Improving. DISCHARGE INSTRUCTIONS: Trauma clinic in one week, phone number [**Telephone/Fax (1) 274**], call to schedule the appointment. Neurosurgery: the patient is to continue the C-collar and follow up with her private neurosurgeon, Dr. [**Last Name (STitle) **]. She is going to call to schedule that appointment, [**Telephone/Fax (1) 26359**]. Hand clinic on Tuesday, [**2172-10-6**], [**Telephone/Fax (1) 26360**], call for an appointment. Diet should be regular. The patient is going to have a home safety evaluation by physical therapy. Her anticipated goal would be return to preadmission functioning. DISCHARGE MEDICATIONS: Continue preadmission meds, Fiorinal p.r.n., aspirin, Prozac, nortriptyline, Neurontin, Klonopin as well as the following medicines: bacitracin ointment to the lacerations twice per day, Percocet 5 one to two tabs p.o. q.four to six p.r.n., Lacri-Lube drops to right eye q.day times seven days, Colace 100 mg p.o. b.i.d. times five days. DISCHARGE DIAGNOSES: 1. Status post motor vehicle crash. 2. Status post left fourth distal phalanx fracture in splint. 3. Ligamentous injury C-4 to C-6 with spinal stenosis C-6 to C-7 without cord compression. 4. Status post right eye subconjunctival hemorrhage with visual blurring. 5. Past medical history of fibromyalgia and hypertension. 6. Known allergy to penicillin, although she tolerated clinda in the hospital. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (NamePattern1) 8344**] MEDQUIST36 D: [**2172-10-2**] 09:47 T: [**2172-10-5**] 14:08 JOB#: [**Job Number 26361**]

Admission Date: [**2106-2-5**] Discharge Date: [**2106-2-26**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: ischemic right foot Major Surgical or Invasive Procedure: [**2-5**] Abdominal aortogram with right lower extremity runoff. [**2-9**] Right above-knee amputation. [**2-9**] Percutaneous endoscopic gastrostomy tube placement. [**2-10**] Exploratory laparotomy, Colectomy including right colon, transverse and descending colon, with Ileostomy. [**2-17**] Exploratory laparotomy, Resection of small intestine, Ileostomy. History of Present Illness: This is an 81-year-old woman who presented with extensive gangrene of the right lower extremity. The patient had noticed [**9-2**] pain and discolouration worsening over the previous 2 weeks. She had been started on cipro/garamycin as an outpatient. Past Medical History: PMHx: depression, anxiety, hypothyroidism, anemia, MRSA ulcers, neuropathy, f/l foot ulcerations PSH: appy '[**93**], b/L foot debridement [**6-28**] Arteriogram ([**2105-7-7**]): LLE 80% stenosis distal PTA, RLE patent Social History: Resident at [**Hospital **] Health Care Centre since [**2105-8-31**] neg tobacco, neg alcohol Family History: non contributory Physical Exam: Temp: not recorded, 120/77, RR 16, 96% CVS: RRR, S1S2 normal, +SEM Ext: LLE: discoloured, bluish discolouration over entire foot (several necrotic lesions), RLE: cold bluish discolouration of the distal portion of the dorsum of the foot, with two large necrotic ulcers over dorsum associated with loss of sensation of the toes Pertinent Results: LABS: [**2106-2-5**] 02:15PM WBC-8.2# RBC-3.93* HGB-12.7 HCT-34.9* MCV-89 MCH-32.2* MCHC-36.3* RDW-15.4 PLT COUNT-121* NEUTS-76.7* LYMPHS-18.7 MONOS-3.4 [**2106-2-5**] 02:15PM PT-14.0* PTT-25.3 INR(PT)-1.3 [**2106-2-5**] 02:15PM GLUCOSE-142* UREA N-34* CREAT-0.7 SODIUM-138 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-26 ANION GAP-10 [**2106-2-5**] 02:20PM LACTATE-1.0 . [**2106-2-10**] 05:30AM BLOOD WBC-15.5*# RBC-3.80* Hgb-12.2 Hct-34.3* MCV-90 MCH-32.0 MCHC-35.6* RDW-16.2* Plt Ct-197# [**2106-2-10**] 05:30AM BLOOD PT-14.0* PTT-30.5 INR(PT)-1.3 [**2106-2-10**] 04:50PM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-138 K-3.8 Cl-111* HCO3-16* AnGap-15 . [**2106-2-17**] 04:18AM BLOOD WBC-33.8* RBC-3.15* Hgb-10.1* Hct-28.1* MCV-89 MCH-32.0 MCHC-35.8* RDW-15.5 Plt Ct-215 [**2106-2-17**] 09:21PM BLOOD PT-20.7* PTT-39.9* INR(PT)-2.0* [**2106-2-17**] 04:18AM BLOOD Glucose-171* UreaN-18 Creat-0.8 Na-140 K-3.0* Cl-109* HCO3-20* AnGap-14 . [**2106-2-21**] 08:00AM BLOOD WBC-29.5* RBC-3.62* Hgb-11.8* Hct-33.1* MCV-92 MCH-32.8* MCHC-35.8* RDW-15.4 Plt Ct-185 [**2106-2-21**] 04:50AM BLOOD Glucose-272* UreaN-26* Creat-1.0 Na-147* K-6.4* Cl-115* HCO3-17* AnGap-21* . [**2106-2-26**] 03:08AM BLOOD WBC-9.6 RBC-3.41* Hgb-10.6* Hct-31.3* MCV-92 MCH-31.1 MCHC-33.8 RDW-15.4 Plt Ct-101* [**2106-2-26**] 03:08AM BLOOD Plt Ct-101* [**2106-2-26**] 03:08AM BLOOD Glucose-145* UreaN-30* Creat-0.9 Na-143 K-4.4 Cl-113* HCO3-24 AnGap-10 . STUDIES: [**2106-2-5**] Abdominal aortogram with right lower extremity runoff. ANGIOGRAPHIC FINDINGS: The abdominal aorta is extremely angulated but smooth. There were patent bilateral common, internal and external iliac arteries. The renal arteries and single and patent bilaterally. The right lower extremity shows a patent common femoral artery, profunda femoral artery and superficial femoral artery, popliteal, anterior tibialis and peroneal arteries. The PT is occluded and both the AT and the peroneal arteries occlude at the ankle. There were vessels seen in the foot. SUMMARY: Either thrombosis or embolism of the right foot arteries. Nonviable foot. Will likely need a right below knee amputation. . [**2-10**] CT abd/pelvis: There is free fluid in the pelvis. There is dilatation of bowel loops with a maximum of 7 cm in diameter. . [**2-13**] CTA abd/pelvis: 1.A slight interval increase in size in the bilateral pleural effusions and adjacent consolidation/atelectasis. 2.The aorta is normal in caliber, all its main branches are widely patent. 3. Hypodense areas in both lobe of the thyroid gland. 4. Mild cardiomegaly. 5. Cholelithiasis. 6. Splenic and cortical renal infarcts. 7. Ascites. . Pathology: Ileocolectomy: Acute hemorrhagic infarction involving the mucosa of the cecum and colon. The infarction extends in the mucosa to the proximal ileal margin. . Brief Hospital Course: Ms [**Known lastname 61764**] was admitted to vascular surgery service with gangrene of the right foot that was likely secondary to thrombosis or embolism of the right foot arteries, as confirmed by angiography. As she was not a candidate for revascularization, she was prepped for right below knee amputation. She was started on broad spectrum antibiotics. Given the patient's poor nutritional status, MIS surgery was consulted regarding PEG placement at the time of amputation. The patient underwent above knee amputation of the right extremity by vascular surgery and PEG placement by MIS surgery on [**2106-2-9**]. Please see operative report for full details. . On post-operative day #1, the patient complained of abdominal pain. Initially, this was not associated with peritoneal signs and the patient underwent CT scan evaluation. This revealed some free air and ascites. Subsequent exam of the patient did reveal abdominal distention and peritoneal signs that were associated with elevation in WBC and decreased urine output. As a result, the patient was taken to the OR for exploratory laparotomy on [**2106-2-10**]. Please see operative report for full details. . In the OR, the patient was found to have ischemic colon without frank perforation extending from the cecum to the end of the descending colon. SHe underwent extended R colectomy and end ileostomy. She was transferred to the SICU for care. . In the SICU, the patient received IV antibiotics. In the week following admission, the patient remained intubated but appeared to be improving slowly. THe patient was extubated on [**2106-2-14**] with a functioning ostomy. The following day, however, the patient developed blood per rectum. This was associated with a fall in her hematocrit. On [**2106-2-17**], the patient was taken back to the OR for exploratory laparotomy. In the OR, 46 cm of necrotic and ischemic bowel was found. The patient underwent resection of small intesting as well as ileostomy. Please see operative report for full details. . Post-operatively, the patient underwent extensive hypercoagulable work-up and was found to be HIT positive. She was started on Agastroband. On [**2106-2-21**], a code was called on the patient for pulseless electrical activity secondary to respiratory distress. She was re-intubated and resuscitated successfully. A family meeting was held on [**2106-2-23**] at which time her code status was changed from full code to DNR/DNI (if successfully extubated). After several days, as the patient was not tolerating extubation, the patient's code status was discussed again with the family. On [**2106-2-26**], the patient was made comfort measures only and she expired at 13:47 on that same day. . Medications on Admission: Levothyroxine Calcium MVI Colace Senna Morphine Remeron Cipro (until [**2106-2-11**]) Vicodin Garamcyin (until [**2106-2-15**]) Discharge Disposition: Expired Discharge Diagnosis: Peripheral Vascular disease Ischemic colitis Respiratory Arrest Cardiac arrest Discharge Condition: expired Completed by:[**2106-3-12**]

Admission Date: [**2111-6-19**] Discharge Date: [**2111-7-3**] Date of Birth: [**2051-6-24**] Sex: M Service: MEDICINE Allergies: Ceftriaxone Attending:[**First Name3 (LF) 613**] Chief Complaint: lower back pain Major Surgical or Invasive Procedure: left knee I&D [**2111-6-20**], [**2111-6-28**] PICC line placement teeth extraction History of Present Illness: Mr. [**Known lastname 17931**] is a 59 yo man with DMII and mitral valve prolapse who presents with several days of severe lower back pain and lower extremity weakness in the context of recent fevers, nightsweats, and left knee effusion. He was in his usual state of health until 2 weeks ago, when he began having night sweats, which soaked through his sheets. He developed myalgias and fever to 103 over the weekend prior to admission ([**6-13**]), which resolved by [**6-15**], when he began having left knee pain and swelling; he went to orthopedic clinic [**6-17**] where his left knee was noted to have a large effusion thought to be related to worsening of his chronic knee osteoarthritis. Arthrocentesis was performed, which improved his pain; he also used vicodin and ibuprofen at home. . The lower back pain began on the day of the arthrocentesis ([**6-17**]) and progressively worsened in severity; he describes it as a sharp pain without any radiation and describes "spasms" of increasing pain. He distinguishes this pain from his past pain associated with degenerative lumbar disease/disc herniations, which produced sciatic symptoms. On the day of presentation, he notes severe back pain and bilateral leg weakness that made him unable to step into the shower. He had no fecal or urinary incontinence, no urinary retention symptoms beyond his baseline BPH symptoms, and no sensory loss of his lower extremities. He had no neurologic symptoms such as weakness or numbness of his upper extremities or trunk. . No recent travel, sick contacts, sexual contacts, risk factors for TB, procedures (other than arthrocentesis), no recent dental cleaning (does have chipped tooth, but does not involve gums). He denies any rashes but notes [**5-28**] "growths" on hand, scrotum; he was seen by a dermatologist, who diagnosed them as benign lesions associated with aging, and removed them with liquid nitrogen. No headache, neck stiffness, or visual changes. No cough, mild SOB, no chest pain. He notes mild worsening of his chronic right knee pain, but denies pain in other joints. He denies abdominal pain, nausea, vomiting, or diarrhea and has a good appetite. +constipation, with no BM x1-2 days. . In the ER his initial VS were: T 97.0 HR 110 BP 155/77 RR 20 O2 sat: 100% on RA. His T max in the ER was 101.5. He was given 2mg IV morphine x 2, then 4mg IV x 2 for pain without much effect. 1mg IV dilaudid improved his pain somewhat. He was given 2L IVF. He was also given tylenol 650mg x 1 and vanc/ceftriaxone. In the ER an MRI (non contrast) was performed which revealed L2-L3 disc protrusion that causes severe canal stenosis with effacement of the thecal sac. In addition there was increased signal of L5-S1 suggesting possible early discitis but there was no contrast. There was no paraspinal soft tissue abnormality. Neuro was consulted and thought a repeat scan with IV contrast should be performed and that the patient had a lower extremity exam that was limited by severe pain but may have some objective weakness of his proximal lower extremities L > R. . Past Medical History: DMII (last A1C 7.7, recently started metformin) Mitral valve prolapse Hiatal Hernia Schatzki's ring (EGD [**6-/2110**]) Social History: Retired, used to work at [**University/College **]as archivist. Lives alone in [**Hospital3 **] facility in [**Location (un) **] in preparation for bilateral knee replacements. Occasional ETOH, no tobacco, no drug use now or any IVDU in the past. Not in a relationship, no recent sexual contact. Family History: Father died at 72 with pulmonary fibrosis. Mother with PVD. Sister with fibromyalgia. Physical Exam: Physical Exam (on floor, [**6-19**] 9am): VS: T 98.7 HR 100 BP 164/91 RR 18 O2 98% on 2L GEN: lying supine, minimal movement, mild distress HEENT: pupils 2mm, minimally reactive to light, sclera anicteric, conjunctivae noninjected, MM dry, fissuring of tongue, oropharynx without lesions or tonsillar exudate, JVP to earlobe but patient supine and unable to sit up due to severe back pain CV: RRR, normal S1, S2, +2/6 systolic murmur at apex, no rubs/gallops PULM: CTAB anteriorly ABD: mildly distended and tense, nontender, no masses or organomegaly LIMBS: WWP, large L knee effusion, patient unable to tolerate exam of knee [**2-24**] pain, left LE swelling BACK: unable to examine [**2-24**] pain SKIN: Warm, dry, anicteric, no rashes NEURO: AOx3, CN2-12 intact (mild decreased hearing on left, but noisy room). Strength 5/5 in upper extremity, proximal and distal; [**5-27**] plantar- and dorsi-flexion bilaterally (unable to examine strength at hip or knee). Sensation to light touch intact throughout. Cerebellar function intact on finger-nose testing; unable to perform heel-shin testing. Gait unable to be examined. Pertinent Results: Arthrocentesis ([**6-17**]): [**Numeric Identifier 100009**] WBCs with 86% PMNs, no crystals, fluid culture grew streptococci . Blood cultures ([**6-19**]): 4/4 bottles positive for gram positive cocci in chains, strep viridans . CBC: [**2111-6-18**] 08:50PM BLOOD WBC-10.0 RBC-4.75 Hgb-12.8* Hct-38.3* MCV-81* MCH-27.0 MCHC-33.4 RDW-13.8 Plt Ct-279 Neuts-82.6* Lymphs-12.5* Monos-3.9 Eos-0.8 Baso-0.2 [**2111-6-24**] 05:43AM BLOOD WBC-8.5 RBC-4.43* Hgb-12.0* Hct-35.5* MCV-80* MCH-27.1 MCHC-33.9 RDW-13.9 Plt Ct-330 [**2111-6-27**] 06:20AM BLOOD WBC-12.2* RBC-4.60 Hgb-12.1* Hct-36.1* MCV-79* MCH-26.3* MCHC-33.5 RDW-13.8 Plt Ct-408. . . Urine: [**2111-6-19**] 12:01AM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-100 Ketone150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-<1 [**2111-6-26**] 03:09AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG . MRI thoracic and lumbar spine ([**2111-6-18**]): Tspine: Small T3-4 right paracentral disc bulge without cord compression. Otherwise unremarkable tspine: no cord compression or epidural abnormality. Lspine: Multilevel degenerative change, progressed compared to [**2106**]. Most severe at L2-3: posterior disc bulge causing severe canal stenosis with complete effacement of the thecal sac at this level. Multilevel neural foraminal narrowing. No epidural or paraspinal abnormality. . MRI with contrast, lumbar spine ([**2111-6-19**]): No evidence of osteomyelitis. . TTE ([**2111-6-19**]): No valvular vegetations of masses. The left atrium is elongated. Left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation. . TEE ([**2111-6-23**]): Procedure unsuccessful due to known Schatzki's ring. . [**2111-6-19**] 06:00AM BLOOD WBC-9.0 RBC-4.34* Hgb-11.7* Hct-35.2* MCV-81* MCH-27.0 MCHC-33.2 RDW-13.6 Plt Ct-306 [**2111-6-20**] 06:45AM BLOOD WBC-8.9 RBC-4.42* Hgb-12.1* Hct-35.5* MCV-80* MCH-27.3 MCHC-34.1 RDW-13.8 Plt Ct-274 [**2111-6-20**] 01:03PM BLOOD WBC-10.0 RBC-4.89 Hgb-13.1* Hct-39.2* MCV-80* MCH-26.8* MCHC-33.5 RDW-13.5 Plt Ct-324 [**2111-6-21**] 07:00AM BLOOD WBC-8.9 RBC-4.69 Hgb-12.4* Hct-37.2* MCV-79* MCH-26.4* MCHC-33.3 RDW-13.4 Plt Ct-311 [**2111-6-22**] 07:30AM BLOOD WBC-8.6 RBC-4.45* Hgb-12.0* Hct-35.8* MCV-80* MCH-26.9* MCHC-33.5 RDW-13.6 Plt Ct-301 [**2111-6-23**] 05:45AM BLOOD WBC-7.8 RBC-4.64 Hgb-12.4* Hct-36.7* MCV-79* MCH-26.8* MCHC-34.0 RDW-13.6 Plt Ct-366 [**2111-6-24**] 05:43AM BLOOD WBC-8.5 RBC-4.43* Hgb-12.0* Hct-35.5* MCV-80* MCH-27.1 MCHC-33.9 RDW-13.9 Plt Ct-330 [**2111-6-25**] 06:12AM BLOOD WBC-8.1 RBC-4.31* Hgb-11.7* Hct-34.6* MCV-80* MCH-27.0 MCHC-33.7 RDW-13.8 Plt Ct-304 [**2111-6-25**] 03:40PM BLOOD WBC-10.2 RBC-4.43* Hgb-11.9* Hct-34.3* MCV-78* MCH-26.9* MCHC-34.8 RDW-13.6 Plt Ct-366 [**2111-6-26**] 06:22AM BLOOD WBC-10.0 RBC-4.26* Hgb-11.4* Hct-33.5* MCV-79* MCH-26.7* MCHC-33.9 RDW-13.6 Plt Ct-370 [**2111-6-27**] 06:20AM BLOOD WBC-12.2* RBC-4.60 Hgb-12.1* Hct-36.1* MCV-79* MCH-26.3* MCHC-33.5 RDW-13.8 Plt Ct-408 [**2111-6-19**] 06:00AM BLOOD Neuts-84.2* Lymphs-10.5* Monos-4.7 Eos-0.4 Baso-0.2 [**2111-6-18**] 08:50PM BLOOD Neuts-82.6* Lymphs-12.5* Monos-3.9 Eos-0.8 Baso-0.2 [**2111-7-1**] 12:00PM BLOOD Plt Ct-525* [**2111-7-1**] 12:00PM BLOOD PT-14.1* PTT-28.2 INR(PT)-1.2* [**2111-6-30**] 06:10AM BLOOD Plt Ct-462* [**2111-6-30**] 06:10AM BLOOD PT-13.5* PTT-25.5 INR(PT)-1.2* [**2111-6-29**] 06:35AM BLOOD Plt Ct-450* [**2111-6-29**] 06:35AM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1 [**2111-6-28**] 06:20AM BLOOD Plt Ct-419 [**2111-6-27**] 06:20AM BLOOD Plt Ct-408 [**2111-7-1**] 12:00PM BLOOD Glucose-232* UreaN-16 Creat-0.8 Na-129* K-4.0 Cl-96 HCO3-28 AnGap-9 [**2111-6-30**] 06:10AM BLOOD Glucose-190* UreaN-11 Creat-0.7 Na-132* K-4.3 Cl-97 HCO3-26 AnGap-13 [**2111-6-29**] 06:35AM BLOOD Glucose-185* UreaN-14 Creat-0.7 Na-131* K-4.4 Cl-95* HCO3-26 AnGap-14 [**2111-6-28**] 06:20AM BLOOD Glucose-198* UreaN-16 Creat-0.7 Na-133 K-4.4 Cl-96 HCO3-30 AnGap-11 [**2111-6-27**] 06:20AM BLOOD Glucose-191* UreaN-14 Creat-0.7 Na-133 K-4.0 Cl-97 HCO3-24 AnGap-16 [**2111-6-25**] 03:40PM BLOOD Glucose-173* UreaN-14 Creat-0.7 Na-134 K-4.0 Cl-100 HCO3-24 AnGap-14 [**2111-6-25**] 06:12AM BLOOD Glucose-209* UreaN-12 Creat-0.7 Na-132* K-4.2 Cl-97 HCO3-27 AnGap-12 [**2111-6-24**] 05:43AM BLOOD Glucose-207* UreaN-15 Creat-0.8 Na-135 K-4.1 Cl-99 HCO3-27 AnGap-13 [**2111-6-23**] 05:45AM BLOOD Glucose-229* UreaN-13 Creat-0.6 Na-134 K-4.2 Cl-97 HCO3-28 AnGap-13 [**2111-6-22**] 07:30AM BLOOD Glucose-244* UreaN-12 Creat-0.6 Na-134 K-3.9 Cl-97 HCO3-27 AnGap-14 [**2111-6-21**] 07:00AM BLOOD Glucose-247* UreaN-10 Creat-0.7 Na-134 K-4.1 Cl-98 HCO3-26 AnGap-14 [**2111-6-20**] 01:03PM BLOOD Glucose-164* UreaN-11 Creat-0.7 Na-137 K-4.0 Cl-101 HCO3-22 AnGap-18 [**2111-6-20**] 06:45AM BLOOD Glucose-207* UreaN-10 Creat-0.7 Na-136 K-3.7 Cl-102 HCO3-24 AnGap-14 [**2111-6-19**] 06:00AM BLOOD Glucose-180* UreaN-11 Creat-0.7 Na-139 K-3.7 Cl-104 HCO3-23 AnGap-16 [**2111-6-29**] 06:35AM BLOOD ALT-17 AST-14 TotBili-0.6 [**2111-6-28**] 06:20AM BLOOD ALT-18 AST-11 [**2111-6-27**] 06:20AM BLOOD ALT-21 AST-16 CK(CPK)-16* AlkPhos-85 [**2111-6-25**] 03:40PM BLOOD CK(CPK)-35* [**2111-6-23**] 05:45AM BLOOD ALT-19 AST-15 [**2111-6-19**] 06:00AM BLOOD ALT-13 AST-15 AlkPhos-75 TotBili-0.5 [**2111-7-1**] 12:00PM BLOOD Calcium-9.7 Phos-4.1 Mg-2.2 [**2111-6-30**] 06:10AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.0 [**2111-6-29**] 06:35AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0 [**2111-6-28**] 06:20AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.1 [**2111-6-27**] 06:20AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0 [**2111-6-26**] 06:22AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0 [**2111-6-25**] 03:40PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0 [**2111-6-25**] 06:12AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 [**2111-6-22**] 07:30AM BLOOD calTIBC-164* Ferritn-424* TRF-126* [**2111-6-25**] 06:12AM BLOOD TSH-2.3 [**2111-6-19**] 06:00AM BLOOD CRP-275.8* [**2111-6-26**] 10:10AM BLOOD Vanco-19.2 [**2111-6-25**] 03:40PM BLOOD Vanco-14.3 [**2111-6-25**] 06:12AM BLOOD Vanco-15.8 . CXR [**6-29**] A thick crescentic opacity in the left lower lobe is more likely atelectasis than pneumonia. The peripheral component has improved slightly since [**6-26**], but the central component has not. Lung volumes remain quite low, but there are no findings to suggest pneumonia elsewhere. There is no pleural effusion or evidence of central adenopathy. Heart size is normal. Ascending thoracic aorta is tortuous or mildly dilated. . ECHO [**6-30**] The left atrium is normal in size. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is mild mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. An eccentric, anteriorly directed jet of mild (1+) mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The estimated pulmonary artery systolic pressure is normal. Compared with the prior study (images reviewed) of [**2111-6-19**], mild mitral valve prolapse of the posterior leaflet is now visible. The severity of mitral regurgitation is slightly increased (but still mild). The other findings are similar. . LENI [**6-30**] IMPRESSION: 1. Deep vein thrombosis seen in the right leg and the right superficial femoral vein extending to the right popliteal vein where it is nonocclusive. DVT in one of the two right posterior tibial veins. 2. DVT seen in the left calf in the two posterior tibial veins and in one of the two peroneal veins. Brief Hospital Course: 59 yo M with DMII and mitral valve prolapse presenting with back pain, left knee pain and effusion in the setting of recent fevers and nightsweats, found to have strep viridans bacteremia and septic left knee joint. . # Septic arthritis, left knee: Fluid from [**6-17**] revealed [**Numeric Identifier 100009**] WBCs with 86% PMNs and the culture grew GPC. He was treated with IV vancomycin. He was seen by orthopedic surgery and the infectious disease services. Received an I&D in the OR on [**6-20**]. POD [**5-28**], knee felt warm, swollen without erythema. Per ortho, received an arthroscopy and washout on [**6-28**]. Pt has continued to improve since this procedure. -Patient can be somewhat discouraged and resistant to pushing himself through PT, but is very cooperative with some encouragement . # Back pain, lower extremity weakness: The history of fever and nightsweats and possible septic joint was concerning for vertebral osteomyelitis via hematogenous seeding. A noncontrast lumbar CT and MRI (with and without contrast) were negative for osteomyelitis or epidural abscess but revealed progression of degenerative disease with nerve root compression at L2-L3, L5-S1. He was seen by neurology in the ED given lower extremity weakness. Once the patient's pain was better controlled (with muscle relaxants and opioids), there was no evidence of lower extremity weakness on exam, though exam continued to be limited by knee pain. The back pain is most likely due to degenerative disease, which may have been exacerbated by antalgic gait due to left knee pain. He had ongoing PT while inpatient and pain was well-managed. . # Bacteremia, ?endocarditis: [**4-26**] blood cultures drawn [**6-19**] were positive for strep viridans. Given his increased risk of endocarditis due to mitral valve prolapse, TTE was obtained and was negative for endocarditis and, notably, for mitral valve prolapse. We then proceeded with a TEE, but this was unsuccessful due to a known Schatzki's ring (dx by EGD in [**11-28**]) which prevented the probe from passing. Given his continued nighttime fevers, there was still concern for both bacteremia and endocarditis and so IV antibiotics continued. However, recent vancomycin troughs were sub-therapeutic(7.0) even with high dosing. IV ceftriaxone was considered, but patient has a ?history of a allergic rash with CTX over the weekend. By ID's recommendation, patient went to the unit overnight to receive a ceftriaxone desensitization. Ceftriaxone desensitization subsequently failed [**2-24**] development of hives. Patient was transferred back to medicine team and continued with IV vanco, again with subtherapeutic troughs and continued nightly fevers. White count trended slightly upward (from 8 to 10). Lung exam became suspicious for pna, see below. Due to low vanc troughs, patient was switched on [**6-26**] to daptomycin. ID weighed in and considering new HAP and suboptimally treated bacteremia, determined new abx regimen of linezolid, aztreonam, and cipro, which patient began on [**6-27**]. Pt was changed back over to daptomycin on [**6-30**]. It was not thought that pt had a HAP given no fever, WBC count or cough. CXR confirmed that LLL opacity was due to atelectasis. . #hypoxia-? Hospital acquired pneumonia: on [**6-26**] CXR showed LLL consolidation. With clinical picture of nightly fevers and trending WBC, patient began treatment of levofloxacin. Patient temporarily required 2L NC on the night of [**6-26**] but quickly weaned to RA. ID recommended abx regimen to cover bacteremia, endocarditis, and HAP: linezolid, aztreonam, and cipro. Repeat CXR found LLL opacity attributable to atelectasis and pneumonia coverage was discontinued per above. In addition, pt with sats of 94% on RA. The initial hypoxia may have been due to a small PE given the known b/l DVTs. However, pt is currently undergoing treatment with lovenox and coumadin. He sure be sure to have a therapeutic INR before his lovenox is discontinued. . #B/l DVT/LLE swelling: Admitting physician noted lower extremity swelling on exam, most likely associated with the septic joint, but DVT was ruled out with LE ultrasound on [**6-19**]. However, pt returned to have swelling repeat LENI showed b/l DVT and pt was started on lovenox with bridge to coumadin. His lovenox should be continued until INR is therapeutic. # Hypertension: Patient had no known history of HTN, but found hypertensive (140s-160s/80s-90s) inpatient. Started on metoprolol 25mg PO BID and hypertension well-controlled. Continue as an outpatient, please follow-up with PCP for HTN [**Name9 (PRE) 100010**] would be a great candidate for an ACEI given DM2 history. . # Hyperglycemia: Patient's fasting FS were in the 200s. He was placed on 7U NPH [**Hospital1 **] with HISS coverage preprandially. . # Constipation: Patient complained of constipation upon admission (no BM in past 1-2 days). Placed on a bowel regimen and had a large BM on day 3. Held off on bowel regimen but continued to follow constipation. . # Urinary retention: Patient has history of untreated BPH, began tamsulosin while inpatient, continue as outpatient and follow-up with PCP for changes to this regimen. Medications on Admission: Metformin 500mg po daily Omeprazole 20mg po bid Vicodin and ibuprofen for knee pain over past few days Multivitamin daily Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever: max daily dose 4g. 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please use this daily until the pain improves, then you may use it as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 2 mg Tablet Sig: 1-3tabs Tablets PO Q3H prn as needed for pain: hold for AMS, resp depression. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours): hold for AMS, resp depression. 9. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain: take with meals. 10. Enoxaparin 100 mg/mL Syringe Sig: 100mg Subcutaneous Q12H (every 12 hours): until INR therapeutic on coumadin. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 12. insulin Home regimen is metformin 500mg [**Hospital1 **], feel free to restart or use Humalog insulin per sliding scale as needed. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: adjust as needed for INR goal [**2-25**]. 14. Daptomycin 500 mg Recon Soln Sig: 600mg Intravenous once a day for 4 weeks: four week regimen: day 1 was [**6-27**], continue until [**2111-7-26**] and as per ID follow up. 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): this can likely be stopped or changed to HCTZ 25mg upon discharge. 17. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) Mucous membrane [**Hospital1 **] (2 times a day). 18. Outpatient Lab Work CBC with diff, ESR, CRP and CPK every monday. All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary: septic arthritis of the left knee strep viridans bacteremia possible SBE endocarditis bilateral lower extemity DVTs . Secondary: diabetes mellitus type 2 Schatzki's ring Discharge Condition: Hemodynamically stable, afebrile, tolerating po meds and diet, pain controlled with dilaudid and MS [**First Name (Titles) **] [**Last Name (Titles) **]: requires assistance Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: . You were admitted to [**Hospital1 69**] for lower back pain and leg weakness. MRI showed degenerative disease of your spine, but no evidence of infection. The lower extremity weakness improved with better pain control. Your blood and the fluid from the knee tap on [**6-17**] grew a type of bacteria called streptococcus, which is being treated with antibiotics. You also had a washout of the left knee by the orthopedics service. You had an ultrasound of your heart to see if the bacteria was infecting your heart valves, but you are already on antibiotics anyway. It was thought that the bacteria came from your mouth. Therefore, you were seen by the dental service and had 2 teeth pulled. In addition, you were found to have blood clots in your legs. For this, you were started on a blood thinning medication. . The following changes to your medications were made: 1) You started daptomycin-an antibiotic 2) You started pain control-dilaudid, MS contin, and a lidocaine patch. Please do not drive while taking this medication. 3) You started anticoagulation-lovenox and coumadin. 4) You started stool softner medication-senna and colace 5) You started blood pressure medication-metoprolol. This can likely be stopped or changed to an ACE inhibitor or hydrochlorothiazide in the outpatient setting. 6) You started peridex after the teeth removal-a cleaning mouthwash. 7) You started tamulosin- a medication to ease urinary flow (Flomax). . Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2111-6-23**] 12:30--> cancelled, need to reschedule . Department: ORTHOPEDICS When: THURSDAY [**2111-7-16**] at 9:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2111-7-16**] at 9:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: FRIDAY [**2111-7-31**] at 8:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . You will need to have blood work performed every monday as per below. . You should follow up with your dentist after your rehab stay. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]