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Admission Date: [**2126-4-12**] Discharge Date: [**2126-4-23**] Service: MED CHIEF COMPLAINT: Constipation and abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old woman, with medical problems that is listed separately below, who presented to the emergency department complaining of 12 days of constipation, diffuse and severe abdominal pain associated with nausea and vomiting in the absence of flatus, melena, or hematochezia. She denied fevers, chills, chest pain, shortness of breath, dysuria, or hematuria. The patient was admitted to [**Hospital3 **] where her abdomen was found to be distended and diffusely tender. A computed tomograph of the abdomen was performed where there was a question of colonic obstruction. An abdominal series of plain films were also performed showing cecal dilation. She was transferred to [**Hospital1 69**] for surgical evaluation after several enemas were given without success. Initially, the patient had diffuse abdominal pain upon transfer to this hospital with occasional nausea. The patient was admitted to the Surgical Intensive Care Unit for serial abdominal examinations and for monitoring. PAST MEDICAL HISTORY: 1. Spinal stenosis. 2. Coronary artery disease status post coronary artery bypass grafting. 3. Hypothyroidism, stable on replacement. 4. Degenerative joint disease. 5. Cataract repair. MEDICATIONS: Medications on transfer included, 1. Meperidine 25 mg subcutaneously q.4h. 2. Vistaril 25 mg subcutaneously q.4h. p.r.n. 3. Gabapentin 100 mg b.i.d. 4. Levothyroxine 75 mcg q.d. 5. Atorvastatin 25 mg q.d. 6. Aspirin 81 mg q.d. 7. Amlodipine 5 mg q.d. 8. Levofloxacin 500 mg intravenously starting on [**2126-4-11**]. ALLERGIES: None known. SOCIAL HISTORY: She has no tobacco, alcohol, or drug exposure. PHYSICAL EXAMINATION: Initial physical examination, the temperature was 96.7 degrees, the heart rate was 116, the blood pressure was 90/60, respiratory rate was 18 and the oxygen saturation was 96% on 2 liters. Generally, she was awake and not in acute distress but not speaking in full sentences. HEENT: The oropharynx is clear and slightly dry. Neck: There was no lymphadenopathy or elevation of the jugular venous distension. Chest: She had crackles at both bases. Heart: Tachycardiac and irregular with normal S1 and S2. There were no extra sounds. Abdomen was distended and tympanitic with hypoactive bowel sounds. It was diffusely tender, especially in the left lower quadrant without rebound or guarding. Extremities: There were weak distal pulses but no edema. The saphenous vein harvest scar was intact. LABORATORY DATA: Laboratory evaluation in the outside hospital showed a white blood cell count of 22,800, the hemoglobin was 14.4, the hematocrit was 42.5%, and the platelets were 207. Chemistry panel was as follows: Sodium 121, potassium 3.9, chloride 89, bicarbonate 22, blood urea nitrogen 25, creatinine 0.9, and glucose 143. The albumin was 3.4, calcium was 8.4, amylase was 20, alkaline phosphatase was 38, ALT was 16, AST was 47, TSH was 8.7, and lipase was 15. Electrocardiogram showed atrial fibrillation with a rate of 132 beats per minute. HOSPITAL COURSE: The patient was initially admitted to the Surgical Intensive Care Unit. Serial abdominal examinations were performed and imaging of the abdomen showed a sigmoid volvulus. Colonoscopy was also performed with resolution of her abdominal pain. The patient received copious volumes resuscitation and was transferred to the Medical Intensive Care Unit for diuresis, where she spent 2 days with prompt response in her volume status. The patient was then transferred to the medical floor, where she again developed left lower quadrant pain. In consultation with her family, the patient decided to pursue comfort measures only, in that she specifically declined surgery or repeat colonoscopy. On hospital day 9, continuous infusion morphine was initiated. The patient expired on [**2126-4-23**] at 2:05 p.m. The patient's daughters were present and declined an autopsy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 27522**] Dictated By:[**Doctor Last Name 34877**] MEDQUIST36 D: [**2126-4-23**] 14:48:04 T: [**2126-4-23**] 23:21:14 Job#: [**Job Number 49793**]

Admission Date: [**2120-1-11**] Discharge Date: [**2120-1-14**] Date of Birth: [**2054-4-29**] Sex: F Service: NEUROSURGERY Allergies: Keflex / Azithromycin Attending:[**First Name3 (LF) 1835**] Chief Complaint: She experienced difficulty seeing her left side. She also had vertigo, seeing colored lights in periphery of her visual field. She experienced headaches at the left occipital region, and it woke her at night. She had nausea, dry heaves, and decreased dexerity with impaired ability to open pill bottle with her left hand. She also had tinnitus in her right ear. Major Surgical or Invasive Procedure: [**2120-1-11**] Suboccipital craniotomy for tumor resection History of Present Illness: [**First Name9 (NamePattern2) 86978**] [**Known lastname 86979**] is a 65-year-old right-handed woman, with history of non-small cell lung cancer. Her neurological problem began in the summer of [**2119**] when she experienced difficulty seeing her left side. She also had vertigo, seeing colored lights in periphery of her visual field. She experienced headaches at the left occipital region, and it woke her at night. She had nausea, dry heaves, and decreased dexerity with impaired ability to open pill bottle with her left hand. She also had tinnitus in her right ear. She initially blamed the symptoms on her diabetes but an MRI of the brain showed a left occipital brain mass with surrounding edema. She was started on dexamethasone 4 mg 3 times daily and her headache disappeared. She was referred to the BTC for evalaution and was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. Past Medical History: Past Medical History: She has a history of type II diabetes (diagnosed 2 years ago), hypertension, coronary artery disease, and COPD. She does not have hypercholesterolemia. Past Surgical History: She had CABG x 1 on [**2118-7-2**], hysterectomy for fibroids, cholecystectomy, carpal tunnel surgeries in both hands, and bladder distension surgery. Social History: She works in retail sales. She smoked 1.5 packs of cigarettes per day for 30 years; she stopped smoking since [**2102**]. She does not drink alcohol or use illicit drugs. Family History: She is adopted and she does not know the biological or medical histories of her parents or siblings. She has 1 daughter and 3 sons; they are all healthy. Physical Exam: PRE OP EXAM: Temperature is 97.8 F. Her blood pressure is 142/60. Heart rate is 60. Respiratory rate is 16. Her skin has full turgor. HEENT examination is unremarkable. Neck is supple and there is no bruit or lymphadenopathy. Cardiac examination reveals regular rate and rhythms. Her lungs are clear. Her abdomen is soft with good bowel sounds. Her extremities do not show clubbing, cyanosis, or edema. Neurological Examination: Her Karnofsky Performance Score is 90. She is awake, alert, and oriented times 3. There is no right-left confusion or finger agnosia. Calculation is intact. Her language is fluent with good comprehension, naming, and repetition. Her recent recall is good. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [**6-7**] at all muscle groups. Her muscle tone is normal. Her reflexes are 2- and symmetric bilaterally. Her ankle jerks are 2-. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. Her gait is normal. She can do tandem gait. She does not have a Romberg. Exam on the day of discharge: [**2120-1-14**] neurologically intact, no field cut apprieciated on exam. patient is independently ambulating in the halls, alert, oriented to person, place and time. strength is full, sensation is full. no pronator drift noted. occipital incision clean dry and intact sutures closing the wound. perrl, pupils 5-3mm bilaterally. Pertinent Results: ADMISSION LABS: [**2120-1-11**] 08:38PM WBC-12.6* RBC-4.61 HGB-12.2 HCT-38.2 MCV-83 MCH-26.4* MCHC-31.9 RDW-18.5* [**2120-1-11**] 08:38PM GLUCOSE-187* UREA N-33* CREAT-1.0 SODIUM-133 POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-24 ANION GAP-19 [**2120-1-11**] 08:38PM CALCIUM-7.9* PHOSPHATE-5.1* MAGNESIUM-1.8 dISCHARGE LABS: na 140, GLUCOSE 120, wbc 12.5, PLATLETS 266, hgb 12.4, HCT 39.3, pt 10.1, ptt 19.7, inr .8 IMAGING: CT Head [**1-11**]: Interval occipital mass resection with pneumocephalus, but no hemorrhage or midline shift MR HEAD W/ CONTRAST Study Date of [**2120-1-11**] 6:47 AM [**Last Name (LF) **],[**First Name3 (LF) **] M. OPT [**2120-1-11**] 6:47 AM MR HEAD W/ CONTRAST Clip # [**Clip Number (Radiology) 86980**] Final Report INDICATION: Left occipital mass. COMPARISON: [**2119-12-29**] MRI brain from [**Hospital3 3583**] and scanned into our PACS system for review. FINDINGS: The right occipital lobe mass is similar in size to the [**2119-11-28**] MRI, measuring today 24 x 27 x 26 mm (AP x ML x SI). The mass has a thick rind of enhancement and a T1 hypointense center. The adjacent edema has decreased slightly, with slight interval expansion of the occipital [**Doctor Last Name 534**] and atrium of the left lateral ventricle and better definition of adjacent sulci. No new lesions are seen. Major intracranial vessels are patent. IMPRESSION: Left occipital lobe mass, necrotic-appearing. This can represent a metastasis from the patient's lung cancer or a primary neoplasm. There has been slight interval decrease in the adjacent vasogenic edema and slight interval decrease in mass effect. Study for surgical planning. Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2120-1-13**] 5:40 PM [**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2120-1-13**] 5:40 PM MR HEAD W & W/O CONTRAST PRELIMINARY RADIOLOGY REPORT 1. Post-surgical changes in the left occipital surgical resection cavity, with small areas of linear nodular enhancement within, which may relate to post-surgical changes/residual tumor or a combination of both. 2. Areas of decreased diffusion in the periphery of the left occipital lobe posteriorly and medially, may relate to acute infarction. Consider followup to assess interval change. Persistent surrounding vasogenic edema and partial effacement of the atrium of the left lateral ventricle and the left occipital [**Doctor Last Name 534**]. Other details as above. Brief Hospital Course: Patient presented electively for suboccipital craniotomy for resection of tumor on [**2120-1-11**]. It was an uncomplicated procedure, and she was admitted to the ICU for Q1 neurochecks and Dexamethasone. She had no issues overnight and her pain was well controlled. On [**2120-1-12**], the morning of POD #1 she felt well and she had no acute issues. SHe was transferred out of the ICU to the floor. She experienced a severe headache and her pain medications were changed with good post operative pain relief. On exam the patient ws stable with right field cut noted. A decadron taper was written. On [**1-13**], the patient ws seen by physical therapy. She was noted to ambulate independently but had higher level balance issues requiring home physical therapy. The patient had her post operative MRI of the brain which was reviwed by Dr [**Last Name (STitle) **] and consistent with expected post operative change. On [**2120-1-14**], the patient was tolerating a regular diet, ambulating in the halls independently. The patient had not had a post operative bowel movement but was passing flatus and has baseline constipation. On exam, a visual field cut was no apprieciated and the patients strength and sensation was full. Pupils were equal and reactive bilaterally. The surgical incision was clean dry and intact. The patient was instructed to begin her Metformin on [**1-15**] hours after her last MRI of the Brain. She was also instructed to resume her home dosing of Humalog insulin. The patient will follow up in Brain [**Hospital 341**] Clinic and with Opthomology. The patient's husband was at her bedside and the patient was looking forward to her discharge home. Medications on Admission: Metformin (held [**3-7**] contrast ). paroxetine, decadron, albuterol, ativan, protonix, albuterol, asa 81mg Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:*60 Tablet(s)* Refills:*1* 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for Wheezing, SOB. 5. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 1 days: start [**2120-1-14**]. Disp:*4 Tablet(s)* Refills:*0* 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: hold for lethargy. Disp:*30 Tablet(s)* Refills:*0* 9. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*2* 10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain: do not exceed 4 grams tylenol in 24 hours. Disp:*50 Tablet(s)* Refills:*0* 11. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours): start this dose [**2120-1-15**]. Disp:*40 Tablet(s)* Refills:*1* 12. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for muscle spasm for 2 weeks: hold for lethargy- do not drive while on this medication. Disp:*20 Tablet(s)* Refills:*0* 13. humalog please resume your home dose of humalog per your primary care physician. [**Name10 (NameIs) 357**] continue to check finger sticks 4 times a day and prior to bed as directed by your primary care physician. Discharge Disposition: Home With Service Facility: VNA [**Hospital3 **] inc Discharge Diagnosis: occipital mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? 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. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? 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. You may resume Aspirin one week following your surgery Please restart your home dose of Metformin on [**2120-1-15**] (48 hours after your MRI that was performedin the hospital) 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: ??????Please return to the office in [**8-12**] 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 [**1-29**] at 9:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. 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 You may resume Aspirin one week following your surgery Please restart your home dose of Metformin on [**2120-1-15**] (48 hours after your MRI that was performed in the hospital which was performed at 6pm [**1-13**]) You will need formal visual field testing performed with Opthomology before you will be able to drive. This should be performed in the next 6 weeks. The office number to call for an appointment is Office Phone:([**Telephone/Fax (1) 5120**],Office Fax:([**Telephone/Fax (1) 22009**] Office Location:E/TCC-5, [**Location (un) 86**], [**Numeric Identifier 718**] You may resume your home dose of humalog insulin as prescribed by your primary care physician. Completed by:[**2120-1-14**]

Admission Date: [**2167-5-21**] Discharge Date: [**2167-5-27**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: shortness of breath and chest wall pain s/p fall w/ blunt trauma to L chest w/ rib fractures and hemothorax Major Surgical or Invasive Procedure: Chest tube placement History of Present Illness: 84 y/o male from Conn, visiting friends on [**Name (NI) **] when fell/? syncopal episode during night w/blunt trauma to left chest, fracturing [**7-9**] ribs @ left, hemothorax, and partial atelectasis of left lung w/ pleural peel. Transferred to [**Hospital1 18**] from [**Hospital 1562**] Hospital [**2167-5-22**] for purpose of surgical evacuation of hemothorax and pleural peel of left side and r/o active bleeding in pleural space. And syncopal w/u. Past Medical History: HTN, dyslipidemia, GERD, heart dz, CAD, s/p TIA, s/p R ing. hernia repair, s/p MI Social History: lives in [**Location 11269**], Conn w/ wife. Retired [**Name2 (NI) **] daughter and son who are involved. Family History: non-contributory Pertinent Results: [**2167-5-21**] 06:33PM GLUCOSE-122* UREA N-25* CREAT-0.9 SODIUM-140 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15 [**2167-5-21**] 06:33PM WBC-9.7 RBC-2.92* HGB-9.9* HCT-29.8* MCV-102* MCH-33.9* MCHC-33.2 RDW-12.5 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2167-5-27**] 05:40AM 11.9* 3.45* 11.4* 33.8* 98 33.0* 33.6 13.9 423 INITIAL Chest XRAY: AP UPRIGHT PORTABLE : Multiple left-sided rib fractures are seen within the mid axillary line, with an underlying left-sided moderate-sized pleural effusion. There is no pneumothorax. Within the right lung, there is patchy opacification involving predominantly the lower two thirds of the right lung consistent with aspiration pneumonia. The surrounding soft tissues reveal a dilated stomach, filled with air and fluid. IMPRESSION: 1) Several left-sided rib fractures with underlying pleural effusion. No evidence of pneumothorax. 2) Right lung aspiration pneumonia. 3) Dilated stomach. CHEST (PA & LAT) [**2167-5-26**] 8:47 AM:INDICATION: Question pneumothorax. Left rib fractures. There is no evidence of pneumothorax. Cardiac and mediastinal contours are stable. Bilateral multifocal pulmonary opacities are again demonstrated affecting the right lung to a much greater degree than the left. Diffuse hazy opacities are noted throughout the right lung. Within the right upper lobe, the opacities become slightly more dense and confluent. Scattered hazy and reticular opacities in the left lung are unchanged. A small left pleural effusion is stable. Left-sided rib fractures are again visualized. ECHO:Conclusions: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. The aortic root is mildly dilated. The ascending aorta is mildly dilated. 3. The aortic valve leaflets are mildly thickened with marked posterior aortic annular calcification. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. CAROTID ULTRA SOUND: IMPRESSION: No stenosis of the right ICA. Less than 40% stenosis of the left ICA. HEAD CT: IMPRESSION: No acute intracranial abnormality visualized. No areas of abnormal enhancement seen. Brief Hospital Course: 84 yr old male transferred from [**Hospital 1562**] Hospital for eval of hemothorax s/p fall ? r/t syncope. Py sustained left rib fractures, hemothorax and resp distress as a result of fall. Pt was directly admitted to the ICU for monitoring and high O2 requirement. Chest XRAY showed edema right > than left w/ bilat effusions and left hemothorax and left rib fractures. Pt was significantly diuresed w/ IV lasix w/ modest improvement in his resp status. A chest tube was placed on [**5-22**] for hemothorax and was removed [**2167-5-26**]. Pt's O2 requirement decreased significantly from 15 liters to presently 3L NP over the course of his hospital stay. He is presently 93% on 3LNP. He was begun on 10 days of augmentin [**5-26**] for persistant ground glass appearance on CXR ( aspiration PNA)and very low grade leukocytosis and absence of fever or cough. He is [**Last Name (un) 1815**] regular diet, OOB to chair and ambulation but has not returned to his previous level of activity thus requiring a brief rehab stay. During his hospitalization a syncope w/u was done including a head CT which was negative, Carotid ultrasound -which showed < 40% on the left ICA and clear on the right. Cardiac Echo showed Trivial Mitral regurg - see results section of summary for specfic details of these reports. A holter monitor study is all that remains to complete the work up- although his telemetry has been unremarkable during his stay. Medications on Admission: Valsartan 160 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Verapamil HCl 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 2. Verapamil HCl 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Valsartan 160 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: beechwood Manor Discharge Diagnosis: Hypertension, dyslipidemia, GERD, CAD, s/p Traansient Ishemic Attack, s/p Right Inguinal hernia repair, s/p Myocardial Infarction Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] for: fever, shortness of breath, chest pain, excessive discharge from chest tube site. Follow w/ Primary Provider for [**Name9 (PRE) 702**] appointment within next 2-4 weeks and or leaving Rehab facility. Holter monitor study needed to complete syncope work up. Followup Instructions: Call Primary Provider for appointment upon discharge from rehab. Completed by:[**2167-5-27**]

Admission Date: [**2137-3-11**] Discharge Date: [**2137-3-12**] Date of Birth: [**2137-3-10**] Sex: F HISTORY: Baby Girl [**Name2 (NI) **] [**Known lastname **], is a 38-6/7 weeks gestation female infant, birth weight 2980 grams, who was admitted to the Intensive Care Unit Nursery on day of life one for monitoring after a dusky episode associated with feeding. The mother is a 38 year old Gravida 4, Para 0, now 1 mother, with uncomplicated pregnancy. Prenatal screens, blood type B positive, antibody screen negative, rubella immune, RPR nonreactive, Hepatitis B surface antigen negative and Group B Strep unknown. PAST OBSTETRIC HISTORY: weeks. Mother presented in labor with spontaneous rupture of membranes around six and a half hours prior to delivery for clear fluid. No maternal fever. Delivery by normal spontaneous vaginal delivery with Apgars scores of 9 and 9 at one and five minutes respectively. HISTORY: The infant initially was admitted to the Newborn Nursery; fed well with Enfamil 20 with iron. Temperature ranged from 97.6 F., to 98.4 F., axillary. Heart rates ran 124 to 140s. Respiratory rate from the 40s to 50s. Around 24 hours of life, noted to have a dusky episode associated with a bottle feeding and burping. Did not require stimulation or oxygen. Was admitted to the Intensive Care Unit nursery for monitoring. PHYSICAL EXAMINATION: On admission, alert, active infant. Skin without rashes, mild jaundice. Head: Anterior fontanel open and flat with some molding and small caput. Eyes with red reflex positive bilaterally. No cleft. Clear and equal breath sounds with comfortable work of breathing. Heart: Regular rate and rhythm without murmur. Plus two femoral pulses. Abdomen soft, nondistended, no hepatosplenomegaly. No masses. Genitalia normal female external genitalia. Spine intact. Extremities stable. Hips stable. Reflexes normal for age. Also noted to have an accessory nipple on the right side with a small skin tag on the left side. HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: Oxygen saturations greater than 95% in room air. Had no further dusky choking episodes, but some mild desaturation was noted with several of the feedings, but none since [**44**]:30 p.m. on [**2137-3-11**]. No episodes of apnea or bradycardia. 2. Cardiovascular: Has been hemodynamically stable since birth. Four extremity blood pressures within normal limits. No murmur. 3. Fluids, Electrolytes and Nutrition: Birth weight 2980 grams (50th percentile); length 45.5 cm (10 to 25th percentile); head circumference 31.5 cm (10 to 25th percentile). Is taking 30 to 60 cc of Enfamil 20 with iron every three to four hours. Voiding and stooling appropriately. 4. Gastrointestinal: Noted to be jaundiced on day of life one; bilirubin total 7.7, direct 0.3; repeat bilirubin on [**3-12**], on day of life two, was a total of 11.5, direct 0.3. 5. Hematology: Hematocrit on admission 58%. 6. Infectious Disease: A CBC and blood culture was done on admission. No antibiotics have been given. White count 20,000 with 68 polys, 4 bands. Platelets 262,000. 7. Neurology: Examination age-appropriate. 8. Sensory: Hearing screening was performed with automated auditory brain stem responses passed in both ears. CONDITION AT DISCHARGE: Stable two-day-old term infant with jaundice. DISCHARGE DISPOSITION: Discharge home with parents. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 724**] at [**Hospital3 **] Community Center, telephone [**Telephone/Fax (1) 40664**], fax number [**Telephone/Fax (1) 40665**]. CARE AND RECOMMENDATIONS: 1. Feeds: Ad lib demand feeds, Enfamil 20 with iron. 2. Medications: None. 3. State Newborn Screen drawn on [**2137-3-12**]. 4. Immunizations received, received Hepatitis B immunization on [**2137-3-12**]. FOLLOW-UP APPOINTMENT SCHEDULE: 1. Follow-up appointment with pediatrician on [**2137-3-13**] at 09:00 a.m. 2. Bilirubin to be checked on [**2137-3-13**], at 9 a.m. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age term female. 2. Rule out sepsis, no antibiotics. 3. Desaturation episode associated with feed. 4. Jaundice. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**] Dictated By:[**Last Name (NamePattern1) 38457**] MEDQUIST36 D: [**2137-3-12**] 15:27 T: [**2137-3-12**] 15:55 JOB#: [**Job Number 40666**]

Admission Date: [**2127-3-23**] Discharge Date: [**2127-3-27**] Date of Birth: [**2051-10-9**] Sex: M Service: [**Hospital6 733**] HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old gentleman with a past medical history significant for coronary artery disease, status post coronary artery bypass graft times four in [**2119**], with a patent graft in [**2126**], congestive heart failure, type 2 diabetes (with neuropathy and retinopathy), status post femoral-to-popliteal bypass for peripheral vascular disease, recurrent urinary tract infections, nephrolithiasis, and abdominal aortic aneurysm repair who was at home when his wife noted significant dizziness and called 911. The patient reports having dizziness and decreased oral intake for the past three days, burning on urination, and diarrhea. On the night prior to admission, he experienced lightheadedness and fell to the floor but did not hit his head. During this time he also continued to take all of his medications including his Lasix. He was brought to [**Hospital1 69**] where his blood pressure was found to be 115/50 which subsequently dropped to 88/39. His lactate was increased at 7.5, and his white blood cell count was 19.5. His temperature was 100.6. He qualified for the sepsis protocol which was initiated in the Emergency Department. The patient was started on dobutamine and Levophed, and he received 3 liters of normal saline in the Emergency Department. He also received levofloxacin and Flagyl intravenously. The patient was transferred to the [**Hospital Ward Name 332**] Intensive Care Unit for further care. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post coronary artery bypass graft times four vessels in [**2119**] with patent grafts in [**2126**]. 2. Congestive heart failure (with a normal ejection fraction). 3. Type 2 diabetes mellitus. 4. Osteoarthritis. 5. Pacemaker. 6. Recurrent urinary tract infections. 7. Nephrolithiasis. 8. Excised skin cancer (basal cell) from right nose. 9. Peripheral vascular disease; status post left popliteal bypass. 10. Abdominal aortic aneurysm repair in [**2119**]. 11. Cataract repair. 12. Status post hernia repair. ALLERGIES: TETANUS SHOT (causes swelling). MEDICATIONS ON ADMISSION: 1. Lopressor 25 mg by mouth twice per day. 2. Lasix 80 mg by mouth twice per day. 3. Lipitor 10 mg by mouth once per day. 4. Aspirin 325 mg by mouth once per day. 5. Diovan 80 mg by mouth once per day. 6. NPH insulin 40 in the morning and 34 in the evening. 7. Neurontin 300 mg by mouth twice per day. 8. Ativan 1 mg by mouth at hour of sleep as needed. 9. Nexium 40 mg by mouth once per day. 10. Sublingual nitroglycerin as needed. SOCIAL HISTORY: The patient has a remote tobacco history. He is a retired carpenter. He drinks only occasionally. He lives with his wife. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99, his blood pressure was 126/41, his pulse was 92, his respiratory rate was 28, and he was saturating 98% on 4 liters. In general, this was a pleasant, conversational, but fatigued-appearing gentleman in no acute distress. Head, eyes, ears, nose, and throat examination revealed a right surgical pupil. The left pupil was reactive. The extraocular movements were intact. The oropharynx was clear. The mucous membranes were dry. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. There was a 2/6 systolic murmur heard best at the left sternal border with no radiation. Pulmonary examination revealed the patient had fair air movement and crackles at the right base. The abdomen was soft and protuberant. Nontender except for the left lower quadrant where there was slight tenderness. Extremities revealed no clubbing, cyanosis, or edema. There were palpable pulses bilaterally. Neurologic examination revealed the patient was alert and oriented. Cranial nerves II through XII were intact. The patient was moving all extremities. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 19.6 (95% neutrophils, and 2% bands, and 2% lymphocytes) and his hematocrit was 33.2. Chemistry-7 was significant for a bicarbonate of 22, blood urea nitrogen of 37, and creatinine of 2.7 (which was increased from his baseline of 1). Liver function tests were within normal limits. His lactate on admission was elevated at 7.1. Creatine kinase was 1022, MB was 12, MB index was 1.2, and his troponin was 0.25. Urinalysis revealed moderate leukocytes, greater than 50 white blood cells, and many bacteria. PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed pacemaker leads. Right internal jugular in place. The lung fields were clear. An electrocardiogram revealed a paced rhythm at 92. A computed tomography of the abdomen and pelvis without contrast revealed hydronephrosis, but no stones. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the [**Hospital Ward Name 332**] Intensive Care Unit for aggressive monitoring on a sepsis protocol. When he had a stable blood pressure and remained off pressors for greater than 24 hours, and was otherwise stable, the patient was transferred to the floor on [**2127-3-25**]. 1. HYPOTENSION ISSUES: The patient's hypotension was likely secondary to hypovolemia given his decreased oral intake and diarrhea, and also sepsis from a urologic source. The patient was continued on the sepsis protocol and was initially started on Levophed and dobutamine through a right internal jugular central venous catheter which had been placed. The patient was eventually weaned from pressors and had stable blood pressures after that. As the patient's blood pressure had been stable for approximately 24 hours, the patient was restarted on his home blood pressure medications and tolerated these well. 2. INFECTIOUS DISEASE ISSUES: The patient with a urinary tract infection and urosepsis. The patient was started on levofloxacin and Flagyl awaiting further culture results. The patient's urine cultures grew gram-negative rods, and he was continued on levofloxacin with a plan for a 14-day course. The patient's stool was sent for Clostridium difficile and ova and parasites; these were negative. The patient's diarrhea improved throughout his hospitalization. The patient's diarrhea was likely due to a viral etiology. 3. CARDIOVASCULAR/CORONARY ARTERY DISEASE ISSUES: The patient with a significant history of coronary artery disease; however, patent grafts in [**2126**]. The patient had an elevated troponin in the setting of acute renal failure. He also had an elevated creatine kinase and MB. The patient likely had a small episode of myocardial infarction secondary to demand ischemia in the setting of hypotension. The patient was continued on his aspirin and statin. His beta blocker and angiotensin receptor blocker were added back as his blood pressure tolerated. The patient had an echocardiogram on [**3-25**] to assess for possible focal wall motion abnormalities given the evidence of a troponin leak and myocardial infarction. The patient's ejection fraction remained at 60%. He had moderately dilated left atrium and right atrium and 1+ mitral regurgitation, which was not significantly changed from prior. 4. ACUTE RENAL FAILURE ISSUES: The patient had a previous baseline creatinine of 0.9 to 1. The patient was admitted with a creatinine of 2.7. This was likely secondary to hypoperfusion as well as prerenal etiologies given the diarrhea and continued diuretic regimen he had been on at home. The patient's medications were originally renally dosed. He was aggressively hydrated, and his creatinine returned to baseline at the time of discharge. 5. ANEMIA ISSUES: The patient with a baseline hematocrit of approximately 28 to 30. His hematocrit dropped from an admission hematocrit of 33 down to 27. After hydration, given the issue of potentially active cardiac ischemia, the patient was transfused one unit of packed red blood cells to a hematocrit of greater than 30. The patient again required another transfusion of one unit during this admission. The patient had no evidence for gastrointestinal bleeding as his stools were guaiac-negative. This was again thought due to dilution. The patient's hematocrit remained stable for two days prior to discharge. 6. ENDOCRINE/TYPE 2 DIABETES ISSUES: The patient was originally maintained on an insulin drip to maintain tight glucose control. As the patient became increasingly stable, he was transitioned to his home medications of NPH insulin and a regular insulin sliding-scale. 7. RESPIRATORY/PULMONARY ISSUES: The patient was continued on oxygen by nasal cannula on admission; however, this was quickly weaned. The patient had no issues with congestive heart failure during this admission, and he remained with good oxygen saturations. The patient did have some episodes of wheezing during this hospitalization which were relieved with Combivent nebulizers. The patient was given a Combivent inhaler to use at home as needed. 8. DISPOSITION ISSUES: Physical Therapy evaluated the patient and deemed him safe for discharge to home with a home safety evaluation. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Urosepsis, urinary tract infection. 2. Hypotension. 3. Acute renal failure. 4. Non-ST-elevation myocardial infarction. 5. Diarrhea. 6. Diabetes. 7. Anemia. 8. Congestive heart failure. MEDICATIONS ON DISCHARGE: 1. Nexium 40 mg once per day. 2. Ativan 1 mg at hour of sleep as needed. 3. Aspirin 325 mg once per day. 4. Lipitor 20 mg once per day. 5. Valsartan 80 mg once per day. 6. NPH insulin increased to home dose gradually of 40 in the morning and 34 in the evening with a regular insulin sliding-scale. 7. Furosemide 80 mg twice per day. 8. Lopressor 37.5 mg twice per day. 9. Neurontin 300 mg twice per day. 10. Levofloxacin (for nine days). 11. Combivent inhaler. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with his primary care physician (Dr. [**Last Name (STitle) **] on [**4-3**]. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2127-3-27**] 17:44 T: [**2127-3-28**] 09:06 JOB#: [**Job Number 94675**]

Admission Date: [**2196-12-23**] Discharge Date: [**2196-12-28**] Date of Birth: [**2137-10-11**] Sex: M Service: MEDICINE Allergies: Tylenol / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2387**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with Drug eluting stents to the Left anterior descending artery and left Circumflex artery History of Present Illness: 59 y/o M with h/o CAD s/p PCI (DES in [**First Name3 (LF) **], OM1, and LAD in [**2191**]), DM, and a heavy tobacco history transfered to [**Hospital1 18**] from [**Hospital3 934**] Hospital for NSTEMI. He reports that 3 days ago he started feeling generally unwell with a fever. His FS were elevated, so he ate less. By 2 days before transfer he felt sick enough that he called 911. In the ambulance to the ED he developed substernal chest pain. He denies SOB, nausea, or palpitations. Of note, he has had a month of worsening DOE and CP with exertion. He was take no [**Hospital3 934**] Hospital where he was admitted for ACS. His pain improved with NTG but recurred. An ECG there showed ST depressions in V4-6 with an intial set of negative CEs, but follow up CEs were positive with a TnI of 1.34 from 0.12 8 hours prior. At that time his WBC was notable for 3.5 and he had a low grade fever. Given his ECG changes and elevated TnI he was transfered to [**Hospital1 18**] for catheterization. . On arrival at [**Hospital1 18**] he was in [**7-30**] CP, diaphoretic, and febrile to 100.7. He underwent cath which showed 80% proximal LAD lesion, 90% [**Date Range **] in stent restenosis, and a fully occluded RCA with collaterals present. He was started on eptifibatide and a NTG drip for ongoing chest pain and transfered to the CCU. . In the CCU his pain was a [**1-31**] and the best he had felt in several days. He denies SOB at rest, orthopnea, or LE edema. He feels feverish. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for presense of chest pain for the past several days for for the past month with exertion as well as dyspnea on exertion. He denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: multiple PCIs with DES in LAD, [**Month/Year (2) **], and OM1 most recent in [**2191**] -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - Cerebral aneurysm - Colostomy with reversal - Ruptured diverticulum s/p Colostomy [**6-23**] - Cerebral aneurysm [**2182**] s/p VP shunt (subsequently removed) - Hernia repair - Hip Surgery [**2156**] - Arthritis - Diabetes, now off hypoglycemics and insulin - HTN - HLD . Social History: - Tobacco: 2PPD age 14 to age 53, 80 or so PYs - etOH: Social only - Illicits: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GEN: NAD, diaphoretic VS: 100.0 82 125/59 21 100% on RA HEENT: JVD to the angle of the jaw, no LAD, neck is supple CV: RR, distant, NL S1S2 no S3S4 +II/VI systolic murmur at the LUSB PULM: Prolonged expiratory phase relative to inspiration, crackles at the bases L>R ABD: BS+, soft, NTND, no HSM LIMBS: No LE edema, mild clubbing SKIN: No hair of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22595**], no skin breakdown NEURO: Reflexes are 2+ diffusely PULSES: Radial, femoral, TP, and DP pulses are 2+ bilaterally POST CATH CHECK groin without murmur, masses, bruit, or hematoma . ECG: Sinus, 82/min, leftward axis, RBBB, ST-T in I, II, aVL, V4-5, TWI in I, II, III, aVF, V1-6, and possible ST-E in aVR and V1. . At discharge: same as above except HEENT: Decreased JVP Pertinent Results: [**2196-12-23**] 11:46PM PT-14.3* PTT-26.8 INR(PT)-1.2* [**2196-12-23**] 11:46PM PLT COUNT-198 [**2196-12-23**] 11:46PM NEUTS-70.5* LYMPHS-20.4 MONOS-7.9 EOS-0.6 BASOS-0.6 [**2196-12-23**] 11:46PM WBC-2.6*# RBC-4.47* HGB-13.4* HCT-37.3* MCV-84 MCH-29.9 MCHC-35.8* RDW-14.9 [**2196-12-23**] 11:46PM %HbA1c-7.2* eAG-160* [**2196-12-23**] 11:46PM ALBUMIN-3.8 CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.9 [**2196-12-23**] 11:46PM CK-MB-3 cTropnT-0.07* [**2196-12-23**] 11:46PM ALT(SGPT)-28 AST(SGOT)-29 LD(LDH)-217 CK(CPK)-179 ALK PHOS-96 TOT BILI-0.8 [**2196-12-23**] 11:46PM estGFR-Using this [**2196-12-23**] 11:46PM estGFR-Using this [**2196-12-28**] 06:40AM BLOOD WBC-4.0 RBC-4.37* Hgb-13.3* Hct-37.0* MCV-85 MCH-30.3 MCHC-35.8* RDW-15.3 Plt Ct-229 [**2196-12-26**] 07:10AM BLOOD Neuts-61.6 Lymphs-26.8 Monos-9.0 Eos-2.0 Baso-0.7 [**2196-12-26**] 07:10AM BLOOD ESR-8 [**2196-12-25**] 05:55AM BLOOD Gran Ct-1600* [**2196-12-28**] 06:40AM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-138 K-4.6 Cl-101 HCO3-25 AnGap-17 [**2196-12-28**] 06:40AM BLOOD CK(CPK)-107 [**2196-12-28**] 06:40AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.2 [**2196-12-23**] 11:46PM BLOOD %HbA1c-7.2* eAG-160* CARDIAC CATH REPORT [**12-23**]:COMMENTS:Coronary angiography in this right dominant system demonstrate three vessel disease. The LMCA had no angiographic evidence of disease. The LAD had a proximal 80% stenosis. The [**Month/Year (2) **] had a 90% instent restenosis with an occluded OM. The RCA was occluded but filled from left to right collaterals. Resting hemodynamic reveal transient systemic hypotension that resolved after fluid resuscitation. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. CABG vs PCI of LAD and [**Last Name (LF) **], [**First Name3 (LF) **] be discussed with primary cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and CT surgery. CXR [**12-24**]: The heart is normal in size and lungs are clear without vascular congestion or pleural effusion. ECHO [**12-26**]:The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis (inferior wall worst affected) There is no ventricular septal defect. 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) 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. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Left Ventricle - Ejection Fraction: 50% to 55%. IMPRESSION: Regional LV systolic dysfunction consistent with CAD (inferior ischemia/infarction). Mild mitral regurgitation. Trace aortic regurgitation. EF 50-55%. [**12-27**] Cath Report: Cath: 80% LAD=> DES x1, [**Month/Year (2) 8714**]=> DES x1, 175cc contrast, integrellin x 18 hours. Brief Hospital Course: 59 y/o M with h/o CAD s/p PCI (DES in [**Month/Year (2) **], OM1, and LAD), DM, and a heavy tobacco histroy who was transfered from an OSH for NSTEMI and was found to have 80% proximal LAD lesion, 90% [**Month/Year (2) **] in stent restenosis, and a fully occluded RCA with collaterals as well as a fever and a possible LLL PNA. . # CAD: NSTEMI with Trop peaking of 2.17 at OSH now s/p cath showing 80% proximal LAD lesion, 90% [**Month/Year (2) **] in stent restenosis, and a fully occluded RCA with collaterals. Patient was initially a candidate for CABG. He was started on a heparin drip with goal PTT 60-100 3 hours after pulling arterial sheath. We stopped simvastatin and start atorvastatin 80 mg PO HS. He was briefly on a NTG drip for pain and to decrease cardiac work. While in hospital, we changed home metoprolol succinate 50 mg PO daily to metoprolol tartrate 25 mg PO daily to decrease cardiac work and cycled his cardiac enzymes. . # PUMP: Initially presenting with some crackles on exam, JVD elevated and mildly hypoxic, but he may have TR on exam and has a heavy smoking history. His CXR was not particularly congested. We continued lisinopril 2.5 mg PO daily to prevent remodelling. . # Diabetes: Per patient, now off hypoglycemics. a1c 7.2%. . # Fever: Febrile on admission and at OSH. CXR here concerning for LLL PNA. He was given an empiric levofloxacin 750 mg PO daily x 7 days for presumed CAP. BCx no growth. He also had a low WBC count, but his workup for possible neutropenia was negative and his WBC count rebounded prior to discharge: (WBC 2.6 on [**12-23**], and up to 4 on [**12-28**]). Medications on Admission: - Aspirin 325 mg PO daily - Simvastatin 20 mg PO HS - Clopidogrel 75 mg PO daily - Metoprolol succinate 50 mg PO daily - Lisinopril 2.5 mg PO daily - Lumigan 1 drop OU [**Hospital1 **] - Timolol 1 drop OU [**Hospital1 **] Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Non ST Elevation Myocardial Infarction Leukopenia Hyponatremia Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and a cardiac catheterization showed some blockages in your heart arteries. Initially we were planning to do surgery but Dr. [**Last Name (STitle) **] decided to place 2 stents in blocked arteries instead. This went well and you will need to be on Aspirin and Plavix every day for at least one year and likely longer. Do not stop taking Plavix and aspirin or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells you it is OK. Your left groin site had some pain last night but there is no evidence of bleeding under the skin this morning. You should watch the site for any new bruising, bleeding or increasing pain. Call Dr. [**Last Name (STitle) **] if you notice this. No lifting more than 10 pounds for one week. No baths or pools for one week. You can shower today. . Medication changes: 1. Increase your simvastatin to 80 mg daily Please keep the rest of your medicines as before Followup Instructions: Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 45127**],MD Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Location (un) **], [**Street Address(1) 4323**],[**Numeric Identifier 4325**] Phone: [**Telephone/Fax (1) 5457**] When: Monday, [**1-9**] at 10am Name: [**Name6 (MD) **] [**Name8 (MD) **],MD Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Location (un) **], [**Street Address(1) 4323**],[**Numeric Identifier 4325**] Phone: [**Telephone/Fax (1) 7960**] When:Monday, [**1-9**]. Please go upstairs to Dr [**Last Name (STitle) **] office after your visit with Dr [**Last Name (STitle) 5456**].

Admission Date: [**2193-7-17**] Discharge Date: [**2193-8-5**] Date of Birth: [**2193-7-17**] Sex: F HISTORY OF PRESENT ILLNESS: [**Known lastname 29633**] [**Known lastname **] is the former 2.585 kg product of a 33 [**3-14**] week gestation pregnancy born to a 30-year-old gravida 3, para 1 woman. Pregnancy was complicated by complete previa and premature rupture of Betamethasone. Prenatal screens, blood type A+, antibody negative, hepatitis B surface antigen negative, RPR non reactive, rubella immune, no group B strep status. Obstetrical history is significant for a stillbirth in [**2190**] at term due to a cord accident. The mother was treated prior to this delivery with Ampicillin and Erythromycin. Infant was born by cesarean section due to the known previa and delivery, was given blow by oxygen. She developed mild grunting, flaring and retracting. Apgars were 7 at one minute and 8 at five minutes. She was admitted to the Neonatal Intensive Care Unit for treatment of prematurity and respiratory distress. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit, weight 2.585 kg, length 47.5 cm, head circumference 31 cm. General, pink, active, non dysmorphic female infant, well saturated and perfused on blow by O2. Skin without lesions. HEENT: Anterior fontanel opened and flat, sutures approximated, symmetric facial features, positive red reflex bilaterally, palate intact. Chest, coarse breath sounds, equal bilaterally, fair air movement. Cardiovascular, regular rate and rhythm without murmurs, normal S1 and S2, femoral pulses +2. Abdomen benign. Hips negative. Spine intact, normal preterm female genitalia. Neuro, non focal and age appropriate exam. HOSPITAL COURSE: 1. Respiratory: Shortly after admission [**Known lastname 29633**] was placed on nasopharyngeal, continuous positive airway pressure. She required the continuous positive airway pressure for the first two days of life. In retrospect this was more likely prolonged retained fetal lung fluid (due to cesarean) than to RDS. She then transitioned to room air and remained in room air through the rest of her neonatal Intensive Care Unit admission. She was monitored for apnea of prematurity and had several episodes with her last being on [**2193-7-30**]. She has not had any episodes for the last five days prior to discharge. 2. Cardiovascular: [**Known lastname 29633**] has maintained normal heart rates and blood pressures during admission. She had some bradycardia associated with her apneic episodes. At the time of discharge her heart rates are in the 140's to 160's. 3. Fluids, Electrolytes & Nutrition: [**Known lastname 29633**] was initially npo and maintained on intravenous fluids. Enteral feeds were started on day of life #1 and gradually advanced to full volume. She received breast milk supplemented at 24 calories. At the time of discharge she is breast feeding ad lib or taking expressed mother's milk 20 calories per oz. Weight on the day of discharge is 2.625 kg with a length of 48.5 cm and a head circumference of 31.5 cm. Serum electrolytes were checked once in the first week of life and were within normal limits. 4. Infectious Disease: Due to the prolonged rupture of membranes and prematurity, [**Known lastname 29633**] was evaluated for sepsis at the time of admission. A complete blood count had a white count of 17,400 with 28% polys, 1% bands. A blood culture was obtained prior to starting intravenous Ampicillin and Gentamycin. The initial blood culture was no growth at 48 hours. On day of life #3 she was noted to have a reddened periumbilical area, a blood count was repeated and a second blood culture was obtained. The second CBC had a white count of 13,200 with 39% polys, 5% bands and the blood culture grew gram positive cocci identified as staphylococcal epidermis. She was treated with Oxacillin and Gentamycin for three days, then changed to Vancomycin for the last two days of a five day course. The repeat blood culture (#3) was no growth. Antibiotics were discontinued after the five day course for the omphalitis. The Steph epidermitis in culture #2 was considered a contaminant. For safety, a lumbar puncture was performed showing one red cells, two white cells, normal glucose and protein. The CSF culture was no growth. 5. Hematological: Hematocrit at birth was 56.1%, most recent hematocrit was on [**2193-7-22**] and was 57.5%. [**Known lastname 29633**] did not receive any transfusions of blood products. She is being discharged home on supplemental iron. 6. Gastrointestinal: [**Known lastname 29633**] was treated for unconjugated hyperbilirubinemia with phototherapy. Her peak serum bilirubin occurred on day of life #3 with a total of 12.3 mg/dl over 0.4 direct. She received 48 hours of phototherapy. Rebound bilirubin on [**2193-7-23**] was 7.2 total over 0.2 direct. [**Known lastname 29633**] did have some heme occult test positive stools and was noted to have a rectal fissure. 7. Neurological: [**Known lastname 29633**] has maintained a normal neurological exam throughout admission and there were no neurological concerns at the time of discharge. 8. Sensory: Hearing screening was performed with automated auditory brain stem responses. [**Known lastname 29633**] passed in both ears. 9. Psychosocial: [**Hospital1 69**] social worker was involved with this family. Contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**]. She can be reached at [**Telephone/Fax (1) 8717**]. 10. Skin: [**Known lastname 29633**] had a mild monilial diaper rash that was treated with miconazole powder. It had resolved by the time of discharge. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. Primary pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42874**], [**Hospital **] [**Hospital6 2399**], [**Location (un) 42875**], [**Location (un) 1456**], [**Numeric Identifier 42876**], [**Telephone/Fax (1) 42877**], Fax #[**Telephone/Fax (1) 42878**]. CARE & RECOMMENDATIONS: 1. Feeding: Ad lib breast feeding or expressed breast milk. 2. Medications: Fer-In-[**Male First Name (un) **] 25 mg per ml dilution, 0.3 cc po q d, Poly-Vi-[**Male First Name (un) **] 1 cc po q d. 3. Car seat position screening was performed with adequate oximetry saturation monitored for 90 minutes. 4. State newborn screening status was sent on day of life #3 and at discharge. No notification of abnormal results to date. 5. Hepatitis B vaccine was administered on [**2193-7-23**]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for those infants who meet any of the following three criteria: 1) Born at less than 32 weeks; 2) Born between 32 and 35 weeks with plans for DayCare during RSV season, with a smoker in the household, or with preschool siblings; 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 6 months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. 7. Follow-up appointments: The [**Hospital6 407**] will be following up at home. Primary pediatrician appointment within one week of discharge. DISCHARGE DIAGNOSIS: 1. Prematurity at 33 3/7 weeks gestation. 2. Transitional respiratory distress/retained fetal lung fluid. 3. Unconjugated hyperbilirubinemia. 4. Suspicion for perinatal sepsis ruled out. 5. Staphylococcal epidermis--presumed as contaminant. 6. Omphalitis, treated for 5 days with antibiotics. 7. Apnea of prematurity, resolved. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33795**], M.D. [**MD Number(1) 35944**] Dictated By:[**Last Name (Titles) 37548**] MEDQUIST36 D: [**2193-8-5**] 06:12 T: [**2193-8-5**] 06:59 JOB#: [**Job Number 42879**] Edited/signed [**2193-8-5**] DKR

Admission Date: [**2171-4-28**] Discharge Date: [**2171-5-7**] Date of Birth: [**2099-9-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: CABG X 2, LIMA>LAD, SVG>OM on [**2171-5-2**] History of Present Illness: 71 y/o male presented to OSH for elective echo, when laid flat, went in to CHF/resp arrest, intubated, and sent for cardiac catherterization. This revealed multivessel CAD, EF 40%. He was transferred to [**Hospital1 18**] for CABG. Past Medical History: COPD PVD s/p right carotid endarterectomy PAF CRI (creat 1.3) Social History: former smoker, quit many years ago denies ETOH retired security guard wife in nursing home Family History: non--contributory Physical Exam: Unremarkable pre-operatively Pertinent Results: [**2171-5-5**] 05:00AM BLOOD WBC-10.0 RBC-3.42* Hgb-9.7* Hct-29.4* MCV-86 MCH-28.4 MCHC-33.0 RDW-15.7* Plt Ct-217 [**2171-5-3**] 03:05AM BLOOD PT-13.9* PTT-30.0 INR(PT)-1.2* [**2171-5-5**] 05:00AM BLOOD Glucose-100 UreaN-24* Creat-1.2 Na-138 K-4.0 Cl-100 HCO3-31 AnGap-11 Brief Hospital Course: Admitted to cardiac surgery service for [**Hospital3 19345**] on [**2171-4-28**]. He was seen pre-operatively by the vascular service due to his carotid disease. After an ultrasound, and MRI, they felt that there was no need for any intervention, and he was taken to the operating room on [**2171-5-2**], where he uncerwent a CABG X 2. PLease see operative note for details of surgery. Post-op he was taken ti the CSRU on epinephrine and phenylephrine. He was extubated the day of surgery, drips were weaned off by the following day, and he was transferred to the telemetry floor on POD # 2. He has remained hemodynamically stable, without post-op AFib, but he has been weak, and slow to ambulate independently. He is ready to be transferred to rehab for physical therapy and progression with mobility. Medications on Admission: Lipitor 80' KCl ASA 162' Pepcid 20' Lasix 20' Atrovent MDI's Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**] Puffs Inhalation Q4H (every 4 hours). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Discharge Disposition: Extended Care Facility: The [**Location (un) **] Discharge Diagnosis: CAD COPD CRI Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks Followup Instructions: with Dr. [**Last Name (STitle) 66587**] in [**2-1**] weeks with Dr. [**Last Name (STitle) 66588**] in [**2-1**] weeks with Dr. [**Last Name (STitle) **] in 4 weeks Completed by:[**2171-5-6**]

Admission Date: [**2189-12-4**] Discharge Date: [**2189-12-10**] Date of Birth: [**2114-4-27**] Sex: M Service: MEDICINE Allergies: Levaquin / Shellfish Derived / Latex / Aranesp Attending:[**First Name3 (LF) 2297**] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: N/A History of Present Illness: 75 yo M hx CAD s/p recent NSTEMI, a. fib not on Coumadin, and recent hospitalization for SIRS [**2189-11-20**] - [**2189-11-30**] without obvious source of sepsis presenting from [**Hospital6 **] with severe chest pain. He said that this chest pain started 8pm last night, right-sided, non-pleuritic, continuous, sharp, [**7-6**]. He was initially brought to [**Hospital6 33**] with SOB and hypotension to 70/50 with CXR showing pneumonia. He was subsequently transferred to [**Hospital1 **]. . In the ED, initial vs were: 96 90 124/70 19 100% NRB (which was weaned down to 97% NC 2-3L. His chest pain had resolved by the time of arrival, and pressure initially in the low 100s before decreasing to the 80s. He was started on vancomycin and zosyn, RIJ placed and started on low dose levophed. He received 2L fluid. Past Medical History: 1) CAD (cath in [**2161**] showed 3-vessel disease, patient states he had MI [**09**] years ago), presented last hospitalization with NSTEMI believed to be secondary to demand 2) Atrial fibrillation (not on coumadin given h/o GI bleeding) 3) [**Company 1543**] Kappa KDR701 dual-chamber placement 4) Cirrhosis (classified as cryptogenic although patient has history of heavy EtOH use 35 years ago) 5) Chronic kidney disease with baseline Cr 2.7 6) Angiodysplasia of stomach and small intestine with serial endoscopic cauterization ([**2186**]) 7) GI bleeding chronic anemia (multifactorial, thought to be [**12-29**] kidney disease + GI bleeding) 8) Prior TIA ([**4-3**], ? [**8-5**]) 9) Melanoma, right forearm 10) Multiple BCCs 11) Diverticulosis 12) Colon polyps 13) Left carotid stenosis with stent ([**2184**]) 14) BPH ([**3-4**]) 15) Gout 16) Pneumonia ([**12-3**]) 17) Portal gastropathy 18) Low grade esophageal varices 19) Remote appendectomy Social History: Lives independently across the street from his daughter. Smoked 1.5 packs/day x 15 years, quit 35 years ago. Former heavy EtOH use, sober x 35 years. No drugs. patient previously worked as a letter carrier for the United States Postal Service. Family History: Notable for MI; Both parents lived to be > [**Age over 90 **] years old. Physical Exam: Patient expired during this hospitalization. He was without heart sounds, without breath sounds, without spontaneous movement and without corneal reflex at the time of death at 12:20pm [**2189-12-10**]. Pertinent Results: [**12-8**] Abd ultrasound 1. No evidence of portal vein thrombosis. 2. There is grossly heterogeneous echotexture of the hepatic parenchyma with [**Month/Year (2) **] architecture related to the patient's history of cirrhosis. 3. There is a questionable hypoechoic area in the right lobe of the liver. A liver lesion cannot be completely ruled out in that area given the limited quality of this portable U/S study. 4. Moderate amount of ascites and a right moderate pleural effusion. [**12-7**] Echo Suboptimal image quality. Moderate pulmonary artery systolic hypertension. Mildly dilated right ventricular cavity with low normal systolic function. Mild symmetric left ventricular hypertrophy with preserved global and regional systolic function. Trivial pericardial effusion. Compared with the prior study (images reviewed) of [**2189-11-25**], the right ventricular cavity is now slightly dilated with low normal systolic function and the estimated pulmonary artery systolic pressure is higher. This constellation of findings is suggestive of a primary pulmonary process (e.g., pulmonary embolism, etc.) [**2189-12-9**] 02:58PM BLOOD WBC-6.4 RBC-2.74* Hgb-9.3* Hct-29.4* MCV-107* MCH-33.8* MCHC-31.5 RDW-21.5* Plt Ct-43* [**2189-12-9**] 02:58PM BLOOD Neuts-93.1* Lymphs-4.7* Monos-2.2 Eos-0 Baso-0 [**2189-12-9**] 02:58PM BLOOD Plt Ct-43* [**2189-12-6**] 04:53AM BLOOD Fibrino-359 [**2189-12-5**] 11:00AM BLOOD FDP-10-40* [**2189-12-9**] 02:58PM BLOOD Glucose-143* UreaN-77* Creat-3.3* Na-143 K-5.2* Cl-113* HCO3-17* AnGap-18 [**2189-12-9**] 05:09AM BLOOD ALT-48* AST-36 LD(LDH)-236 AlkPhos-168* TotBili-2.5* [**2189-12-5**] 11:00AM BLOOD proBNP-5939* [**2189-12-9**] 05:09AM BLOOD FSH-3.6 LH-2.8 [**2189-12-6**] 12:30PM BLOOD Cortsol-15.7 [**2189-12-6**] 11:09AM BLOOD Cortsol-13.5 [**2189-12-6**] 11:07AM BLOOD Cortsol-5.4 [**2189-12-8**] 11:55PM BLOOD Type-ART pO2-93 pCO2-38 pH-7.26* calTCO2-18* Base XS--9 Brief Hospital Course: 75 yo M hx CAD s/p recent NSTEMI, a. fib not on Coumadin, and recent hospitalization for SIRS now with pneumonia on CXR and hypotension. In the MICU patient with worsening renal failure, encephalopathy, without clear source of infection. Medical team spoke with family, and the decision was made to make the patient CMO. . # Altered Mental Status: Patient had progressive decline of mental status throughout admission, and the etiology was multifactorial likely include hepatic encephalopathy, ICU delirium, and infection. Patient was initially put on lactulose and zyprexa. His sleep wake cycle was normalized. . # Hypotension/tachycardia/hypothermia: Unclear etiology, and likely related with SIRS. No clear source identified throughout work up. Patient was initially covered with broad spectrum antibiotics with early goal directed therapy. Cultures were persistently negative. He also underwent pituitary and more central workup - the cortical stim was somewhat abnormal, but other findings were negative. He remained on pressors and was taken off when the decision was made to make him CMO. . # Acute on Chronic Kidney Disease: Crt to 3.2 without clear etiology. Urine with increase in whites/red blood cells. Most likely related to relative hypotension. Started HRS therapy yesterday without improvement. . # SBP. Repeat diagnostic para with 4 white blood cells. This was initially suspected as a possible source of the patient's infection as initial diagnostic para was borderline positive. It was not consistent with the patient's presenting symptoms, however. Patient was initially covered by antibiotics for treatment. . # Right pleural effusion. Patient had a chronic right pleural effusion, but could not lower out a right lower lobe pneumonia. Etiology of the effusion likely to be hydrothorax, however. Patient was covered with antibiotic treatment. . # Chest pain/recent NSTEMI. Chest pain had resolved. Enzymes flat. No EKG Changes. . # End stage liver disease. Labeled crytogenic but patient with previous heavy alcohol use. . # Pancytopenia. Thrombocytopenia likely [**12-29**] liver disease. Platelets stable. HIV negative. Medications on Admission: - Clotrimazole cream to buttocks - Docusate 100 [**Hospital1 **] - FeSO4 325 before lunch - Furosemide 20 [**Hospital1 **] - Levothyroxine 50 before breakfast - MVI daily - Omeprazole 20 before breakfast - Senna 2 daily - Simvastatin 80 qhs - Sodium bicarb 650 [**Hospital1 **] - TBC Spray topically to heels - Acetaminophen prn - Bisacodyl prn - Sarna prn - Hydrocortisone 2.5% q12h - Lactulose prn - Sorbitol prn Discharge Medications: Patient expired; Discharge Disposition: Expired Discharge Diagnosis: Patient expired; Primary diagnosis: - SIRS Discharge Condition: Patient expired; Discharge Instructions: Patient expired; Followup Instructions: Patient expired; Completed by:[**2189-12-10**]

Admission Date: [**2167-10-23**] Discharge Date: [**2167-10-29**] Date of Birth: [**2098-10-30**] Sex: F Service: CCU REASON FOR ADMISSION: Reason for transfer from an outside hospital was for further treatment of severe congestive heart failure. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old woman with a history of coronary artery disease (status post myocardial infarction in [**2161**] and status post right coronary artery stent), rheumatic heart disease (with 2 to 3+ mitral regurgitation, moderate mitral stenosis with a valve area of 0.9 cm2 and a gradient of 11 mmHg), congestive heart failure (with an ejection fraction of 20% to 25%), atrial fibrillation (status post biventricular pacemaker placement but not cardioverted due to left atrial clot seen on [**2167-7-19**] and [**2167-9-18**] transesophageal echocardiograms). The patient also had a chronic right pleural effusion (status post therapeutic thoracentesis) in the recent past and severe chronic obstructive pulmonary disease (on home oxygen). She presented to an outside hospital with weakness, hemoptysis with dime-size clots, and worsening dyspnea on exertion. The initially impression at the outside hospital was that she was in decompensated congestive heart failure and was given Lasix as well as antibiotics for a possible pneumonia. Her Coumadin was held as her INR was supracervical at 4.7. She was diuresed with Lasix and was becoming hypotensive. She was started on dopamine and dobutamine and transferred to the [**Hospital1 190**] for further management. PAST MEDICAL HISTORY: 1. Cardiomyopathy with a left ventricular ejection fraction of 25%, severe mitral regurgitation, and mitral stenosis secondary to rheumatic fever. 2. Coronary artery disease; status post myocardial infarction in [**2161**] and status post right coronary artery stent, atrial fibrillation (on Coumadin). 3. Cerebrovascular accident in [**2167-7-19**] with subsequent left-sided weakness. 4. Chronic obstructive pulmonary disease and chronic right lower lobe infiltrate (on home oxygen). ALLERGIES: Allergies include AMOXICILLIN. MEDICATIONS ON TRANSFER: Medications at the time of transfer included aspirin, Ambien, multivitamin, Lipitor, digoxin 0.125 mg p.o. q.d., captopril 12.5 mg p.o. t.i.d., spironolactone 25 mg p.o. q.d., Lasix 120 mg p.o. b.i.d., Carvedilol 3.125; Coumadin was held. SOCIAL HISTORY: Social history was not obtainable. PHYSICAL EXAMINATION ON PRESENTATION: Examination on admission revealed the patient was afebrile with a temperature of 97.4, heart rate was 104, blood pressure ranged from 96 to 108/62 to 70, respiratory rate was 35. In general, she appeared uncomfortable and was tachypneic. She had mild scleral icterus. Her lungs had decreased breath sounds; particularly at the right base, with dullness to percussion and diffuse rales. Her heart examination revealed normal first heart sound and second heart sound with a 2/6 systolic ejection murmur with a diastolic soft component. Her abdomen was soft and nontender. Her liver was palpable approximately 8 cm below the right costal margin. Her extremities had 1 to 2+ peripheral edema with dopplerable pulses bilaterally. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories at the time of admission revealed white blood cell count was 15.1, hematocrit was 39.3, and platelets were 262. INR was 4.6. Chemistry-7 was unremarkable except for a bicarbonate of 19, a blood urea nitrogen of 22, and creatinine of 1. INR was repeated at the time of arrival which was 3.4. HOSPITAL COURSE: CARDIOVASCULAR SYSTEM: On the morning following admission, the patient was found to be in worsening respiratory distress using multiple accessory muscles for respiration and was found to be tiring. She was again asked if she wanted to be intubated, and she responded in the affirmative. Anesthesia was called, and the patient was electively intubated and placed on ventilator. Shortly thereafter she had a Swan-Ganz catheter placed which showed elevated filling pressures with pulmonary artery filling pressures of 60/35, and a wedge pressure of 30. Using these numbers, she was diuresed accordingly with intravenous Lasix. She was tried on multiple combinations of pressors including dopamine, dobutamine, Milrinone, and Natrecor; none of which effectively increased her renal perfusion and urine output nor her cardiac output and index. On [**2167-10-26**], she became febrile; spiking temperatures up to 102. Her white blood cell count was increasing; reaching a peak of 29. Cultures were sent including sputum, blood cultures, and urine cultures. Sputum cultures ultimately grew out Staphylococcus aureus and Pseudomonas aeruginosa. The urine cultures had gram-negative rods which were not yet typed at the time of this dictation. The patient developed septic physiology with a transient increase in her cardiac output and a decrease in her systemic vascular resistance. She was treated with broad spectrum antibiotics and continued on pressors. Her liver function tests continued to climb with her transaminases reaching near 200, and her total bilirubin reaching a peak of 8.2. The patient's skin became further jaundiced, and a right upper quadrant ultrasound had been ordered to evaluate for acute cholecystitis as gallstones had been seen on ultrasounds from the prior hospitalization. The right upper quadrant ultrasound was actually never performed. On [**2167-10-26**], the patient's right pleural effusion was tapped; removing 1400 cc of cloudy pleural fluid. The cultures from the fluid grew no organisms, and this appeared to be exudative; likely a parapneumonic effusion. By this time, her pressors were changed to Levophed and Vasopressin to maintain blood pressures. On [**2167-10-28**], the Coronary Care Unit resident had a long conversation with the patient's family regarding prognosis and possible quality of life following this hospitalization. If the patient were ever to be extubated, it was decided at that time that her prognosis was very poor and hope for a quality of life equal to what she had prior to admission was unlikely. The family decided at that time to make the patient do not resuscitate/do not intubate status; specifically, treating as comfort measures only. Antibiotic and pressor support were withdrawn after morphine constant infusion was initiated, and there was every assurance that the patient was comfortable. She expired on [**2167-10-29**] at 8:38 a.m. The patient family was notified and declined postmortem evaluation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**] Dictated By:[**Name8 (MD) 3491**] MEDQUIST36 D: [**2167-10-29**] 15:37 T: [**2167-11-3**] 09:39 JOB#: [**Job Number 45017**]

Unit No: [**Telephone/Fax (5) 16346**] Admission Date: [**2190-12-10**] Discharge Date: [**2190-12-17**] Service: Orthoepdic Surgery DISCHARGE STATUS: The patient is deceased. HISTORY OF PRESENT ILLNESS: Ms. [**Known firstname **] [**Known lastname 16343**] is a 96-year old female patient who presented from her rehab with an injury to her left lower extremity. She had recently undergone an open reduction and internal fixation for a hip fracture in [**2190-7-26**], and she was now at the rehab undergoing physical therapy with good result. However, she was in the bathroom trying to get up from the toilet and she fell sustaining a fracture to her distal left femur. The patient denied any dizziness, lightheadedness, blurry vision, headache, diaphoresis, chest pain or palpitations. She was found to have a complex distal femoral fracture and a hematocrit of 24 in the emergency room. She was admitted to the medical service for medical assessment and preoperative workup towards surgical management. She was consulted by the orthopaedic surgery service, and she was transfused 2 units of packed red blood cells and was given a stress dose of steroids for her hx of adrenal insuffiency. adrenal insufficiency. PAST MEDICAL HISTORY: Mrs. [**Known firstname **] [**Known lastname 16343**] has a very complex past medical history. She has a history of coronary artery disease, and has had a myocardial infarction in [**2144**] and [**2185**]. She also has significant aortic stenosis with an ejection fraction of 55%. She has a pacemaker for sick sinus syndrome. She has hypertension. She has atrial fibrillation and has required cardioversion. She is diabetic. She has sleep apnea. She has anemia, osteoarthritis, spinal stenosis, gastroesophageal reflux, osteoporosis, primary pulmonary hypertension and recently underwent a hip fracture. She also has a hx of adrenal insufficency. PAST SURGICAL HISTORY: Includes a cholecystectomy, pacemaker placement, hysterectomy, and open reduction and internal fixation of her left hip fracture. MEDICATIONS ON ADMISSION: Include aspirin, atenolol, Atacand, Prilosec, glyburide, Avandia, insulin, Lasix, Zoloft, Neurontin, Vicodin, Colace, senna, simethicone, Tylenol, Maalox, enemas, Tums, multivitamins. ALLERGIES: She is allergic to SULFONAMIDES, IODINE, PROCAINAMIDE and AMIODARONE. PHYSICAL EXAMINATION: Initial orthopaedic physical examination focused on her left lower extremity, which had a closed fracture of the distal femur. Small ecchymosis noticed on anterior thigh. She had a swollen thigh but was soft with significant pitting edema. Her extremities appeared to be well perfused and appeared to be sensory intact. She had no other orthopaedic injuries. Assessment for additional physical exam yielded a regular heart rate, a soft abdomen, a supple neck. She was clear to auscultation bilaterally bu had reduced breath sounds at the lower base. Her extremities showed 1+ radial pulses bilaterally in upper extremities, and dorsalis pedis pulses were noted by Doppler. She was alert and oriented. Cranial nerves were grossly intact. Had decreased sensation distally in her lower extremities bilaterally but appeared to be sensate when assesed by light touch. HOSPITAL COURSE: The patient was admitted to the medical service, and a preoperative workup was performed including a geriatric service consultation who deemed her to be at high risk for the OR given her moderate aortic stenosis. Discussion with the family yielded a request for full code and for addressing the fracture surgically in order to facilitate mobilization. The patient was stabilized overnight, transfused, rehydrated and was able to undergo surgical repair of her femoral fracture with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 101**] plate on the 17th. The surgical repair went uneventfully, and the patient was taken to the post anesthesia care unit. However, she had difficulty after extubation requiring her to be reintubated. She also had difficulty sustaining her blood pressure requiring pressors. She was admitted to the medical ICU on the 18th. She required an additional transfusion. On her first medical ICU day, she failed a second attempt at weaning her off the ventilator. She was able to be extubated on [**12-13**]. At that point, some evidence of acute renal failure was also resolving; and she improved to the point where she was ready to be transferred back to the regular floor for further nursing and postoperative care. She was transferred to the floor on [**12-13**]. On the evening of [**2190-12-14**] a trigger event was called because the patient was noted to be hypotensive with a systolic pressure of 86. Initial floor management consisted of normal saline infusion without improvement requiring [**Hospital **] transfer to the intensive care unit at that time. The patient went in the ICU where she was found to have persistent hypotension. There was no evidence of septic or distributive shock. Her hematocrit was 32. Her ABGs showed a pH of 7.26; a lactate of 0.8; and she responded to a liter of normal saline. The patient remained extubated and breathing spontaneously. By [**12-16**], the patient remained in the ICU. Her hypotension had stabilized. She had evidence of poor peripheral vasoconstriction. She remained extubated and breathing spontaneously, but with some worsening shortness of breath. This had responded initially to diuresis, but at this point diuresis was held secondary to peripheral vasoconstriction. The patient remained full code at this point. Due to a rising creatinine, a renal consult was obtained for management of renal failure. Diuresis was recommended with an increase of the Lasix dosage. The patient's respiratory status, however, decompensated on the evening of [**2190-12-17**] requiring an urgent intubation. She also became hypotensive and required using pressors as well in the form of Levophed. On the early morning of [**12-17**], the son was [**Name (NI) 653**] by the medical service who expressed the patient's desires not to be persistently intubated. The patient subsequently was made comfort care measures only and expired on [**2190-12-17**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16347**] Dictated By:[**Last Name (NamePattern1) 16348**] MEDQUIST36 D: [**2191-6-21**] 08:59:36 T: [**2191-6-21**] 11:17:00 Job#: [**Job Number 16349**]

Admission Date: [**2184-1-17**] Discharge Date: [**2184-1-18**] Date of Birth: [**2106-8-18**] Sex: F Service: MEDICINE Allergies: Penicillins / Vitamin B12-Intrinsic Factor Attending:[**First Name3 (LF) 338**] Chief Complaint: pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: 77 year-old female with COP/hypersensitivity pneumonitis, on chronic steroids and O2, presents from NWH with abdominal pain, n/v and hypotension. Patient was at rehab and had episode of nausea and vomiting X [**11-15**] yesterday, she was taken to NWH where cxr with bilateral PNA, WBC 22K, 95% poly, creat 1.4 and pt noted to be hypotensive to 70s, she was given NS and started on dopamine, also given azithro, vanc and ceftriaxone, decadron 10 mg IV and transferred to [**Hospital1 18**] for further care. . In [**Hospital1 18**] ER patient given 4L NS, hydrocortisone 50mg IV X 1and unasyn 3gm IV and taken off dopamine with stable BP in 100s. Initial labs with WBC 26K, she was febrile to 101.2, had abdominal ultrasound which showed distended gallbladder but no CBD dilation. After discussion with ERCP fellow, pt not likely need emergent ERCP given normal [**Female First Name (un) 7925**]. Initially goals of care DNR/DNI and no CVL however after a rediscussion plan was changed and a central line placed. She was evaluated by surgery and is now being transferred to MICU for futher care. . On transfer to the MICU, patient complained of sob. Denied any abdominal pain or chest pain. Denies n/v/d. Past Medical History: cryptogenic organizing pneumonia and hypersensitivity pneumonitis (formerly known as BOOP)--on steroids DM2 COPD s/p b/l cataract repair t7, t11, t12 compression fx s/p R hip fx Social History: lives with daughter, pt from [**Country **] > 15 years ago denies tob, etoh, drugs Immunizations/Travel: + pneumovax Family History: NC Physical Exam: Vitals: 95.7, HR 99 BP 119/39 RR 12 O2 sat 100% 10L NRB GEN: Elderly female with mild respiratory discomfort HEENT: dry mucous membranes CHEST: CTAB, no crackles CVR: RRR, II/VI systolic ejectio murmor LLSB ABD: Soft, nt, nd, small umbillical hernia. EXT: No edema NEURO: A&O X 3, moves all extremities well. Pertinent Results: [**2184-1-17**] 08:08PM TYPE-[**Last Name (un) **] TEMP-37.2 O2 FLOW-4 PO2-41* PCO2-56* PH-7.21* TOTAL CO2-24 BASE XS--6 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2184-1-17**] 08:08PM O2 SAT-68 [**2184-1-17**] 05:40PM GLUCOSE-214* UREA N-21* CREAT-1.2* SODIUM-139 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13 [**2184-1-17**] 05:40PM CALCIUM-7.0* PHOSPHATE-3.3 MAGNESIUM-1.8 [**2184-1-17**] 09:35AM LACTATE-1.6 [**2184-1-17**] 09:30AM GLUCOSE-247* UREA N-21* CREAT-1.5* SODIUM-137 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 [**2184-1-17**] 09:30AM estGFR-Using this [**2184-1-17**] 09:30AM ALT(SGPT)-197* AST(SGOT)-305* CK(CPK)-38 ALK PHOS-346* AMYLASE-2504* TOT BILI-0.4 [**2184-1-17**] 09:30AM LIPASE-4580* [**2184-1-17**] 09:30AM CK-MB-NotDone cTropnT-0.04* [**2184-1-17**] 09:30AM NEUTS-80* BANDS-18* LYMPHS-2* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2184-1-17**] 09:30AM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-OCCASIONAL TARGET-OCCASIONAL STIPPLED-OCCASIONAL [**2184-1-17**] 09:30AM PLT SMR-NORMAL PLT COUNT-245 [**2184-1-17**] 09:30AM PT-14.9* PTT-48.6* INR(PT)-1.3* [**2184-1-17**] 09:30AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025 [**2184-1-17**] 09:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG [**2184-1-17**] 09:30AM URINE RBC-[**4-6**]* WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-[**4-6**] TRANS EPI-[**4-6**] [**2184-1-17**] 09:30AM URINE HYALINE-<1 [**2184-1-17**] 09:07AM O2 FLOW-15 PO2-142* PCO2-62* PH-7.23* TOTAL CO2-27 BASE XS--2 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [**2184-1-17**] 09:07AM GLUCOSE-246* LACTATE-0.9 NA+-136 K+-4.0 CL--105 [**2184-1-17**] 09:07AM freeCa-1.05* Brief Hospital Course: Pt was admitted with pancreatitis and congestive heart failure. Her amylase and lipase improved and it was felt she likely had had a GB stone obstructing her CBD which passed. The pt refused BIPAP and was DNR/DNI. She remained tachypneic with O2 sats in the 70s-80s with little urine output to increasing doses of Lasix. She became very somnolent and family discussion resulted in CMO status. Morphine gtt was initiated and titrated for comfort. She expired at 8:55 PM of respiratory arrest in the setting of CHF. Family was at the bedside and attending was notifited. Medications on Admission: fosamax 1 tab qTueasday avandia 4mg daily lisinopril 5mg daily prednisone 10 mg daily vitamin D 400 IU daily Omeprazole 20mg [**Hospital1 **] lidoderm patch topically daily every 12 hours 5% colace 100 [**Hospital1 **] heparin sc tid Calcium Carbonate 500mg tid gabapentin 300mg qhs Cipro 500mg [**Hospital1 **] for 10 days started [**1-14**]. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Pancreatitis CHF Discharge Condition: Expired Discharge Instructions: none Followup Instructions: none

Admission Date: [**2151-11-17**] Discharge Date: [**2151-11-27**] Date of Birth: [**2107-10-14**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: Fatigue, shortness of breath Major Surgical or Invasive Procedure: [**2151-11-17**] Cardiac Catheterization [**2151-11-19**] Bentall Procedure utilizing a 23mm Homograft with Repair of a Sinus Valsalva Fistula [**2151-11-24**] Placement of Dual Chamber Permanent Pacemaker(Guidant Insignia Ultra DR) History of Present Illness: Mr. [**Known lastname 76674**] is a 44 year old male who was diagnosed with rectal abscess and alpha hemolytic Streptococcus aortic valve endocarditis on [**2151-10-15**]. He completed a course of Flagyl and Ceftriaxone. Serial echocardiograms showed severe AI with a L->R shunt from the sinus of valsalva to right ventricle. At time of admission, he reported worsening fatigue associated with shortness of breath with minimal activity and frequent palpitations. He was admitted for further evaluation and treatment. Past Medical History: Aortic Valve Endocarditis(Alpha Hemolytic Streptococcus) Aortic Insufficiency Rectal Abscess History of Pancreatic Pseudocyst - s/p Percutaneous Drainage History of Gallstone Pancreatitis History of Lap Chole History of Duodenal Stricture - s/p Gastrojejunostomy History of Renal Cell Carcinoma - s/p Cryoablation Prior Toe Surgery Social History: Married works as a project manager and has been working from home over the past few weeks. No children. He denies any alcohol use or IVDU. He reports smoking 1/2ppd x 20 years, quit on [**2151-10-15**]. Family History: Denies any family history of premature CAD. States his father had an MI in his 70s, still living. Possible CAD on his mother's side of the family. No history of known sudden death. Physical Exam: Blood pressure was 113-133/31-41 mm Hg while seated. Pulse was 109 beats/min and regular, respiratory rate was 16 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. There was pale conjunctiva without cyanosis of the oral mucosa. The neck was supple with JVP of 8 cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs has bibasilar rales. Palpation of the heart revealed a prominent PMI. There were no thrills, lifts or palpable S3 or S4. He is tachycardic with a [**1-20**] holosystolic murmur best appreciated at LUSB. The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2151-11-27**] 05:44AM 5.5 3.31* 9.3* 28.0* 85 27.9 33.0 15.9* 264 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2151-11-27**] 05:44AM 101 15 1.1 137 4.4 100 31 10 [**2151-11-17**] Cardiac Catheterization: 1. Coronary angiography in this right dominant system revealed no angiographically apparent coronary artery disease in the LMCA, LAD, LCx, and RCA (although coronaries could not be well opacified due to severe aortic regurgitation). 2. Resting hemodynamics revealed markedly elevated left and right sided filling pressures with mean PCW of 21 mmHg and RVEDP of 25 mmHg. There was severe pulmonary arterial hypertension with PASP of 66 mmHg. The cardiac index was preserved at 3.2 L/min/m2. There was normal systemic arterial pressure with SBP of 114 mmHg and DBP of 56 mmHg. There was a left-to right shunt with oxygen step-up at RV flow and a possible fistula from sinus of Valsalva to RV demonstrated by selective injection and supravalvular aortography. [**2151-11-17**] TEE: Right ventricular systolic function is normal. Overall left ventricular function is normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. There are three aortic valve leaflets. There is a moderate to large sized vegetation on the aortic valve involving the right and non-coronary cusps. The vegetation measures 0.4cm x 1.5cm. The left coronary cusp is moderately thickened. There is no aortic root abcess cavity seen. Severe (4+) aortic regurgitation is seen with reversal of flow in the descending thoracic aorta. There is prominent color flow in the area of the right coronary cusp which may represent a sinus of valsalva fistula (aortic root to RA/RVOT). The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. [**2151-11-18**] Abdominal CT Scan: 1. No retroperitoneal hematoma. 2. Right upper quadrant pericolonic and peripancreatic induration at least some of which may be secondary to known previous procedures. This may represent recurrent or acute pancreatitis and as patient cannot receive contrast, MRI may also be informative. Note also higher density contents of right colon (question intraluminal blood) compared to the remainder bowel. Is patient guaiac positive? 3. Persistent contrast opacification kidneys, now greater than 24 hours past contrast administration indicative of ATN. Note additional density abnormality right lateral kidney. ?is this site of patient's previous known RF ablation for renal cell cancer? 4. Small amount of free intraperitoneal fluid and small-to-moderate size right pleural effusion, neither of which measure blood density. 5. Mildly enlarged spleen. 6. Diverticulosis. [**2151-11-21**] Chest/Abdominal CT Scan: 1. Large areas of consolidation seen within the lungs bilaterally, with air bronchograms, concerning for infection. 2. New diffuse patchy ground-glass airspace opacities seen bilaterally, right greater than the left. 3. No evidence of retroperitoneal hematoma. Small amount of nonspecific free fluid in pelvis. Stranding in pelvic soft tissues possibly represent small amount of interstitial hemorrhage. 4. Post-operative changes seen within the chest, with multiple lines and tubes. Pneumomediastinum and small bilateral pneumothoraces seen, consistent with post-operative changes. [**2151-11-22**] TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve appears to be a homograft. The aortic valve prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. RADIOLOGY Final Report CHEST (PA & LAT) [**2151-11-27**] 10:46 AM CHEST (PA & LAT) Reason: check atel [**Hospital 93**] MEDICAL CONDITION: 44 year old man with REASON FOR THIS EXAMINATION: check atel CLINICAL HISTORY: Pacer placed, check for pneumothorax, unable to raise left arm. CHEST: The position of the pacemaker is unchanged. No pneumothorax is present. The left lung appears clear. Patchy opacities are again noted within the right lung, not significantly changed since the prior chest x-ray of [**11-25**]. These probably represent areas of pneumonia. IMPRESSION: No significant change since [**11-25**]. DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**] Brief Hospital Course: Mr. [**Known lastname 76674**] was admitted and underwent cardiac catheterization and transesophageal echocardiogram which confirmed aortic valve endocarditis, severe aortic insufficiency and a sinus of Valsalva fistula. Coronary angiography showed normal coronary arteries. His creatinine on admission was noted to be 1.8. He remained on intravenous Ceftriaxone per ID recommendations. Based on the above, cardiac surgery was consulted and further evaluation was performed. He was cleared for surgery by dental, but will require extractions after he recovers from surgery. His acute renal insufficiency was attributed to hypoperfusion given his severe aortic insufficiency. He was also noted to be anemic which required several blood transfusions. An abdominal CT scan was performed which ruled out a retroperitoneal bleed. He otherwise remained stable on medical therapy and was eventually cleared for surgery. On [**11-19**], Dr. [**First Name (STitle) **] performed a Bentall procedure with a homograft along with repair of sinus of Valsalva fistula. Given that his hospital stay was greater than 24 hours prior to surgery, he was given Vancomycin for perioperative coverage. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He remained anemic and continued to require intermittent blood transfusions. There was no evidence of active bleeding. Following extubation, he experienced poor oxygenation along with some hemoptysis. Chest x-rays were notable for extensive bilateral consolidations and bilateral pleural effusions. Right sided chest tube was placed and diagnostic/therapeutic bronchoscopy was performed. Blood tinged secretions were noted in the lower lobes along with an occlued right middle lobe by mucosal edema. Bronchoalveolar lavage was performed and sent for culture. Antibiotic coverage was temporarily broadend for nosocomial pneumonia. Cultures eventually grew out MRSA and antibiotics were titrated accordingly per ID recommendations. Over several days, his oxygenation gradually improved. All chest tubes were eventually removed without complication. Since the operation, he was noted to have complete heart block and remained entirely pacer dependent. The EP service was consulted and recommended permananent pacemaker which was successfully placed on [**11-24**] without complication. He continued to make clinical improvements and eventually transferred to the SDU for further care and recovery. His renal function normalized, and he continued to respond well to antibitioc therapy. Per ID recommendation, he will need to remain on Levofloxacin until [**2151-11-28**] and Vancomycin until [**2151-12-5**]. The remainder of his postoperative course was uneventful and he was medically cleared for discharge on postoperative day 8. Medications on Admission: Omeprazole 40 [**Hospital1 **], Atorvastatin 40 qd, Zyrtec 10 qd, Klor con 20 qd, Lasix 120 qam, Lorazepam 2 [**Hospital1 **], Ambien 12.5 qhs, Ceftriaxone Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: AV endocarditis(Strep viridans) and Aortic Insufficiency Postoperative Complete Heart Block Postoperative MRSA Pneumonia Postoperative Pleural Effusions Anemia Acute Renal Insufficiency Hypertension Hyperlipidemia Rectal Abscess Discharge Condition: Good. Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. 6)Complete course on antbiotics as directed Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-19**] weeks(cardiologist) - call for appt Dr. [**Last Name (STitle) 76675**] in [**12-19**] weeks(PCP) - call for appt Dr. [**Last Name (STitle) **] in [**2-19**] weeks(cardiac surgeon)- call for appt EP Device Clinic in 1 week - call for [**Telephone/Fax (1) 76676**] Dr. [**First Name (STitle) 1075**] in Infectious Disease Clinic - call for appt. @ [**Telephone/Fax (1) **] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2151-11-27**]

Admission Date: [**2195-2-22**] Discharge Date: [**2195-3-2**] Date of Birth: [**2151-12-23**] Sex: M Service: SURGERY Allergies: Magnesium Citrate / Penicillins / Gabapentin Attending:[**First Name3 (LF) 1556**] Chief Complaint: LUE weakness s/o fall Major Surgical or Invasive Procedure: n/a History of Present Illness: 42YO transfered from OSH c sudden onset sharp R sided neck pain associated with LUE weakness after pt fell tripping voer his oxygen tank. OSH suspected C1 ring fracture based on CT. Past Medical History: COPD GERD HTN R sided partial hemiparesis s/p electrocution Nissen Appendectomy Chole Social History: 2ppd x 25yrs, 5L)2 at home, CPAP Physical Exam: RRR [**Month (only) **] NS no;at sft. NT, ND hemiparesis on R, FROM 4+ strength, 1+ DTRs on L Pertinent Results: [**2195-2-22**] 03:30PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 [**2195-2-22**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-8.0 LEUK-NEG [**2195-2-22**] 03:30PM PLT COUNT-285 [**2195-2-22**] 03:30PM WBC-6.1 RBC-4.42* HGB-13.8* HCT-37.5* MCV-85 MCH-31.2 MCHC-36.8* RDW-12.7 [**2195-2-22**] 03:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [**2195-2-22**] 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2195-2-22**] 03:30PM UREA N-11 CREAT-1.1 [**2195-2-22**] 03:30PM GLUCOSE-149* SODIUM-141 POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-23 ANION GAP-23* [**2195-2-22**] 03:37PM HGB-13.8* calcHCT-41 Brief Hospital Course: Neurology and neurosurgery were consulted regarding the possibility of C1 fracture seen on Cspine CT at OSH. Repeat Ct showed nonunion of previous C1 fracture involving the anterior and posterior arches. Per neuro reccs a methylprednisolone drip was started and pt was kept in a hard collar. A MRI of the C spine was obtained. Pt was intubated [**1-29**] agitation during MRI. The study showed elevated T2 signal at C3-C4 interspace c/w acute v chronic injury. After this read at neurosurgery's recommendation the methylprednisolone drip was stopped and pt was transferred to the floor from the TSICU. Neurosurgery recommended the pt remain CSI x 6 weeks and f/u with them for repeat imaging for 4 weeks. Neurology was consulted when the pt developed tingling sensations along his L side. They recommended performing a MRI of the brain, which was normal. The pt's symptoms improved and Neurology will continue to follow the pt as an outpatient. Physical therapy consulted on the pt and felt he was unsafe to return home [**1-29**] his chronic R hemiparesis. The pt insisted that he was safe at home. Therefore, PT evaluated him with all of his home equipment. He continued to show an inability to function at home s difficulty. Therefore, the pt agreed to go to rehab for further therapy. A bed was arranged and the pt was transferred to rehab in improved condition. Medications on Admission: Methadone Valium Seroquel Ambien Diazepam Gemfibrazole Lopressor Bumex Senna KCl Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-2**] hours as needed for pain. Disp:*25 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 5. Quetiapine 300 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Fall Discharge Condition: stable Discharge Instructions: You have signs of a heart attack. This is an emergency. Call 911 or 0 (operator) for an ambulance to get to the nearest hospital or clinic. Do not drive yourself! Chest pain that spreads to your arms, jaw, or back. Nausea (sick to your stomach). Trouble breathing. Sweating. You have any of the following signs of a stroke. This is an emergency.Call 911 or 0 (operator) to get to the nearest hospital or clinic. Do not drive yourself! Sudden numbness or weakness of face, arm, or leg, especially on one side of the body. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, or loss of balance. Sudden severe headache with no known cause. Sudden fainting, convulsions or coma (person will not wake up). Followup Instructions: Follow up with your regular doctor this week. You also need to call [**Telephone/Fax (1) 44**] to obtain an appointment with Neurology in the next 2 weeks. Call [**Telephone/Fax (1) 1669**] to obtain an appointment with Neurosurgery in 4 weeks; inform the office that you will need a repeat CT scan for this appointment.

Admission Date: [**2136-3-27**] Discharge Date: [**2136-4-5**] Date of Birth: [**2073-11-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: UGIB Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 62 yo Cantonese speaking M w/ h/o HBV c/b HCC s/p rupture in [**2127**] who is transferred from OSH w/ UGIB. Patient presented w/ sudden onset epigastric pain this AM with hematemesis x2-3 episodes. Was taken to [**Hospital3 **], where NGL showed 30cc bright red blood, which cleared with 250cc. His labs there were notable for INR of 1.5 and hct of 28.8 (hct was 35.3 on [**3-21**]); Na 131, BUN 10 and Cr 0.73. He was given 1 unit FFP and started on octreotide gtt and protonix bolus. He was transferred to [**Hospital1 18**] for further management. Per patient's daughter, he had an EGD at [**Name (NI) 3278**] in the recent past, which was normal. . In the ED, initial VS were: 97.3 94 120/72 16 96% 2L NP. NGT was in place and was lavaged with 500 cc, with retrieval of 200 cc of pink fluid w/ clots. Guaiac negative. CT Abdomen was performed which showed large mass and ascites, splenomegaly, and stable thrombus within the portal vein and IVC. Octreotide and protonix gtt were continued and hepatology was consulted who plan to see patient after admission. Labs in ED were notable for hct of 27.8. Two units of RBCs were ordered, 1 L NS given, and patient was admitted to MICU for further management. VS on xfer were HR95 BP110/70 96%RA RR17. . On arrival to the MICU, patient is comfortable and reports mild [**2134-2-13**] epigastric pain. No nausea currently. He reports he has had 2 days of abdominal pain, several days of decreased appetite and urine output. Also with increased nausea and increasing abdominal distention over the past few days. Denies black or bloody stools. No diarrhea, + constipation. Past Medical History: Hepatitis B Metastatic Infiltrating Hepatocellular Carcinoma Diabetes mellitus- type 2 Hypertension Social History: Patient born in [**Country 651**], emigrated to the US approximately 40 years ago. Cantonese-speaking, daughter and wife english-speaking. Family History: NC Physical Exam: Admission Physical Exam: Vitals: T: 98.4 BP: 114/77 P: 100 R: 22 O2: 94-97% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry membranes with dried blood on surface, but otherwise clear oropharynx, NG tube in place, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, but regular rhythm, normal S1 + S2, no murmurs, rubs, gallops; port palpated in R upper chest Lungs: Mild rales in bases, but otherwise clear to auscultation bilaterally Abdomen: soft, non-tender, distended w/o fluid wave, bowel sounds present, no appreciable organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, motor and sensation grossly normal, gait deferred, finger-to-nose intact . Discharge PE; pt was comfort measures only and vitals were not obtained He was comfortable with family at bedside, in NAD Pertinent Results: Pertinent Labs: [**2136-3-27**] 10:35AM BLOOD WBC-5.6 RBC-3.00* Hgb-8.8* Hct-27.8* MCV-93 MCH-29.2 MCHC-31.6 RDW-18.5* Plt Ct-197 [**2136-3-29**] 11:45AM BLOOD Hct-32.5* [**2136-3-30**] 12:26PM BLOOD Hct-30.4* [**2136-3-30**] 12:26PM BLOOD Glucose-199* UreaN-53* Creat-2.1*# Na-138 K-5.8* Cl-109* HCO3-18* AnGap-17 [**2136-3-28**] 03:44AM BLOOD ALT-38 AST-45* AlkPhos-160* TotBili-2.3* [**2136-3-28**] 03:44AM BLOOD Calcium-7.5* Phos-4.0 Mg-1.8 [**2136-3-27**] 07:01PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-5 FiO2-100 pO2-298* pCO2-40 pH-7.30* calTCO2-20* Base XS--5 AADO2-376 REQ O2-67 -ASSIST/CON Intubat-INTUBATED . . CHEST (PORTABLE AP) Study Date of [**2136-3-28**] 9:20 AM The fundic balloon of the [**Last Name (un) **] device is grossly unchanged. ET tube is in standard position. Right IJ catheter tip is in the upper right atrium. Cardiomegaly is stable. Small bilateral pleural effusions are unchanged. Large bibasilar atelectases have improved, still larger on the left. There is vascular congestion. There is no pneumothorax. . EGD: Prior to the procedure the gastric balloon was fully deflated and the [**Last Name (un) 10045**] tube was removed. Numerous cords of grade III esophageal varices were seen with high risk features consistent with recent bleeding. In the mid esophagus there were also multiple cords of grade III varices and some areas of ulceration possibly from pressure related to the [**Last Name (un) 10045**] tube. There continued to be a large amount of blood at the GE junction, some appearing fresh, some appearing old. Multiple attempts at banding were made, a total of five bands were fired. Approximately 3 varices could be visualized banded. One band misfired and the other could not be visualized thorugh the blood. Given that the portal hypertension is irreversable and being unable to stop the bleeding. The procedure was completed and a long discussion was had with the family and ICU team regarding how to plan next. As per the family discussion prior to the procedure, the [**Last Name (un) 10045**] was not placed back. Stomach: Other Blood was noted throughout the stomach. The Antrum had minimal blood in it. The fundus could not be cleared due to thick clotted blood. Duodenum: Not examined. Impression: Blood was noted throughout the stomach. The Antrum had minimal blood in it. The fundus could not be cleared due to thick clotted blood. Otherwise normal EGD to pylorus Recommendations: Continue care per MICU team Additional notes: The attending was present for the entire procedure. The patient's home medication list is appended to this report. FINAL DIAGNOSIS are listed in the impression section above. Estimated blood loss = >300cc. No specimens were taken for pathology. Brief Hospital Course: 62 yo M w/ h/o hepatitis B and metastatic infiltrative HCC presenting with hematemesis. . # UGIB: Mr. [**Known lastname **] had an NGL at an OSH which showed BRB, consistent with hematesmis as the source of his bleeding. An initial EGD by GI revealed variceal bleeding. The patient required intubation because he was difficult to sedate, as well as for airway protection during the porcedure. EGD after intubation showed massive bleeding and banding could not be performed. There was concern for perforation due to severe abdominal rigidity during procedure, but no free air on imaging s/p procedure. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was placed, and the patient was made CPR not indicated. Initially, he had received 2L NS, 8 units pRBCs, and calcium. his HCT trended up from 27 to 37.8 after 6 units, but his UOP remained low. He was in sinus tachycardia in the 120s his night of admission, but BP remained in the 110s. He was also placed on a PPI and octreotide gtt, and given CTX for infection prophylaxis in he setting of GI bleed and cirrhosis. The next day, a repeat EGD was performed, which showed numerous cords of grade III esophageal varices, with high risk features consistent with recent bleeding. In the mid esophagus there were also multiple cords of grade III varices and some areas of ulceration possibly from pressure related to the [**Last Name (un) 10045**] tube. There continued to be a large amount of blood at the GE junction, some appearing fresh, some appearing old. Multiple attempts at banding were made, a total of five bands were fired. Approximately 3 varices could be visualized banded. One band misfired and the other could not be visualized thorugh the blood. Given that the portal hypertension is irreversable and being unable to stop the bleeding. The procedure was completed and a long discussion was had with the family and ICU team regarding how to plan next. As per the family discussion prior to the procedure, the [**Last Name (un) 10045**] was not placed back. The discussion with the family also inovlved how to keep the patient as comfortable as possible. His Octreotide was DC'ed, but he was placed on Nadolol 10 mg PO DAILY in order to try to prevent new variceal bleeding that would cause an upsetting hematemesis. Pallative care was consulted, and recommended 1-2mg of Dilaudid q1h PRN pain and Ativan 1-2mg q1h PRN anxiety/respiratory distress. These medications were switched to PO once pt stabilized. # Metastatic HCC/HBV: S/p rupture in [**2127**] followed by RFA and excision but with recurrence and spread- large right exophytic segment VI lesion, infiltration of liver, adrenal metastasis, and portal vein thrombosis. Just completed inteferon alpha 2b and 5FU and plan for doxorubicin and cisplatin next week per oncology. Last HBV viral load on [**2136-2-22**] was undectable. Given CMO status, no further plans for oncologic care. # Cirrhosis: Mild hyponatremia at OSH and ascites on CT, with possible portal gastropathy/varices given UGIB. No encephelopathy. He was initally treated with CTX 1 g daily for prophylaxis, but this was subsequently DC'ed. # Hyponatremia: Initially had been trended, improved from Na 131 at OSH to 138 at last check here. Further lab draws were not performed given CMO status # Diabetes mellitus: Holding home medications given CMO # Hypertension: Holding home medications given CMO Medications on Admission: BETAMETHASONE DIPROPIONATE -0.05 % Cream - 1 application twice a day GLIPIZIDE - 10 mg Tablet - 1 Tablet(s) by mouth three times a day INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 16 units at bedtime LIDOCAINE-DIPHENHYD-[**Doctor Last Name **]-MAG-[**Doctor Last Name **] [FIRST-MOUTHWASH BLM] - 400 mg-400 mg-40 mg-25 mg-200 mg/30 mL Mouthwash - 15-30 mL every four (4) hours as needed for mouth sores Swish and spit LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day LORAZEPAM - 0.5 mg by mouth QHS and TID PRN NIFEDIPINE - 60 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day ONDANSETRON HCL - 8 mg Tablet TID prn nausea OXYCODONE - 5 mg Tablet - 0.5-1 Tablet(s) PO q6hr PRN PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime PROCHLORPERAZINE MALEATE - 10 mg PO TID prn SAXAGLIPTIN [ONGLYZA] - 2.5 mg Tablet - 1 Tablet(s) by mouth daily TENOFOVIR DISOPROXIL FUMARATE [VIREAD] - 300 mg Tablet po daily Discharge Medications: 1. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2* 2. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:*1 bottle* Refills:*2* 3. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*2* 4. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for agitation / anxiety/hiccups . Disp:*qs Tablet(s)* Refills:*1* 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q1H (every hour) as needed for pain / SOB. Disp:*qs Tablet(s)* Refills:*1* 7. hydromorphone (PF) 1 mg/mL Syringe Sig: [**2-13**] Injection Q1H (every hour) as needed for respiratory distress / pain. Disp:*qs syringes * Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Hepatocellular Carcinoma Esophageal Varices Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with bleeding through into your stomach. We put a small camera in your stomach in an attempt to stop the bleeding which was unsuccessful. In discussion with your family and you we together have decided to focus now on making you comfortable and to maximize the quality of your life. You were discharged home with hospice care. Followup Instructions: No appointments needed

Admission Date: [**2171-9-14**] Discharge Date: [**2171-9-21**] Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 4071**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization with a stent placed in the left anterior descending artery. History of Present Illness: Ms. [**Known lastname 6164**] is an 87 yo woman with h/o 3 vessel CAD s/p multiple PCIs, complete heart block s/p pacer, who presents after an episode of chest pain. She has trouble sleeping usually, and when she awoke at 4am, she noted substernal pressure in the lower chest at about [**7-24**]. She took 1 nitroglycerin sublingual tablet which did not help. She denied shortness of breath and nausea, but she did have 1 episode of vomiting. She states that she was experiencing diaphoresis prior to the pain, but she has had night sweats for over a year regularly. The pain lasted until about 10am, after which her son called EMS to bring her to the ED. In the ED, initial Vital Signs were T 98.1 BP 123/74 HR 62 RR 16 O2Sat 100%. Troponin was positive at 1.05 with CK of 391 and MB of 42. She was given plavix 300mg and started on a heparin gtt and was guaiac Neg. Upon arrival to the floor, patient denies chest pain, shortness of breath, nausea, vomiting, diarrhea. She admits to decreased appetite for many months and 25 lb loss (200lbs --> 175lbs) in the last seven months, though stable weight for the last [**2-15**] months. She endorses nightsweats for over a year off and on. She has a little cough for the last couple of years which has been stable, but she reports no recent coughing; she has been using cough syrup for the last couple of years. The cough sometimes has phlegm. She has difficulty swallowing and has difficulty chewing because of no teeth. She endorses ankle edema, joint pain and body pain "all over" chronicly. She denies dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea. She denies recent fevers, chills or rigors. She denies urinary symptoms and diarrhea but states that she doesn't urinate much in general; she doesn't drink much fluid. Past Medical History: - hx complete heart block status post pacemaker in 03/[**2166**]. [**Company 1543**] Sigma Dual - coronary artery disease - s/p NSTEMI on [**2169**] with BMS placement ** MI [**6-16**] w stent to prox RCA but TIMI II flow in distal RCA ** PCI/BMS to ramus branch [**7-21**] - HTN - Hyperlipidemia - asthma - s/p thyroidectomy [**11/2163**] - OA and chronic pain - GERD - Chronic Sweats: TSH and PPD normal - Glaucoma - shoulder bursitis Social History: Denies tobacco or ETOH current or in past. Worked as a [**Year (4 digits) **]. Lives alone w/ family nearby. Lives in [**Location (un) 538**]. Uses walker at home. From [**State 9512**] originally. Pt unable to [**State **] for herself now. Lives on [**Location (un) **]. Elevators in building. Her son, [**Name (NI) **], is taking care of her and visits her frequently, nearly every day. Her daughter, [**Name (NI) 402**], who lives in [**Name (NI) 669**] takes care of her medications. Her daughter, [**Name (NI) 108632**], in [**Name (NI) 8**] brings her to all her medical appointments. [**Last Name (LF) **], [**First Name3 (LF) 402**], and [**First Name4 (NamePattern1) 108632**] [**Last Name (NamePattern1) **] meals for her. She has another daughter in [**Name (NI) 5110**], a son in [**Name (NI) 4565**], and a son in [**State 9512**]. She all together has 9 children. Three have died. Has a sister in [**Name (NI) 4565**]. Husband died after they were separated many years ago. Family History: Mother with MI at age 70. No other cardiac hx, DM, or cancer. Physical Exam: VS: T= 98.0 BP= 132/78 HR= 62 RR= 16 O2 sat= 100%/ 2L GENERAL: well developed woman lying down in NAD. Oriented x3. Mood, affect appropriate. HEENT: EOMI. moist mucus membranes. CARDIAC: Reg Rhythm, Normal Rate LUNGS: CTAB, mild expiratory wheezing. Respirations unlabored. ABDOMEN: Soft, diffusely tender to mild palpation. No guarding or rebound tenderness. EXTREMITIES: tender to palpation over bones and muscles; bilateral lower extremity edema, nonpitting ; No right or left sided femoral bruit PULSES: Right: DP 2+ ; Left: DP 2+ Pertinent Results: [**2171-9-14**] 12:52PM BLOOD WBC-4.9 RBC-4.42 Hgb-12.9 Hct-39.5 MCV-89 MCH-29.2 MCHC-32.7 RDW-14.0 Plt Ct-229 [**2171-9-20**] 07:03AM BLOOD WBC-4.6 RBC-3.02* Hgb-9.1* Hct-27.9* MCV-92 MCH-30.0 MCHC-32.5 RDW-14.5 Plt Ct-187 [**2171-9-21**] 07:35AM BLOOD WBC-4.8 RBC-2.99* Hgb-8.8* Hct-27.5* MCV-92 MCH-29.4 MCHC-32.0 RDW-14.7 Plt Ct-221 [**2171-9-19**] 09:50AM BLOOD PT-12.1 PTT-26.3 INR(PT)-1.0 [**2171-9-14**] 12:52PM BLOOD Glucose-117* UreaN-13 Creat-0.9 Na-137 K-4.1 Cl-99 HCO3-25 AnGap-17 [**2171-9-21**] 07:35AM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-138 K-4.0 Cl-105 HCO3-23 AnGap-14 [**2171-9-14**] 12:52PM BLOOD CK(CPK)-391* [**2171-9-14**] 07:35PM BLOOD CK(CPK)-549* [**2171-9-15**] 02:08AM BLOOD CK(CPK)-473* [**2171-9-16**] 06:31AM BLOOD CK(CPK)-334* [**2171-9-14**] 12:52PM BLOOD CK-MB-42* MB Indx-10.7* proBNP-937* [**2171-9-14**] 12:52PM BLOOD cTropnT-1.05* [**2171-9-14**] 07:35PM BLOOD CK-MB-49* MB Indx-8.9* cTropnT-1.93* [**2171-9-15**] 02:08AM BLOOD CK-MB-37* MB Indx-7.8* cTropnT-1.07* [**2171-9-16**] 06:31AM BLOOD CK-MB-29* MB Indx-8.7* EKG: In the ED: Atrial pacing. Twave inversions in V2-V4, Twave flattening in V5, V6, I, aVL. Prolonged QTc (471). Compared to prior EKG from [**2170-5-11**]: A-V paced rhythm w left axis, wide QRS. Prior EKG from [**11-17**]: Ectopic atrial rhythm w normal axis; the precordial Twave inversions and lateral flattening are not present. CXR [**2171-9-14**]: No acute cardiopulmonary abnormality. TTE [**2171-9-16**]: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypo/akinesis of the distal half of the anterior septum and anterior wall. The apex is mildly dyskinetic. The remaining segments contract normally (LVEF = 30-35 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2166-7-23**], new regional left ventricular systolic function is now present c/w interim infarction/ischemia. Cardiac cath [**2171-9-16**]: 1. Selective coronary angiography of this right dominant system revealed 3 vessel CAD. The LMCA was large, ectatic, with mild disease. The proximal LAD was large, ectatic with mild disease. The mid LAD was heavily calcified and subtotally occluded, with serial 80-90% stenosis more distally. The distal LAD had a 50% stenosis and apical LAD had an 80% stenosis. The D1 had a 50% origin stenosis. D2 had a 50% origin stenosis. THe LCX was a small caliber (2mm) diffusely diseased vessel with an 80% origin stenosis but supplied very little LV. The RCA had an upward takeoff with a mid-vessel 20% ISR and more diffuse disease distally. The RPDA had serial 50% stenoses. 2. Successful PTCA and stenting of the mid LAD with a 3.0 x 24mm Driver bare metal stent and POBA of the distal LAD with a 2.5 x 20 NC [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 108633**]. Final angiography revealed no residual stenosis in the stent, no angiographically apparent dissection, and TIMI 3 flow. (see PTCA comments for details.) 3. Resting hemodynamics demonstrated systemic arterial hypertension (153/65 mmHg), mild pulmonary arterial hypertension (38/19/26 mmHg), and mildly elevated right and left sided filling pressures (mean RAP 11mmHg, RVEDP 13 mmHg, mean PCWP 13 mmHg). Cardiac index was severely depressed (1.6 L/min/m2). 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate to severe left ventricular systolic dysfunction. 3. Successful PTCA and stenting of the mid LAD and POBA of the distal LAD. 4. Mild left ventricular diastolic dysfunction. 5. Mild pulmonary arterial hypertension. Non-contrast CT pelvis [**2171-9-20**]: Small hematoma in the right proximal thigh anteriorly but no evidence of lower abdominal or pelvic retroperitoneal hematoma. Brief Hospital Course: Ms. [**Known lastname 6164**] is an 86yo woman with known CAD who was admitted for NSTEMI. # NSTEMI->STEMI: Ms. [**Known lastname 6164**] presented to the hospital after having six hours of substernal chest pressure which had resolved on its own. Her cardiac enzymes were elevated and peaked with a troponin-T of 1.9. She presented with T-wave inversions in V2-V4 and Twave flattening in V5-V6 on EKG; serial EKGs showed impressive T-wave changes, deepening T-waves in V1-V6 with no ST depressions or elevations. She was being treated with IV heparin while awaiting cardiac catheterization when she was noted to have marked ST elevations on telemetry. When prompted, she endorsed recurrence of her chest pain and she was sent for emergent cardiac catheterization and transferred to the cardiology ICU. Catheterization revealed 3 vessel disease with subtotal 80-90% occlusion of her mid LAD. She received a bare metal stent to mid LAD and angioplasty of distal LAD. Echocardiogram showed EF 30-35%. She was discharged on ASA, plavix, beta blocker, statin, and [**Last Name (un) **]. # Anemia: Patient's hematocrit dropped from 40->28 in the course of her hospitalization. This occurred in the setting of catheterization and volume resuscitation. Over the last 3 days of her hospitalization, her hematocrit remained stable. Nevertheless, a CT pelvis was obtained and did not show evidence of retroperitoneal bleed or significant hematoma. # Acute on chronic systolic heart failure: Shortly after her cardiac cath, Ms. [**Known lastname 6164**] had low blood pressures and low urine output. This was felt to be due to volume loss/blood loss with decreased systolic function. She improved with IV fluids. However, several days later she became somewhat volume overloaded on exam and required some gentle IV diuresis. She is not being discharged on lasix, but her volume status should be monitored as an outpatient. # Abdominal tenderness: Significant reflux disease with very tender abdomen. Patient reported that this was a chronic issue. She was given ranitidine to treat GERD as PPIs should be avoided while she is on plavix. # HTN: Nifedipine was stopped and olmesartan was changed to losartan. Her metoprolol dose was decreased. Please refer to discharge med list. # Hyperlipidemia: Increased simvastatin. # S/p thyroid thyroidectomy, Glaucoma, Asthma, h/o PPM for complete heart block, Depression: Not active during her stay. Her home meds were continued. Medications on Admission: Albuterol 90 mcg HFA Aerosol Inhaler one to two puffs inhaled every six (6) hours as needed for wheezing Brimonidine [Alphagan P] 0.1 % Drops 1 drop left eye twice a day Clopidogrel [Plavix] 75 mg Tablet one Tablet(s) by mouth once a day Clotrimazole 1 % Cream apply to affected areas twice a day 30 gram tube Dorzolamide [Trusopt] 2 % Drops 1 drop left eye twice a day Fluoxetine 40 mg Capsule one Capsule(s) by mouth once a day Fluticasone [Flonase] 50 mcg Spray, Suspension one spray nasally once a day Fluticasone [Flovent HFA] 110 mcg/Actuation Aerosol two puffs inhaled once a day Hydrocortisone 2.5 % Cream apply tid sparingly to itchy areas Latanoprost [Xalatan] 0.005 % Drops 1 drop left eye at bedtime Levothyroxine [Levoxyl] 112 mcg Tablet one Tablet(s) by mouth once a day Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr one Tablet(s) by mouth once a day Nifedipine [Nifedical XL] 60 mg Tablet Extended Rel 24 hr (2) one Tab(s) by mouth once a day Nitroglycerin 0.3 mg Tablet, Sublingual 1 Tablet(s) sublingually q 5 mins prn; if 3 needed [**Name8 (MD) 138**] md Olmesartan [[**Name8 (MD) 108631**]] 20 mg Tablet one Tablet(s) by mouth once a day Simvastatin 40 mg Tablet one Tablet(s) by mouth once a day Triamterene-Hydrochlorothiazid [Dyazide] 37.5 mg-25 mg Capsule one Capsule(s) by mouth once a day Ammonium,Pot.& Sodium Lactates [AmLactin XL] Lotion Apply to affected areas Aspirin 325 mg Tablet one Tablet(s) by mouth once a day Carbamide Peroxide Famotidine [Pepcid AC] 20 mg Tablet one Tablet(s) by mouth twice a day Food Supplement, Lactose-Free [Ensure] Liquid 1 Liquid(s) by mouth twice a day Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): In left eye. 7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): Place drops in left eye. 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): Place in left eye. 9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3 times a day) as needed for itching. 12. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a day. 13. 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* 14. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 17. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 18. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 19. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Primary Diagnosis: STEMI (heart attack) Secondary Diagnosis: NSTEMI (heart attack) Acute on Chronic systolic heart failure Arthritis Blood loss Anemia Hypertension Discharge Condition: All vital signs were stable. Patient has no nausea or vomiting. Discharge Instructions: You were admitted to the hospital because of a myocardial infarction (heart attack). We treated you by giving medications to help your heart and performing a cardiac catheterization. This procedure helped to visualize the blood vessels that supply your heart. During this procedure a stent was placed in one of your arteries. Because the stent was placed, it is very important for you to continue taking clopidogrel (Plavix). The following medications were were started or changed during your stay: Losartan 25 mg Metoprolol Succinate 50 mg Ranitidine 150 mg Simvastatin 80 mg The following medications were stopped: Nifedipine XL 60 mg Olmesartan 20 mg Sucralfate 1 g every 6 hours Simvastatin 40 mg Metoprolol succinate 100 mg You should continue taking the following medications: albuterol inhaler 1-2 puffs every 6 hours as needed aspirin 325 mg daily brimonidine eyedrops clopidogrel (plavix) 75 mg- Continue taking for life unless you develop a bleeding complication. clotrimazole cream dorzolamide eyedrops fluoxetine 40 mg fluticasone inhaler fluticasone nasal spray hydrocortisone cream latanoprost eyedrops lactic acid lotion levothyroxine 112 mcg Dyazide 37.5/25 Please go to the emergency room, call your doctor, or call 911 if you have recurrent chest pain, shortness of breath, nausea, fever, dizziness, or any other concerning symptom. Followup Instructions: 1. Please keep your appointments with the Device Clinic and Dr. [**Last Name (STitle) 73**], your cardiologist, for [**9-23**]: The DEVICE CLINIC appointment is scheduled at 10:30 and Dr. [**Last Name (STitle) 73**] will see you at 11:00am. [**Hospital1 18**] [**Hospital Ward Name **], [**Hospital Ward Name 23**] building, [**Location (un) 436**]. Phone:[**Telephone/Fax (1) 62**] 2. We scheduled an appointment for you with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your primary doctor: [**10-14**] at 10:20am. Phone: [**Telephone/Fax (1) 250**]. 3. Please keep your previously scheduled appointment with rheumatology: Provider: [**Name10 (NameIs) 3712**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2171-10-14**] 9:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**] Completed by:[**2171-9-21**]

Admission Date: [**2141-7-19**] Discharge Date: [**2141-7-31**] Date of Birth: [**2082-3-4**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Fentanyl / Nickel Attending:[**First Name3 (LF) 7141**] Chief Complaint: Diarrhea, tenesmus, abdominal bloating. Major Surgical or Invasive Procedure: Exploratory laparotomy, supracervical hysterectomy with bilateral salpingo-oophorectomy, omentectomy, sigmoid resection with rectal anastamosis, repair of cystotomy and tumor debulking. History of Present Illness: The patient is a 59-year-old G2, P2 who presented with a several-week history of diarrhea, tenesmus, and abdominal bloating. She had a CT of the abdomen and pelvis on [**2141-7-4**] at [**Hospital1 18**], which revealed a small amount of ascites. There was para-aortic lymphadenopathy measuring up to 12 mm. The left adnexum had a 5.6-cm mass. There was an additional 9-mm enhancing peritoneal implant in left pericolic gutter. Other peritoneal implants could not be excluded. A CA-125 was noted to be elevated at 1587. The patient otherwise feels well. She is tolerating a regular diet. She denied any urinary complaints. She has had no vaginal bleeding. Her weight has been stable. She had a colonoscopy several years ago which was normal per her report. She denied any rectal bleeding. Past Medical History: Significant for adenoid cystic carcinoma of the right jaw, status post maxillectomy and radiation therapy in [**2137**]. She has been disease free since then. She is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7610**] at [**Hospital6 1708**]. She reports that she had a chest CT several months ago which revealed a question of an enlarged lymph nodes and was to have followup for this. Also, history of NSAID nephropathy, postoperative atrial fibrillation following maxillectomy, squamous cell carcinoma of the face status nose surgery. PAST SURGICAL HISTORY: As above. ALLERGIES TO MEDICATIONS: Penicillin and fentanyl. CURRENT MEDICATIONS: Evoxac, Tylenol, oral rinse, and vitamins. OB HISTORY: Vaginal delivery x2. [**Hospital6 **] HISTORY: Last Pap smear was recently normal. Last mammogram was recently abnormal but followup was recommended. SOCIAL HISTORY: The patient neither smokes nor drinks. FAMILY HISTORY: Significant for a maternal aunt who had breast cancer in her 70s, another maternal aunt with esophageal cancer, and paternal relatives with lung cancer. Physical Exam: GENERAL: Well developed and thin. HEENT: Sclerae were anicteric. There were postoperative and post-radiation changes on the right side of the face. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. BREASTS: Without masses. ABDOMEN: Soft and moderately distended and without palpable masses. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was normal to palpation. Bimanual and rectovaginal examination revealed a large firm mass in the cul-de-sac which was somewhat immobile. There was a question of cul-de-sac nodularity. The rectal was intrinsically normal. Pertinent Results: [**2141-7-19**] 08:35PM BLOOD WBC-11.5* RBC-3.28* Hgb-10.1* Hct-30.7* MCV-94 MCH-31.0 MCHC-33.0 RDW-13.2 Plt Ct-498* [**2141-7-19**] 08:35PM BLOOD Glucose-150* UreaN-12 Creat-0.6 Na-139 K-4.1 Cl-105 HCO3-25 AnGap-13 [**2141-7-19**] 08:35PM BLOOD Calcium-8.2* Phos-3.9 Mg-1.5* . [**2141-7-19**] Surgical pathology: 1. Uterus, right fallopian tube and ovary, hysterectomy and salpingo-oophorectomy (A-H): A. Carcinoma in myometrium and para-metrial soft tissue, present at inked parametrial soft tissue margin. B. Carcinoma in paratubal soft tissue. C. Unremarkable endometrium. D. Unremarkable ovary and fallopian tube. 2. Ovary and fallopian tube, left, salpingo-oophorectomy (I-N): A. Papillary serous carcinoma, ovary. B. Unremarkable fallopian tube. 3. Cul de sac tumor, biopsy (O): Carcinoma in fibrous tissue. 4. Lymph nodes, peri-aortic, biopsy (P-S): Metastatic carcinoma in three lymph nodes ([**2-18**]). 5. Omentum, excision (T): Carcinoma in adipose tissue. 6. Cecum, tumor, biopsy (U): Carcinoma in fibrous tissue. 7. Rectosigmoid colon, resection (V-AA): A. Carcinoma in bowel mesentery. B. Blood vessels with lymphoplasmacytic and granulomatous "vasculitis". SEE NOTE. 8. Lymph node, peri-aortic, biopsy (AB-AG): Metastatic carcinoma in seven lymph nodes ([**6-24**]). Extra-nodal extension of tumor is present. 9. Rectum, proximal donut, excision (AH): A. Blood vessels with lymphoplasmacytic and granulomatous "vasculitis". SEE NOTE. B. No malignancy identified. 10. Rectum, distal donut, excision (AI): A. Blood vessels with lymphoplasmacytic and granulomatous "vasculitis" and vascular thrombus. SEE NOTE. B. No malignancy identified. 11. Lymph node, left gutter, biopsy(AJ): Metastatic carcinoma in one lymph node ([**12-19**]). . [**2141-7-21**] Echo: The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 70-80%). There is severe focal hypokinesis/dyskinesis of the apical half free wall of the right ventricle. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. trivial mitral regurgitation. mild pulmonary artery systolic hypertension. . [**2141-7-25**] Echo: Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) The right ventricular cavity is dilated. There is focal hypokinesis of the apical free wall of the right ventricle. Right ventricular systolic function appears depressed. The aortic valve leaflets (3) are mildly thickened. mild pulmonary artery systolic hypertension. Compared with the findings of the prior study (images reviewed) of [**2141-7-21**], overall rtight ventricular contractile function appears somewhat improved. Brief Hospital Course: Ms. [**Known lastname 7611**] was admitted after undergoing an exploratory laparotomy, supracervical hysterectomy with bilateral salpingo-oophorectomy, omentectomy, sigmoid resection with rectal anastomosis, repair of cystotomy and tumor debulking for a pelvic mass previously visualized on CT. Prior to her surgery, an epidural was placed by anesthesia for post-operative pain management. Her post-operative course was complicated by hypotension, right ventricular hypokinesis, NSTEMI, a-fib, anemia and oxygen desaturation. She was admitted to the ICU on post-op day four for management of post-operative a-fib. # Hypotension: On post op day one and two, the patient was hypotensive to the 80s/40s. There was no evidence of acute blood loss as her HCT remained stable post-operatively. Her urine output was adequate. An epidural was in place for pain control. Her SBP was maintained > 90 with aggressive fluid management. The ddx for her hypotension included epidural induced sympathectomy versus myocardial ischemia. Her EKG was unchanged. When the hypotension did not resolve after capping the epidural an Echocardiogram performed which showed focal right ventricular hypokinesis. She had a positive troponin which peaked at 0.2 on post-op day two. # Elevated cardiac enzymes: No known h/o CAD prior to this hospitalization. Troponin bumped to max of 0.20, then trended down slightly to 0.06. MBI negative x3. CEs sent initially in the setting of hypotension and finding on TTE of RV free wall hypokinesis. Reportedly this was prior to a. fib w/ RVR so troponin leak appears to predate the rapid a. fib. Picture is suggestive of perioperative NSTEMI per cardiology. Differential, however, includes ischemia vs. less likely myocarditis as cause of elevated troponin. EKG when in NSR in the setting of hypotension did not reveal evidence of ischemia, but w/ atrial fibrillation now has new TWI in I, aVL which may represent demand ischemia in LCx distribution. A statin, BB, and ASA were started for risk factor modification per cardiology. # Right ventricular hypokinesis: Severe free wall motion hypokinesis on echocardiogram likely represents small RV NSTEMI. CEs elevated, but plateaued prior to a. fib w/ RVR. The patient was initially hypotensive requiring IVF boluses and 2u RBC, but remained hemodynamically stable for the remainder of her ICU course. Repeat TTE [**2141-7-25**] showed somewhat improved RV contractile function. # Atrial fibrillation: Pt. reportedly has h/o post op a. fib after her surgery in [**2137**] which responded well to Lopressor and was self limited. She denies any further episodes since. Rate responded poorly to IV and PO metoprolol on the floor, but improved control after second dose of diltiazem (15mg IV on the floor, 20mg IV in the ICU), approximately 100 down from 140s on transfer with rate ~110s-120s on diltiazem 5mg/hr gtt. She was loaded with amiodarone on [**7-23**] and cardioverted to NSR on [**7-24**] at noon. At this point the diltiazem drip was discontinued and she was started on PO lopressor. Remains in NSR with HR 70s - 80s. She was started on Lovenox for thromboembolic prophylaxis. An attempt to transition her to Coumadin was abandoned after her INR was noted to be 4.7 after three days of Coumadin at 5mg qd. She was given vitamin K, her HCT was monitored serially, and there was no evidence of acute bleeding as her INR returned to baseline. Bridging to Coumadin may be re-attempted as an outpatient once her nutritional status improves. # Hypoxia: Mid 90s on 2L NC. CXR does show evidence of b/l pleural effusions and possible LLL opacity vs. atelectasis, o/w without significant pulmonary edema. No evidence of left ventricular wall motion abnormalities nor depressed EF to suggest significant risk for pulmonary edema, but has been receiving fluids for BP maintenance given RV wall motion abnormalities and mild bibasilar crackles were heard on exam . Likely hypoxia is secondary to fluid overload and dependent atelectasis. Responded well to 20mg IV Lasix during ICU course with good response (neg. 1700cc) which resulted in improved pulmonary function and oxygenation at 99% on 2L. Pt ruled out for PE on CTA. # Leukocytosis: WBC was max 17.0 without left shift with pt afebrile. She denies cough, UA did show occ. bacteria, neg. nitrites, small amount of leuk. esterase, lg. blood. Treated with 3 days of Cipro for presumed UTI, however urine cx showed no growth. No diarrhea. At the time of discharge she was afebrile and her WBC had trended downward to 10.7. # Anemia: Previously normal baseline, but most recently 30-33 in early [**Month (only) 205**]. Postoperatively hct has been 24-27, without evidence of bleeding. up 34.0 [**2141-7-24**] s/p 2u PRBCs then dropped to 27.3 [**7-25**]. Stabilized around 30.4. # Proph: Lovenox Pt was transferred out of the ICU on POD8 and did well on the floor, maintaining her O2 sats well on room air, ambulating, and tolerating a regular diet. She was discharge on post-op day twelve in stable condition. She has follow up with her PCP, [**Name10 (NameIs) **] Oncology and Cardiology. Medications on Admission: Evoxac Tylenol Oral rinse Vitamins 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. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous [**Hospital1 **] (2 times a day). Disp:*30 syringe* Refills:*0* Discharge Disposition: Home With Service Facility: Greater [**Location (un) 1468**] VNA Discharge Diagnosis: Pelvic mass Discharge Condition: Stable Discharge Instructions: You may resume your regular diet. Please resume your regular home medications. Please do not lift anything heavier than 10 pounds for 6 weeks. No intercourse for 4 weeks. You may shower, but not tub baths or swimming for 6 weeks. Please call Dr. [**First Name (STitle) 1022**] if you have increasing pain, fever, chills, nausea, vomiting, shortness of breath or chest pain. Followup Instructions: Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **]. Phone: [**Telephone/Fax (1) 7612**]. Date/Time: [**2141-8-4**] 11:30 (Cardiology [**Hospital **] Clinic) Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2141-8-7**] 10:00 (Cardiology) Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2141-8-31**] 1:30 Completed by:[**2141-8-3**]

Admission Date: [**2151-3-13**] Discharge Date: [**2151-3-20**] Date of Birth: [**2111-4-11**] Sex: M Service: MEDICINE Allergies: Dimetapp DM Attending:[**First Name3 (LF) 1257**] Chief Complaint: fever Major Surgical or Invasive Procedure: Liver abscess drainage [**2151-3-18**] PICC line placement [**2151-3-19**] History of Present Illness: 39 M with hx of HTN and DMII, who presents with fevers, productive cough for 2-3 weeks and night sweats. Pt has been feeling ill since [**Month (only) **], but worse over last 3 weeks. He went to his PCP [**Last Name (NamePattern4) **] [**3-9**] and had blood tests, and there was concern for blood in stool. A colonscopy and CT abd were ordered. He went to his PCP gain today prior to his CT and was hypotensive with BP 60/40. BP improved with 1 liter NS. The CT showed a loculated liver hypodense lesion with concern for neoplasm vs. abscess. Also small cavitary lesion at the lung base. Pt denies risk factors for TB. No foreign travel. Pt did go camping in the summer and swam in a [**Doctor Last Name **] near [**Location (un) 3320**]. He reports some recent strong smelling stools, but does not know if there was blood or a tar color to them. No abd pain or emesis. No SOB, CP, HA, or dysuria. Rapid flu at PCP [**Name Initial (PRE) **]. Guaiac + at PCP. . Pt was transferred to [**Hospital1 18**]. In ER VS were 97.4 102 117/68 18 96%. Surgery was consulted, they recom Med admit with ID consult. Pt became febrile up to 105.9 with sinus tach to 150s. Pt was given tylenol, motrin, vanco, and zosyn. IVF x 4 liters with HR to 120s. On transfer VS were HR 120s BP 107/37 RR 28 O2 98%RA. Surgery will follow. Hct 26. Guaiac neg. PIV access. Past Medical History: HTN Hyperlipidema DM Social History: Lives with wife, mother-in-law and brother-in-law. Currently not working, but works in constuction. Smoked [**1-31**] ppd until last few weeks, he quit. Drank 12 ppk beer per day up till end of Decemeber, now 2 beers occaionally since, only had 2 beers this week on [**3-9**]. Past drug use, no IVDU. Family History: COPD in father DM in mulitple family members Physical Exam: VS: 98.2 121 106/50 26 96%RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, RESP: CTA b/l with good air movement throughout CV: RR, no m/r/g, 2+ pulses ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, some mild NT <1cm iguinal lymphadenopathy EXT: no c/c/e SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. RECTAL: in ER guaiac neg with brown stool Brief Hospital Course: This is a 39 year old man who was found to have streptococcus Bacteremia and sepsis with associated liver abscess and 2 small lung abscesses (STREPTOCOCCUS ANGINOSUS MILLERI seen on blood cultures x 2 on [**3-12**] which subsequently cleared from blood). Patient responded to IV fluids but was continued to be febrile (he has been hemodynamically stable). He was treated with Vancomycin, Zosyn, and Flagyl initially which were changed to IV Ceftriaxone and Flagyl. On [**3-18**], he underwent IR drainage which relieved 35 cc of pus. A drain was attached but did not drain more than 5 cc over the next 24 hours. He was then sent back to IR for flushing of the catheter which revealed the catheter was patent. Therefore, given the low output, the drain was pulled. He was also seen by hepatobiliary surgery who thought the morbidity of surgery would be high given that he was responding to medical therapy (this was likely the better option). There are still un-drained collections in his liver, these will need serial imaging and long term IV antibiotics. He was discharged home with ceftriaxone IV and PO Flagyl for a 6 week course tentatively. He has ID f/u and will likely undergo repeat imaging near the end of the antibiotic course. In addition he will f/u with a dentist and undergo a colonoscopy to look for underlying source predisposed him to STREPTOCOCCUS ANGINOSUS (MILLERI) bacteremia. For the lung lesion, he was ruled out for TB. The abscesses are small from hematogenous seeding of strep. He had anemia of chronic inflammation but he was guaiac + at his PCP office and will undergo a colonoscopy. Total discharge time 34 minutes. Medications on Admission: (unsure on names and doses...will need to be confirmed) Enalapril Simvastastin Viagra Amlodipine Metformin [**Hospital1 **] Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Health Services Discharge Diagnosis: Primary Diagnosis: Strep Bacteremia / septicemia Liver Abscess Lung Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a fever and found to have a liver abscess, you were treated with IV antibiotics and will need to continue this at home. Please take your medications as prescribed and make your follow up appointments. Please stop taking Amlodipine and enalapril (blood pressure medications) until you follow up with your primary care physician. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] R. Address: [**Street Address(2) 9646**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 3183**] Appt: [**4-2**] at 1:45pm Department: DIGESTIVE DISEASE CENTER When: TUESDAY [**2151-4-27**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: TUESDAY [**2151-4-27**] at 10:00 AM Please call the infectious disease clinic on Tuesday ([**Telephone/Fax (1) 457**]), you tentatively have an appointment with the [**Hospital **] clinic (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9461**]) on [**4-1**] on 2:10p.m., but you need to call to confirm this. Please see a dentist in 6 weeks as we are looking for the source for the bacteria in your blood that caused the liver abscess. For the same reason you will need a colonoscopy, this has been scheduled for you on [**4-27**].

Admission Date: [**2130-1-16**] Discharge Date: [**2130-1-23**] Service: MEDICINE Allergies: Chicken Protein Attending:[**First Name3 (LF) 2901**] Chief Complaint: Presenting for revascularzation of left leg. Major Surgical or Invasive Procedure: Lower Extremity Vascular Cath x 2 History of Present Illness: 86 y/o female with PMH significant for PVD and chronic renal failure admitted for planned percutaneous revascularization of the left leg. Pt initially presented to [**Hospital 1474**] Hospital on 0/29 with three to four weeks of claudication that had progressed to rest pain. Work up at [**Hospital1 1474**] included bilateral carotid US that showed 80 to 99% stenosis and ABIs that were consistent with claudictaion. Pt was transferred to [**Hospital1 18**] at that time and received a stent to the [**Country **]. At that time, her hospital course was complicated by renal failure secondary to the dye load from her cath. Pt then returned to [**Hospital1 18**] from [**1-9**] to [**1-13**] for the SFA stent and this went well with no renal failure. At this point of time the patients only complaint is pain in her L leg. The pain is greatest in her foot but also involves her L posterior thigh. Otherwise the patient feels well and denies: CP, SOB, N/V, Abd pain, problems with urination or bowel function, fevers, chills, palpitations, PND, or orthopnea. Past Medical History: 1. PVD s/p left fem-[**Doctor Last Name **] bypass, stent to the [**Country **], and stent to the right SFA. 2. HTN 3. Hyperlipidemia 4. CAD 5. CHF 6. Bilateral heel ulcers 7. Chronic renal failure 8. Former smoker- quit 40 years ago 9. Former ETOH abuse- quit 40 years ago 10. Glaucoma Social History: Former smoker, quit 40 years ago. She has a 60-75 pack-year history. She also quit drinking alcohol 40 years ago, and had a problem with EtOH abuse. Family History: Her father had PVD and CHF. Physical Exam: 98.0 140/40 96 20 97% on RA Gen - Alert and oriented x 3, somewhat confused HEENT - surgical lenses in both eyes, no JVD, no LAD, no carotid bruits Cor - RRR II/VI sys murmur Chest - CTA B Abd - S/NT/ND +BS Ext - R and L fem bruits, no edema hands warm, well perfused, good cap refill R foot - pink, scaly skin, not painful, heel ulcer L foot purple starting at metatarsal, 3 cm black necrotic ulcer on bottom of L foot. Pertinent Results: [**2130-1-16**] 05:42PM WBC-14.9* RBC-4.55 HGB-13.8 HCT-40.4 MCV-89 MCH-30.3 MCHC-34.1 RDW-13.7 [**2130-1-16**] 05:42PM PLT COUNT-277 [**2130-1-16**] 05:42PM PT-13.4 PTT-25.6 INR(PT)-1.1 [**2130-1-16**] 05:42PM GLUCOSE-127* UREA N-39* CREAT-1.3* SODIUM-136 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-23 ANION GAP-21* [**2130-1-16**] 05:42PM CALCIUM-9.2 PHOSPHATE-4.8* MAGNESIUM-2.1 EKG - NSR 97, LAD, nl intervals, T wave flatening in V4-6 which is new, q in III and aVF which is new. [**1-17**] Cath lower ext 1. Arterial access retrograde from RFA. 2. Initial hemodynamics demonstrated an entry pressure of 197/53 mm hg. 3. Initial angiography demonstrated moderate proximal [**Month/Year (2) 32365**] disease. The [**Female First Name (un) 7195**] and LIIA bifurcation had severe diffuse disease with occlusion of the [**Female First Name (un) 7195**]. The LCFA was not visualized and the profunda reconstituted via the IIA collaterals the the PFA. 4. Successful angiojet thrombectomy and stenting of the LCFA, [**Female First Name (un) 7195**] and [**Female First Name (un) 32365**] using overlapping 6.0 x 28, 8.0 x 60 mm, 9.0 x 40 mm and 9.0 x 20 mm Smart control stents, psot dilated with 8.0 x 40 mm agiltrac balloon at 10 atms with no residual stenosis, no dissection. Distal embolization into the AT/DP was treated with overnight thrombolysis via Unafuse. [**1-18**] Cath lower ext 1. Arterial access retrograde via the RFA. 2. Limtied hemodynamics demonstrated 167/44 mm hg in the RFA. 3. Limited angiography demonstrated patent [**Last Name (LF) 32365**], [**First Name3 (LF) 7195**] and LCFA stents. The Graft was patent into the popliteal artery. The AT was patent with a focal 99% stenosis in the DP. 4. Successful PTCA of the DP with a 1.5 x 9 mm maverick balloon at 10 atms. Brief Hospital Course: 86 y/o female with PMH significant for PVD and chronic renal failure admitted for planned percutaneous revascularization of the left leg. Patient with severe PVD resulting in necrosis of the feet. She has already had procedures to her R leg with reestablishment of blood flow. The patient was first taken to cath and found to have a great deal of thrombus in the L leg. She was cathed with atents to the [**Last Name (LF) 32365**], [**First Name3 (LF) 7195**] and LCFA. A catheter was left in overnight for a slow infusion of TPA. She was kept in the CCU during this infusion. Then she was brought back to the cath lab where the DP was opened using PTCA. After this the patient's L foot became less mottled and had dopplerable fellow. After the second procedure the patient was found to have a decreased mental status and difficult to control blood pressure. She was also found to have a fever and a white count. By Issue: **Hypertension - She was having SBP's in the 180's to 200's following the second procedure. Blood pressure goal in the unit was 160 in order to properly perfuse the leg. Lopressor was not successful in controling her blood pressure. Diltiazem was much more effective. She was brought down to the 160's using diltiazem and hydralazine. By the next morning the patient was awake enough to take po meds. Her oral meds were titrated up to keep her blood pressure in the 130 to 140 range. The blood pressure goal ia a compromise between having high enough pressure to perfuse her foot but not too high to rupture the cath site. The patients BP meds have been steadily titrated up with good effect although her BP at discharge was still slightly high in the 150's. **Infection - Patient was admitted with a UTI being treated with levofloxacin. Patient spiked a fever on [**1-18**] and was started on zosyn. Her prior urine culture [**1-17**] grew Klebsiella, resistant to levo and sensitive to zosyn. Also she was found to have a pneumonia LLL on CXR. Furthermore, the patient was found to have a MRSA infection on bedside wound swab. She was also started on vancomycin. Unfortunately the patient can not have an MRI due to her stents so osteo is difficult to rule out. The patient will need to continue zosyn for a total of 2 weeks and vancomycin for a total of 6 weeks. **Mental Status - Upon returning from the cath lab for the second time the patient has a severe waxing and [**Doctor Last Name 688**] of mental status consistent with delerium on top of her baseline mild dementia. She ranged from aggitated (screaming at nurses) to somnolent (barely arousable). A non-contrast head CT was performed given the high blood pressures and recent TPA infusion which was negative for mass or bleed. Neuro was also consulted and felt the patient had a toxic metabolic delerium rather than a stroke. The patient defervesed on zosyn and her mental status improved. By the morning of [**1-22**], she was back to her slight baseline dementia. 2) CAD - Pt has a history of CAD. Enzymes were cycled for T wave flattening and were negative. Patient continued on [**Date Range **], lipitor, plavix. Also her BP meds were continued includine a bblocker, ACE, and, imdur. 3) Glaucoma - Continued on brimonidine drops. FEN - Cardiac, low sodium diet patient allergic to chicken DNR/DNI - documented in chart Medications on Admission: 1. MVT 1 tab daily 2. Ranitidine 75 mg [**Hospital1 **] 3. Ferrous sulfacte 325 mg daily 4. Zinc sulfate 220 mg daily 5. Folic acid 1 mg daily 6. Atorvastatin 40 mg daily 7. Docusate 100 mg [**Hospital1 **] 8. Plavix 75 mg daily 9. Nortriptyline 30 mg daily 10. Senna 1 tab [**Hospital1 **] 11. Aspirin 325 mg daily 12. Hydrochlorothiazide 25 mg daily 13. Lactulose 30 mg Q8H PRN 14. Brimonidine tartrate 0.2% drops OU Q8H 15. Diltiazem 120 mg daily 16. Metoprolol 50 mg [**Hospital1 **] 17. Lisinopril 20 mg daily 18. Isosorbide mononitrate 45 mg daily 19. Tylenol 1000 mg QID PRN 20. Oxycodone 5 mg [**1-28**] tab PO Q6H PRN Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nortriptyline HCl 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 9. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q4H (every 4 hours) as needed for throat pain. 10. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO four times a day. 11. Nitroglycerin 2 % Ointment Sig: One (1) inch Transdermal QD (): please place on dorsum of left foot once a day. 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 14. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 17. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 19. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 21. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 22. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 8 days. 23. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) for 40 days. Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: Primary: Severe Peripheral Vascular Disease Secondary: HTN Hyperlipidemia CAD CHF CRI Glaucoma Discharge Condition: Stable Discharge Instructions: 1. Please keep all follow up appointments. 2. Please take all medications as prescribed. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, abdominal pain, pain in your legs, or other concerning symptoms. Followup Instructions: Dr. [**Last Name (STitle) 911**] ([**Telephone/Fax (1) 920**]) (cardiology) will call the patient's proxy ([**Name (NI) 2411**] [**Name (NI) 57341**]) to set up an appointment for next week [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

Admission Date: [**2120-10-15**] Discharge Date: [**2120-10-17**] Service: MEDICINE Allergies: Prochlorperazine / Erythromycin Base Attending:[**First Name3 (LF) 2279**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 84 y/o F with history of HTN, dementia, TTP, CKD admitted to the ICU for hypoxia. Per the patients husband, she complained of feeling tired in the morning, and then around noon felt generally unwell and short of breath. The patient was brought to the nurse at the independent living facility where her and her husband live where she was found to have low oxygen saturation, and, per the family, an irregular heart rate. In general, she denies fevers, chills, shortness of breath. She reported some pain in her right ankle the day prior to admission. denies calf pain, abdominal pain, nausea vomitting. . She was taken initially to [**Hospital3 **] where her D-dimer was negative, CXR with no focal infiltrate, negative VQ scan, and she was afebrile. The family requested she be transferred to [**Hospital1 18**], as most of her other care is here. . In the ED, her she was afebrile (98.6) HR 110 initially, 70-80 later, BP 165/88, RR 22, 91% on RA. Patient initially on NRB for sats in low 80s, and then weaned down 5L NC with sats in mid 90s. She was ruled out for PE with a CTA, and treated with 1L D% with 3 amps of bicarb prior to contrast, 1mg ativan Past Medical History: Dementia, recently evaluated by behavioral neurology at [**Hospital1 18**] Chronic renal insufficiency, likely secondary to TTP in early 90s hypertension hypercholesteremia TTP possible TIA's low back pain migraine headaches status post cholecystectomy and ERCP with sphincterotomy MICU course: Echo with bubble showing ASD with unexpected left to right shunt. LENIs bilaterally negative. Weaned from NRB to RA in hours CTA negative (4mm nodule for outpt f/u) Ruled out for MI. urine cultures pending. Social History: Patient smoked over 40 years ago, drinks very little. Currently lives in independent living facility with her husband. [**Name (NI) **] children live close by and are very involved in her care. Family History: Her brother had [**Name (NI) 4278**] disease. Her mother had hypertension, and her father had throat cancer. There is no other family history for heart disease, diabetes, or cancer. Physical Exam: Vitals: T: 97.6 BP: 121/58 P: 74 RR: 20 O2Sat 97% on 2L Gen: teary, but confused A&0x1 HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: delirious, apparently sundowning Pertinent Results: [**2120-10-14**] 09:29PM BLOOD WBC-9.2 RBC-4.53 Hgb-13.8 Hct-40.9 MCV-90 MCH-30.5 MCHC-33.8 RDW-13.9 Plt Ct-313 [**2120-10-17**] 05:50AM BLOOD WBC-6.4 RBC-3.66* Hgb-11.3* Hct-33.7* MCV-92 MCH-31.0 MCHC-33.6 RDW-14.0 Plt Ct-312 [**2120-10-14**] 09:29PM BLOOD Neuts-73.2* Lymphs-21.4 Monos-3.9 Eos-1.3 Baso-0.3 [**2120-10-15**] 03:05AM BLOOD Neuts-80.5* Lymphs-14.2* Monos-3.4 Eos-1.6 Baso-0.4 [**2120-10-15**] 03:05AM BLOOD Plt Ct-313 [**2120-10-17**] 05:50AM BLOOD Plt Ct-312 [**2120-10-14**] 09:29PM BLOOD Glucose-104 UreaN-34* Creat-1.5* Na-140 K-4.1 Cl-107 HCO3-18* AnGap-19 [**2120-10-17**] 05:50AM BLOOD Glucose-97 UreaN-31* Creat-1.6* Na-142 K-4.0 Cl-108 HCO3-21* AnGap-17 [**2120-10-14**] 09:29PM BLOOD CK(CPK)-113 [**2120-10-15**] 12:43PM BLOOD CK(CPK)-108 [**2120-10-15**] 12:43PM BLOOD CK-MB-4 cTropnT-<0.01 [**2120-10-14**] 09:29PM BLOOD Calcium-10.4* Phos-2.9 Mg-2.1 [**2120-10-17**] 05:50AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1 [**2120-10-15**] 03:05AM BLOOD Osmolal-309 [**2120-10-15**] 03:05AM BLOOD VitB12-674 [**2120-10-15**] 12:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6.1 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2120-10-14**] 09:29PM BLOOD GreenHd-HOLD [**2120-10-14**] 09:31PM BLOOD Type-ART FiO2-21 pO2-47* pCO2-25* pH-7.51* calTCO2-21 Base XS-0 Intubat-NOT INTUBA [**2120-10-15**] 11:32AM BLOOD Type-ART pO2-90 pCO2-29* pH-7.44 calTCO2-20* Base XS--2 [**2120-10-14**] 10:36PM BLOOD Lactate-1.4 [**2120-10-15**] 11:32AM BLOOD Glucose-134* Lactate-2.2* Na-139 K-4.3 Cl-109 [**2120-10-14**] 09:31PM BLOOD O2 Sat-86 COHgb-1 MetHgb-0 [**2120-10-15**] 11:32AM BLOOD freeCa-1.20 [**2120-10-14**] 11:23PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 [**2120-10-14**] 11:23PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2120-10-14**] 11:23PM URINE RBC-<1 WBC-[**3-27**] Bacteri-OCC Yeast-NONE Epi-0-2 RenalEp-<1 [**2120-10-14**] 11:23PM URINE AmorphX-OCC [**2120-10-15**] 09:03PM URINE Hours-RANDOM Creat-122 Na-49 K-63 Cl-69 [**2120-10-14**] 11:23PM URINE Hours-RANDOM . BILAT LOWER EXT VEINS Study Date of [**2120-10-15**] 9:37 PM TECHNIQUE AND FINDINGS: Grayscale, color flow and Doppler images of the lower extremities were obtained. Common femoral veins, superficial femoral veins and popliteal veins demonstrate normal compressibility, respiratory variation in venous flow and venous augmentation. IMPRESSION: No DVT in both lower extremities. . CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2120-10-15**] 12:04 AM TECHNIQUE: Axial MDCT images were obtained from the thoracic inlet to the upper abdomen after administration of 100 cc of Optiray intravenously. No oral contrast was used. Sagittal and coronal reformatted images were obtained. CTA OF THE CHEST: No filling defect is noted within the main pulmonary artery and its branches to suggest pulmonary embolism. The aorta has normal appearance with no acute pathology. Diffuse calcification of the coronary arteries are noted. Multiple nodes are noted in the mediastinum. The largest node is noted in anterior subcarinal space and measures 11 mm in short axis. Diffuse calcification of coronary arteries are noted. 4-mm pulmonary nodule is noted in the right upper lobe. Atelectatic changes are noted at the bases. Visualized part of the upper abdomen including the adrenal glands and the spleen are unremarkable. Pneumobilia is noted within the left biliary system. BONE WINDOWS: Wedge compression fracture of the mid thoracic vertebral body is noted. IMPRESSION: No pulmonary embolism and no dissection. 4-mm pulmonary nodule of the right upper lobe. One-year followup is recommended to ensure stability. . The left atrium is elongated. The interatrial septum is aneurysmal. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. Left ventricular wall thickness, cavity size and 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 arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Interatrial septal aneurysm with left to right flow at rest, consistent with small atrial septal defect. Normal global and regional biventricular systolic function. Mild mitral regurgitation. Compared with the report of the prior study (images unavailable for review) of [**2104-6-2**], a small intracardiac shunt is identified. . ECG Study Date of [**2120-10-14**] 9:15:22 PM Baseline artifact Sinus tachycardia Left axis deviation could be due to left anterior fascicular block and/or prior inferior myocardial infarction Delayed R wave progression with late precordial QRS transition - is nonspecific Since previous tracing of [**2118-1-10**], sinus tachycardia now present Brief Hospital Course: Pt is an 84 year old woman with history of hypertension and dementia who presented with hypoxia of unknown etiology. Hypoxia/Shortness of breath: The patient was initially admitted to the MICU for hypoxia of an unclear etiology, and was quickly weaned from non-rebreather oxygen to room air. The patient was evaluated for pulmonary embolism by a CT angiogram which did not show any abnormalities. The pt did not have fever or leukocytosis and there was no evidence of consolidation on chest x-ray to suggest an infectious cause of hypoxia. The pt had an echocardiogram which showed an intra-atrial aneurysm with left-to-right shunting, but this did not seem like the likely source of the pt's hypoxia. Shunt unlikely, no significant atelectasis on CT, no history of AVMs. Cardiac biomarkers were cycled and the patient did not show any evidence (on EKG or cardiac enzymes) of coronary disease. On the floor the pt oxygenated well with no de-saturations on room air, and was able to ambulate without any desaturations on room air. Ultimately the patient's hypoxia was attributed either to a temporary mucous plug or to a transient aspiration pneumonitis. . Hypertension: The patient was continued on her home medications: Atenolol 50 mg daily, Norvasc 10mg daily, hydrochlorothiazide 12.5 mg daily. . Hypercholestermia: The patient was continued on her home dose of Crestor. . Dementia: The patient was confused in the ICU, and oriented only to self. Initially on the floor the patient was agitiated, trying to get out of bed. Given the family's concern that the pt's memory was not benefitting from Aricept and Namenda, and that the Aricept and Namenda were actually causing memory impairments, the Aricept and Namenda were discontinued. The pt was continued on her home doses of her anti-depressant medications venlafaxine and paroxetine. . Chronic renal failure: The patient's creatinine was noted to be at baseline (1.2 to 1.9) during this hospitalization. Nephrotoxins were avoided. . DNR/DNI: The patient's code status was DNR DNI during this admission, and this was confirmed with the patient and her family. Medications on Admission: Amlodipine 10mg daily Atenolol 50mg daily Aricept 2.5mg daily hydrochlorothiazide 12.5 daily namenda 5mg faily Paroxetine Actonel 35mg weekly Crestor 20mg [**Last Name (un) **] Venlafaxine 75mg daily Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 6. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week. 8. Colace 50 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 9. B-12 DOTS 500 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Aspiration pneumonitis . Secondary diagnosis: Dementia Hypertension Discharge Condition: Good. Discharge Instructions: You were admitted with shortness of breath and decreased oxygen saturation. You were transferred the the medical intensive care unit and quickly taken off nasal cannula oxygen. You had a normal chest xray that did not show pneumonia and you also had a normal CT scan of your chest that showed a small pulmonary nodule. You have not had additional shortness of breath in the hospital and your blood oxygen saturations have been normal. . You have the below appointments, it is very important that you attend your follow-up appointments. . We have discontinued the Aricept and Namenda that you were taking, since your family did not think that you were benefitting from these medications. . We have continued all of your other home medications. Please continue taking your other home medications. . If you develop any sudden shortness of breath, chest pain, dizzyness, nausea and vomiting or lightheadedness, please call your primary care doctor or go to the emergency room. Followup Instructions: A small pulmonary nodule was noted on the CT scan of your chest. The recommendation from the radiology department was to follow this up with a repeat scan in 1 year. Please discuss this further with your primary care physician. . Dr.[**Name (NI) 99120**] secretary at [**Location (un) 5481**] will call you to schedule a follow up appointment with Dr. [**Last Name (STitle) 22477**] within the next week. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

Admission Date: [**2142-8-14**] Discharge Date: [**2142-8-29**] Date of Birth: [**2095-1-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2142-8-14**] Emergent Replacement of Ascending Aorta and Subtotal Arch with Aortic Valve Replacement utilizing a 25mm Pericardial Valve. [**2142-8-16**] Re-exploration for Bleeding History of Present Illness: Mr. [**Known lastname 7842**] is a 47 year old male who presented to OSH with left sided chest pain, dizziness and diaphoresis while showering. CTA revealed Type A aortic dissection. He was emergently med flighted to the [**Hospital1 18**] for surgical intervention. Past Medical History: Hypertension Dyslipidemia s/p Vasectomy Social History: Employed as Financial Advisor. Married, lives with his wife. Denies tobacco but admits to occasional marijuana. Denies history of ETOH abuse. Family History: No premature coronary artery disease. Physical Exam: At the time of discharge, Mr. [**Known lastname 7842**] was found to be awake, alert, and oriented. His heart was of regular rate and rhythm. His lungs were clear to auscultation bilaterally. His sternal incision was clean, dry, and intact. His sternum was stable. His abdomen was soft, non-tender, and non-distended. +1 edema was noted in his extremities. Pertinent Results: [**2142-8-14**] Intraop TEE: PREBYPASS - The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%) Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The ascending aorta is markedly dilated. The descending thoracic aorta is mildly dilated. A mobile density originating from the right sinus of Valsalva is seen in the ascending aorta, transverse arch and descending thoracic aorta consistent with an intimal flap/aortic dissection. The aortic valve leaflets (3) are mildly thickened. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. POSTBYPASS - LV systolic function remains normal. There is a well seated, well functioning bioprosthesis in the aortic position. There is mild valvular AI. A graft appears in the ascending aorta and transverse arch. The disection flap is still present in the distal arch and descending thoracic aorta. Flow is visualized in the true lumen. The study is otherwise unchanged from prebypass. [**2142-8-15**] Renal Ultrasound: No renal arterial abnormality detected. Normal renal arterial waveforms. [**2142-8-19**] Head MRI: Probable chronic small vessel infarct within the inferolateral aspect of the right cerebellar hemisphere. [**2142-8-28**] 09:17AM BLOOD WBC-9.5 RBC-2.92* Hgb-8.7* Hct-25.8* MCV-88 MCH-29.7 MCHC-33.6 RDW-15.0 Plt Ct-449* [**2142-8-29**] 05:55AM BLOOD Glucose-108* UreaN-13 Creat-1.1 Na-137 K-3.9 Cl-104 HCO3-26 AnGap-11 [**2142-8-28**] 09:17AM BLOOD ALT-76* AST-36 AlkPhos-192* TotBili-1.3 Brief Hospital Course: Mr. [**Known lastname 7842**] was emergently brought to the operating room where Dr. [**First Name (STitle) **] performed replacement of his ascending aorta and subtotal arch along with aortic valve replacement. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU in critical condition. Initially coagulopathic, he required multiple blood products. Postoperative TEE was notable worsening pericardial effusion with questionable signs of early tamponade. He concomitantly had a slight decline in renal function. Renal ultrasound showed no evidence of aortic dissection into the renal arteries. On postoperative day two, he returned to the operating room for re-exploration. Given prolonged period of sedation and intubation, tube feedings were started for nutritional support. As sedation was weaned he became extremely agitated with question of nonpurposeful movements. Head CT scan and MRI were obtained which did not show any large area of territory infarct. Neurology service was consulted and attributed his altered mental status to most likely toxic-metablolic encephalopathy. He remained hypertensive and continued to require Labetolol drip for adequate blood pressure control. He also experienced postop fevers, and pan-cultures were obtained. He was empirically started on antibiotics for possible ventilator associated pneumonia along with positive blood cultures. Over several days, clinical improvements were noted. He was eventually extubated on postoperative day nine. He was transferred to the step down floor. He was seen in consultation by the physical therapy service. He was gently diuresed. A PICC line was placed and he was screened for rehab. By post-operative day 15 he was ready for discharge to rehab. Medications on Admission: Transfer meds: IV Esmolol, IV Nipride Home meds: HCTZ 25 qd, Zocor, Lisinopril 10 [**Hospital1 **], Viagra prn Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): completes [**2142-9-7**]. 2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): completes [**2142-9-7**]. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 5. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection twice a day for 7 days. Disp:*qs * Refills:*0* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Type A Aortic Dissection, Aortic Insufficiency - s/p Repair Postoperative Bleeding/Pericardial Effusion - s/p Re-exploration Postoperative Toxic-Metabolic Encephalopathy Hypertension Dyslipidemia Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks, call for appt Dr. [**Last Name (STitle) **] in [**3-11**] weeks, call for appt CTA scan in 3 months to evaluate aneurysm Please follow weekly LFTs/BUN/Creatinine while on antibiotics [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2142-8-29**]

Admission Date: [**2121-12-18**] Discharge Date: [**2122-1-6**] Date of Birth: [**2043-2-2**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Heparin Agents / Levofloxacin Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Ongoing hypotension, hypothermia, anasarca, and inability to tolerate HD for fluid removal Major Surgical or Invasive Procedure: Tunnelled Left Internal Jugular Hemodialysis Catheter Left Femoral Hemodialysis Catheter Right Femoral Triple Lumen Catheter Left PICC line Debridement of Sacral Decubitus History of Present Illness: Ms. [**Known lastname **] was admitted on [**2121-12-18**] for [**Date Range 1106**] surgery evaluation of right heel ulcer. She was started on vanco/cipro/flagyl on admission to cover an infection. On hospital day 2 ([**2121-12-19**]), she underwent right peroneal angioplasty on [**2121-12-19**] and was put on an argatroban drip for 24 hours following the procedure. On [**12-20**], she was noted to be hypotensive to 72/37 and hypothermic to 94.6. Cardiac enzymes were checked and were noted to be positive. She was transfused 2 units packed red blood cells on [**12-20**]. Plastic surgery was consulted for evaluation of sacral decubuti, but declined to debride wound due to aspirin/plavix/argatroban use. She underwent HD on [**2121-12-21**], but they were unable to remove fluid due to low blood pressures. When renal evaluted her on that day, there was concern that her mental status was not at baseline and her words were not well enunciated. They recommended sending blood cultures and broadening antibiotics but no intervention was undertaken at this time. Cardiology was consulted on [**12-21**] for bradycardia, hypotension, and elevated cardiac enzymes and recommended discontinuation of beta-blockers. An echo was performed on [**12-22**] which showed new regional wall motion abnormalities. Given hypotension, anasarca, and inability to tolerate HD due to low blood pressures, patient was transfered to MICU for CVVHD. . Upon arrival to the MICU, patient reports right hand pain. She denies any other complaints. No abdominal pain, nausea, vomiting, diarrhea, fevers, chills, shortness of breath, chest pain. Past Medical History: Type 2 DM ESRD on HD Tue/Thurs/Sat CAD s/p MI in [**2103**] and [**2113**], s/p CABG x 2 Diagstolic CHV (EF 60-65%0 PAF (not anticoagulated due to GI bleeds) HTN Hypothyroidism Anemia of chronic disease Thrombocytopenia HIT in [**2116**] H/o MRSA endocarditis Chronic GI bleeds due to AVMs PUD, Barrett's Asthma PSH: CABG x 2 Cholecystectomy BSO -- patient with uterus on CT scan 11/08 L BKA [**2121-12-2**] Social History: The patient is primarily Spanish speaking but does speak fair English. She is wheelchair bound and lives in a [**Hospital1 1501**]. The patient is widowed, a retired factory worker. Tobacco: None ETOH: None Illicits: None Family History: CAD, HTN, and DM Physical Exam: Tcurrent: 36.2 ??????C (97.2 ??????F)HR: 66 bpm BP: 72/28(38)RR: 22 SpO2: 92% RA Physical Examination General Appearance: Well nourished, obese, anasarcic Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal) Peripheral [**Hospital1 **]: (Right radial pulse: dopplerable), (Left radial pulse: dopplerable), (Right DP pulse: dopplerable), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: Clear : anteriorly) Abdominal: Soft, Non-tender, Bowel sounds present, obese Extremities: Right: 3+, Left: 3+, Right heel ulcer, Left BKA Skin: Sacral decub, bilaterial ischial decubiti, right heel ulcer, RUE erythema/warmth . On discharge Tcurrent: 36.6 ??????C (97.8 ??????F)HR: 69 bpm BP: 80/40 mmHg RR: 21 insp/min, SpO2: 96% RA Wgt (current): 79.5 kg (admission): 112.5 kg, DRY 78.5 KG General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral [**Hospital1 **]: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Bowel sounds present, No(t) Tender: Extremities: Right: Trace, Left: Trace Musculoskeletal: Unable to stand Skin: Warm, Rash: right arm remains with ischemic blisters, less tender. Sacral and ischial decubiti - stage III Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): self, location, Movement: spontaneous Pertinent Results: TRANSFER TO UNIT: [**2121-12-24**] 06:00AM BLOOD WBC-27.7*# RBC-3.33* Hgb-10.5* Hct-30.9* MCV-93 MCH-31.4 MCHC-33.9 RDW-18.5* Plt Ct-173 [**2121-12-24**] 06:00AM BLOOD Neuts-89.7* Lymphs-4.0* Monos-5.5 Eos-0.4 Baso-0.3 [**2121-12-24**] 06:00AM BLOOD PT-19.7* PTT-38.1* INR(PT)-1.8* [**2121-12-24**] 06:00AM BLOOD Glucose-81 UreaN-24* Creat-2.9* Na-130* K-4.0 Cl-96 HCO3-24 AnGap-14 [**2121-12-24**] 06:00AM BLOOD ALT-13 AST-25 LD(LDH)-247 AlkPhos-212* TotBili-1.1 [**2121-12-24**] 05:06PM BLOOD Calcium-8.2* Phos-1.7* Mg-1.6 . IRON STUDIES [**2121-12-19**] 08:20AM BLOOD calTIBC-113* Ferritn-488* TRF-87* Iron-26* [**2121-12-20**] 09:00AM BLOOD calTIBC-104* TRF-80* Iron-39 . CARDIAC MARKERS [**2121-12-20**] 03:37AM BLOOD CK-MB-NotDone cTropnT-0.20* [**2121-12-20**] 09:00AM BLOOD CK-MB-NotDone cTropnT-0.20* [**2121-12-20**] 04:30PM BLOOD CK-MB-NotDone cTropnT-0.15* . TFTs [**2121-12-25**] 12:23AM BLOOD TSH-3.7 [**2121-12-25**] 12:23AM BLOOD T4-3.4* . CORTISOL STEM TEST [**2121-12-25**] 07:43AM BLOOD Cortsol-17.0 [**2121-12-25**] 08:54AM BLOOD Cortsol-24.8* . INFLAMMATORY MARKERS [**2121-12-24**] 11:48AM BLOOD ESR-55* [**2122-1-4**] 04:07AM BLOOD ESR-109* [**2121-12-21**] 03:00AM BLOOD CRP-177.2* [**2122-1-4**] 04:07AM BLOOD CRP-55.2* [**2121-12-25**] 06:39AM BLOOD Lactate-4.0* [**2122-1-2**] 05:07AM BLOOD Lactate-2.3* . RADIOLOGY ECHO [**2121-12-22**]: EF 55%, Normal left ventricular cavity size with regional systolic function most c/w CAD. Mildly dilated RV with mild global hypokinesis. Mild pulmonary arterial systolic hypertension. Mild mitral regurgitation. . RIGHT HEEL [**2121-12-24**]: FINDINGS: Comparison is made to prior radiographs from [**2116-3-19**]. There is no soft tissue gas or large ulceration within the right posterior heel. There are large plantar spur which is unchanged since [**2116**] study. Extensive [**Year (4 digits) 1106**] calcifications are seen. There is no bony destruction to indicate acute osteomyelitis. There is overall demineralization of the bony structures. . RIGHT UE VEINS 11/25,[**12-24**] No evidence of deep venous thrombosis. Patent AV fistula, right antecubital fossa. . RIGHT ARM ARTERIAL DOPPLERS [**2121-12-29**]: Findings as stated above which indicate poor right radial artery flow with improvement with compression. Note of radial artery calcification. Calcifications are new when compared to a prior AV fistula study performed in [**2116**]. . RIGHT FOREARM [**12-26**] Interstitial edema. No evidence of abscess. . CT ABDOMEN/PELVIS [**12-26**]: IMPRESSION: 1. Soft tissue wound inferior to the coccyx, with induration and inflammatory changes within the subcutaneous fat extending to the rectum, with inflammatory changes involving the posterior wall of the rectum. 2. 4.3 cm fat-containing anterior abdominal wall lesion, consistent with a fat-containing hernia, not significantly changed in size compared to [**2117-1-1**] with a focus of central hyperdensity which may represent an engorged vessel. 3. Fractures of the right lateral ninth and eighth ribs. 4. A 15 mm cystic lesion inferior to the pancreatic head, which may represent a side branch IPMN or other mucinous lesion, for which further evaluation with MRCP is recommended. 5. Nodular appearance of the liver surface, consistent with cirrhosis. 6. Anasarca and ascites. 7. Left inguinal lymphadenopathy, with a single prominent node measuring up to 11 mm in short axis diameter. . TRANSVAGINAL ULTRASOUND [**2121-12-31**]: The patient is post-menopausal. Transabdominal examination is significantly limited due to large patient body habitus and poor echo penetration. Transvaginal examination was attempted; however, due to the patient's condition she had difficulty complying with endovaginal ultrasound probe maneuvers. . PICC [**2122-1-2**]:Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the left brachial venous approach. Final internal length is 41 cm, with the tip positioned in SVC. The line is ready to use. . Non-Tunneled LIJ HD [**2121-12-26**]: Uncomplicated placement of left-sided 12-French 20-cm triple lumen temporary hemodialysis catheter via the left internal jugular vein. . DISCHARGE LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2122-1-6**] 03:48AM 13.6* 2.75* 8.9* 25.8* 94 32.3* 34.4 20.1* 74* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2122-1-6**] 03:48AM 115* 28* 3.9* 127* 4.7 90* 25 17 Brief Hospital Course: Ms. [**Known lastname **] is a 78 year old female with type 2 DM, ESRD on HD, PVD s/p BKA, CAD s/p MI with septic shock, volume overload. . 1. Septic Shock: Due to MDR Acinetobacter line infection and RESOLVED. Had initially been treated empirically with Daptomycin, Colistin, Flagyl and Unasyn. Daptomycin and Flagyl were discontinued as there were no gram positive bacteria in blood cultures, and negative C. difficile x 3. Acinetobacter coverage narrowed to high dose Unasyn to complete a 14-day course from the date of the first negative blood culture. Unasyn day 1=[**12-25**], to complete [**1-7**]. . 2. Hypotension: Baseline SBP 70s-80s per the renal team that follows her as an outpatient; suspect bad PVD preventing accurate measurement of true BP. The patient mentates well at this blood pressure. We initiated midodrine and this was continued for discharge. . 3. Sacral /ischial decubiti: Plastic Surgery debrided the sacral ulcer. Given rise in ESR from 55 to 109, were are treating for now for presumptive osteomyelitis. She should continue Vancomycin and Ceftazidine for a two-week course and monitor ESR. If ESR persists high, discuss continuation of antibiotics with Plastics. The patient has follow-up scheduled with Plastic Surgery. . 5. End-stage renal disease on hemodialysis: Patient negative 30L on CVVHD during her admission to the MICU, and she is felt to be near her dry weight. Patient is tolerating HD. Continuing midodrine as above. . 6. Right Arm Pain: There is some steal from her AV fistula, but no current change in management is recommended at this time after consultation with the Hand Surgeons. Her neuropathic pain is improved. She has a good radial pulse currently. Further consideration of neurontin or other treatments may be appropriate after discharge. . 7. Anemia: History of chronic GI bleed from AVMs. We targeted a Hct of 25 for transfusion and recommend follow-up monitoring for signs of GI bleeding. . 8. Heel ulcer/peripheral [**Month/Year (2) 1106**] disease: Status post right peroneal angioplasty on [**2121-12-19**]. Continued weight-sparing boot. The patient has follow-up scheduled with [**Date Range 1106**] surgery. . 8. Thrombocytopenia: She has a history of thrombocytopenia and her counts are stable at discharge. The patient has a history of heparin-induced thrombocytopenia and therefore heparin was avoided and heparin-free lines only were used. . 9. Type 2 diabetes: We continued sliding scale insulin and stopped her fixed dose 70/30 in setting of hypoglycemia. . 11. Elevated INR: Likely nutritional and somewhat improved with vitamin K 5 mg PO x 3 days. . 12. Vaginal bleeding: The patient had a small amount of vaginal bleeding during admission. She has a uterus and cervix, but CT scan and transvaginal ultrasound with limited views show no pathologic features. Further evaluation is deferred to the outpatient setting. Medications on Admission: Home Meds: 1. Acetaminophen 2. albuterol MDI 3. ASA 4. colace 5. advair diskus (250/50) 6. synthroid 7. metoprolol XL 8. neutra-phos 9. pantoprazole 10. simvastatin . Medications on Transfer: Carbamide Peroxide ear drops Vancomycin D1 = [**2121-12-22**] Insulin SS Toprol 12.5 XL Silver sulfadiazine Hydromorphone prn Aspirin 81 mg daily Plavix 75 mg daily Flagyl 500 q 8, D1 = [**12-18**] Cipro 500 mg daily, d1 = [**12-18**] Colace Fluticasone/Salmeterol [**Hospital1 **] Simvastatin 40 mg daily Pantoprazole 40 mg daily Levothyroxine 175 daily Albuterol prn Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Severe Sepsis d/t Acinetobacter Bacteremia Sacral Decubitus, Stage III Bilateral Ischial Decubiti, Stage II End stage renal disease requiring CVVHD Osteomyelitis of Sacrum Discharge Condition: Stable, afebrile, 98% RA, SBPs 80/40 Discharge Instructions: You were admitted for revascularization of your right leg. You developed a blood infection that is being treated with antibiotics. For a time you required medications to support your blood pressure. You underwent continuous hemodialysis to remove 30 liters of extra fluid. You also came in with a dead tissue covering an ulcer that needed to be removed. The dead tissue and fat were removed from your sacrum and you were started on antibiotics to treat a potential bone infection related to your ulcer. You improved on antibiotics and have resumed normal hemodialysis. You are ready to go to a rehabilitation facility to continue your recovery. You will need to complete all your antibiotics. You have a special intravenous line called a PICC to allow you to receive these antibiotics. You will continue to receive hemodialysis at your rehabilitation facility. You have been started on a new medication MIDODRINE to help support your blood pressure. If you experience temperature < 95.0 F, or > 101.5, chest pain, inability to breath, or any other concerning symptoms please go to the Emergency Department. Followup Instructions: You will receive hemodialysis on Monday/Wednesday/Friday. Follow-up with plastic surgery: Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time: [**2122-1-16**] 02:30pm Location: [**Hospital1 18**], [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) 470**]. Follow-up with [**Location (un) 1106**] surgery: [**Last Name (LF) 1111**],[**Name8 (MD) 1112**], MD Phone: [**Telephone/Fax (1) 3121**] Date/Time:[**2122-2-5**] 12:50pm Location: [**Hospital1 18**], [**Hospital Ward Name 12837**], [**Hospital **] Medical Building, [**Location (un) 442**]. Follow-up with Primary Care: [**Name6 (MD) **] [**Name8 (MD) 1447**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-2-19**] 02:00pm Location: [**Hospital3 **], [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) **].

Admission Date: [**2178-7-2**] Discharge Date: [**2178-7-5**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Intracranial hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 86 year-old left-handed Chinese man with a history of hypertension, dyslipidemia, prior stroke with mild left hemiparesis (on Plavix), and legally blind from macular degeneration who presents as a transfer from [**Hospital6 **] this evening for concern of intracranial hemorrhage. The patient was in his usual state of health until awakening this morning at 5 am, when he noted difficulty moving his left leg. He had tried to stand and go to the bathroom, but could not do so without the assistance of his wife, a former OB/GYN in [**Country 651**]. His wife noted that he seemed to hold his left hand in a flexed position. He seemed to "tilt" to the left side, according to his wife. She noted that he seemed to be urinating more frequently, but noted no incontinence. He convinced his wife that he was all right, but she decided to take him to [**Hospital6 **] at 4 pm for further evaluation when deficits persisted. At [**Hospital3 **], his blood pressure was 187/100 on arrival. He was noted to have 3 mm pupils, left facial weakness, and left arm weakness was noted in his grasp. They report that the patient complained of left-sided sensory deficits, which he denies currently. He seemed to keep his eyes closed, but opened on command; his left eye did not seem to open as much as the right. A CBC was notable for a platelet count of 129, while his basic metabolic panel was unremarkable. INR was one and other coagulation studies were normal. A CT of the head reportedly revealed an acute 2.6 x 1.7 cm acute hematoma of the right thalamus with 3 mm shift to the left, as well as bilateral basal ganglia lacunes with extensive chronic ischemic white matter changes. He was therefore transferred to [**Hospital3 **] for further evaluation. His wife notes that he has been yawning quite a bit this evening, but that he remains clear in his thinking. Review of Systems: He denies headache, fever, chest pain, dysarthria, dysphagia, and incomprehension. Other pertinent positives as above. Past Medical History: -Hypertension -Dyslipidemia, diet-controlled -Stroke in [**2173**], with mild left-sided weakness -BPH -Cholelithiasis, s/p cholecystectomy last [**Month (only) 205**] -Hernias, s/p repair years ago -Constipation Social History: Electrical engineer from [**Country 651**], came to the United States ~20 years ago. A daughter lives [**Name2 (NI) 83396**]. He denies a history of tobacco, alcohol, and drug use. Family History: No known neurologic disease, though there is a history of hypertension Physical Exam: Vitals: T 98.6 F BP 175/94 P 74 RR 16 SaO2 100 RA General: NAD, well-nourished, tends to keep eyes closed but opens when asked, yawning frequently HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx Neck: no nuchal rigidity, no bruits Lungs: clear to auscultation CV: regular rate and rhythm, no MMRG Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: his left leg is cool but with good pulses and without pain, no edema Skin: no rashes Neurologic Examination: Mental Status: Awake and alert, able to relay history, cooperative with exam, normal affect Oriented to person, place, month and year Attention: can say days of week backward Language: fluent, accented, non-dysarthric speech, no paraphasic errors, naming (allowing for language difference), comprehension, repetition intact; [**Location (un) 1131**] intact Calculation: can determine 7 quarters in $1.75 Memory: registration: [**3-24**] items, recall [**3-24**] items at 3 minutes No evidence of apraxia. He seems to attend more to right space rather than left. Cranial Nerves: Fundoscopic examination technically limited; visual fields appear full to confrontation. Pupils equally round and reactive to light, 2 and minimally reactive bilaterally. Extraocular movements intact, no nystagmus, but tends to look toward the right. Facial sensation intact bilaterally. Left upper motor neuron pattern droop. Hearing intact to finger rub bilaterally. Palate elevates midline. Tongue protrudes midline, no fasciculations. Trapezii full strength bilaterally. Motor: Normal bulk and tone throughout. Left pronator drift. No tremor. His left hand is held in a flexed position. D T B WE FiF [**Last Name (un) **] IP Q H TA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] EDB Right 4+ 4+ 5 4+ 4+ 5 4+ 5 4+ 5 5 5 5 Left 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: No deficits to light touch, pin prick, temperature (cold), vibration, and proprioception throughout. No extinction to DSS in the arms. Reflexes: B T Br Pa Pl Right 2 2 2 2 1 Left 2 2 2 3 1 Toes were upgoing on the left and downgoing on the right. Coordination: No intention tremor noted. No dysmetria on HKS bilaterally. Some mild dysmetria on FNF on left, perhaps related to weakness. Gait: Deferred given critically ill state Pertinent Results: [**2178-7-2**] 11:57PM %HbA1c-6.1* [**2178-7-2**] 07:50PM GLUCOSE-124* UREA N-20 CREAT-1.0 SODIUM-140 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14 [**2178-7-2**] 07:50PM ALT(SGPT)-18 AST(SGOT)-22 LD(LDH)-193 TOT BILI-0.7 [**2178-7-2**] 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2178-7-2**] 07:50PM WBC-6.7 RBC-4.37* HGB-14.2 HCT-40.8 MCV-94 MCH-32.5* MCHC-34.8 RDW-13.6 [**2178-7-2**] 07:50PM NEUTS-78.4* LYMPHS-16.3* MONOS-3.8 EOS-1.0 BASOS-0.4 [**2178-7-2**] 07:50PM PT-12.7 PTT-28.9 INR(PT)-1.1 [**2178-7-3**] 02:22AM BLOOD Triglyc-67 HDL-42 CHOL/HD-4.1 LDLcalc-117 [**7-2**] and [**7-3**] CT Head - stable right thalamic bleed with layering of bld in lateral ventricles [**7-3**] MRI Head: Wet read: Redemonstration of thalamic hematoma, without evidence of underlying mass. The appearance and location are most consistent with hypertensive hemorrhage, however, given presence of microhemorrhages, amyloid angiopathy is in differential diagnosis. [**2178-7-5**] 06:40AM BLOOD WBC-6.1 RBC-4.09* Hgb-13.2* Hct-38.2* MCV-94 MCH-32.4* MCHC-34.7 RDW-13.5 Plt Ct-146* [**2178-7-5**] 06:40AM BLOOD PT-13.3 PTT-31.0 INR(PT)-1.1 [**2178-7-5**] 06:40AM BLOOD Glucose-141* UreaN-27* Creat-1.4* Na-136 K-3.6 Cl-101 HCO3-24 AnGap-15 [**2178-7-3**] 02:22AM BLOOD CK(CPK)-108 [**2178-7-5**] 06:40AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.2 Brief Hospital Course: 86 year-old left-handed Chinese man with a history of hypertension, dyslipidemia, prior stroke with mild left hemiparesis, and legally blind from macular degeneration presents with right thalamic hemorrhage with intraventricular spread. His neurologic examination is notable for a right gaze preference, left facial droop, breakable left hemiparesis, mild hemisensory loss to pain, and hyper-reflexia in the left lower extremity. Hypertensive etiology is most likely. Pt admitted to ICU and transferred to floor [**7-3**]. Exam at discharge: Pt is arousable, prefers eyes closed, very poor vision, oriented to all but exact day. Follows all commands, slight weakness left side w/ preference for right. Neuro: No underlying mass or vascular malformation was seen on MRI. However he was found to have multiple small bleeds consistent with amyloid angiopathy. His head CT remained stable while in the ICU overnight with approximately 6cc bleed in right thalamus. Plan is to hold Plavix and all other anti-platelet/anticoagulant agents for 7 days. Given amyloid angiopathy, plan is to start baby [**Name (NI) 17408**] 7 days after bleed and not restart plavix. PT and OT consulted. CV: BP was controlled with his po dose atenolol 62.5mg qam. Nicardipine drip was only necessary for a few hours overnight in the ICU. SBP was kept 120-160. FEN/GI: He passed his swallow evaluation and was ok for modified diet. Follow up Cr and fluid balance given slight increase in Cr on day of discharge. Endo: SSI was used to maintain euglycemia. HbA1C was mildly elevated at 6.1 and should be followed up as an outpatient. ID: MRSA + on screening swab. No other active infectious issues GU: Grossly bldy urine after foley attributed to trauma from foley and BPH. Foley removed [**7-4**] and pt voiding, incontinent of urine but no retention. Medications on Admission: -Plavix 75 mg daily (started at the time of his stroke) -Atenolol 65 mg daily -Proscar 5 mg daily -Multivitamin -No herbal remedies Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 2. Atenolol 25 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Academy Manor of [**Location (un) 7658**] - [**Location (un) 7658**] Discharge Diagnosis: Hypertensive right thalamic hemorrhage with intraventricular extension Secondary: HTN, h/o stroke Discharge Condition: Improved Discharge Instructions: You were admitted to the neurology ICU service for bleeding into the right side of your brain in a region called the thalamus. This was most likely caused by high blood pressure. You were also found to have "amyloid angiopathy" on the MRI of your brain. We recommend stopping plavix as amyoloid puts you at higher risk to have bleeding into your brain. You should start on [**Location (un) 17408**] 81mg daily on [**7-9**]. . Please take all medications as perscribed. If you have concerns about the medications, please call your PCP before changing the doses. . Please call your PCP or return to the emergency room if you experience any worsening in your symptoms or have other concerns. Followup Instructions: [**Hospital 4038**] clinic - call [**Telephone/Fax (1) 2574**] Monday to schedule an appointment with Drs. [**Last Name (STitle) 1794**] and [**Name5 (PTitle) **] in 1 month. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2178-7-5**]

Admission Date: [**2164-12-12**] Discharge Date: [**2164-12-22**] Date of Birth: [**2094-10-19**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [**2164-12-12**] Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to OM1 with y-graft to Diag, SVG to OM2, SVG to PDA) History of Present Illness: 70 y/o asymptomatic female who was found to have an abnormal EKG by PCP. [**Name10 (NameIs) **] stress test which was also abnormal. Then referred for cardiac cath which revealed severe three vessel disease. She was then referred for surgical revascularization. Past Medical History: Hypertension, Hyperlipidemia, Diabetes (diet controlled), Chronic headaches, Osteoporosis, s/p cholecystectomy, s/p bilat. cataract surgery, s/p ovarian cyst removal Social History: Denies tobacco or ETOH use. Family History: non-contributory Physical Exam: VS: 85 20 211/99 (137/81 post-cath) 5'4" 139# Gen: NAD Skin: Unremarkable HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD, -carotid bruits Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2164-12-12**] 12:26PM BLOOD WBC-8.0# RBC-3.23*# Hgb-9.4* Hct-25.8* MCV-80* MCH-29.0 MCHC-36.4* RDW-15.2 Plt Ct-131* [**2164-12-12**] 12:26PM BLOOD PT-16.1* PTT-54.3* INR(PT)-1.4* [**2164-12-12**] 04:05PM BLOOD UreaN-9 Creat-0.7 Cl-120* HCO3-23 [**2164-12-13**] 03:51AM BLOOD Phos-3.2 Mg-2.0 [**2164-12-19**] 10:15AM BLOOD WBC-12.3* RBC-3.58* Hgb-10.3* Hct-30.5* MCV-85 MCH-28.8 MCHC-33.8 RDW-17.5* Plt Ct-382# [**2164-12-19**] 10:15AM BLOOD Plt Ct-382# [**2164-12-18**] 08:50AM BLOOD PT-14.8* INR(PT)-1.3* [**2164-12-13**] 03:51AM BLOOD PT-14.3* PTT-32.6 INR(PT)-1.2* [**2164-12-12**] 04:05PM BLOOD PT-16.6* PTT-45.5* INR(PT)-1.5* [**2164-12-17**] 07:10AM BLOOD Glucose-107* UreaN-13 Creat-1.0 Na-142 K-4.2 Cl-107 HCO3-26 AnGap-13 [**2164-12-16**] 06:25AM BLOOD Glucose-117* UreaN-17 Creat-1.0 Na-139 K-4.6 Cl-107 HCO3-27 AnGap-10 [**2164-12-15**] 06:45PM BLOOD Glucose-129* UreaN-16 Creat-1.1 Na-138 K-4.6 Cl-103 HCO3-28 AnGap-12 [**2164-12-19**] 10:15AM BLOOD PT-35.6* PTT-28.3 INR(PT)-3.8* [**2164-12-16**] Chest x-ray: The patient is status post sternotomy. There is cardiomegaly and an enlarged cardiomediastinal silhouette, with ill-definition of the aorta knob. There are small bilateral pleural effusions, with underlying collapse and/or consolidation. There is increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. There is upper zone redistribution, without other evidence of CHF. No pneumothorax is detected. Brief Hospital Course: Ms. [**Known lastname **] was a same day admit following work-up after cardiac cath. On [**12-13**] she was brought to the operating room where she [**Month/Year (2) 1834**] a coronary artery bypass graft x 5. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She was transfused 3 units of PRBCs for postoperative anemia. On post-op day one she was weaned from sedation, awoke neurologically intact and extubated. Beta blockers were started on this day and titrated during hospital course. On post-op day two her chest tubes were removed and she was started on diuretics. She was gently diuresed towards her pre-op weight. Later on this day she was transferred to the telemetry floor for further care. She had some short bursts of atrial fibrillation. She eventually started on Amiodarone and Warfarin for paroxsymal atrial fibrillation. Her postoperative course was otherwise uneventful. At discharge, she was in a normal sinus rhythm. She was ready for discharge to home on POD #8. Prior to discharge, arrangements were made with Dr. [**First Name (STitle) **] to monitor Warfarin as an outpatient. Goal INR should be between 2.0 - 2.5. Medications on Admission: Fosamax 70mg weekly, HCTZ 25mg qd, Plavix 300mg ([**2164-11-30**]) Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*1* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. 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* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 4 days: Then decrease to 1 tab(200mg) [**Hospital1 **] for seven days, then decrease to 1 tab(200mg) daily until follow up with cardiologist. Disp:*60 Tablet(s)* Refills:*1* 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed by Dr. [**First Name (STitle) **]. Daily dose may vary according to INR. Disp:*60 Tablet(s)* Refills:*1* 10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*60 Tablet(s)* Refills:*1* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: please take with KCL. Disp:*20 Tablet(s)* Refills:*0* 12. Potassium Chloride 20 mEq Packet Sig: One (1) PO DAILY (Daily) for 10 days: please take with Lasix. Disp:*10 packets* Refills:*0* Discharge Disposition: Home With Service Facility: .[**Hospital **] homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5, Postoperative Atrial Fibrillation PMH: Hypertension, Hyperlipidemia, Diabetes (diet controlled), Chronic headaches, Osteoporosis, s/p cholecystectomy, s/p bilat. cataract surgery, s/p ovarian cyst removal Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. 6)Dr. [**First Name (STitle) **] will manage Warfarin as an outpatient. INR should be checked on [**2163-12-22**]. Warfarin should be adjusted for goal INR between 2.0 - 2.5. Results should be called/faxed to Dr. [**First Name (STitle) **] - office phone [**Telephone/Fax (1) 24216**] and fax [**Telephone/Fax (1) 75817**] Followup Instructions: Wound check on [**Hospital Ward Name 121**] 6 in 2 weeks Dr. [**First Name (STitle) **] in [**12-19**] weeks Dr. [**Last Name (STitle) **] in [**1-20**] weeks Dr. [**Last Name (STitle) **] in 4 weeks Completed by:[**2164-12-20**]

Admission Date: [**2165-8-15**] Discharge Date: [**2165-9-6**] Date of Birth: [**2101-11-3**] Sex: M Service: CARDIOTHORACIC Allergies: Celebrex Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2165-8-19**] Cardiac Cath [**2165-8-22**] Coronary Artery Bypass Graft x 2 (SVG to RCA, SVG to OM), Mitral Valve Replacement w/ 31mm [**Company 1543**] mosaic porcine valve, MAZE procedure, Left Atrial Appendage Ligation [**2165-8-22**] Re-exploration for bleeding History of Present Illness: 63 yo M with h/o polyneuropathy, CAD s/p stent to LCX in [**2160**], mitral regurg and mitral stenosis who presents with progressive dyspnea. Past Medical History: Coronary Artery Disease s/p stent to LCX [**2160**], Mitral Stenosis/Regurgitation, Atrial Fibrillation, Hypertension, Hyperlipidemia, Obstructive Sleep Apnea, Polyneuropathy, Spinal Stenosis, ?TIA, ?COPD, Depression, s/p cataract surgery, Peripheral Vascular Disease s/p R CEA, s/p back surgery, s/p cataract surgery, Anemia Social History: married and has one daughter in college. lives in [**Location 8117**], NH. Used to work in the shoe business and now is disabled. Studying law at home. Smoked [**3-2**] ppd but quit in [**2158**]. Denies current alcohol use. No IVDU. Family History: Father and brother deceased from myocardial infarction Physical Exam: VS: T 98.2 BP 113/72 HR 76 RR 20 O2sat 97% 2L NC Gen: Pleasant 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. Neck: Supple with JVP of 12 cm. CV: RRR, normal S1, S2. 2/6 systolic murmurs heard at apex and rusb. Also 1/4 systolic murmur at RUSB and [**3-3**] diastolic murmur at apex. No thrills, lifts. No S3 or S4. Chest: Resp were unlabored, no accessory muscle use. Bilateral crackles about 2/3 up lung fields. Abd: +BS, Soft, NTND. No HSM. Ext: 1+ bilateral LE edema. Neuro: CN II-XII in tact. Strength in lower extremities is [**2-1**] bilaterally in the proximal muscle groups (he can lift his legs about 20 degrees off the bed to gravity). Upper extremities [**5-2**] bilaterally in distal and proximal muscle groups. Sensation diminished to light touch in the distal lower extremities. . Pulses: Right: Carotid 2+ DP 1+ PT 1+ Left: Carotid 2+ DP 1+ PT 1+ Pertinent Results: [**2165-9-6**] 06:10AM BLOOD WBC-12.1* Hct-38.4* Plt Ct-629* [**2165-8-14**] 11:00PM BLOOD WBC-8.2 RBC-4.01* Hgb-11.6* Hct-35.5* MCV-88 MCH-29.0 MCHC-32.8 RDW-14.6 Plt Ct-295# [**2165-9-6**] 06:10AM BLOOD Plt Ct-629* [**2165-9-6**] 06:10AM BLOOD PT-22.2* PTT-31.2 INR(PT)-2.2* [**2165-9-5**] 06:25AM BLOOD PT-25.9* PTT-32.6 INR(PT)-2.6* [**2165-8-14**] 11:00PM BLOOD Plt Ct-295# [**2165-8-14**] 11:00PM BLOOD PT-26.7* PTT-34.0 INR(PT)-2.7* [**2165-9-6**] 06:10AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-134 K-4.7 Cl-93* HCO3-27 AnGap-19 [**2165-8-14**] 11:00PM BLOOD Glucose-99 UreaN-19 Creat-0.7 Na-132* K-4.6 Cl-96 HCO3-26 AnGap-15 [**2165-8-30**] 03:59AM BLOOD ALT-35 AST-34 LD(LDH)-393* AlkPhos-63 Amylase-38 TotBili-0.7 [**2165-8-29**] 02:14PM BLOOD Lipase-19 [**2165-8-15**] 07:15PM BLOOD CK-MB-12* MB Indx-5.8 cTropnT-0.04* [**2165-8-15**] 10:35AM BLOOD CK-MB-14* MB Indx-6.1* cTropnT-0.06* [**2165-8-14**] 11:00PM BLOOD CK-MB-16* MB Indx-5.0 cTropnT-0.05* proBNP-1458* [**2165-9-6**] 06:10AM BLOOD Mg-2.1 [**2165-8-15**] 10:35AM BLOOD calTIBC-376 VitB12-1573* Folate-GREATER TH Ferritn-94 TRF-289 [**2165-8-21**] 01:00PM BLOOD %HbA1c-4.8 [**2165-8-29**] 06:09AM BLOOD TSH-1.4 RADIOLOGY Preliminary Report ABDOMEN (SUPINE & ERECT) [**2165-9-6**] 9:44 AM ABDOMEN (SUPINE & ERECT) Reason: ? obstruction [**Hospital 93**] MEDICAL CONDITION: 63 year old man with s/p CABG REASON FOR THIS EXAMINATION: ? obstruction STUDY TYPE: Plain abdominal radiograph, supine and erect. INDICATION: 63-year-old man status post CABG. Please evaluate for obstruction. COMPARISON: Plain radiograph from [**2165-9-2**]. FINDINGS: Interval removal of nasogastric tube is noted. There is contrast material which has moved further along and is now present in the rectosigmoid area. There is no evidence of pneumoperitoneum or pneumatosis. The bowel gas pattern is nonobstructive. Air-fluid level in the stomach is noted. Extensive vascular calcification, which was also present on previous radiographs. IMPRESSION: No evidence of acute obstruction. Contrast material has moved further along in the rectosigmoid region compared to the previous radiograph suggesting improvement in ileus. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] RADIOLOGY Final Report CHEST (PA & LAT) [**2165-9-5**] 9:16 AM CHEST (PA & LAT) Reason: check pulm edema [**Hospital 93**] MEDICAL CONDITION: 63 year old man s/p CABG REASON FOR THIS EXAMINATION: check pulm edema INDICATION: Status post CABG, query pulmonary edema. COMPARISON: [**2165-9-2**]. CHEST, TWO VIEWS: Interval removal of a nasogastric tube. Intact median sternotomy wires and radiographic stigmata of a mitral valve replacement again seen. Persistent mild cardiomegaly; mediastinal and hilar contours are unchanged. There is no pneumothorax. Trace left pleural effusion improved from prior. Kerley B lines bibasally. Persistent increased interstitial markings. IMPRESSION: Improved study with no overt alveolar edema; residual interstitial edema remains. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Approved: FRI [**2165-9-6**] 11:04 AM RADIOLOGY Final Report VIDEO OROPHARYNGEAL SWALLOW [**2165-9-5**] 9:16 AM VIDEO OROPHARYNGEAL SWALLOW Reason: r/o aspiration [**Hospital 93**] MEDICAL CONDITION: 63 year old man with s/p mvr/MAZE REASON FOR THIS EXAMINATION: r/o aspiration HISTORY: Evaluate for aspiration in 63-year-old male status post mitral valve repair and MAZE procedure. VIDEO OROPHARYNGEAL SWALLOW STUDY. This study was performed in conjunction with speech pathology department. Multiple consistencies of barium were administered to the patient under continuous fluoroscopic observation. Patient demonstrated abnormal oral phase swallow disfunction with delay of bolus initiation, premature spillover, and abnormal tongue bolus propulsion. A moderate amount of residual was noted to pool within the piriform sinuses and valleculae, and there was incomplete epiglottic deflection. A 13 mm barium tablet was noted to pass freely through the esophagus into the stomach. No evidence of aspiration or penetration was identified. For full details, please consult speech pathology report available on CareWeb. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**] Approved: [**Doctor First Name **] [**2165-9-5**] 8:13 PM RADIOLOGY Final Report CT PELVIS W/CONTRAST [**2165-8-29**] 12:19 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: r/o bowel obstruction Field of view: 38 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 63 year old man with s/p MVR/CABG/MAZE REASON FOR THIS EXAMINATION: r/o bowel obstruction CONTRAINDICATIONS for IV CONTRAST: None. CT OF THE ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST CLINICAL HISTORY: Status post MVR/CABG, evaluate for bowel obstruction. COMPARISON: None. TECHNIQUE: Multiple continuous 5-mm thick axial CT images of the abdomen and pelvis were obtained from the lung bases to upper thighs with intravenous contrast. Subsequently, coronal and sagittal reformatted images were performed. ABDOMEN FINDINGS: Small amount of retrosternal fluid is noted, likely post- operative in nature. Bilateral moderate pleural effusions are seen, right greater than left, with adjacent areas of passive atelectasis. The heart is moderately enlarged. There is interstitial thickening and ground- glass opacities in the visualized bilateral bases. No free air, or loculated or free fluid is seen. The liver, spleen, pancreas and adrenal glands are within normal limits. Small hypodense lesions are noted in the kidneys, too small to be adequately characterized, and likely representing cysts. There is no hydronephrosis or hydroureter. The gallbladder is visualized. A few small sub-centimeter retroperitoneal lymph nodes are noted, with no lymphadenopathy. Nasogastric tube is seen coiled within the stomach with its tip in the fundus. The stomach is moderately distended. The remainder of the bowel and mesentery are unremarkable. The appendix is within normal limits. Moderate-to-severe calcification is seen in the distal abdominal aorta and common iliac arteries, the major abdominal vessels are within normal limits. PELVIS FINDINGS: Trace fluid is noted in the presacral region. There is no pelvic lymphadenopathy. Foley catheter is seen within the urinary bladder, which demonstrates air fluid level. The prostate gland is mildly measured. Degenerative changes are seen through the lumbosacral spine, with possible areas of central canal stenosis. Median sternotomy wires are noted. Subcutaneous tissues are unremarkable, except for mild fat stranding involving the proximal thighs. IMPRESSION: 1. No bowel obstruction. However, the stomach is moderately distended inspite of presence of nasogastric tube. 2. No inflammatory process, mass or lymphadenopathy. 3. Tiny left renal interpolar hyperdense lesion, too small to be adequately characterized and likely representing a cyst. 4. Bilateral small to moderate pleural effusion, right greater than left, with adjacent areas of passive atelectasis. 5. Moderate cardiomegaly, with bibasilar interstitial thickening and ground- glass opacities, findings suggestive of CHF. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**] Approved: [**Doctor First Name **] [**2165-8-29**] 5:05 PM Cardiology Report ECHO Study Date of [**2165-8-22**] PATIENT/TEST INFORMATION: Indication: H/O cardiac surgery. Tamponade. Height: (in) 64 Weight (lb): 130 BSA (m2): 1.63 m2 BP (mm Hg): 112/68 HR (bpm): 90 Status: Inpatient Date/Time: [**2165-8-22**] at 22:36 Test: Portable TTE (Focused views) Doppler: No Doppler Contrast: None Tape Number: 2007W001-0:00 Test Location: West SICU/CTIC/VICU Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] INTERPRETATION: Findings: GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency study performed by the cardiology fellow on call. Conclusions: Extremely limited echo windows. In the subcostal view (clip [**Clip Number (Radiology) **]), the right ventricular cavity appears grossly normal in size. The free wall appears to contract vigorously. There is an echo filled space anterior to the right ventricle of undertain etiology - ?thrombus ?hemopericardium ?liver. The left ventricle is not well seen. If clinically indicated a TEE is suggested. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2165-8-23**] 10:34. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J. Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was admitted with increasing dyspnea and found to be in congestive heart failure. He was treated accordingly by the medical/cardiology team over several days. Echo on day of admission showed moderate MR. [**Name13 (STitle) **] eventually underwent a cardiac cath which revealed two vessel coronary artery disease. Cardiac surgery was consulted and he underwent usual pre-operative work-up. On [**2165-8-22**] he was brought to the operating room where he underwent a mitral valve replacement, coronary artery bypass graft x 2 and maze procedure with left atrial appendage ligation. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. During his initial post-op course there continued to be extensive post-op bleeding. Also found to have a right pneumothorax and right chest tubes was placed. Later that evening he continued to have bleeding with possible tamponade and was eventually brought back to the operating room for re-exploration of mediastinum. Please see operative report for details. Following surgery he once again returned to the CSRU for invasive monitoring. On post-op day one he was weaned from sedation, awoke neurologically intact and extubated. Over next several days he was also weaned from his multiple pressors. Chest tubes were removed on post-op day two. Beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight. On post-op day three epicardial pacing wires were removed. On post-op day four he appeared to be doing well and was transferred to the telemetry floor for further care. Over next couple of days beta blockers were titrated for maximum hemodynamics and he worked with physical therapy for strength and mobility. On post op day 6 he had abdominal distention with nausea he was transfered to the ICU for monitoring. He underwent ct scan that revealed gastric ileus with no obstruction. He remained in the ICU for hyponatremia and was corrected with fluid restriction and salt tabs. He was transferred to the floor and continued to progress. He was doing well on post-op day 15 and was ready for discharge to rehab for continued physical therapy, occupational therapy and speech/swallow. Medications on Admission: Acular *NF* 0.5 % OU daily, Advair, Aspirin 81 mg PO DAILY, Furosemide 60 mg PO daily, Metoprolol XL (Toprol XL) 25 mg PO BID, Namenda *NF* 10 mg Oral [**Hospital1 **], PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **], Tiotropium Bromide 1 CAP IH DAILY, Warfarin 5 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA) ON Tuesday, Wed, Thurs, Sat, Sun., Warfarin 7.5 mg PO 2X/WEEK (MO,FR) On Mon, Friday, WelChol *NF* 1825 mg Oral [**Hospital1 **] , Zymar *NF* 0.3 % OU daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Acular 0.5 % Drops Sig: One (1) Ophthalmic once a day. 5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Colesevelam 625 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 14. Gatifloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 16. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal TID (3 times a day). 18. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: please dose for INR 2-2.5 s/p MAZE check PT/INR mon-wed-fri. 19. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 20. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 weeks. 21. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 2 weeks. 22. Outpatient Lab Work K, Cr please check qweekly while on lasix 23. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: St. [**Hospital 11042**] Hospital Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2 Mitral Stenosis/Regurgitation s/p Mitral Valve Replacement Atrial Fibrillation s/p MAZE procedure, Left Atrial Appendage Ligation Congestive Heart Failure PMH: Hypertension, s/p stent to LCX [**2160**], Hyperlipidemia, Obstructive Sleep Apnea, Polyneuropathy, Spinal Stenosis, ?TIA, ?COPD, Depression, s/p cataract surgery, Peripheral Vascular Disease s/p R CEA, s/p back surgery, s/p cataract surgery, Anemia Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule all appointments Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) 2739**] after discharge from rehab [**Telephone/Fax (1) 2740**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2165-9-26**] 3:00 Completed by:[**2165-9-6**]

Admission Date: [**2151-10-9**] Discharge Date: [**2151-10-15**] Date of Birth: Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old white gentleman with no significant past medical history who had the worst headache of his life along with positive nausea and vomiting since 7 p.m. on the day of admission. The patient states he took aspirin and ibuprofen and went to sleep. The pain worsened over the next few hours, and the patient presented to [**Location (un) 1468**] Emergency Room where he was found to have a subarachnoid hemorrhage on computed tomography looking like a right middle cerebral artery distribution. The patient denies weakness of extremities, visual changes, dizziness, or lethargy. The patient reports having consumed several shots of Southern Comfort on the afternoon of admission. PAST MEDICAL HISTORY: The patient denies. PAST SURGICAL HISTORY: The patient denies. MEDICATIONS ON ADMISSION: Aspirin and ibuprofen which he took on admission. ALLERGIES: The patient denies any known drug allergies. SOCIAL HISTORY: The patient quit smoking 10 months ago. He does drink daily; he has a few shots per day. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed the patient's white blood cell count was 10, his hematocrit was 41.4, and his platelets were 227. Chemistry-7 was pending at the time of this dictation. His INR was 0.9. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed the patient's heart rate was 70, his blood pressure was 168/90, and his respiratory rate was 20. His pupils were equal, round, and reactive to light and accommodation. The extraocular movements were full. The lungs were clear. Cardiovascular examination revealed a regular rate and rhythm. No murmurs. The abdomen was soft and nondistended. Extremity examination revealed no edema. Cranial nerves II through XII were intact. Neurologically, the patient was alert, awake, and oriented times three. The patient was conversant with appropriate speech. He followed commands bilaterally. Pupils were equal, round, and reactive to light and accommodation. The extraocular movements were full. No nystagmus. The visual fields were full to confrontation. The neck was supple. No pronator drift. Muscle strength was [**5-10**] in the upper and lower extremities. The toes were downgoing. No dysmetria. The face was symmetric. The tongue was midline. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Neurology Intensive Care Unit and was started on nimodipine 60 mg by mouth q.4h. and morphine as needed for pain. Neurologic checks were performed every hour with gastrointestinal prophylaxis. He was to keep his blood pressure less than 130. He was to go to angiogram later on in the day. On the morning of [**2151-10-10**] the patient's temperature maximum was 98.9 degrees Fahrenheit. His blood pressure was 134/64 with a heart rate of 78. His hematocrit was 41.4, his white blood cell count was 10.6, and his platelets were 227. His sodium was 141. His potassium was 4.1. His prothrombin time was 12. His partial thromboplastin time was 20.4. His INR was 0.9. The patient was alert, awake, and oriented times three. The pupils were equal, round, and reactive to light at 2.5 mm to 2 mm. The face was symmetric. An arterial line was placed. On [**2151-10-10**] the patient had an angiogram done which was negative. Postoperatively, his vital signs were stable. His blood pressure was 126/63, his heart rate was 57, his respiratory rate was 17, and his oxygen saturation was 97% on 2 liters. The patient was alert, awake, and oriented times three. He was following commands. The extraocular movements were full. No drift. His strength was [**5-10**] in both the upper and lower extremities. No hematoma. His dorsalis pedis pulses were 2+ bilaterally. He was kept on best rest. His systolic blood pressure was less than 130s. The patient remained in the Intensive Care Unit in stable neurologic condition. The patient stayed in the Intensive Care Unit until [**10-14**]. He remained neurologically intact. He had a repeat angiogram on [**10-14**] which showed no definite aneurysm; however, there was an irregularity at the origin of the posterior communicating artery. He had no complications. Postoperatively, he had a mild headache. His vital signs remained stable. After the angiogram the patient wanted to be discharged home and talked about leaving against medical advice. However, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] did speak with the patient and told him there was no definite source of hemorrhage; however, the angiogram showed mild evidence of cerebral vasospasm, and he was advised to stay in the hospital. The patient did decide to stay. However, on [**2151-10-8**] the patient wanted to leave the hospital and did leave against medical advice. He was told to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] and again reminded that our advice would be to remain in the hospital in order to insure that the vasospasm visualized on angiography did not become symptomatic. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern4) 26792**] MEDQUIST36 D: [**2151-12-15**] 11:33 T: [**2151-12-17**] 13:55 JOB#: [**Job Number 50085**]

Admission Date: [**2167-8-6**] Discharge Date: [**2167-8-19**] Date of Birth: [**2098-10-30**] Sex: F Service: [**Hospital Unit Name 196**] HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old woman with chronic congestive heart failure, who presented to [**Hospital3 **] with increasing dyspnea for the last two to three months and associated orthopnea and pedal edema. The patient also had paroxysmal nocturnal dyspnea. The patient denied any frank chest pressure or pain. She was noted at the outside hospital to have a chronic right lower lobe effusion/infiltrate. At the outside hospital the patient was diuresed eight pounds, but remained in congestive heart failure, and also had hyponatremia, which was resolving upon transfer. Additionally, the patient had hyperkalemia at the outside hospital, which was resolved and ruled out for Addison disease by a cortisol level. The patient also developed herpes zoster on [**2167-7-29**]. A stress MIBI performed at the outside hospital showed left ventricular dilation at rest and post Persantine, a large inferior, posterior, lateral infarct without ischemia and global hypokinesis with an ejection fraction of 24%. The patient was transferred to the [**Hospital1 188**] for further diuresis and intervention. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [**2161**] with PTCA and stent of the RCA. There is evidence of a previous posterior myocardial infarction and a new anterior MI with a ejection fraction of 35% at that time. 2. Cerebrovascular accident in [**2167-5-18**] with right-sided weakness. 3. Chronic obstructive pulmonary disease with chronic right lower lobe infiltrate. The patient has been treated for pneumonia twice without resolution of the infiltrate. 4. Mitral stenosis secondary to rheumatic fever. 5. Atrial fibrillation for which the patient is on Coumadin. MEDICATIONS: 1. Coumadin 3 mg PO q.d. 2. Digoxin 0.25 mg PO q.d. 3. Lopressor 12.5 mg PO b.i.d. 4. Capoten 12.5 mg PO b.i.d. 5. Lasix 80 mg PO q.d. 6. Lipitor 10 mg PO q.d. ALLERGIES: The patient is allergic to AMOXICILLIN, WHICH CAUSES ITCHING AND NAUSEA. SOCIAL HISTORY: The patient lives alone. The patient is widowed. Her daughter lives next door. The patient walks with a cane at home and uses two liters of oxygen. She is only able to walk a few steps without shortness of breath. The patient quit smoking tobacco in [**2161**]. She has a greater than 50 pack per year smoking history. The patient denies alcohol or drug use. FAMILY HISTORY: There is no history of coronary artery disease. PHYSICAL EXAMINATION: GENERAL: The patient is an elderly female resting in no acute distress. Temperature 96.4, blood pressure 104/68, pulse 68. Respirations 36. Oxygen saturation 98% on four liters. Weight 136.5 pounds. HEENT: normocephalic, atraumatic. NECK: Supple, no JVD. PULMONARY: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm; 1-2/6 systolic murmur. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds. EXTREMITIES: No clubbing or cyanosis. Right groin site without hematoma or bruit; 1+ dorsalis pedis pulses bilaterally. LABORATORY DATA: Laboratory data revealed the following: White count 4.8, hematocrit 40.8, platelet count 153,000, sodium 131, potassium 4.2, chloride 92, bicarbonate 35, BUN 28, creatinine 1.0, glucose 74, calcium 8.8. EKG: Atrial fibrillation with a left bundle branch block. Ventricular rate of 71 beats per minute. Chest x-ray: Study performed on [**2167-7-21**], showed right lower lobe infiltrate, cardiomegaly, mild pulmonary vascular redistribution, right small effusion. HOSPITAL COURSE: #1. CARDIOVASCULAR: Upon transfer to the [**Hospital1 346**], the patient was taken to the Coronary Catheterization Laboratory, which revealed on left ventriculography 3+ mitral regurgitation, left ventricular ejection fraction 25% with inferobasilar akinesis, anterior apical severe hypokinesis. In addition, the patient had a 30% in-stent narrowing within the mid RCA. It was thought that the patient's severe left ventricular dysfunction was related to her prior infarction with likely additional nonischemic cardiomyopathy. The patient had nonsignificant coronary artery disease with severe mitral regurgitation and moderate-to-severe mitral stenosis. Echocardiogram performed on [**2167-8-7**] showed an ejection fraction less than 20% with left atrial and left ventricular dilation. There was left ventricular anteroseptal apical and inferior akinesis with hypokinesis elsewhere and in the right ventricular free wall. There was 1+ AR, 3+ MR, 2+ TR and moderate pulmonary artery hypertension with a small pericardial effusion. Because the patient was markedly volume overloaded, status post catheterization and had evidence of severe systolic left ventricular dysfunction, the patient was diuresed aggressively with Lasix and Natrecor drips. Maximal diuresis achieved while on the hospital floor was 800 cc a day. however, the patient remained grossly volume overloaded and required more aggressive diuresis, which was achieved upon transfer to the coronary care unit on [**2167-8-8**]. While in the coronary care unit the patient was continued on a Lasix and Natrecor drips. The patient was also started on Zaroxolyn for diuresis. The patient was diuresed approximately 8.5 liters during her four day coronary care unit stay. She was transferred out of the coronary care unit on [**2167-8-15**] in stable condition without any signs and symptoms of congestive heart failure. The patient's Natrecor and Zaroxolyn were discontinued once the patient arrived to the floor and the patient's Lasix dose, which changed to 120 mg PO q.d. In addition, the patient was started on Aldactone 25 mg PO q.d. The patient was maintained on her cardiac regimen including aspirin, statin, Captopril 12.5 mg PO t.i.d., Digoxin 0.125 mg PO q.d. Although upon initial admission it was thought that the patient may benefit from mitral valve replacement repeat echocardiogram revealed that the patient's mitral stenosis was not significant. It was thought that the patient would rather benefit from the placement of biventricular implantable cardiac defibrillator with pacing ability to improve the patient's cardiac input. A transesophageal echocardiogram performed on [**8-17**], prior to placement of the biventricular ICD device, however, revealed the presence of a left atrial appendage thrombus, which precluded the cardioversion prior to placement of the ICD device. In addition, the ICD device could not be tested given the presence of the thrombus. The patient will need the ICD device tested after four weeks of anticoagulation. There were no complications after placement of the biventricular device. The patient remained in atrial fibrillation with ventricular packing at 85 beats per minute upon discharge. In addition, throughout the [**Hospital 228**] hospital stay, the patient required heparin anticoagulation for her atrial fibrillation, as well as for her apical akinesis. The patient was restarted on a new heparin algorithm once the ICD device was placed and the patient's Coumadin was again restarted. The goal INR is 2.5 go 3.0. The patient will require heparin until the patient's INR is greater than 2.0. The patient will need her INR checked every week until a repeat transesophageal echocardiogram is performed in six to seven weeks. In addition, given the patient's severe left ventricular dysfunction, it was thought that the patient would highly benefit from starting a beta blocker. The patient was placed on Carvedilol 3.125 mg PO b.i.d. with food once her biventricular ICD device was placed. PULMONARY: The patient's COPD remained stable during her hospital stay. She received Albuterol and Ipratropium nebulizers as needed. The patient's oxygenation remained stable at 98% to 99% on two liters upon discharge. INFECTIOUS DISEASE: The patient had a urinalysis, which showed trace leukocyte esterase and trace blood with 11 to 30 RBCs and 11 to 20 WBCs and few bacteria. However, urine culture revealed mixed flora consistent with contamination. Because the patient was not complaining of any dysuria or urgently, the patient was not started on any antibiotic treatment for a UTI. The patient was placed on Vancomycin 100 mg IV q.12h. after placement of the biventricular ICD, and the patient will need this antibiotic changed to Keflex 500 mg PO q.6h. for six more doses total. HEMATOLOGY: As noted above, the patient was maintained on IV heparin drip, while she was in the hospital for her atrial fibrillation and apical akinesis. The patient had been restarted on Coumadin once her biventricular ICD was placed. The patient will need IV heparin until the INR reaches greater than 2.0. The patient's INR will need to be checked every week until the repeat transesophageal echocardiogram and ICD check in six to seven weeks. The goal INR is 2.5 to 3.0. The patient will be discharged on Coumadin 5 mg PO q.d. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: The patient is discharged to [**Hospital1 **] Rehabilitation. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Cardiomyopathy. 3. Coronary artery disease status post myocardial infarction times two. 4. Atrial fibrillation status post biventricular ICD placement. 5. Chronic obstructive pulmonary disease. 6. Rheumatic heart disease with mitral stenosis. 7. Cerebrovascular accident. DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg PO q.d. 2. Ambien 5 mg PO q.h.s. 3. Multivitamin one capsule PO q.d. 4. Lipitor 10 mg PO q.d. 5. Digoxin 0.125 mg PO q.d. 6. Captopril 12.5 mg PO t.i.d. 7. Miconazole powder 2% one application t.i.d.p.r.n. breast rash. 8. Potassium chloride. 9. Spironolactone 25 mg PO q.d. 10. Lasix 125 mg PO q.d. 11. Peri-Colace one cap PO b.i.d. 12. Coumadin 5 mg PO q.d. with a goal INR of 2.5 to 3. 13. Tylenol 325 mg to 650 mg PO q.4h. to 6h.p.r.n. pain. 14. Carvedilol 3.125 mg PO b.i.d. with meals. 15. Keflex 500 mg PO q.6h. times six dose total. 16. Heparin IV with the following algorithm: For PTT less than 40, increase heparin dose by 200 units per hour without bolus; for PTT 40 to 49, increase dose by 100 units per hour without bolus; for PTT 50 to 70, continue the same dose; for PTT 71 to 90, hold the infusion for 30 minutes then decrease the heparin dose by 100 units per hour and restart the infusion; for PTT 91 to 110, hold the infusion for 60 minutes, then decrease the heparin dose by 200 units per hour and restart the infusion; for PTT greater than 110, hold the heparin infusion for two hours, then decrease the infusion by 300 units per hour, then restart the infusion. FOLLOW UP APPOINTMENTS: 1. Electrophysiology laboratory-[**Location (un) **] [**Hospital Unit Name 723**] at the [**Hospital1 69**] on [**2167-10-13**], at 10 AM. Telephone #: [**Telephone/Fax (1) 45015**]. 2. Device Clinic, [**Location (un) 436**], [**Hospital Ward Name 23**] Clinical Center, on Tuesday, [**2167-8-23**] at 1:30 PM. Telephone #: [**Telephone/Fax (1) 21817**]. [**Doctor First Name 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. [**MD Number(1) 9632**] Dictated By:[**Last Name (NamePattern1) 1336**] MEDQUIST36 D: [**2167-8-18**] 15:52 T: [**2167-8-18**] 16:13 JOB#: [**Job Number 45016**]

Admission Date: [**2163-4-15**] Discharge Date: [**2163-4-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4654**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Dialysis History of Present Illness: 86 y/o f c/ CHF EF 25%, CAD, ESRD on HD M/W/F, woke from sleep with increased SOB and worsening cough. She reports 3 days of increasing cough and sputum production. CXR at her nursing home 2 days ago was consistent with PNA and oral antiobiotics were initiated. She denies any chest pain, palpitations, fevers, chills, or nightsweats with these symptoms. She has noted lower extremity edeam which is not baseline for her and [**2-8**] loose stools/day since initiation of antibiotics. She is due for her regularly scheduled hemodialysis today. Despite initiation of abx her cough worsened, she also vomited qam x 2 days [**2-7**] coughing 3 days PTP- non bloody, non-bilious emesis. No sick contacts. Does not report further diarrhea. No constipation, no dysuria. No arthralgias. . In ED, vitals were T98.3 HR93 BP129/78 RR32 POx99. Sats 88% RA on arrival and improved with 2 nebs to 96% 4L with ABG 7.43/47/74. Patient received albuterol/ipratropium nebs, levofloxacin 750mg IV, Methylprednisolone 125mg IV, 1gm ceftriaxone, 1gm vancomycin. Lactate 1.7. Patient was transferred to the [**Hospital Unit Name 153**] for tachypnea. . On arrival to the [**Hospital Unit Name 153**], patient was comfortable reporting significant improvement since receiving nebulizer treatment in the ED. She continues to report cough but denies SOB, DOE, nausea, vomiting, CP, fevers, chills, pleuritic pain, abdominal pain, dysuria. . In the [**Hospital Unit Name 153**] the patient received broad spectrum abx and nebulizers. With that her O2 requirement decreased and her respiratory status improved. She also underwent regularly scheduled HD on the day of transfer during which 2 kg of fluid was removed. Past Medical History: Coronary Artery Disease with Coronary artery bypass graft x 3 [**2162-8-16**] (LIMA-LAD, SVG-OM, SVG-PDA) Mitral valve annuloplasty [**2162-8-16**] Systolic CHF (LVEF 30% on TTE [**2162-8-27**]) Chronic Kidney Disease Hyperlipidemia Hypertension Gout Diverticulosis Depression Status post choleycystectomy Status post hernia repair Status post hip fracture repair Social History: She is a retired travel [**Doctor Last Name 360**]. She recently quit smoking but previously smoked one pack per week for 70 years. She denies alcohol use. No illicit drug use. She is now coming from rehab but previously lived with her husband until he had an MI. She has two children [**Location (un) 86**] and [**Hospital1 614**] who are very involved. Family History: Mother had hypertension. Father had hypertension and CVA. No family history of cardiac disease or sudden cardiac death. Physical Exam: Presentation VS: Temp = 96.2F, BP = 116/61, HR = 68, RR = 28, 97% on 2L GENERAL - chronically ill-appearing elderly female comfortable, speaking in full sentences, appropriate. Good recall of events. She can clearly tell me about her PMH. No evidence of delirium. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMD, lower dentures in place NECK - supple, appears elevated but difficult to assess JVD [**2-7**] right IJ HD catheter LUNGS - patient refused to let me listen to her lungs- tired HEART - HS distant, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, pitting edema b/l to just below knees, 1+ peripheral pulses (radials, DPs), left heel exophytic ulceration 4x5 cm unable to stage without drainage SKIN - 1x1cm 0.5cm deep sacral decubitus ulcer, no drainage - per ICU note LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-10**] throughout, sensation grossly intact throughout Contracted lower extremities. Pertinent Results: CXR: [**4-11**] [**2163**]- cardiolmegaly, CHF, RLL infiltration from NH . [**2163-4-15**] CXR - b/l pleural effusion, bibasilar atelectasis and dense retrocardiac opacity, atelectasis vs. pneumonia, right hilar fullness, recommend f/u w/ PA/L to further evaluate hilar fullness, cardiomegaly baseline . [**10-13**] TTE: Normally-functioning mitral annuloplasty ring. Severe regional left ventricular systolic dysfunction, c/w multivessel CAD. Moderate pulmonary hypertension. . [**2163-4-15**] EKG: NSR 88, Nl axis, IVCD, t-wave inversion in V6 isolated as compared with old [**2162-10-15**]. <br> [**2163-4-15**] 06:00PM CK(CPK)-26 [**2163-4-15**] 06:00PM CK-MB-3 cTropnT-0.10* [**2163-4-15**] 09:13AM TYPE-ART RATES-/33 PO2-75* PCO2-47* PH-7.43 TOTAL CO2-32* BASE XS-5 INTUBATED-NOT INTUBA [**2163-4-15**] 06:51AM LACTATE-1.7 [**2163-4-15**] 06:10AM GLUCOSE-109* UREA N-30* CREAT-4.0* SODIUM-139 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-19 [**2163-4-15**] 06:10AM CK(CPK)-25* [**2163-4-15**] 06:10AM cTropnT-0.10* [**2163-4-15**] 06:10AM CK-MB-NotDone proBNP-[**Numeric Identifier 106286**]* [**2163-4-15**] 06:10AM ALBUMIN-3.2* [**2163-4-15**] 06:10AM WBC-7.3 RBC-3.48*# HGB-11.6*# HCT-36.7# MCV-106* MCH-33.2* MCHC-31.5 RDW-16.4* [**2163-4-15**] 06:10AM NEUTS-90.7* LYMPHS-6.4* MONOS-1.7* EOS-1.2 BASOS-0 [**2163-4-15**] 06:10AM PLT COUNT-120* <br> PA AND LATERAL CHEST, [**4-16**]. . HISTORY: End-stage renal disease and CHF with shortness of breath. . IMPRESSION: PA and lateral chest compared to [**8-15**]: . Mild interstitial edema has cleared from the left lung, persists at the right base. Lateral view shows small right pleural effusion collected posteriorly. Moderate cardiomegaly unchanged. No pneumothorax. Dialysis catheter ends in the SVC. <br> CXR [**4-17**]: REASON FOR EXAM: CHF and tachypnea. . Comparison is made with prior studies [**4-15**] and 11. . Moderate cardiomegaly is unchanged. Mild interstitial pulmonary edema is unchanged, asymmetric and greater on the right side. Small-to-moderate bilateral pleural effusions are increased on the right side. Retrocardiac opacity is consistent with atelectasis. Right supraclavicular catheter is in place. Sternal wires are aligned. The patient is status post MVR. Brief Hospital Course: 86 y/o f c/ CHF, CAD, ESRD on HD presenting from nursing facilty with SOB and worsening cough x5 days admitted to [**Hospital Unit Name 153**] with concern for respiratory distress. Hospital Course as below: <br> #. Respiratory Distress - sx improving as of am of [**4-16**], CXR demonstrating retrocardiac opacity consistent with PNA and b/l pleural effusions, with repeat CXR [**4-16**] showing improvement but persistant R base findings - cont tx for PNA. Etiology likely multifactorial in setting of CHF, ESRD on HD and PNA. Improved after starting on Abx and particularly especially w/ regularly scheduled HD with improved volume status. Overall, CXR suggestive more of R-sided PNA after fluid taken out - plan to cont abx. Noted events with increased SOB sx overnight [**4-16**] - overall pt 1.6L positive for [**4-16**] - mildly increased fluid on exam/CXR - with PNA process pt with lower threshold for fluid as prior - in addition with noted upper resp secretions - declined deep suctioning, but improved with mucolytics agents and with min secretions as of [**4-18**]. Pt recieved HD [**4-18**] - doing well following - plan to complete 8 day course of antiobiotic (finishing [**4-22**]) - changed to po cefopodixime today, cont IV vanc post HD). - HD as below, (noted pt can only make scant urine) - decreased fluid intake [**4-17**] - pt doing better - change nebs to q6h PRN - cont mucomyst nebs and guaifensin to [**Month/Year (2) **] w/ secretions for next 2 days - can then change to just PRN - origninally treated for for healthcare associated PNA, especially as known MRSA, was treated with broad spectrum abx with report failed to fluroquinolone prior - it was confirmed that the abx was levoquin (started [**4-11**]) - based on this d/c levoquin as of [**4-16**] - unable to obtain adequate sputum cx - tx as above <br> #. Acute on Chronic systolic Heart Failure - EF 25% at baseline, appears volume overloaded on exam (fluctuates with HD). W/ Known pulm HTN likely exacerbated by underlying pulmonary infectious process. Cardiac enxymes below baseline, BNP elevated. - manage volume status w/ HD - continue aspirin, statin, BB - ruled out for ACS - d/c to NH today - ***noted pt will have extra volume taken of at HD tomorrow - renal service here had communicated this with her outpt center so will proceed as such tomorrow <br> #. ESRD on HD - M/W/F - HD done yesterday, cont prior regime - with Vanc IV to be given post HD AND po cefopodoxime 200mg to be given after (2 more doses pending for W and F HD -as above, - ***noted pt will have extra volume taken of at HD tomorrow - renal service here had communicated this with her outpt center so will proceed as such tomorrow <br> #. Skin Breakdown - has heel and sacral decub on admission - wound care to heel as recommended by wound care nurse - needs close monitoring and follow-up - clears recs per d/c summary/instructions - wound care to sacral decub per recs - alb noted 2.8 <br> Vascular wounds: Pt refused a thorough exam thus difficult to assess if she has PVD wounds as per dtr. Dtr wanted pt to be seen by vascular surgery while in house since she has an appt with Dr. [**Last Name (STitle) 2716**] on Tuesday. As pt in-house on [**4-19**] - pt will be d/c and sent to clinic appt and transported to NH following <br> #. h/o Afib - currently rhythm and rate controlled - continue amiodarone, BB, aspirin <br> #. Depression - continue home mirtazipine/citalopram <br> # thrombocytopenia - mildly lower than mid 100s baseline - hep sc d/c [**4-17**] - mildly improved on [**4-18**] to 98 from 83. Given improvement - can be monitored more as outpt unless clinical situation changes. <br> #. FEN - low Na/cardiac/renal diet, manage lytes with HD, low phos diet . #. Access - PIV . #. PPx - -DVT ppx changed as above to scds -Bowel regimen prn -Pain management with tramadol -GI prophylaxis with home PPI . #. Code - FULL - Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - [**Telephone/Fax (1) 106287**] Note following discussion per nocturnist on admission to medical floor [**4-16**]: Spoke to dtr for 30 [**Name2 (NI) **] on admission. Dtr initially very upset to be called in the middle of the morning. [**Name8 (MD) **] RN children have been abusive to ICU staff as well. Dtr apologized for outburst and said that she understands that we are trying to give her mother good care but she is an overwhelmed caregiver. . With regards to code status- she was DNR/DNI but she had to reverse it to have her sternal wound repaired. She thinks her mother would not want to be a full code and would like to be DNR/DNI. . # Contact: [**Name (NI) **] [**Last Name (NamePattern1) **]-PLEASE DO NOT CALL EARLY IN THE MORNING OR LATE AT NIGHT. . Disposition: pt medically improved now and stable - pt to be d/c now and sent to outpt vasc [**Doctor First Name **] appointment then to be transferred back to nursing home - pt was not d/c [**4-18**] due to prior NH not accepting pt back due to prior financial obstacles and no safe disposition was available - daughter informed - able to work out problem - pt accepted again today - and able to be d/c back to NH Medications on Admission: Accuzyme topical dosage unknown albuterol solution Q4-6 hours prn Amiodarone 200mg daily Aspirin 81mg daily Calcitriol 0.25mg QOD Citralopam 30mg daily Omeprazole 20mg daily Simvistatin 80mg Daily Lopressor 25mg [**Hospital1 **] Hydralazine 50mg [**Hospital1 **] Lidoocaine patch 5% daily Megestrol 40mg [**Hospital1 **] Mirtazapine 7.5mg QHS MVI Senna prn Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Tramadol 50 mg Tablet Sig: 0.25 Tablet PO Q8H (every 8 hours) as needed for pain. 14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours): PLEASE CHANGE THIS MEDICATION TO ONLY PRN FOR SECRETIONS STARTING [**2163-4-21**]. 15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for for increased secretions: PLEASE CHANGE TO ONLY PRN FOR SECRETIONS STARTING [**2163-4-21**]. 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 18. Cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO QHD (each hemodialysis) for 4 days: ***TO BE GIVEN 2 MORE TIMES TOTAL - ON WEDNESDAY ([**4-20**]) AND FRIDAY ([**4-22**]), AFTER HD, THIS WILL COMPLETE PT'S 8 DAY PNA TREATMENT COURSE. 19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol) for 4 days: ***TO BE GIVEN 2 MORE TIMES TOTAL - ON WEDNESDAY ([**4-20**]) AND FRIDAY ([**4-22**]) AFTER HD, THIS WILL COMPLETE PT'S 8 DAY PNA TREATMENT COURSE. 20. Megestrol 40 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] of [**Location (un) 55**] Discharge Diagnosis: # CHF Exacerbation # ESRD - HD dependent # Pneumonia # Pressure Ulcers (from prior) # h/o Atrial Fibrillation # Depression # mild thrombocyopenia - Please tell your future provider to be cautious and to closely monitor your platelets when anyone uses heparin Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1L per day (or less) <br> Your diagnosis are as below - you are to resume treatment for your PNA with antibiotics to be given as prescribed following your next Wed and Fri HD sessions - will then be completed. Limit your usual fluid intake as above as with this mild infection your ability to tolerate extra fluid in your lungs are even less. <br> If your breathing gets worse - if you are having more secretion problems - get immediate mucomyst neb and albut/ipratrop nebs - cont/resume your Guaifenesin and scheduled mucomyst nebs for next 2 days if you have improving sx to initial treatment. If worsens and developing new fevers/chills - or any other concerning symptoms - return to the hospital. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2163-4-19**] 2:15 <br> Please call and arrange a follow-up appointment with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 569**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**] in [**2-8**] weeks. [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] Completed by:[**2163-4-19**]

Admission Date: [**2156-1-9**] Discharge Date: [**2156-1-19**] Date of Birth: [**2156-1-9**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [**Doctor First Name 59180**] [**Known lastname 59181**] is a former 2.925 kilogram product of a full term uncomplicated gestation pregnancy born to a 27 year old G-2, P-0 now 1 woman. Prenatal screens - Blood type O positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta Strep negative. Prior OB history was notable for an ectopic pregnancy. There was a spontaneous onset of labor and rupture of membranes occurred seven hours prior to delivery. There was no maternal intrapartum fever. The infant was born by spontaneous vaginal delivery. Apgar's were 9 at one minute and 9 at five minutes. He transitioned normally and was admitted to the newborn nursery with normal vital signs. In the mother's room he was noted to develop grunting respirations and poor color. He was transferred to the Neonatal Intensive Care Unit for further evaluation. PHYSICAL EXAMINATION: Temperature 99.4 rectally, heart rate 180, respiratory rate 40, oxygen saturation 96 percent. General - Nondysmorphic term male in moderate respiratory distress. HEENT - Anterior fontanelle soft and flat, left parietal cephalohematoma, small positive red reflex bilaterally, palate intact. Chest - Grunting respirations, breath sounds audible bilaterally, negative transillumination for pneumothorax. Cardiovascular - S1 and S2, grade II/VI systolic murmur at the left sternal border, brachial and femoral pulses palpable. Abdomen - Soft with no distension, no masses. GU - Normal male. Neurologic - Tone normal, activity level overall reduced but responsive to stimulation with strong cry. Blood pressure 65/37 with a mean of 50. HOSPITAL COURSE: 1. Respiratory. [**Doctor First Name 59180**] continued with grunting respirations. He was placed in nasal cannula O2 at 200 cc to maintain oxygen saturations greater than 95 percent. A chest x-ray showed a normal heart size with asymmetric opacification predominantly right-sided suggestive of pneumonia. Blood gases were within normal limits except for some mild metabolic acidosis. The oxygen was weaned to room air by day of life number four and [**Doctor First Name 59180**] has remained on room air since that time. 2. Cardiovascular. With the presentation with poor perfusion, there was initially suspicion for congenital heart disease. Four limb blood pressures were within normal limits and the EKG was within normal limits. Cardiac silhouette on the chest x-ray was within normal limits. He was presumed to be in septic shock and required normal saline boluses and eventually dopamine at a maximum administration of 17 mcg/kg/min to maintain adequate perfusion and blood pressure. The dopamine was weaned off by day of life number 4. 3. Fluids, electrolytes and nutrition. This baby was initially NPO and maintained on intravenous fluids. An umbilical arterial catheter was placed for central access. He required several boluses of sodium bicarbonate to treat his metabolic acidosis. Enteral feeds were initiated on day of life number 5 and gradually advanced. At the time of discharge he is ad lib breastfeeding to taking Similac formula. Weight on the day of discharge is 3.22 kilograms with a length of 49.5 cm. Serum electrolytes were monitored during the initial period of illness and were within normal limits. 4. Infectious disease. A blood culture and complete blood count were obtained upon admission to the Neonatal Intensive Care Unit. The white blood cell count was remarkable for severe neutropenia with a count of 1,900 with a differential of 6 percent polys and 1 percent bands. The blood culture grew gram positive cocci within eight hours and was later identified as group B Streptococcus. Intravenous ampicillin and gentamicin were initiated after the initial blood culture was drawn. [**Doctor First Name 59180**] received seven days of gentamicin, five days of ampicillin which was then changed to Penicillin to complete a ten day course. Repeat blood cultures on [**1-10**] and [**2156-1-11**] were no growth. A lumbar puncture was performed on day of life number three and had 1 red blood cell and 8 white blood cells per high power field, normal glucose and protein. CSF cultures were also no growth. 5. Hematological. Hematocrit on admission was 41.4 percent and hematocrit repeated on day of life number three was 35.1 percent. The white blood cell count normalized over the first two days of antibiotic treatment. Most recently on day of life four the white blood cell count was 14,400 with a differential of 43 percent polys, 2 percent bands. Initial platelet count was 280,000 and platelets fell to 107,000 on day of life number three and repeated on day of life number four were stable at 119,000. All of the abnormal CBC results are consistent with his group B Strep sepsis. 6. Gastroenterology. Serum bilirubin's were monitored. Peak serum bilirubin occurred day of life number two with a total of 7.5/0.5 direct. He did not require any treatment. 7. Neurology. [**Doctor First Name 59182**] neurological exam has been unremarkable with only some initial mildly reduced activity and irritablity which resolved over the course of the admission. 8. Sensory. Audiology - Hearing screening was performed with automated auditory brain stem responses. [**Doctor First Name 59180**] passed in both ears. CONDITION ON DISCHARGE: Good. DISPOSITION: Home with parents. The primary pediatrician is Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], [**Hospital1 **], 26 City [**Doctor Last Name **] Mall, [**Location (un) 1468**], [**Numeric Identifier 5689**], phone number [**Telephone/Fax (1) 55217**]. CARE AND RECOMMENDATIONS: 1. Ad lib breastfeeding or supplemented with Similac formula. 2. No medications. 3. Car steat position screening not indicated. 4. State newborn screen was sent on [**2156-1-13**] with no notification of abnormal results to date. 5. Hepatitis B vaccine was administered on [**2156-1-16**]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria. The first is born at less than 32 weeks; second 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 sibling; or thirdly 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 care-givers. Follow-up appointments recommended: 1. Appointment with primary pediatrician, Dr. [**Last Name (STitle) **], has been scheduled for Wednesday [**1-21**]. 2. VNA referral made - they will visit on Thursday [**1-22**]. DISCHARGE DIAGNOSES: 1. Group B Strep Sepsis. 2. Septic shock - resolved. 2. Rule out congenital heart disease - resolved. 3. Hyperbilirubinemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**] Dictated By:[**Last Name (Titles) 59183**] MEDQUIST36 D: [**2156-1-19**] 03:44:55 T: [**2156-1-19**] 05:55:11 Job#: [**Job Number 59184**]

Admission Date: [**2194-8-22**] Discharge Date: [**2194-8-28**] Date of Birth: [**2143-4-24**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Iodine Containing Agents Classifier Attending:[**First Name3 (LF) 78**] Chief Complaint: Right sided Motor seizures Major Surgical or Invasive Procedure: Left frontal/parietal crani for tumor resection History of Present Illness: 51 y/o female who initially presented to the ED after having a right sided motor seizure while ridding her bike. CT revealed a left parasagital tumor. Past Medical History: High cholesterol, migraines Social History: Lives at home with husband 3 kids 16/19/22 Family History: NC Physical Exam: Exam on Discharge: awake, alert and oriented x3 PERRL, EOMI face symmetric, tongue midline strengths: t d b tr g ip q h at [**Last Name (un) **] g R 1 1 1 1 0 4+ 4+ 3 2 3 1 sensation intact to light touch, symmetric ambulating with cane no clonus tolerating PO diet. No pain. Voiding without difficulty Incision- well healing. staples intact, no drainage x3 days Pertinent Results: [**2194-8-22**]: Post operative CT: The patient is status post left frontoparietal craniotomy with resection of large falcine mass in the left frontal lobe. There is postoperative pneumocephalus, fluid, and edema. There is no evidence of hemorrhage, infarct, mass, or mass effect outside of the surgical field. There are no osseous abnormalities other than craniotomy. Sinuses and mastoid air cells are well pneumatized. IMPRESSION: Expected postoperative appearance, status post left frontal craniotomy and mass resection. [**2194-8-23**]: MRI head: IMPRESSION: Status post resection of falx meningioma with expected post-surgical changes. Normal enhancement of the superior sagittal sinus is noted. Mild meningeal enhancement is seen. No evidence of acute infarcts or hydrocephalus. [**2194-8-25**] Head CT:IMPRESSION: Expected post-surgical changes as above, showing interval decrease in the volume of pneumocephalus. NOTE ADDED AT ATTENDING REVIEW: There has been a slight increase in the volume of hemorrhage at the surgical site. There is not enough to produce mass effect, but continued close follow up is recommended. This information was paged to Dr. [**First Name (STitle) **] at 10:20 am on [**2194-8-25**]. [**2194-8-26**] Head CT: IMPRESSION: Stable appearance of the brain with post surgical changes and persistent left vasogenic edema. No evidence of new abnormalities. [**Date range (1) 3923**] EEG: pending. verbal preliminary report- slowing but no definitive seizure activity. [**8-28**] MRI head: pending Brief Hospital Course: Mrs. [**Known lastname 634**] was admitted on [**8-22**] to udergo an elective craniotomy for tumor resections. After a MRI for Operative planning she was brought to the operating room. She was quite hypertensive pre-operatively. Surgical course was uncomplicated. Post operatively she was taken to the ICU for Q one hour neuro checks and blood pressure control, which only required and responed well to a few doses of hydralazine. Her physical exam was noted to be a different post operatively, particularly with right extremity weakness particularly in her trap, delts and triceps. She also was noted to have distal right lower extremity weakeness. Given the extensive edema that was seen on CT we increased her decadron dose to 6mg Q 4 and noted an improvement in her exam by POD #2. Post operative Head CT and MRI were stable, revealing post operative changes. She was safe and stable and transfer to the floor was written for on [**8-23**]. PT and OT and were consulted and recommended discharge home with outpatient PT. On [**8-24**] PM She developed right sided ascending paresthesias that lasted a few minutes and left her right arm plegic. A head CT was performed but stable. EEG monitoring was ordered and Keppra was increased to 1500mg [**Hospital1 **]. On [**8-25**] her incision began oozing with large clots. Her SQH was discontinued. On [**8-26**] her neurological exam was slightly improved. A repeat Head CT was obtained prior to the EEG leads being attached. This was found to be stable. EEG monitoring was initiated. On [**8-27**] EEG monitoring was continued. her neurological exam remained stable. Preliminary [**Location (un) 1131**] on EEG is significant for slowing but no definitive seizure activity. At this time it was discontinued and an MRI with perfusion was requested. On [**8-28**] she was again neurologically stable. MRI was completed and she was fitted for an AFO brace to be worn when out of bed. She was cleared at this time for discharge home with outpatient PT. Medications on Admission: Lipitor 10mg QD Singular 10mg QD ? Protonix Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*3* 8. 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* 9. Dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 4 weeks: * 2 tabs Q6hrs [**Date range (1) 87118**] * 2 tabs Q8hrs [**Date range (1) 87119**] * 2 tabs Q12hrs [**Date range (1) 39444**] * 1 tab Q12hrs [**Date range (1) 4215**] * [**12-21**] tab Q12hrs [**Date range (1) 60429**] * [**12-21**] tab Qday [**Date range (1) 17948**]. Disp:*qs Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: s/p Craniotomy and meningioma excision Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: General Instructions ?????? 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 after 72 hours from your surgery, you should initially just use a mild shampoo or just water run over it. ?????? 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, unless you have been instructed not to. 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, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions/ ??????Please return to the office Next Thursday [**9-4**] for removal of your staples/sutures and/or a wound check. This appointment can be made with the NP or PA. 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. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.[**First Name (STitle) **] , to be seen in ___4____weeks. ?????? You have a Brain [**Hospital 341**] clinic appointment on [**9-22**] at 9:30AM on [**Hospital Ward Name 23**] 8. Completed by:[**2194-8-28**]

Admission Date: [**2198-6-8**] Discharge Date: [**2198-6-9**] Date of Birth: [**2160-1-22**] Sex: F Service: NEUROSURGERY Allergies: shrimp Attending:[**First Name3 (LF) 78**] Chief Complaint: L ICA aneurysm Major Surgical or Invasive Procedure: [**2198-6-8**]: Cerebral angiogram for a stent assisted coiling History of Present Illness: 38F elective admission for a stent assisted coiling of the L ICA aneurysm Past Medical History: Hypothyroidism C-section Social History: Married, has 14 month old twins. Nonsmoker. Family History: Family history is negative for aneurysm of any kind, or bleeding disorders. Her father has lymphoma and her mom has hypertension. Physical Exam: Pre-op: Nonfocal exam, MAE [**4-19**]. Upon discharge: xxxxxxxxxxxx Pertinent Results: [**2198-6-8**] 07:00AM PT-13.1 PTT-34.8 INR(PT)-1.1 [**2198-6-8**] 07:00AM PLT COUNT-224 [**2198-6-8**] 07:00AM NEUTS-68.9 LYMPHS-22.1 MONOS-6.2 EOS-1.7 BASOS-1.0 [**2198-6-8**] 07:00AM WBC-5.3 RBC-3.98* HGB-12.8 HCT-36.3 MCV-91 MCH-32.2* MCHC-35.2* RDW-12.7 [**2198-6-8**] 07:00AM estGFR-Using this Brief Hospital Course: 38F elective admission for a L ICA stent assisted coiling, angioseal was used. Post-angio she was admitted to the ICU for observation. She was started on a Heparin drip for a PTT goal of 50-70. ASA was restarted. On [**6-9**], she remained stable. The angio site was dry with no hematoma. She was discharged home. Medications on Admission: Levoxyl 25 mcg Daily MVI Plavix 75 mg Daily (for 5 days prior to procedure) Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 4. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-17**] Tablets PO Q4H (every 4 hours) as needed for headache. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: L ICA aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily for one month. ?????? Take Plavix (Clopidogrel) 75mg once daily for one month. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin 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 or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a MRI/MRA Brain w/ and w/o contrast (Dr [**First Name (STitle) **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2198-6-20**]

Admission Date: [**2120-12-2**] Discharge Date: [**2120-12-23**] Date of Birth: [**2054-7-23**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: [**2120-12-2**] Five vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending; saphenous vein grafts to diagonal, first and second obtuse marginals, and posterior descending artery [**2120-12-5**] Exploratory laparotomy, liver biopsy and cholecystectomy History of Present Illness: This 66 year old woman has a history of hypertension, hyperlipidemia and diabetes. Several weeks prior to admission, she reported that she has had two episodes of chest pain and shortness of breath. The first occurred while having to climb up 32 steps at a movie theatre during a fire drill. She describes having very severe shortness of breath and a feeling that there was no way she would make it to the top. The second episode occurred while trying to walk [**State 101220**]to go from her parking lot to the theatre. She again described having severe shortness of breath and chest pains, resolving with relaxation. She states that she recently saw her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3845**] who told her that her EKG looked significantly different compared to the one from several years back. She has since seen Dr. [**First Name (STitle) 33428**] [**Name (STitle) **] in consultation and underwent stress testing that was positive for ischemia. Subsequent cardiac catheterization on [**2120-11-21**] revealed three vessel coronary artery disease and a reduced ejection fraction without evidence of mitral regurgitation calculated at 34%. Coronary angiography showed a codominant system; the LAD showed a 80% stenosis of the midsegment followed by sequential 80% stenosis in the distal segment, accompanied by a 80% proximal D1 stenosis; the LCX was a large, codominant vessel with an 80% midsegment stenosis and 80% OM2 and 80% OM3 stenoses; the RCA showed an 80% midsegment stenosis with a 100% distal occlusion and left to right collaterals filling the codominant RPDA. Based on the above results, she was referred for cardiac surgical intervention. At the time of cardiac catheterization, she underwent routine preoperative evaluation. She was cleared and discharged home per cardiology. She now presents for elective surgical coronary revascularization. Past Medical History: Coronary artery disease; Obesity; NIDDM; HTN; GERD; Hyperlipidemia; Hypothyroidism; Neuropathy; Osteoarthritis; Bells Palsy; History of Foot Ulcers, Osteomylelitis with MRSA Social History: Patient is widowed and lives alone. Denies tobacco and ETOH. Family History: Father with rheumatic fever as a child and valve disease. He died suddenly at age 51. Mother died at a young age of unknown causes. Physical Exam: Vitals: BP 150/60, HR 79, RR 14, SAT 97% on room air General: well developed female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2120-12-2**] 07:25PM BLOOD WBC-6.9 RBC-2.62*# Hgb-7.3*# Hct-21.9* MCV-84 MCH-28.0 MCHC-33.5 RDW-14.5 Plt Ct-87* [**2120-12-2**] 07:25PM BLOOD PT-17.1* PTT-31.5 INR(PT)-2.0 [**2120-12-2**] 08:42PM BLOOD UreaN-16 Creat-0.8 Cl-109* HCO3-24 [**2120-12-5**] 09:10PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2120-12-19**] 04:21AM BLOOD WBC-10.9 RBC-3.78* Hgb-10.8* Hct-32.0* MCV-85 MCH-28.5 MCHC-33.7 RDW-17.5* Plt Ct-383 [**2120-12-19**] 04:21AM BLOOD PT-21.5* INR(PT)-3.3 [**2120-12-20**] 07:21AM BLOOD Glucose-149* UreaN-19 Creat-1.9* Na-142 K-3.6 Cl-104 HCO3-26 AnGap-16 [**2120-12-17**] 02:40AM BLOOD ALT-67* AST-22 LD(LDH)-300* AlkPhos-117 Amylase-77 TotBili-0.7 [**2120-12-19**] 04:21AM BLOOD Procain-1.9* NAPA-13.2 Brief Hospital Course: Patient was admitted and underwent five vessel coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. The operation was uneventful and she transferred to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated. She weaned from inotropic support without difficulty and transferred to the SDU on postoperative day one. On postoperative day two, she developed atrial fibrillation which was treated with Amiodarone and beta blockade. Early on postoperative day three, she complained of right sided abdominal pain and concomitantly experienced altered mental status. Initial abdominal ultrasound was unremarkable while a head CT scan found no evidence for hemorrhage, or acute major vascular territorial infarction. She rapidly declined clinically, becoming unresponsive and hypotensive with increasing oxygen requirements and decreased urine output. She emergently returned to the CSRU where she underwent intubation and resuscitation. Monitoring lines were placed. Amiodarone was discontinued. She required pressors and was profoundly acidotic with an elevated lactate, low bicarbonate and high white count. Her creatinine also rose. Based upon this clinical picture and strong suspicion for mesenteric ischemia, she was taken without delay to the operating room. On [**2120-12-5**], an exploratory laparotomy, liver biopsy and cholecystectomy was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Operative findings were notable for severe liver and gall bladder congestion - there was no evidence of mesenteric ischemia as the large and small bowel appeared normal. Liver pathology was consistent with ischemia while gall bladder findings revealed mild chronic cholecystitis. She returned to the CSRU for further invasive monitoring and medical management. She was kept intubated and sedated while broad spectrum antibiotics were continued. Her acute renal failure was attributed to acute tubular necrosis secondary to hypoperfusion. Her creatinine peaked to 5.1. The renal service was consulted. She temporarily required CVVH. A renal ultrasound was unremarkable. Her urine output and hyperkalemia gradually improved with intravenous Lasix and Diurel. Her shock liver gradually improved as well. During her hospitalization, her AST and ALT peaked at 6339 and [**Numeric Identifier 101221**]; LDH and Alk Phos peaked at [**Numeric Identifier 101222**] and 276; and Total bili peaked at 2.9. A repeat abdominal ultrasound on [**12-6**] remained unremarkable. She concomitantly continued to experience episodes of atrial fibrillation and sinus bradycardia. Several cardioversions were attempted, but unsuccessful. Pronestyl and Procainamide therapies were eventually started in attempts to maintain a normal sinus rhythm. She was eventually started on tube feedings for nutritional support. Over several days, her clinical status improved. By postoperative day 10, she weaned from sedation and was re-extubated without incident. She remained neurologically intact and weaned from pressor support without difficulty. Her renal and liver function continued to improve. She maintained mostly a normal sinus rhythm with a rate in the 60-70's but continued to experience paroxsymal atrial fibrillation. Warfarin was eventually initiated. Procain and NAPA levels were monitored closely and titrated accordingly while serial ECGs were obtained to assess QTc interval. Tube feedings were eventually discontinued and her diet was slowly advanced as tolerated. On postoperative day 15, she returned to the SDU. Antibiotics were empirically continued. Medical therapy was optimized and Warfarin was dosed for a goal INR around 1.5 - 2.0. She continued to work with physical therapy and make clinical improvements. Due to poor IV access, a double lumen PICC line was temporarily placed in her right upper arm. She was eventually cleared for discharge to rehab on postoperative day 18. At discharge, her BP was 140-150/70-80 with a HR of 60-70 in sinus rhythm with oxygen saturations of 97% on room. Her sternotomy and laparotomy incisions appeared clean and dry while her bilateral lower extremity incisions appeared moderately erythematous and slightly warm to touch. There was also pitting edema. Given concern for wound infection/cellulitis, the lower leg staples were removed just prior to discharge and she will need to continue on antibiotic therapy. Of note, given her history of MRSA, she will need to remain on contact precautions. In addition, Warfarin at discharge will continue to be on hold for a supratherapeutic INR. Medications on Admission: Cardizem CD 120mg daily Metformin 1000mg every morning and evening, 500mg mid day Omeprazole 20mg daily Lipitor 20mg twice a day Armour thyroid "1grain" daily (patient will bring in bottle for review) Aspirin 81mg, three tablets every morning Glipizide 20mg twice a day Iron supplement Foltx one tablet twice a day Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO DAILY (Daily). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 10 days. 12. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 13. Procanbid 500 mg Tablet Sustained Release 12HR Sig: 1.5 Tablet Sustained Release 12HRs PO twice a day. 14. Warfarin 1 mg Tablet Sig: [**1-14**] Tablet PO once a day: Please hold for two days - [**12-21**], [**12-22**], and recheck INR. Dose should be adjusted for goal INR between 1.5 - 2.0. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: Coronary artery disease, s/p coronary artery bypass grafting; Postoperative Mesenteric Ischemia; Postoperative Hepatic Failure/Shock Liver; Postoperative atrial fibrillation; Postoperative Acute Renal Failure; Lower Leg Cellulitis; Obesity; NIDDM; HTN; GERD; Hyperlipidemia; Hypothyroidism; Diabetic Neuropathy; Osteoarthritis; History of Bells Palsy; History of Foot Ulcers, Osteomylelitis with MRSA Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Local wound care and monitor wounds for signs of infection. Patient needs to elevate legs and wear compression stockings. Warfarin should be dosed for goal INR around 1.5 - 2.0. Please arrange Warfarin follow up as outpatient with PCP prior to discharge from rehab. Please call with any concerns or questions. Followup Instructions: 1)Cardiac surgeon in [**4-16**] weeks, Dr. [**Last Name (STitle) **] - [**Telephone/Fax (1) 170**], call for appt. 2)Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3845**] - call office for appt prior to discharge from rehab. Dr. [**Last Name (STitle) 3845**] will need to monitor Warfarin as outpatient. 3)Local cardiologist, Dr. [**Last Name (STitle) **] - call office for appt prior to discharge from rehab. 4)Transplant surgery, Dr. [**First Name (STitle) **] - appt on [**2120-12-30**] @ 3PM at Transplant center in [**Hospital Unit Name **] [**Location (un) 436**] Completed by:[**2120-12-20**]

Admission Date: [**2162-1-21**] Discharge Date: [**2162-2-1**] Date of Birth: [**2077-12-11**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: Cornary Artery Bypass Surgery x 4 with LIMA-->LAD, reverse saphenous vein graft-->diagonal artery, posterior descending artery, obtuse marginal artery History of Present Illness: 84F with DM, CAD s/p IMI & PCI in [**2156**], PAF (not on coumadin due to a hematoma), and CKD presenting with 1 week history of malaise worsening last evening and associated with burning sensation in her chest. The patient denies any actual chest pain per se. The patient went to her PCP [**Last Name (NamePattern4) **].[**Name (NI) 10094**] office complaining of these symptoms which were similar to during her previous MI, albeit less severe than back then, and was sent here to [**Hospital1 18**] for cardiac catherization. The symptoms did not worsen with exertion. She also stated that she had some nausea associated with this sensation. She also reports that she has had some shortness of breath that has been chronic. She is able to walk about 300-400 feet before having to stop. On review of symptoms, the patient reports nocturia, but denies palpitations, orthopnia, paroxysmal nocturnal dyspnia, diarrhea, rectal bleeding or hemoptysis. She denies any pain. Past Medical History: CAD s/p IMI & PCI with Cipher stent to mid-RCA [**2156**] Paroxysmal atrial fibrillation DM with neuropathy CKD glaucoma hip replacement hypertension Social History: -Tobacco history: No tobacco history -ETOH: Social alcohol -Illicit drugs: None Family History: Brothers both had MIs, otherwise non-contributory Physical Exam: Admission exam: VS: T=...BP=147/76 HR=64 RR=18 O2 sat= 98% on RA GENERAL: Pleasant woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Unable to assess JVP due to neck girth. CARDIAC: Irregularly irregular, s1 s2, no m/r/g LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 1+ radial pulses bilaterally, unable to palpate DP bilaterally. Pertinent Results: Date/Time: [**2162-1-26**] at 09:18 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Left Ventricle - Ejection Fraction: 55% >= 55% LEFT ATRIUM: Mild spontaneous echo contrast in the LAA. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: No MS. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Small pericardial effusion. PRE-BYPASS: Mild spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global 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. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is a small pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and was AV paced. 1. Biventricular function is unchanged. 2. Aortic contours appear intact post decannulation. 3. Other findings are unchanged [**2162-1-30**] 07:50AM BLOOD WBC-11.6* RBC-3.27* Hgb-9.5* Hct-28.6* MCV-87 MCH-29.1 MCHC-33.3 RDW-14.5 Plt Ct-244 [**2162-1-31**] 07:00AM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2* [**2162-1-30**] 07:50AM BLOOD Glucose-59* UreaN-30* Creat-1.1 Na-131* K-4.4 Cl-100 HCO3-22 AnGap-13 [**2162-2-1**] 07:50AM BLOOD WBC-10.7 RBC-3.11* Hgb-9.3* Hct-27.7* MCV-89 MCH-30.0 MCHC-33.7 RDW-14.4 Plt Ct-289 [**2162-2-1**] 07:50AM BLOOD PT-16.6* PTT-28.5 INR(PT)-1.5* [**2162-1-31**] 07:00AM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2* Brief Hospital Course: 84 y.o woman with history of IMI s/p PCI to RCA in '[**56**], here with unstable angina and dyspnea now s/p cardiac catherization and evidence of 3 vessel disease. #Coronary artery disease - the patient underwent cardiac catherization that showed diffuse disease that was most amenable to re-vascularization by CABG. Cardiac surgery was consulted and pre-operative carotid ultrasounds, transthoracic echo was obtained. The patient was maintained on IV heparin due to her unstable angina and underwent CABG on [**2162-1-26**]. See operative note for full details. She was transferred to the intensive care unit on neosynephrine and propofol in stable condition. She was weaned from all vasoactive medication and extubated without incident. She was transferred to the step down unit. Chest tubes and pacing wires were removed per caridac surgery protocol. There was a small medial apical left pneumothorax seen on chest xray after chest tubes were pulled, which was stable at the time of discharge. Her foley had to be reinserted due to failure to void but the second attempt of removal was successful. Physical therapy continued to work with her to increase strength and endurance. On post operative day #6 she was tolerating a full oral diet, her incisions were healing well and she was ambulating with assistance. She was felt safe for discharge home with VNA services at this time. The patient remained in sinus rhythm throughout the hospital course with brief bursts of a-fib post-operatively. Per request of her cardiologist, Dr. [**Last Name (STitle) **], anti-coagulation with coumadin was initiated. Medications on Admission: lipitor 80 qd hctz 12.5 qd plavix 75 qd omeprazole 20 qd nifedipine 60 qd lisinopril 20 qd lopressor 25 [**Hospital1 **] ASA 325 MVI Novolin N 34 qam/10 qpm Novolin R SS Colace 100mg qhs Ativan [**Hospital1 **] lumigan drops Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Lisinopril 5 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Metoprolol Tartrate 25 mg Tablet Sig: .5 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Omeprazole Magnesium 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*qs * Refills:*0* 10. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension Sig: One (1) Subcutaneous twice a day: NPH 34units at breakfast, and 10 units at dinner- as you were taking pre-op. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Dr. [**Last Name (STitle) **] to manage for goal INR [**2-24**]. Dose will change daily. Disp:*30 Tablet(s)* Refills:*2* 14. Outpatient Lab Work serial PT/INR dx: atrial fibrillation goal INR [**2-24**] Results to Dr. [**Last Name (STitle) **]: [**Telephone/Fax (1) 10095**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease 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**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr [**Last Name (STitle) **] on [**3-4**] at 1:15 PM [**Telephone/Fax (1) 170**] Primary Care Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-23**] weeks [**Telephone/Fax (1) 10096**] Cardiologist Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 5768**] in [**1-23**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Dr. [**Last Name (STitle) **] to follow INR- confirmed with [**Name8 (MD) **], RN. VNA to draw on [**2-2**] and fax to [**Telephone/Fax (1) 10095**] Completed by:[**2162-2-1**]

Admission Date: [**2147-2-6**] Discharge Date: [**2147-2-15**] Date of Birth: [**2098-5-30**] Sex: M Service: SURGERY Allergies: Penicillins / Aspirin Attending:[**First Name3 (LF) 1390**] Chief Complaint: s/p Self inflicted stab wound to chest/abdomen Major Surgical or Invasive Procedure: [**2147-2-6**] Exploratory laparotomy History of Present Illness: 48 year old man with unknown past medical history with self inflicted anterior cheststab wounds. Per report, patient's roommate found him lying in his own blood with two stab wounds to his anterior chest (slightly left of sternum). Per report, patient stated that he "fell on the kitchen knife." He was taken to an area hospital where he was intubated secondary to combativeness and left chest tube placed with < 100 cc of immediate output (200 cc output upon arrival to [**Hospital1 18**]). Given penetrating abdominal trauma, he was taken to the OR immediately for exploration and was found to have a 2 cm left lateral lobe liver laceration. Also, given concern for possible mediastinal injury and possible pericardial tamponade, the mediastinum was explored. Past Medical History: Unknown Family History: Unknown psych family history Pertinent Results: [**2147-2-6**] 10:30PM GLUCOSE-365* LACTATE-6.1* NA+-132* K+-4.1 CL--101 TCO2-16* [**2147-2-6**] 10:20PM WBC-42.6* RBC-3.42* HGB-9.7* HCT-29.8* MCV-87 MCH-28.4 MCHC-32.6 RDW-13.6 [**2147-2-6**] 10:20PM PLT COUNT-464* [**2147-2-6**] 10:20PM PT-13.0 PTT-26.2 INR(PT)-1.1 Micro/Imaging: [**2147-2-7**] CXR Subtle decrease of the pre-existing retrocardiac opacity [**2147-2-7**] XR Left foot no plain film findings that suggest osteomyelitis [**2147-2-7**] wound cx GS - no polys, no orgs; Cx - BETA STREPTOCOCCUS GROUP B [**2147-2-7**] elevations [**2147-2-7**] urine cultur no growth [**2147-2-7**] sputum culture GS - 1+GPCs pairs; Cx - sparse growth commensal resp flora [**2147-2-6**] CXR LLL opacity [**2147-2-6**] KUB No abnormal radiopaque foreign body identified [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Findings LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Aortic valve not well seen. MITRAL VALVE: Mild (1+) MR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or electrodes. Conclusions Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Grossly preserved biventricular systolic function. No pericardial effusion. Brief Hospital Course: He was admitted to the Trauma Service and taken directly to the operating room because of hemodynamic instability where he underwent an exploratory laparotomy and a pericardial window was created. He was found to have a 2 cm liver laceration. He was taken to the ICU for hypotension and tachycardia ; he was found to have a Grade II liver laceration. Post operatively he was taken to the Trauma ICU where he remained intubated and sedated. Upon initial admission to the ICU he remained hypotensive and tachycardia; he received IVF and 6 units of PRBCs (his Hct on [**2-11**] was 22 and on [**2-13**] 24.8). Cardiology was also consulted for evaluation and management of ST elevations. Recommendations included to monitor serial enzymes and if remained stable no need to continue cycling. Also follow daily ECG and it was felt that because patient was without signs of pericarditis that no further treatment was warranted. If he did develop any signs of pericarditis then NSAID's would be treatment. An ECHO was also done which showed grossly preserved biventricular systolic function and no pericardial effusion. He was noted with increase in his diastolic blood pressure without any other associated symptoms such as headache, dizziness or chest pain. Lopressor was started for this. On [**2-7**], podiatry was consulted for left foot ulcer. Upon removal of hyperkeratotic tissue, there was a < 1cm in diameter ulceration noted to the plantar aspect of the 2nd metatarsal head tracking dorsally into the 1st and 2nd interspace and 2nd and 3rd MPJs. Erythema noted along the medial longitudinal arch as well as dorsally to the level of the midfoot. Synovial fluid was drained and sent for culture. The wound probed to skin but not to bone; left foot xray done and without evidence of osteomyelitis. Empirical Vancomycin and Zosyn were started. He was later changed to Levofloxacin 500 mg for a total of 14 days. His sedation was weaned and eventually he was extubated and was transferred to the floor on [**2-9**]. He has made significant gains in terms of his hemodynamic stability and his functional abilities. He has worked with Physical and Occupational therapy for ambulation and is independent with his walker. He is on a regular diet and is tolerating this without any difficulties. His current vitals signs are T 98.9 BP 122/67 HR 74 (90 w/ activity then back down to 70's) room air sats 95%. His hematocrit as mentioned previously has run low and has been followed closely along with other hemodynamic monitoring. There are no signs of any active bleeding at this time. He failed an initial voiding trial and the Foley was replaced and he was started on Flomax. The Foley should remain in place for at least another several days before another voiding trial is initiated. For pain control he is receiving Tylenol and prn Dilaudid. His abdominal staples remain in place, wound edges are well approximated. The staples will need to be removed in [**10-19**] days post procedure date. Medications on Admission: Unknown Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 13 days. 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day. 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] Discharge Diagnosis: s/p Self inflicted stab wounds to chest & abdomen Grade II liver laceration Left foot ulcer/infection Acute blood loss anemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were hospitalized following self inflicted stab wounds to your chest & abdominal regions and were taken to the operating room for exploration of your injuries. You were found to have an injury to your liver. You are being treated with an oral antibiotic called Levofloxacin which will need to continue until [**2147-2-26**]. Followup Instructions: Follow up next week with Dr. [**Last Name (STitle) **], Trauma Surgery for removal of your staples. If you are discharged to [**Hospital1 **] 4 the nurse from that unit may contact the trauma resident pager [**Numeric Identifier 85877**] during the week of [**2-19**] to have them removed. Completed by:[**2147-4-19**]

Admission Date: [**2199-7-5**] Discharge Date: [**2199-7-13**] Date of Birth: [**2123-4-14**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Descending colostomy [**2199-7-6**] History of Present Illness: 76 yo female with Paget's disease of the anus who presents with a large bowel ostruction. She was taken to the operating room on [**2199-7-6**] for descending colostomy. Past Medical History: Colon cancer s/p lap resection '[**93**] HTN Paget's disease s/p resection [**12-2**] Family History: Noncontributory Physical Exam: Vitals: T 98.8 HR 104 BP 110/54 RR 16 96% RA Gen: A&Ox3 CV: regular rate and rhythm Pulm: Clear to auscultation bilaterally Abdomen: Soft, tender at LLQ, distended with tympany; no rebound tenderness Rectal: tight anal stricture Pertinent Results: [**2199-7-5**] 02:19PM GLUCOSE-131* UREA N-48* CREAT-2.0* SODIUM-137 POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17 [**2199-7-5**] 02:19PM ALT(SGPT)-21 AST(SGOT)-19 ALK PHOS-97 AMYLASE-48 TOT BILI-0.4 [**2199-7-5**] 02:19PM LIPASE-42 [**2199-7-5**] 02:19PM ALBUMIN-4.3 [**2199-7-5**] 02:19PM WBC-15.1*# RBC-3.40* HGB-10.6* HCT-30.5* MCV-90 MCH-31.1 MCHC-34.7 RDW-12.9 [**2199-7-5**] 02:19PM PLT COUNT-471*# CT ABDOMEN W/O CONTRAST [**2199-7-5**] 5:23 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: eval colitis, eval obstruction. - oral contrast only. Field of view: 36 [**Hospital 93**] MEDICAL CONDITION: 76 year old woman with hx of Paget's dz of rectum, chronic incontinence now with no stool output past 3days. REASON FOR THIS EXAMINATION: eval colitis, eval obstruction. - oral contrast only. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 76-year-old female with history of Paget's disease of the rectum and chronic incontinence. COMPARISONS: None. TECHNIQUE: MDCT axial images were obtained from the thoracic inlet through the pubic symphysis without intravenous contrast. Multiplanar reconstructions were performed. CT ABDOMEN WITHOUT IV CONTRAST: No pulmonary nodules, opacities or pleural effusions are present at the lung bases. There are extensive coronary artery calcifications. Evaluation of the visceral organs is limited secondary to lack of intravenous contrast. Allowing for this factor, the liver, pancreas, spleen and adrenal glands appear grossly normal. There is moderate right hydronephrosis with hydroureter extending from the renal pelvis to the level of the pelvic inlet. No definite obstructing calculi or mass is identified. Extensive gas and stool is seen within mildly dilated loops of large bowel. There is no evidence of bowel wall thickening, pneumatosis or intraperitoneal air. There is extensive atherosclerosis involving the abdominal aorta and its branches. No intraperitoneal fluid is present. A normal appendix is seen in the right lower quadrant. No mesenteric or retroperitoneal lymph nodes are pathologically enlarged. CT PELVIS WITH IV CONTRAST: A large amount of stool and air is seen within the sigmoid colon with mild wall thickening. Extensive soft tissue density is seen in the region of the rectum without evidence of rectal stool or air. Several suture lines are seen within the lower pelvis. A Foley catheter is seen within a partially distended bladder. Air within the bladder is likely iatrogenic. There is no free pelvic fluid. There are several borderline enlarged left inguinal lymph nodes. BONE WINDOWS: No suspicious osteolytic or sclerotic lesions are identified. There are significant degenerative changes within the lower lumbar spine. IMPRESSION: 1. Coronary artery calcifications. 2. Right hydronephrosis and hydroureter without evidence of obstructing calculi or mass. 3. Air and stool seen within dilated loops of large bowel. Moderate soft tissue density is seen involving the rectum. Air is not definitely seen in the rectum and obstruction at this level cannot be excluded. Correlation with colonoscopy/flex sigmoidoscopy is recommended. Cardiology Report C.CATH Study Date of [**2199-7-7**] *** Not Signed Out *** BRIEF HISTORY: 76 yo female with history of rectal cancer and hypertension who presented to the hospital with rectal obstruction. She underwent diverting colostomy and in the PACU developed mild hypotension and and was noted to have new STE V1-V3 on ECG. She was taken emergently to the cath lab. INDICATIONS FOR CATHETERIZATION: STE on ECG PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 6 French pulmonary wedge pressure catheter, advanced to the PCW position through an 8 French introducing sheath. Cardiac output was measured by the Fick method. Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French left [**Last Name (un) 2699**] catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 6 French JR4 catheter, with manual contrast injections. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.74 m2 HEMOGLOBIN: 10.4 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 11/7/5 RIGHT VENTRICLE {s/ed} 37/9 PULMONARY WEDGE {a/v/m} 17/12/9 AORTA {s/d/m} 99/56/72 **CARDIAC OUTPUT HEART RATE {beats/min} 84 RHYTHM SR O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 45 CARD. OP/IND FICK {l/mn/m2} 4.8/2.8 **RESISTANCES SYSTEMIC VASC. RESISTANCE 1117 **% SATURATION DATA (NL) PA MAIN 67 AO 99 **ARTERIAL BLOOD GAS INSPIRED O2 CONCENTR'N 21 **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA DIFFUSELY DISEASED 2) MID RCA DISCRETE 100 2A) ACUTE MARGINAL DIFFUSELY DISEASED **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN DISCRETE 20 6) PROXIMAL LAD DIFFUSELY DISEASED 6A) SEPTAL-1 DIFFUSELY DISEASED 7) MID-LAD DIFFUSELY DISEASED 8) DISTAL LAD DIFFUSELY DISEASED 9) DIAGONAL-1 NORMAL 10) DIAGONAL-2 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX DISCRETE 60 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 NORMAL TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 21 minutes. Arterial time = 20 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 55 ml Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 0 units IV Other medication: Fentanyl 25 mcg Midazolam 0.5 mg Cardiac Cath Supplies Used: 200CC MALLINCRODT, OPTIRAY 200CC - ALLEGIANCE, CUSTOM STERILE PACK COMMENTS: 1. Selective coronary angiography of this right dominant system revealed 2 vessel coronary artery disease. The LMCA had a 20% ostial stenosis. The LAD had moderate diffuse disease throughout. The LCX had a 50-60% stenosis in the mid vessel and the RCA was totally occluded in after the marginal branch and filled via left to right collaterals. 2. Resting hemodynamics revealed normal filling pressures and a preserved cardiac index. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Normal filling pressures and cardiac index. CHEST (PORTABLE AP) [**2199-7-7**] 2:35 AM CHEST (PORTABLE AP) Reason: r/o Pulmonary edema, EKG changes [**Hospital 93**] MEDICAL CONDITION: 76 year old woman POD 1 with EKG changes REASON FOR THIS EXAMINATION: r/o Pulmonary edema, EKG changes PORTABLE CHEST [**2199-7-7**] AT 02:44 INDICATION: EKG changes postop. COMPARISON: [**2199-7-5**]. FINDINGS: Again seen is an elevated right hemidiaphragm. Since the prior study, there is subsegmental left basilar atelectasis but otherwise no evidence for new infiltrate and no evidence for interval development of CHF. There has been placement of an NG tube with the tip overlying the left upper quadrant of the abdomen. IMPRESSION: Left basilar atelectasis. No significant interval change versus prior. Brief Hospital Course: Ms. [**Known lastname 17832**] was admitted to the hospital on [**2199-7-6**]. That same day, she underwent a diverting colostomy for anal stricture due to Paget's disease of the anus. In the PACU, post-op, she had low urine output, for which she received a total of 2 L of bolused fluids. Her urine output remained marginal, and then dropped off again. She then had an EKG, and Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] were informed. The on-call cardiologist was contact[**Name (NI) **] and became involved. Ms. [**Known lastname 17832**] was then taken to the catheterization suite, where she was diagnosed with a complete right coronary artery occlusion with collateralization and a mid- to high-grade occlusion of the left circumflex artery. She was not anticoagulated, as both lesions appeared chronic in nature. She was followed in the ICU until HD3, observed to be stable, and then transferred to the floor. The ostomy nurse began teaching Ms. [**Known lastname 17832**] to change and care for her stoma. On hospital day 7, she experienced one bout of nausea with vomiting. She vomited 200 cc, but had flatus and bowel sounds. On hospital day 8, she was tolerating a regular diet, she had passed much of the residual stool in her colon, and her incision appeared clean, dry and intact. She was discharged to her home in good condition with strong family support. Discharge Medications: 1. Aspirin 325 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): hold for loose stools. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Milk of Magnesia 800 mg/5 mL Suspension Sig: [**12-31**] PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Bowel obstruction Discharge Condition: Good Discharge Instructions: Return to the emergency room if you develop fevers, chills, nausea, vomiting, abdominal pain, diarrhea and/or any othr syptoms that are concerning to you. Follow up with Dr. [**Last Name (STitle) **] next week in clinic. Follow up with your primary doctor [**First Name (Titles) 4120**] [**Last Name (Titles) 51794**] a stress test. Followup Instructions: Please follow up with your Primary Care Doctor to receive a cardiac stress test. Please call and schedule an appointment. Call [**Telephone/Fax (1) 6439**] for an appointment with Dr. [**Last Name (STitle) **] in Surgery CLinic next week.

Admission Date: [**2168-1-29**] Discharge Date: [**2168-2-1**] Service: [**Hospital Unit Name 196**]-Gold CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: This is an 82 year old gentleman with a history of coronary artery disease, status post coronary artery bypass graft times three in [**2150**], inferior myocardial infarction in [**2159**], status post percutaneous transluminal coronary angioplasty at [**Hospital 36653**] Clinic in [**2158**], who is transferred from an outside hospital for chest pain, left arm numbness and nausea. The patient noted the night before admission and the day of admission chest pain across his chest associated with left arm numbness and nausea. He denied shortness of breath or diaphoresis. His pain was noted by daughter who had taken him home from the nursing home for lunch and took him immediately back to the nursing home when he told her that he had chest pain. The patient is unsure of how long the chest pain lasted the day before admission but lasted one to two hours on the day of admission. The patient is an extremely poor historian secondary to his parkinsonian's dementia. Electrocardiogram on presentation showed [**Street Address(2) 4793**] elevations in 3, AVF and downsloping ST depression in precordial leads V4 through V6. His initial CPK was 30 and troponin was negative. He was started on nitroglycerin GTT, heparin GTT, Integrilin and Lopressor and was transferred to [**Hospital6 1760**] for possible catheterization at an outside hospital. On presentation to the Emergency Department at [**Hospital6 1760**] he was chest pain free and was maintained on the same GTT. In the AM while still in the Emergency Department the patient had more chest pains and associated shortness of breath and was given intravenous Lasix. He was given steroids, Zantac and Benadryl for shellfish allergy and was taken to the Catheterization Laboratory. Complicated catheterization required 300 cc of dye in order to visualize the graft. PCW 30, PA saturation 76%, V wave 35, right atrial pressure 12, right ventricular pressure 64/8, left ventricular end diastolic pressure 35. The patient had no significant left main disease but left anterior descending was occluded at the origin and severe proximal stenosis at the origin of obtuse marginal 1 was noted. Also mid left circumflex occlusion and proximal occlusion of right coronary artery. In terms of the patient's graft, the saphenous vein graft to obtuse marginal was patent with complex severe distal stenosis, the saphenous vein graft to left anterior descending was patent was 90% distal stenosis with thrombus and the saphenous vein graft to right coronary artery has 90% proximal stenosis with thrombus. Transthoracic echocardiography was performed demonstrating an ejection fraction of 20 to 30% with global reduction of left ventricular systolic function. The inferior wall was noted to be akinetic and trace aortic regurgitation was mild 11+ mitral regurgitation was noted. The patient was transferred out of the catheterization laboratory to the Coronary Care Unit for observation and consideration of further options. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft at [**Hospital3 **] in [**2150**]. Status post inferior myocardial infarction and percutaneous transluminal coronary angioplasty at [**Hospital 36653**] Clinic in [**2158**]. 2. Abdominal aortic aneurysm, stable. 3. Parkinson's disease times two years. 4. Hypertension. 5. Low back pain. 6. Status post cholecystectomy. 7. Hypercholesterolemia. MEDICATIONS AS OUTPATIENT: 1. Atenolol 25 mg b.i.d. 2. Captopril 25 mg t.i.d. 3. Aspirin 4. Digoxin 0.25 mg q. day 5. Klonopin 0.5 mg q. 6 hours prn 6. Nitroglycerin prn 7. Norvasc 2.5 mg q. day 8. Lipitor 10 mg q. day 9. Aricept 5 mg q. day 10. Celexa 10 mg q. day 11. Imdur 60 mg q. day 12. Requip 1.5 mg t.i.d. 13. Darvocet N 100 mg q. 6 hours prn MEDICATIONS ON TRANSFER: 1. Integrilin GTT 2. Nitroglycerin GTT 3. Heparin GTT 4. Lopressor 25 mg t.i.d. 5. Captopril 25 mg t.i.d. 6. Aspirin 325 mg q. day 7. Digoxin 0.25 mg q. day 8. Lipitor 10 mg q. day 9. Aricept 5 mg q. day 10. Celexa 10 mg q. day 11. Imdur 60 mg q. day 12. Requip 1.5 mg t.i.d. 13. Darvocet N 1 tablet q. 6 hours prn pain, maximum 6 tablets per day 14. Klonopin 0.5 mg p.o. q. 6 hours prn ALLERGIES: Shellfish SOCIAL HISTORY: Lives in nursing home. By patient report, quit tobacco 50 years ago. No current alcohol or tobacco use. PHYSICAL EXAMINATION: Physical examination on admission from the Emergency Room, temperature 90.6, pulse 79, blood pressure 157/86, respiratory rate 16, 95% on 2 liters. In general this is a thin elderly male in no acute distress. Oropharynx is benign. Pupils are equally round, and reactive to light and accommodation. Pupils 2 mm. Heart is regular rate and rhythm with S1 and S2, no murmurs, rubs or gallops noted. Jugulovenous pressure at 4 cm. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended with good bowel sounds. Extremities with 2+ dorsalis pedis pulses. LABORATORY DATA: Notable laboratory data on admission are BUN 18, creatinine 1.1, white blood cells 6.1 with 61 neutrophils, 23 lymphocytes, hematocrit 43, platelets 214. At an outside hospital CK is 30 and troponin is negative. Bilirubin is slightly elevated at 1.1, but ALT 25, AST 13, alkaline phosphatase 110, PT 11.4 with INR of 0.8. Electrocardiogram demonstrates at outside hospital normal sinus rhythm, axis and intervals within normal limits. Q in 2, 3 and AVF, [**Street Address(2) 4793**] elevations in 3 and AVF, [**Street Address(2) 1766**] depressions in V2, V3 and downsloping ST depressions in V4 through V6 which at [**Hospital6 256**] was similar. Chest x-ray demonstrated unusual tracheal course secondary to a possible thyroid mass and some emphysematous changes. HOSPITAL COURSE: 1. Cardiovascular - A. Ischemia, the patient proceeded to rule in for myocardial infarction with CKs of 192, 1122, 1362, 1131, and then proceeded to taper down to 739, 127 on [**1-31**]. The patient underwent catheterization with results as above and was transferred to Coronary Care Unit without intervention. Discussion ensued with family and patient who decided that high risk PCI was not desirable at this time and the patient should be medically managed. The patient was continued on Beta blocker, ACE inhibitor and Aspirin therapy as well as Plavix q. day. Lipitor and Imdur were continued and the patient underwent 48 hour course of Integrilin. Lopressor and ACE inhibitor were titrated up as an inpatient and will continue to be titrated up as an outpatient as the patient tolerates. B. Pump, the patient was noted to have an ejection fraction of 20% on transthoracic echocardiography and will continue medical management. Lasix was begun and the patient will continue Captopril and Digoxin. C. Rhythm, the patient remained in normal sinus rhythm with occasional runs of premature ventricular contractions but no more than 3 at a time were noted. Telemetry was continued during this hospitalization. 2. Neurological - The patient with a history of Parkinson's with associated symptoms of dementia. Aricept and Ropinirole were continued throughout this hospitalization with no issues. 3. Code Status - The patient is Do-Not-Resuscitate, Do-Not-Intubate. This status was temporarily suspended during the patient's catheterization but was reinstated in the post procedure period. 4. Fluids, electrolytes and nutrition - The patient was maintained on cardiac diet during this admission with no further issues. DISPOSITION: The patient will be discharged to rehabilitation once his medical management is optimized and a rehabilitation bed is available. DISCHARGE DIAGNOSIS: 1. Severe coronary artery disease 2. Abdominal aortic aneurysm 3. Hypertension 4. Parkinson's disease 5. Hypercholesterolemia MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg p.o. q. day 2. Lopressor 50 mg p.o. q. day 3. Captopril 12.5 mg p.o. q.d. (this will be titrated up as tolerated to 25 mg p.o. t.i.d.) 4. Digoxin 0.25 mg p.o. q. day 5. Aspirin 325 mg p.o. q. day 6. Imdur 60 mg p.o. q. day 7. Lipitor 10 mg p.o. q.h.s. 8. Nitroglycerin 0.4 mg sublingually prn 9. Klonopin 0.5 mg p.o. q. 6 hours prn 10. Aricept 5 mg p.o. q. day 11. Celexa 10 mg p.o. q. day 12. Requip (Ropinirole) 1.5 mg p.o. t.i.d. 13. Darvocet N 1 tablet q. 6 hours prn pain 14. Tylenol 500 mg p.o. q. 8 hours prn pain or fever 15. Dulcolax 10 mg p.o./p.r. q. 24 hours prn constipation 16. Trazodone 25 mg p.o. q.h.s. prn insomnia DISCHARGE CONDITION: Fair. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-269 Dictated By:[**Last Name (NamePattern1) 19212**] MEDQUIST36 D: [**2168-1-31**] 17:05 T: [**2168-1-31**] 18:52 JOB#: [**Job Number 38238**]

Admission Date: [**2130-9-12**] Discharge Date: [**2130-10-14**] Date of Birth: [**2087-10-29**] Sex: M Service: CSU CHIEF COMPLAINT: Patient is a postoperative admit, who was admitted directly to the operating room, where he underwent an Bentall procedure with repair of the ascending aortic aneurysm and AVR with a number 27 mechanical valve and ligation of the PDA. Chief complaint prior to admission was dyspnea on exertion. HISTORY OF PRESENT ILLNESS: A 42-year-old man in the hospital in [**2128**] for sleep apnea, pulmonary hypertension, cor pulmonale, treated with diuretics, but at that time noted to have a bicuspid aortic valve and dilated ascending aorta. Cardiac echocardiogram done in [**2130-6-6**] showed an ejection fraction of 65 percent with an ascending aortic arch. The aorta at the ascending arch was 4 cm, 1 plus AI, and bicuspid aortic valve. On [**8-2**], she had a cardiac catheterization that showed 3 plus aortic regurgitation, 1 plus mitral regurgitation, and EF of 50 percent, a long ascending aortic aneurysm greater than 5 cm above the valve, mild pulmonary hypertension, and no coronary disease. PAST MEDICAL HISTORY: Obesity. Obstructive-sleep apnea. Pulmonary hypertension. Right heart failure. Left eye prosthesis. Gout. Recently diagnosed with diabetes mellitus and placed on oral agents. MEDICATIONS PRIOR TO ADMISSION: 1. Atenolol 25 q.d. 2. Digoxin 0.125 q.d. 3. Aldactone 25 mg q.d. 4. Lisinopril 5 mg q.d. 5. Lasix, which was stopped a week prior to admission. 6. Glipizide 5 mg q.d. 7. Avandia 4 mg q.d. ALLERGIES: Patient states no known drug allergies. FAMILY HISTORY: Mother and father are both alive in their 70's. SOCIAL HISTORY: Lives with parents. Runs a heating and air conditioning company. Denies tobacco use. Alcohol [**3-14**] drinks once or twice per month. No other recreational drug use. Patient also had a cardiac MRI prior to this catheterization, which showed right ventricular EF of 53 percent, bicuspid aortic valve with moderate AI. Severely dilated ascending aorta with dilated sinus of Valsalva. Left ventricular EF was 69 percent. Forward flow ejection fraction estimated at 44 percent. Mild bilateral atrial enlargement, moderately dilated main PA artery. PHYSICAL EXAMINATION: Heart rate 62, blood pressure 106/59, respiratory rate 20, and O2 saturation 96 percent on room air, 5'7", weight 230 pounds. General: Obese young man. Skin: Small scab ulcer around the pinnae from the BiPAP mask. HEENT: Nonicteric. Left eye prosthesis. Right eye reacts to light. Neck is supple. No JVD, no bruits. Chest was clear to auscultation. Heart: Regular, rate, and rhythm, S1, S2, no murmur. Abdomen is soft, nontender with no hepatosplenomegaly or CVA tenderness. Extremities are warm and well perfused with no clubbing, cyanosis, or edema. Two plus dorsalis pedis and posterior tibial pulses. Neurologic: Cranial nerves II through XII are grossly intact, nonfocal exam, 5/5 strength in all four extremities. LABORATORY DATA: White count 7.7, hematocrit 37.6, platelets 256. PT 12.9, PTT 25, INR 1.1. Sodium 134, potassium 4.5, chloride 101, CO2 25, BUN 17, creatinine 1.1, and glucose 299. LFTs are all within normal limits. Chest x-ray: No acute cardiopulmonary process. Finding consistent with known ascending aortic aneurysm. HOSPITAL COURSE: As stated previously, the patient was a direct admission to the operating room. Please see the operative report for full details. In summary, the patient had Bentall procedure with repair of ascending aortic aneurysm with a number 28 wave graft and a number 30 conduit and aortic valve replacement and a number 27 St. [**Male First Name (un) 923**] mechanical valve and a PDA ligation. Patient's cardiopulmonary bypass time was 243 minutes with a cross- clamp time of 211 minutes. Patient was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was in sinus rhythm at 78 beats per minute with a CVP of 12 and a PAD of 16. He was on Neo-Synephrine drip at 0.5 mcg/kg/minute and propofol at 20 mcg/kg/minute as well as milrinone infusion. Patient did well in the immediate postoperative period. His anesthesia was reversed. During the course of the postoperative day and through that evening, he was weaned from an IMV to CPAP. He remained intubated overnight with CPAP pressure support ventilation. He continued to do well on the morning of postoperative day one and wean was continued to CPAP 5 and 5. With that, the patient became acutely hypotensive and was begun on a Nipride infusion following which the patient was successfully extubated. Over the next several days, the patient continued to struggle from a respiratory standpoint complaining of shortness of breath and sporadically desaturating. By the 7th, he continued to complain of increasing shortness of breath. He had a chest x-ray that showed pleural effusion, following which a chest tube was placed and the effusion was drained for approximately 400 cc. However, following that, the patient continued to complain of shortness of breath and therefore an echocardiogram was done to assess for a pericardial effusion. An echocardiogram at that time showed a small to moderate size pericardial effusion. Repeat echocardiogram done on the 10th showed 3 cm circumferential effusion following which the patient went to the Cath Lab and had a pericardial tap for 650 cc. On the 11th, the patient continued to complain of shortness of breath. Bronchoscopy done at that time showed left lower lobe compression with airway edema. Patient was reintubated following bronchoscopy secondary to respiratory distress at that time. A Swan-Ganz line was placed as well as a femoral A-line and Interventional Pulmonology was consulted. On [**9-21**], the patient had periodic episodes of ventricular tachycardia. He was started on amiodarone and cardioverted, and Electrophysiology was consulted. Following cardioversion, the patient had alternating periods of A-V block and SVT rhythm. EP service placed a temporary pacing wire. Patient was returned to the Cath Lab at that time, and recatheterized, which showed no apparent CAD. An ablation was done by the Electrophysiology service at that time as well. On the 13th, the patient had an elevated white blood cell count and a fever. Infectious Diseases were consulted. She was returned to the operating room for mediastinal washout and placement of permanent bipolar pacing leads. Patient tolerated this operation well and was transferred back to the Cardiothoracic Intensive Care Unit. Please see the OR report for full details. Over the next week, the patient was hemodynamically stable. Several attempts were made to wean the patient from the ventilator all unsuccessfully. Interventional Pulmonology continued to consult on the patient and on the [**9-29**], the patient was brought back to the operating room at which time tracheal and left main stents were placed. On the 21st, the patient had a follow-up bronchoscopy and was successfully extubated. He did well over the next several days. Passed a swallow test, and on the 24th, he was again bronched as a followup, at which time copious secretions were removed. Bronch also showed that the patient had migration of the tracheal stent and he was brought again to the operating room at which time the tracheal stent was removed, and he was reintubated. The patient did well during this procedure, and was transferred back to the Cardiothoracic Intensive Care Unit. Again on the following day, the patient was bronched in the morning. It was shown that he had patent airways, and following the bronchoscopy, he was successfully extubated. On the [**10-5**], the patient had a PICC line placed for antibiotics as well as blood draws, and on the [**10-6**], he was transferred from the Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 121**] 2 for continuing postoperative care and cardiac rehabilitation. Over the next week, the patient's activity level was advanced with the assistance of the nursing staff and Physical Therapy. His anticoagulation doses were adjusted to bring his INR up to approach his therapeutic range of [**4-12**].5. At this time it is anticipated that he will be ready for discharge in the next 1-2 days. Vital signs: Temperature 98.3, heart rate 87 A sensed, V paced. Blood pressure 107/65, respiratory rate 24, and O2 saturation 97 percent on room air. Weight at this time is 94.7 kg. At time of admission, it was 104.5 kg. Laboratory data on the day of dictation: White count 10.3, hematocrit is 32.1, platelets 587. PT 16, PTT 87.7. INR 1.6. Potassium 4.7, BUN 13, creatinine 1.0. Physical exam: Neurologically: Alert and oriented times three, moves all extremities, and follows commands. Respiratory: Diminished on the left and clear on the right. Cardiovascular: Regular rate and rhythm with click. Sternum is stable. Incision is healing well, no erythema or drainage. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities are warm and well perfused with 1-2 plus edema. CONDITION ON DISCHARGE: Good. DISPOSITION: He is to be discharged to home with VNA. FO[**Last Name (STitle) **]P INSTRUCTIONS: He is to have followup with Dr. [**First Name (STitle) **] in [**3-14**] weeks. Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-13**] weeks. Follow up with Dr. [**Last Name (Prefixes) **] in four weeks. Follow up with [**Last Name (un) **] nurse educator. Follow up with Dr. [**Last Name (STitle) 13421**] from [**Last Name (un) **] on [**12-26**]. DISCHARGE DIAGNOSES: Status post Bentall procedure with repair of the ascending aortic aneurysm. Status post aortic valve replacement with a number 27 St. [**Male First Name (un) 923**] mechanical valve. Posterior descending artery ligation. Status post left main bronchus and tracheal stent placement and status post tracheal stent removal. Status post permanent pacemaker. Obstructive-sleep apnea. Left eye prosthesis. DISCHARGE MEDICATIONS: 1. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h prn. 2. Amiodarone 200 mg q.d. x1 month. 3. Warfarin as directed. The patient is to take 7.5 mg on [**10-12**], dose to be adjusted thereafter. 4. Lasix 20 mg q.d. 5. Aspirin 81 mg q.d. 6. Potassium chloride 20 mEq q.d. 7. Metformin 1000 mg q.a.m., 500 mg q.p.m. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2130-10-12**] 16:37:48 T: [**2130-10-13**] 07:16:16 Job#: [**Job Number 13422**]

Admission Date: [**2170-2-25**] Discharge Date: [**2170-3-3**] Date of Birth: [**2090-12-9**] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 783**] Chief Complaint: cough and shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 79 yo F with a past history stage IIIb NSCLC dx in [**2168**], finished chemo/rad in [**6-4**], doing well until 4-5 days ago, when she began to develop SOB, cough, sputum, persistent fevers/chills. She presented to the OSH [**2-25**], and was felt to have post obstructive pna. She had a chest CT, c/w post obstructive PNA. She was given vanco/zosyn and transferred to [**Hospital1 18**] for IP procedure. Of note, her WBC there was 19.5 with a left shift, afebrile, O2sats 93% RA. . ED COURSE: remained afebrile and was seen by IP, plan to bronch and ?stent. She was found to be hypertensive to the 170's/60's and received her regular dose of nadolol. She also received a dose of levofloxacin, zosyn, vanc, motrin and zofran. . IP SUITE COURSE: Pt taken to IP suite for bronch, BAL done, received 50Fentanyl, 2Midaz, underwent a lavage, RUL notable for complete obstruction, 30min post procedure began to cough, notable for acute hypoxia O2 sats 79%. Subsequently placed on 100% NRB, , ABG 7.11/90/150, 40min later VBG 7.16/75/55 transferred to MICU for closer monitoring, BiPAP. . MICU COURSE: Initially started on BiPAP with rapid improvement in ventilation and oxygenation. Sedating meds were minimized and the patient was quickly weened to 2L NC. The patient was continued on Vanc/Zosyn Past Medical History: -NSCLC diagnosed in [**2168**], Stage IIIb, with mets to subcarinal and supraclavicular nodes; XRT/Chemo [**5-/2169**], Onc care at [**Hospital 1562**] Hosp (Dr. [**Last Name (STitle) 27009**], [**Telephone/Fax (1) 66058**]) -Post obstructive PNA [**Hospital 1562**] Hospital [**2169-4-9**], bronch w/MSSA treated with zosyn -COPD ---PFTs: FEV1 of 74% predicted with a predominantly obstructive pattern on flow volume curves. -Hypertension -Hyperlipidemia -Chronic low back pain Social History: The patient lives with her husband in [**Name (NI) 73266**], [**State 350**]. She had a 100-pack-year smoking history, but quit approximately 10 years ago. She denies any alcohol intake. She is currently retired, but previously worked as an office manager. She has seven children. Family History: M: died at the age of 40-lung cancer. F: died at age 63 from myocardial infarction. Sister: kidney cancer Brother: prostate cancer Physical Exam: VS: 97.1 BP 150/80 HR 78 16 93% RA GEN: AOx3, NAD, pleasant HEENT: PERRL, NCAT, no LAD or thyromegaly appreciated RESP: diminished BS on RUL field, minimal end expiratory wheezing/sqeak, no crackles, no accessory muscle use, no paradoxical breathing CV: Reg Nml S1, S2, 2/6 SEM at RUSB ABD: Soft ND/NT +BS EXT: No peripheral edema, warm, 2+DP pulses b/l NEURO: A&Ox, following commands appropriately, no focal deficits, strength 5/5 throughout, sensation intact to gross . Pertinent Results: [**2170-2-26**] 05:15AM BLOOD WBC-17.2* RBC-3.25* Hgb-9.5* Hct-30.5* MCV-94 MCH-29.1 MCHC-31.0 RDW-14.4 Plt Ct-581* [**2170-2-26**] 04:11PM BLOOD WBC-23.3* RBC-3.65* Hgb-10.8* Hct-35.0* MCV-96 MCH-29.7 MCHC-30.9* RDW-14.1 Plt Ct-708* [**2170-2-27**] 05:56AM BLOOD WBC-20.2* RBC-3.54* Hgb-10.5* Hct-33.7* MCV-95 MCH-29.5 MCHC-31.0 RDW-15.2 Plt Ct-617* [**2170-2-28**] 05:35AM BLOOD WBC-16.2* RBC-3.35* Hgb-10.0* Hct-32.5* MCV-97 MCH-29.8 MCHC-30.7* RDW-14.5 Plt Ct-631* [**2170-3-1**] 05:35AM BLOOD WBC-11.5* RBC-3.16* Hgb-9.2* Hct-29.9* MCV-95 MCH-29.2 MCHC-30.9* RDW-15.0 Plt Ct-612* [**2170-2-27**] 05:56AM BLOOD Neuts-95.3* Bands-0 Lymphs-2.3* Monos-1.9* Eos-0.3 Baso-0.1 [**2170-2-26**] 05:15AM BLOOD PT-14.2* PTT-29.1 INR(PT)-1.2* [**2170-3-1**] 05:35AM BLOOD Plt Ct-612* [**2170-2-26**] 05:15AM BLOOD Glucose-91 UreaN-18 Creat-0.8 Na-141 K-4.4 Cl-102 HCO3-30 AnGap-13 [**2170-2-26**] 04:11PM BLOOD CK(CPK)-32 [**2170-2-26**] 04:11PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2170-2-26**] 05:15AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 [**2170-2-26**] 04:11PM BLOOD Type-ART pO2-150* pCO2-90* pH-7.11* calTCO2-30 Base XS--3 [**2170-2-26**] 04:52PM BLOOD Type-ART Temp-37 pO2-55* pCO2-76* pH-7.17* calTCO2-29 Base XS--2 Intubat-NOT INTUBA [**2170-2-26**] 06:22PM BLOOD Type-ART pO2-81* pCO2-53* pH-7.33* calTCO2-29 Base XS-0 CXR: There obviously is a large right hilar mass with extensive mediastinal and apical components. The visible parts of the right lower lung show increase in interstitial markings that could be suggestive of lymphangosis. The left lung is unremarkable. The size of the cardiac silhouette is borderline. There are no pleural effusions. IMPRESSION: No pneumothorax is detected. OSH CT: Informal read here shows RUL cavitary lesion with air fluid levels surrounded by lunch parenchyma. BAL Cytology: REPORT APPROVED DATE: [**2170-3-1**] SPECIMEN RECEIVED: [**2170-2-27**] 08-[**Numeric Identifier **] BRONCHIAL WASHINGS SPECIMEN DESCRIPTION: Received 7.5ml cloudy fluid. Prepared 1 ThinPrep slide. CLINICAL DATA: H/O NSCLC with new obstructive PNA. PREVIOUS BIOPSIES: [**2169-4-13**] 07-[**Numeric Identifier 73267**] LYMPH NODE [**2169-4-13**] 07-[**Numeric Identifier 73268**] LYMPH NODE REPORT TO: DR. [**First Name11 (Name Pattern1) 734**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS. Bronchial epithelial cells, squamous cell, macrophages and mixed inflammatory cells. DIAGNOSED BY: [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) **], CT(ASCP) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73269**], M.D. Bronchoscopy report: PREOPERATIVE DIAGNOSIS: 1. Stage 3B nonsmall cell lung cancer. 2. Status post obstructive pneumonia. POSTOPERATIVE DIAGNOSIS: 1. Stage 3B nonsmall cell lung cancer. 2. Status post obstructive pneumonia. SURGEON: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. ASSISTANT: None. INDICATIONS: Mrs. [**Known lastname 73270**] was seen in consultation as well as for a flexible bronchoscopy in the pulmonary procedure unit on [**2170-2-26**]. She is a 79-year-old woman with a past history of right hilar nonsmall cell cancer consistent with adenocarcinoma, concurrent radiation and completed treatment in [**2169-5-28**]. Since that time she has been relatively well. She recently developed a call associated with purulent phlegm as well as a febrile state. She was admitted to the hospital in [**Hospital1 1562**] and then transferred to the [**Hospital1 69**] for evaluation. She was transferred from nursing unit in stable condition. She was placed respiratory and hemodynamic monitoring. DESCRIPTION OF PROCEDURE: Once on monitoring she was administered 2 mg of Darvon and 50 mcg fentanyl for IV sedation. She was topicalized with 1% Xylocaine. Following topicalization, the adult Olympus bronchoscope was passed via the oral route down to the level of the vocal cords. The vocal cords appeared normal. The vocal cords were topicalized with 1% Xylocaine. Following this, the bronchoscope was passed through the vocal cords and into the trachea. The trachea appeared normal. The bronchoscope was advanced down to the level of the right bronchial tree. All the segments and subsegments of the right bronchial's were visualized in sequence. Of note, there was circumferential extrinsic compression of the bronchi of the right upper lobe. There was only the posterior segment of the right upper lobe which did appear to remain even somewhat patent. Unfortunately, it was not possible to fully intubate even the segment. The remainder of the right bronchial tube was inspected and appeared normal. The left bronchial tube was visualized and all appeared normal. 120 ml of sterile saline were instilled into the residual right upper lobe bronchus and 30 ml were aspirated back. Specimens were sent for cytology as well for microbiology including fungal studies. The patient initially tolerated the procedure well, however during the recovery she developed profound hypercapnia with pCO2 rising to 90 and pH associated with this at 711. She was bag mask ventilated in order to try to drive down her CO2. She was transferred to the ICU to the MICU-7 for BIPAP in order to blow off her CO2. There was a suggestion on her desk that she has a CO2 retainer although this was not known preprocedure. Likely the further elevation of the CO2 was on the basis of her medications. The patient was stable at the time of transfer. The results of the bronchoalveolar lavage are pending. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(2) 73271**] Brief Hospital Course: RUL Pneumonia: The patient was initially transferred to [**Hospital1 18**] for consideration of a RUL stent to alleviate what was initially thought to be a post-obstructive pneumonia. The patient tolerated the initial bronchoscopy well but shortly after the patient developed hypoxia and hypercarbia, likely a side effect of the sedation used. She was transferred to the MICU for BiPAP. She rapidly improved with resolution of her hypercarbia and significant improvement in her hypoxia within 12 hours. She was then transferred to the floor in stable condition. The interventional pulmonary service felt that a stent would not be beneficial in her. They felt it would block off more bronchioles than it would open and that the RUL was essentially unsalvagable given the large cavitary lesion seen on CT. There is also high suspicion of a small bronchopleural fistula, given the return of mesothelial cells on the BAL. However, the patient did not show any signs pneumothorax on exam or CXR. She will require close monitoring for this complication. In discussion with interventional pulmonary, it was decided not to pursue drainage of the cavity given the concern for cancer recurrence and the creation of a non-healing tract from the puncture site, greatly increasing her pneumothorax risk. It was decided that she would complete 6 weeks of antibiotics to treat her cavitary pneumonia. A BAL showed no AFB on concentrated smear, ruling out TB. The culture returned with MSSA. The patient was discharged on a 6 week course of Augmentin. She will follow up with her PCP and oncologist and receive a repeat CT scan after completion of her antibiotic course to evaluate for possible progression of her lung cancer. She will also return to interventional pulmonary clinic with her CT in hand for follow up of her possible bronchopleural fistula. Non-small cell lung cancer: The patient was diagnosed with stage IIIb NSCLC in [**4-4**] with chemo/rads treatment completed in [**6-4**]. Her last PET/CT scan in [**12-5**] showed now growth in the tumor per the patient. It is unclear at this time to what extent this RUL process represents a recurrence of her lung cancer as the infectious process is clouding the imaging. However, the BAL did not return any malignant cells. In discussion with her primary oncologist, it was decided not to actively pursue cancer treatment at this time until the infectious process is resolved. She will follow up with her oncologist and should receive a repeat CT scan after completion of her 6 week course of antibiotics. Further cancer treatment will be discussed at this time. She will also follow up with the intervential pulmonary clinic after the completion of her six week antibiotic course to evaluate for interval improvement. HTN: The patient was initially hypertensive on presentation with SBPs in the 170s with associated anxiety. She was continued on her outpatient naldolol and her lisinopril was uptitrated with good effect. Her anxiety was treated with very small doses of Ativan with good effect. Back/Scapula pain: The patient is s/p surgical correction of a cervical spinal body fracture in [**1-5**] with residual chronic neck/back/scapula pain. The pain was initially controlled with motrin was noted to be limited by her back pain by physical therapy. Her pain was then controlled with low dose oxycontin with percocet for break through pain. PPx: Hep SC, PPI Code: Full, confirmed with pt Communication: Duaghter [**Doctor First Name 8513**] [**Telephone/Fax (1) 73272**] H; [**Telephone/Fax (1) 73273**] cell HCP=Husband, pls call daughter to reach husband. Medications on Admission: Nadolol 40 mg p.o. b.i.d. ezetimibe 10 mg p.o. daily lisinopril 5 mg p.o. daily Protonix 40 mg p.o. daily Spiriva 18 mcg daily Discharge Medications: 1. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*1* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-7**] MLs PO Q6H (every 6 hours) as needed for COUGH. Disp:*150 ML(s)* Refills:*0* 11. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 6 weeks. Disp:*84 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Right upper lobe pneumonia Non-small cell lung cancer Hypertension Discharge Condition: All vital signs stable, afebrile, on room air Discharge Instructions: You were admitted with a right upper lobe pneumonia. This pneumonia was severe enough to destroy some of your lung and form a cavity. The interventional pulmonologists used a scope to look into your lungs and take samples for culture. They felt that you would not benefit from a stent as it would probably close off more airways than it opened. Furthermore, draining the cavity with a needle from the outside would leave a non-healing hole that would greatly increase your risk for a collapsed lung. The best course of action is to take 6 weeks of antibiotics to treat the pneumonia and then re-evaluate the lung with another CT scan. You should coordinate this with Dr. [**Last Name (STitle) 27009**]. You will also need to follow up with the interventional pulmonologists here. Please bring the CD of the CT scan with you to this visit. Please take all of your medications as prescribed. Please make all of your recommended follow up appointments. Please call your doctor or return to the emergency room if you experience worsening shortness of breath, chest pain, fevers, chills, severe lightheadedness or any other symptom that concerns you. Followup Instructions: Please schedule a follow up appointment with Dr. [**Last Name (STitle) 69694**] at [**Telephone/Fax (1) 69695**] in the next 2-4 weeks. Please call Dr. [**Last Name (STitle) 27009**] at [**Telephone/Fax (1) 66058**] to schedule a follow up appointment in the next 1-3 weeks. Please schedule a CT scan of your chest after 6wks. Please call the Pulmonary Clinic at ([**Telephone/Fax (1) 513**] to schedule an appointment after you finish your 6 weeks of antibiotics. Please bring the CD of your CT scan to this visit [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

Admission Date: [**2135-8-30**] Discharge Date: [**2135-9-5**] Date of Birth: [**2063-5-31**] Sex: F Service: MEDICINE Allergies: Codeine / Percodan Attending:[**First Name3 (LF) 689**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 72 y.o. woman with history of afib, bronchiectasis, past breast ca who presents with fatigue and fevers x5 days. She was otherwise well until thursday of last week when she developed significant fatigue, anorexia and vaginal pain. She attributed these symptoms to the heat and a vaginal infection, for which she tried Monostat cream. This resolved her vaginal symptoms, but Saturday morning she was awakened from sleep by severe pain ([**11-18**]) in her RLQ. She also noted night sweats, chills, rigors and subjective fever Friday night. However, she was afebrile at 97.5 that morning. On Saturday evening, she began to have high fevers to 102-103 and chills for which she took tylenol. She denied any back pain at that time, but did notice foul smelling urine with some suprapubic discomfort. . Patient denies any recent travel or sick contacts, though she does volunteer at [**Hospital1 18**] oncology once/week. She denies dysuria, HA, CP, SOB, cough, nausea/vomitting. Patient did have one episode of loose stool on Friday, but no bowel movement over the weekend due to anorexia. . ROS: As noted above. Also negative for rash. Past Medical History: - Stage III left breast cancer in [**2108**]. This was treated more than 15 years ago. She underwent mastectomy and chest wall radiation therapy. She received adjuvant chemotherapy with CMF and then five years of adjuvant tamoxifen. She has been off tamoxifen for nearly ten years and remains continuously recurrence free. - Afib s/p cardioversion (4 years) - Bronchiectasis since [**2096**] - h/o TB at age 9, spent 5 yrs at sanitorium - [**2096**] major lung hemorrhage s/p L upper lobectomy - [**Last Name (un) **] - HTN (40 years) Social History: Lives alone, independent in ADLs. Retired, but volunteers at [**Hospital1 18**] oncology once/week. Denies EtOH or tobacco or recreational drug use. Family History: Mother: HTN, died of Parkinsons at 86. Father died of PNA at 33. No other FH of CAD, HTN, Diabetes, CA. Physical Exam: VS: T 98.6, BP 94/60, HR 70, RR 20, 94%RA Gen: awake, alert and well appearing HEENT: EOMI, anicteric sclera, MM dry with white film over tongue Neck: supple, no LAD Lung: CTAB no wheeze or crackles or rales, surgical noted Heart: RRR, nl S1 S2 with faint S3, no murmurs or rubs Abd: thin, soft, with mild RLQ tenderness to palp, no rebound or guarding, + BS Back: No midline or CVA tenderness to palp Ext: warm, well perfused no edema Skin: no rash. multiple telangiectasias over L breast, legs Neuro: CN II-XII intact, awake and alert/oriented, walking without limp Pertinent Results: Admission Labs: WBC-24.8*# Hgb-10.7* Hct-31.3* MCV-84 MCH-28.5 Plt Ct-240 Neuts-93.0* Lymphs-3.7* Monos-2.7 Eos-0.6 Baso-0.1 PT-39.7* PTT-46.0* INR(PT)-4.3* Glucose-142* UreaN-35* Creat-1.0 Na-131* K-3.5 Cl-93* HCO3-26 . Discharge Labs: WBC-10.0 Hgb-8.7* Hct-25.7* MCV-87 MCH-29.3 Plt Ct-407 PT-25.4* INR(PT)-2.5* Glucose-91 UreaN-25* Creat-0.6 Na-139 K-3.8 Cl-101 HCO3-30 Calcium-8.6 Phos-4.5 Mg-1.6 calTIBC-189* Ferritn-1332* TRF-145* . Studies: [**2135-8-30**] CT Abd & pelvis w/ and w/o contrast IMPRESSION: 1. Right kidney pyelonephritis, currently uncomplicated. 2. Multiple low-density lesions in the left kidney, the largest measuring 6 x 5 cm, most likely renal cysts. 3. Vascular atherosclerotic calcifications. 4. Small liver cysts, too small to characterize. . [**2135-8-31**] AP CXR IMPRESSION: 1. Signs of old TB. 2. New pneumonia in the right middle and lower lung. 3. Interstitial pulmonary edema. . [**2135-9-1**] TT ECHO Conclusions The left atrium is elongated. The estimated right atrial pressure is 0-10mmHg. 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mildly dilated right ventricle with preserved biventricular systolic function. Mild aortic regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. These findings are most consistent with chronic pulmonary disease (parenchymal, vascular, etc.) Compared with the report of the prior study (images unavailable for review) of [**2132-2-29**], left ventricular function appears normal, however there is now pulmonary hypertension and RV is slightly dilated. . [**2135-9-2**] CXR: In comparison with the study of [**9-1**], there is little interval change. Again, there is extensive pleural calcification with opacification in the right apex and retraction of the trachea to this side, consistent with old tuberculosis and consequent volume loss in the right upper lobe. Continued interstitial and alveolar edema. The opacifications in the right mid and lower lung zones may be slightly improved. . Brief Hospital Course: 72 year old female with afib, bronchiectasis, past breast cancer s/p surgery/radiation presenting with high fevers, chills, RLQ pain and CVA tenderness consistent with pyelonephritis. . 1. Pyelonephritis: The patient's presentation with high fevers, chills, RLQ abd pain right-sided CVA tenderness, foul smelling urine, and lekocytosis and her CT scan were all consistent with pyelonephritis. Blood cultures x2 were sent and were negative. Her urine culture grew Klebsiella Pneumonia sensitive to ciprofloxacin. She was treated with ceftriaxone empirically in the ED, but was switched to PO levofloxacin on admission to the floor due to diarrhea (see below). . 2. Dyspnea: On the morning of [**9-1**], the patient developed significant shortness of breath, requiring 6L O2 to maintain a saturation above 90 (from baseline 92% RA). A CXR was obtained and showed bilteral patchy infiltrates, consistent with PNA or pulmonary edema. An echo showed normal LVEF, new pulmonary hypertension, and slight RV dilation. There was no mention of diastolic dysfunction. There was normal ventricular contractility. The patient was transferred to the ICU, and Cefipime 2g IV q24h was added for possible psuedomonal infection. Levofloxacin was changed to 750mg IV q48h. The patient was also given 20mg IV lasix, with significant improvement in subjective symptoms. She was returned to CC7 during the afternoon on [**9-2**], though still required 6L to maintain an O2 saturation of 94%, but with improved subjective dyspnea. Her WBC count began to trend downward on [**9-3**] (17.4->15.8), the patient became afebrile, and was weaned from O2. She received a second dose of 20mg Lasix on the evening of [**9-2**], and was -1L that day. The patient was initially fluid restricted in the ICU and on admission to the floor, but fluid restriction was removed on [**9-3**] AM given clinical improvement. Cepefime was discontinued on [**9-3**] due to low probability of pseudomonal infection. On the day of discharge, the patient no longer required supplemental oxygen to maintain her sats above 90% and she was discharged on levofloxacin through [**2135-9-12**] to finish a 14 day course of antibiotics. . 3. Diarrhea: After receiving IV ceftriaxone in the ED for treatment of pyelonephritis, the patient experienced significant diarrhea with 12-14 bowel movements during the night, for which she was unable to reach the comode. Stool culture was negative for C. Diff, Campylobacter, Shigella, Salmonella. Symptoms resolved once ceftriaxone was discontinued. The patient remained without diarrhea for remainder of the hospital stay. . 4. Hypertension: The patient was initially hypotensive at 94/60 on admission without blood pressure medications. This was likely secondary to her severe infection. Her blood pressure improved quickly, and by discharge she was normotensive and had resumed atenolol. Blood cultures X2 from [**8-30**] showed no growth. . 5. Hypokalemia: The patient became hypokalemic to 3.2 after IVF were given for diarrhea. She was repleted with 80mEq IV potassium in 1L NS with improvement in potassium to 3.8. The patient became hypokalemic again (3.1) after receiving lasix in the ICU, and was repleted with 80mEq PO upon arrival to the floor, with improvement to 3.8. She had no further difficulties maintaining her potassium level. . 6. Atrial fibrillation: The patient's afib remained stable. She was continued on her home medications consisting of both amiodarone and atenolol. She had a supratherapeutic INR on admission (4.4) and her was held. On addition of a flouroquinolone for treatment of a UTI, the patient's INR rose acutely to 9.8. She was given 1mg IV Vitamin K to reverse anticoagulation on [**9-2**] AM. Her INR was 2.1 on [**9-3**], and she was restarted on Coumadin at 2mg DAILY ([**2-9**] home dose). Medications on Admission: ALENDRONATE 70 mg once a week AMIODARONE 100 mg once a day ATENOLOL 25 mg once a day HYDROCHLOROTHIAZIDE 25 mg once a day LISINOPRIL 20 mg once a day WARFARIN 4mg daily Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Last day is [**Last Name (LF) 766**], [**9-12**]. Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnoses: Pyelonephritis Dyspnea Secondary Diagnoses: Diarrhea Hypokalemia Discharge Condition: Stable, breathing comfortably on room air Discharge Instructions: You were admitted to the hospital with a fever and kidney infection and received antibiotics to treat the infection. You should continue to take the antibiotic levofloxacin through [**Last Name (LF) 766**], [**9-12**] to finish treating the infection. Antibiotics can affect the levels of your coumdin. Your dose has been reduced from 4 mg to 2 mg. A nurse will come and draw your blood to check your INR on Wednesday. Your dose may need to be adjusted. While you were hospitalized you also became short of breath and stayed briefly in the ICU. Your breathing improved and you no longer require supplemental oxygen therapy. However, because of your history of lung disease, you should establish care with a pulmonologist. Please see below for recommendations by Dr. [**Last Name (STitle) **]. You should also attend a follow-up appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**], as listed below. Because you had such a severe infection, you should take it easy and not do anything strenuous for the next week to allow your body to heal. Your lung and kidney function should return to where they were before your infection, but it will take some time for them to do so. If you have any additional fevers, shortness of breath, difficulty urinating, or any other concerning symptoms, you should call your physician or return to the hospital. Followup Instructions: Primary care follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] on [**2135-9-12**] at 2:15 PM. Phone: [**Telephone/Fax (1) 2205**] You should establish care with a pulmonologist. The following physicians were recommended by Dr. [**Last Name (STitle) **]: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**] or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], phone: [**Telephone/Fax (1) 612**]

Admission Date: [**2153-6-14**] Discharge Date: [**2153-7-24**] Date of Birth: [**2114-4-24**] Sex: M Service: [**Last Name (un) 7081**] ADDENDUM: The patient is currently on postoperative day 38. He has been preparing for discharge to rehabilitation for the past several days and it was decided that the patient was stable and ready to be discharged on this day. At the time of this dictation, the patient's physical examination is as follows - temperature is 96.9, heart rate 94, sinus rhythm, blood pressure 133/60, respiratory rate 23, O2 saturation 97% on a 50% tracheostomy mask. The patient's lab data on the day of discharge reveals a white count of 8.9, hematocrit 30.3, platelets 478, INR 1.1, sodium 140, potassium 4.0, chloride 104, CO2 of 29, BUN 13, creatinine 0.4, glucose 118. PHYSICAL EXAMINATION: He is alert and oriented in responses. He moves all extremities and follows commands with a nonfocal exam. Respiratory - breath sounds are somewhat diminished although clear bilaterally. He has a strong productive cough. GI - PEG feeding tube is intact and his abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well-perfused with no edema. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Status post ascending aortic dissection repair with a No. 28 Gelweave graft. Also, status post aortic valve replacement with a No. 25 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. 2. Status post tracheostomy. 3. Status post PEG. 4. Status post respiratory failure. 5. Status post postoperative atrial fibrillation. 6. Status post PICC placement. 7. Asthma. 8. GERD. FOLLOW UP: The patient is to have follow-up with Dr. [**Last Name (STitle) 70**] in 6 weeks. DISCHARGE MEDICATIONS: Aspirin 81 mg daily, Flovent 2 puffs b.i.d., albuterol 2 puffs q.4h., Atrovent 2 puffs q.6h., lansoprazole 30 mg daily, Norvasc 10 mg daily, labetalol 200 mg b.i.d., heparin 5000 units t.i.d., amiodarone 400 mg daily x7 days, then 200 mg daily x1 month, Lasix 20 mg daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2153-7-24**] 10:54:03 T: [**2153-7-24**] 11:12:05 Job#: [**Job Number 61481**]

Admission Date: [**2115-7-27**] Discharge Date: [**2115-7-30**] Date of Birth: [**2046-10-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Sigmoidoscopy ([**2115-7-28**]) EGD ([**2115-7-28**]) History of Present Illness: 68M with one day history of abdominal distention, decreased bowel function and nausea, no emesis. Has a history of gastric lymphoma treated with subtotal gastrectomy and radiation, and followed by chemotherapy for recurrence. Has had multiple episodes of small bowel obstructions and associated GI bleeds. He is followed by Dr. [**First Name4 (NamePattern1) 1939**] [**Last Name (NamePattern1) 2305**]. His last EGD and colonoscopy were in [**8-/2113**] and demostrated diverticulosis and a diverticulum at the GE junction. Past Medical History: PMH: CAD s/p inferior MI ([**5-/2113**]), dyslipidemia, gastric MALT lymphoma (s/p subtotal gastrectomy and radiation in [**2095**]) with recurrence in [**2110**] (s/p CHOP x 8 cycles), history of GI bleeds and small bowel obstructions (never requiring surgery), BPH PSH: subtotal gastrectomy for gastric lymphoma ([**2095**]), R open inguinal hernia repair Social History: Social history is significant for the absence of current tobacco use. Pt smoked from age 16-31. There is no history of alcohol abuse. He drinks 3-4 alcoholic drinks per week. Pt works as a research scientist, has a lab in [**Location (un) 23940**], MA. On pathology staff at [**Hospital1 18**]. Works with cell analysis instrumentation. Lives with wife in [**Name (NI) 1562**]. Family History: There is no family history of premature coronary artery disease or sudden death. HTN, DM and lymphoma in family Physical Exam: Physical Exam: 98.5 72 100/85 14 100RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: distended abdomen, moderately tender to palpation DRE: guiac negative Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2115-7-27**] 11:50AM BLOOD WBC-11.6*# RBC-4.77 Hgb-14.4 Hct-43.5 MCV-91 MCH-30.2 MCHC-33.1 RDW-14.0 Plt Ct-220 [**2115-7-27**] 04:45PM BLOOD WBC-10.5 RBC-3.34*# Hgb-10.5*# Hct-30.5*# MCV-91 MCH-31.4 MCHC-34.4 RDW-13.9 Plt Ct-191 [**2115-7-27**] 08:26PM BLOOD Hct-23.5* [**2115-7-28**] 12:15AM BLOOD Hct-24.6* [**2115-7-28**] 02:00AM BLOOD Hct-26.6* [**2115-7-28**] 04:15AM BLOOD WBC-5.0# RBC-3.43* Hgb-10.5* Hct-29.8* MCV-87 MCH-30.7 MCHC-35.3* RDW-15.6* Plt Ct-104* [**2115-7-28**] 08:20AM BLOOD WBC-6.3 RBC-3.74* Hgb-11.0* Hct-32.2* MCV-86 MCH-29.4 MCHC-34.1 RDW-15.5 Plt Ct-122* [**2115-7-28**] 02:14PM BLOOD Hct-33.0* [**2115-7-28**] 06:04PM BLOOD Hct-30.0* [**2115-7-29**] 02:10AM BLOOD WBC-5.9 RBC-3.97* Hgb-11.9* Hct-34.2* MCV-86 MCH-30.0 MCHC-34.7 RDW-15.3 Plt Ct-135* [**2115-7-30**] 03:15AM BLOOD WBC-5.4 RBC-3.80* Hgb-11.3* Hct-32.5* MCV-86 MCH-29.8 MCHC-34.9 RDW-14.8 Plt Ct-146* Brief Hospital Course: The patient was initially seen in the ED for obstructive symptoms. While in the ED he became hypotensive and his Hct was found to have dropped. He also had a large bloody BM. He was transfused 1u PRBC in the ED and admitted to the SICU. He was tranfused 5 more units of PRBC overnight, as well as 3u FFP and 1u platelets. He underwent a tagged RBC scan overnight which failed to demonstrate a source of bleeding. GI was consulted overnight and declined to scope him until the next day. After that his Hct was stable. He underwent flexible sigmoidoscopy and EGD on HD2 ([**2115-7-28**]), the results of which are listed below. He had no further bloody BM. He was started on clears on HD3 and advanced to a regular diet on HD4. He was discharged on HD4 ([**2115-7-30**]). CT A/P ([**2115-7-27**]) - Findings compatible with a small-bowel obstruction, with transition point difficult to ascertain, though likely in the left mid abdomen. Radiopaque densities seen within the cecum are likely related to ingested material. Cholelithiasis and a mildly distended gallbladder with no secondary signs of cholecystitis. Anterior abdominal wall hernia containing fat though with associated stranding suggesting inflammatory change. GI Bleeding Study ([**2115-7-27**]) - No definite evidence of GI bleed. However, there is a questionable mild area of uptake in the rectum on the lateral view, and active bleed cannot be entirely excluded. Sigmoidoscopy ([**2115-7-28**]) - Diverticulosis of the sigmoid colon. Normal mucosa in the sigmoid colon. Stigmata of recent bleeding was seen up to the distal sigmoid colon. The endoscope could not be traversed past the distal sigmoid colon. EGD ([**2115-7-28**]) - Evidence of a previous subtotal gastrectomy was seen. Areas of erythema likely secondary to NGT trauma. Anastomosis patent. Normal duodenum. Esophageal diverticulum. There was bile in stomach. No evidence of bleeding. No ulcers. Anastomosis patent. Otherwise normal EGD to second part of the duodenum. Medications on Admission: 1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Fluticasone Nasal 6. Multivitamin Oral Discharge Medications: 1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Fluticasone Nasal 6. Multivitamin Oral Discharge Disposition: Home Discharge Diagnosis: GI bleed of indeterminate source Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized with a GI bleed of undeterminate source. The bleed has resolved on it's own without intervention. It is important that you avoid anything that you feel is associated with these events, such as Chinese food. Otherwise you have no activity restrictions. Be sure to return to the ED or seek medical care should you have bloody or dark bowel movements, emesis with blood or obstructive symptoms such as decreased flatus and bowel movements, nausea and vomiting, and abdominal pain and distention. Followup Instructions: Please follow-up with your GI doctor, Dr. [**First Name4 (NamePattern1) 1939**] [**Last Name (NamePattern1) 2305**]. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2115-9-23**] 9:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

Admission Date: [**2137-10-14**] Discharge Date: [**2137-10-22**] Date of Birth: [**2057-5-11**] Sex: F Service: MEDICINE Allergies: Aspirin / Bactrim / Nsaids Attending:[**First Name3 (LF) 358**] Chief Complaint: shortness of breath, productive cough Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: The patient is an 80-year-old female with a past medical history significant for chronic bronchiectesis, MV-repair/tricuspid valve replacement, CHF, and atrial fibrillation who presented to to her primary care physician's office at [**Company 191**] just prior to this hospital admission complaining of worsening dyspnea and cough. At baseline, the patient has moderate amount of yellow sputum and is on 2.5 L oxygen via home NC with typical oxygen saturations ranging from 95-96%. Prior to presentation she describes having 3-4 days of extreme fatigue, nausea, weakness and worsening sputum production that was darker yellow-greenish in color along with a more frequent cough. She was sent from the [**Hospital 191**] clinic visit over to the ED for further workup. In clinic she had a temperature of 100.3 F, RR 33 and she had notable accessory muscle use and obvious labored breathing. . In the [**Hospital1 18**] ED her vitals were: Temperature of 101.6F, HR 80, SBP 130s, and oxygen saturations were in the low 90's on 4L NC and remained in low 90s with higher rates on non-rebreather mask. Despite her presentation, she had no significant WBC elevations. On exam, she had rales throughout both lung fields. On EKG she was V-paced as she has a pacemaker. She also had evidence of atrial fibrillation on EKG. CXR in ED showed both RUL and LLL opacities. She was given nebulizer treatments with little effect. IV Vancomycin and Levofloxacin were also initiated in the emergency room soon after her arrival. She was felt to be too unstable for the general medical floor and was admitted to the MICU service. . Following admission to MICU the patient continued to have increased work of breathing and productive cough with low oxygen saturations and was felt to be in hypoxic respiratory distress with some hypercarbia as well as ABG showed a pO2 of 63mmHg and pCO2 of 49. Fortunately, she did not require intubation but she was started on non-invasive ventilation. She was mostly normotensive with a few drops of SBP into the high 80s but she did not require any pressors. IVFs were used sparingly given her CHF history. She has a history of resistant pseudomonas so there was some concern for re-infection, especially since gram negative rods were found on sputum culture. Urine legionella testing was sent off as well and she was continued on her Levofloxacin coverage at time of her transfer to the general medical floor until urine legionella results returned. Vancomycin was discontinued at time of transfer out of MICU. While in the MICU she also underwent daily chest PT and received ongoing nebulizer treatments. Upon arrival to the general medical floor she had been successfully weaned down to 4-5L on nasal cannula with oxygen saturation levels of 93%-95%. In general, she stated she was feeling "much better" with more energy and less shortness of breath at time of her transfer. Despite her CHF history she did not seem to have any signs of fluid overload as her JVD was 5-6cm and she had no crackles on lung exam and no pedal edema. She was continued on her usual Coumadin therapy for her atrial fibrillation and tricuspid valve replacement but she had to hold her Coumadin for a few evenings due to a high INR. Because of her bronchiectasis her INR goal is uniquely 2.0 so the team made note of this fact during her stay. . Past Medical History: 1. CAD - Cath ([**3-/2134**]) - LMCA and LCx, no disease; LAD: proximal and mid vessel 30% stenoses; RCA - mild luminal irregularities - Pacemaker/ICD ([**Company 1543**] Sigma SDR303 B pacemaker), in [**1-/2132**] 2. Atrial fibrillation, status post AVJ ablation and DDD pacer 3. Congestive heart failure (EF 30% in [**2135**]) 4. MV repair and TVR ([**4-/2132**]) 5. Bronchiectasis with presumed pseudomonal colonization ([**2135-12-19**] and treated with ceftazidime and azithromycin): Previously suffered exacerbations in [**Month (only) **] and [**2135-8-19**] that were treated with meropenem/ciprofloxacin and ceftazidime as outpatient 6. Depression 7. Hyperparathyroidism Social History: Lives in [**Location (un) 55**]. She worked as a lecturer on Egyptology at the MFA in [**Location (un) 86**]. Husband is deceased. She lives with her son and has an aid most days of the week. Has three sons, [**Name (NI) **], [**Doctor First Name **] and [**Doctor Last Name **]. Quit smoking 30 years ago, had a 5 pack year history. Previously, she drank one drink/day but no ETOH now for many years. Family History: Her father and mother are both deceased. Her father had HTN. Her mother had [**Name (NI) 19917**] disease and died as an elderly woman. There is a negative family history of colon cancer, breast cancer, diabetes, and premature coronary artery disease. She has three natural children who are alive and well and one brother who is alive and well. Physical Exam: PHYSICAL EXAM: VS: 97.6, HR 81, BP 128/50, RR20s, 93% (92-97%) on 4L NC GENERAL: no distress at rest, mild nasal flaring with respirations but no accessory muscle use noted, alert and oriented to person, place and time, pleasant demeanor HEENT: moist mucosal membranes, EOMI, OP clear of exudates, mild erythema at posterior pharynx Neck: JVD at 5-6cm, supple, no thyromegaly, no lymphadenopathy CVS: Loud S2 noted, regular S1, pulse is irregular,no murmurs/rubs/gallops Pulm: Diffuse coarse rhonchi throughout lung fields bilaterally and decreased lung sounds at LLL. No dullness to percussion. Abd: Normoactive BS throughout, NT/ND, no hepatosplenomegaly Extrem: no edema, 2+ DP and PT pulses distally at lower extremities Skin: No rashes, warm, pink complexion Neuro: CNs [**1-29**] in tact, no focal motor or sensory deficits noted, appropriate affect . Pertinent Results: ADMISSION LABS: . [**2137-10-14**] BLOOD WBC-9.2 RBC-4.86 Hgb-14.0 Hct-42.2 MCV-87 MCH-28.7 MCHC-33.1 RDW-14.3 Plt Ct-237, differential: Neuts-73.6* Lymphs-19.5 Monos-5.8 Eos-0.5 Baso-0.7 [**2137-10-14**] BLOOD PT-17.4* PTT-23.9 INR(PT)-1.6* [**2137-10-14**] BLOOD Glucose-127* UreaN-18 Creat-0.8 Na-134 K-4.4 Cl-97 HCO3-28 AnGap-13, Calcium-10.7* Phos-2.8 Mg-2.3, Glucose-122, Lactate-1.3 K-4.5 . INITIAL URINE : [**2137-10-14**] URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022 [**2137-10-14**] URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2137-10-14**] URINE RBC-[**5-28**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 . OTHER TESTS/IMAGING: . [**2137-10-14**] EKG : Rate 80 and ventricular paced with slow atrial fibrillation noted, no ST changes. Compared with EKG [**2137-6-9**] . [**2137-10-14**] CXR: Chronic interstitial lung disease with increased right upper lobe and LLL opacities which may represent atypical pneumonia or atelectasis. . [**2137-10-16**] CXR: The lungs are again well expanded. Evidence of bronchiectasis is better seen on CT. Wedge-shaped opacity behind the left heart appears slightly more consolidative; while this could represent atelectasis related to impacted airways, if the patient had fever, this could also represent consolidation. Ill-defined opacity in the right upper lung is worse. Opacity seen on CT in the left lung apex is not evident radiographically. No new area of consolidation is noted. No evidence of pneumothorax or pleural effusion is seen. Cardiomediastinal contours are unchanged. A left-sided transvenous pacemaker with right atrial and right ventricular leads remain in place. Sternotomy wires remain in place, tricuspid valve prosthesis and possible mitral annular prosthesis remain in place. . MICROBIOLOGY: . [**2137-10-17**] Blood cultures x2 -No growth [**2137-10-14**] Blood cultures x2 -No growth [**2137-10-14**] Urine culture -No growth [**2137-10-15**] Urine Legionella Antigen -negative [**2137-10-15**] MRSA nasal swab -negative [**2137-10-15**] Sputum Culture: GRAM STAIN (Final [**2137-10-15**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2137-10-22**]): SPARSE GROWTH OROPHARYNGEAL FLORA. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.MODERATE GROWTH. UNABLE TO PERFORM SENSITIVITIES DUE TO LACK OF INTERPRETATION.. . DISCHARGE LABS: . [**2137-10-22**] 05:58AM BLOOD WBC-10.6 RBC-4.08* Hgb-11.7* Hct-35.2* MCV-86 MCH-28.6 MCHC-33.2 RDW-13.4 Plt Ct-324, Plt Ct-324 [**2137-10-22**] 05:58AM BLOOD Glucose-80 UreaN-14 Creat-0.5 Na-137 K-4.2 Cl-98 HCO3-35* AnGap-8, Calcium-9.4 Phos-3.0 Mg-2.1 Brief Hospital Course: In summary, the patient is an 80-year-old female with chronic bronchiectasis and home oxygen dependence, MV-repair/tricuspid valve replacement, and atrial fibrillation who presented with fevers, worsening cough, and shortness of breath which progressed to hypoxic respiratory failure in the setting of suspected new acute PNA which was corroborated by CXR. . # Hypoxic respiratory failure: At time of transfer to the regular medicine [**Hospital1 **] from the MICU the patient's oxygen requirements had improved and her hypoxia appeared to be resolving well. She had an ABG with pO2 63 and pCO2 of 49 in MICU shortly after admission consistent with hypoxic failure mixed with hypercarbia. Patient has chronic bronchiectasis which was initially noted in the late [**2108**] per patient and on further discussion with the patient's pulmonologist it was noted that the root of her bronchiectasis dates back to a severe pertussis infection many years ago. She has had repeated PNAs and URIs since that time with progressive decompensation and shortness of breath leading to home oxygen dependency. At time of her transfer out of the MICU she had been waened to 4-5L on nasal cannula with oxygen saturations in the mid-90s. At home her baseline oxygen saturations range between 94-97 % on 2.5L nasal cannula per patient and her family. She progressed steadily and her shortness of breath improved throughout her hospital course with ongoing antibiotics and resolution of her PNA and additional albuterol nebulizers and chest PT. Her ipatropium regimen was changed to tiotropium and advair was continued. By time of discharge she was back at her baseline of 2.5 L nasal cannula with oxygen saturations in the high 90s. . # Pneumonia: Despite no leukocytosis, she presented with worsened cough from her baseline, respiratory distress (RR >30), fevers to 101 range, and CXR with consolidations noted at LLL and RUL which were all suggestive of a new PNA. The patient was also known to be colonizated with Pseudomonas in the past and she had been treated in the past several times with various antibiotics. Per records, her last recorded sputum had grown out GNR (non-pseudomonas) sensitive to Ceftazidime, Levofloxacin, Meropenem, and Zosyn. Given these sensitivity patterns and her significant underlying lung pathology with bronchiectasis she was continued on Levofloxacin initally for coverage for atypicals/Legionalla PNA but once urine legionella returned negative the levofloxacin was discontinued. She was continued on broad coverage with Doripenem and switched to Meropenem just prior to discharge. A PICC line was placed and home services were arranged to help Mrs. [**Known lastname **] administer her antibiotics as an outpatient until [**2137-10-28**] when she will complete a full 14 days of antibiotics. Blood cultures all returned negative. She continued her chest PT and spirometry at the bedside and she was given daily mucinex, nebulizers alongside her antibiotics and her cough and phlegm production gradually improved. Her fevers gradually tapered as well and by time of discharge she had been afebrile for several days. . # Bronchiectasis: As mentioned, her initial bronchiectasis and pulmonary scarring was secondary to an older Pertussis infection > 15 years ago. On this admission she had no hemoptysis noted but cough and baseline sputum were much worse than usual at admission per patient. She was continued on her Albuterol Nebs, Advair, and Mucinex twice daily. The patient was encouraged to continue her home inhalers, and ongoing chest PT as an outpatient as she is predisposed to PNAs from her baseline bronchiectasis. . # Systolic CHF: Last EF was 30% in [**2135**]. She had JVD=3-4cm on exam, no crackles on lung exam, and no evidence of pedal edema to indicate volume overload. She was in no apparent CHF distress despite her acute PNA. During her hospital course she was continued on Furosemide at 20mg dose with eventual taper to her home dose of 10mg daily. She was also continued on Lisinopril 2.5mg PO daily and Spironolactone daily. . # Atrial fibrillation: She was placed on continuous telemetry monitoring and several EKGs were assessed as well. She remained V-paced with HR in 80s and occasional PVCs with no other notable ectopy. Anticoagulation was continued with Coumadin with her INR goal kept at 2.0 because of her extensive bronchiectasis. She has a CHADS score 2. Coumadin dose was held for a few days due to a brief period of time while her INR was supratherapeutic but it was restarted prior to discharge with instructions for her home services nurses to draw her blood on Wednesday [**10-23**] and have her INR/PT levels sent to the [**Hospital 197**] Clinic at [**Company 191**] in order to make sure her Coumadin level was within a proper range. Mrs.[**Known lastname 109589**] INR was 1.9 at time of discharge. . # Hyperlipidemia: She was continued on her usual daily dose of 20mg Simvastatin for her hypercholesterolemia management. She had no chest pain or angina during her hospital stay. . # Anxiety: The patient had well controlled anxiety levels throughout her hospital course despite the undoubted stress of being admitted to an intensive care unit in repiratory distress. She was maintained on her usual home Citalopram 20 mg daily and Lorazepam 1.0 mg QHS as needed. . # Fluids, electrolytes and nutrition: Mrs. [**Known lastname **] was given a regular cardiac healthy diet and her electrolytes were checked daily and replete on an as-needed basis. PO intake was encouraged and IVFs were used sparingly due to her CHF history. . # Prophylaxis Issues: She was continued on Coumadin for anticoagulation which also provided DVT prevention as well, protonix was given for GI protection and Senna and Colace to promote stool regularity. . The patient was maintained as a full code status for the entirety of her hospitalization as communication occured directly with the patient on a daily basis and with her three sons as requested per patient. The patient's primary pulmonologist,Dr. [**Last Name (STitle) **], was also updated on Mrs.[**Known lastname 109589**] status during her hospital stay. Medications on Admission: 1. Albuterol prn 2. Alendronate 70 mg qweek 3. Citalopram 20 mg daily 4. Advair [**Hospital1 **] 5. Furosemide 10 mg daily 6. Lisinopril 2.5 mg daily 7. Lorazepam 0.5-1.0 mg QHS PRN 8. Omeprazole 20 mg daily 9. Simvastatin 20 mg daily 10. Spironolactone 12.5 mg daily 11. Spiriva daily 12. Warfarin 1 mg daily 13. Calcium + Vit D 14. Guaifenisen 1200 mg [**Hospital1 **] PRN 15. MVI Discharge Medications: 1. Outpatient Lab Work Please check INR on Wednesday [**10-23**] and call results to [**Hospital 191**] [**Hospital 197**] Clinic at [**Telephone/Fax (1) 2173**], report will be forwarded to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] 2. PICC line care Routine PICC line care. Please flush PICC line with normal saline [**4-27**] mL flushes PRN and heparin 10 units/mL [**2-20**] mL PRN for line maintenance. Discontinue PICC upon completion of antibiotics. 3. Meropenem 1 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 6 days. Disp:*18 * Refills:*0* 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: .5 Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 11. Albuterol Inhalation 12. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Guaifenesin 600 mg Tablet Sustained Release Sig: [**12-19**] Tablet Sustained Releases PO BID (2 times a day). 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation AS DIR. 15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please continue to have regular [**Company 191**] coumadin level checks as directed by PCP . 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Pneumonia Dyspnea / Hypoxic respiratory failure Bronchiectasis . Secondary: Coronary Artery Disease Systolic congestive heart failure Primary hyperparathyroidism Osteoporosis Atrial fibrillation s/p ablation and pacemaker Depression Discharge Condition: At time of discharge the patient was clinically doing well with stable vital signs and her oxygen requirements had returned to her usual baseline on 2.5L oxygen via nasal cannula which was her pre-admission home oxygen requirement. The patient's cough had lessened in severity and she was in no distress. Discharge Instructions: It was a pleasure taking care of you during your hospital stay here at [**Hospital1 69**]. You were admitted with worsening shortness of breath and a productive cough and found to have a pneumonia. This diagnosis was supported on additional imaging and lab studies. Your shortness of breath was so severe that you needed to be admitted to the medical intensive care unit for a few days prior to transferring to a general medical floor once you were more stable. Your were given high flow, non-invasive oxygen therapy to help resolve your respiratory distress. You were also given frequent nebulizer treatments to help your shortness of breath. Antibiotics were given to treat your pneumonia. Your additional medical issues which include atrial fibrillation, coronary artery disease, depression, hyperparathyroidism and a history of congestive heart failure were all monitored and managed during your hospitalization. Please continue with your usual outpatient physical therapy and home health services. A script with instructions for your blood to be drawn at home on Wednesday [**10-23**] has been included in your discharge paperwork. Your INR level will be checked sent to the [**Hospital 197**] Clinic at [**Company 191**] in order to make sure your Coumadin level is correct. Medication Instructions: During your hospital stay a PICC line was placed for ongoing antibiotic therapy which must be given intravenously. You will continue to get your daily Meropenem antibiotic through your PICC line (1g Meropenem every 8 hours)for a total of 2 weeks of antibiotic therapy which are scheduled to end [**2137-10-27**]. The PICC will be removed once antibiotic therapy is completed. Because of your history congestive heart failure it is important to weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs as this may indicate fluid overload in your body. Adhere to 2 gm sodium diet daily. Please call your primary care physician or return to the Emergency Department immediately if you experience fever, chills, sweats, dizziness, lightheadedness, chest pain, palpitations, shortness of breath, worsening of your baseline cough, abdominal pain, vomiting, diarrhea, bloody or dark stools, leg swelling or pain, numbness, weakness, or tingling. Followup Instructions: Please follow-up with your primary pulmonologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on [**12-4**] at 11:30a.m. Phone # [**Telephone/Fax (1) 612**]. Dr. [**Name (NI) 76864**] office has been contact[**Name (NI) **] to try to get an earlier appointment and you will be contact[**Name (NI) **] to arrange a [**Name (NI) **] appointment. Please follow-up with your primary care physician at [**Name9 (PRE) 191**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**11-13**] at 1:40pm. Phone # [**Telephone/Fax (1) 250**] Completed by:[**2137-10-26**]

Admission Date: [**2132-3-28**] Discharge Date: [**2132-4-10**] Date of Birth: [**2069-7-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Incidental finding of right upper lobe nodule Major Surgical or Invasive Procedure: Right upper lobectomy [**3-27**] for Right upper lobe nodule History of Present Illness: 62 year oldg entleman who has had a right upper lobe nodule incidentally noted on a chest CT dated [**2130-2-2**]. Serial follow up of this scan has noted an increase from 9 mm in size to 13 mm. Past Medical History: recurrent falls executive dysfunction and dementia- s/p extensive neurologic work-up Seasonal allergies Thyroid carcinoma s/p thyroidectomy. Depression/ dementia Hypercholesterolemia Mediastinoscopy for lymph node dissection [**2132-3-14**] Recent largngoscopy showing findings consistent with recurrent right laryngeal nerve palsy Social History: No history of ethanol, tobacco, drugs. He formerly worked as a customer service representative for a telephone company, but is currently unemployed. He is divorced and has two kids who are very involved in his care. They both live in [**Hospital1 614**], but one is planning to move to [**Location (un) 86**] shortly. He currently lives with his mother. Family History: Father died of myocardial infarction at the age of 68. Mother is alive and is OK. He has no siblings. Physical Exam: General- older appearing middle/elderly male, NAD. poor historian HEENT- dry mucous membranes, EOMI, PERRLA; Lungs-clear to ausculatation bilat Cor-RRR Abd-soft, NT, ND Ext- no edema, 2+ DP, PT [**Name (NI) 111708**], oriented x2, fleeting attention, resting tremor in left thumb and index finger, rhythmic movements in both lower extremities; Strength 5/5 throughout; balance-poor, need 2 full assist; gait- limited LE movement. Pertinent Results: [**2132-3-28**] 06:48PM PLT COUNT-285# [**2132-3-28**] 06:48PM WBC-13.7*# RBC-4.10* HGB-13.0* HCT-37.5* MCV-91 MCH-31.7 MCHC-34.7 RDW-13.6 [**2132-3-28**] 06:48PM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.8 [**2132-3-28**] 06:48PM GLUCOSE-152* UREA N-30* CREAT-1.4* SODIUM-140 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [**2132-3-28**] 09:17PM TYPE-ART PO2-171* PCO2-43 PH-7.35 TOTAL CO2-25 BASE XS--1 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2132-4-2**] 06:25AM 11.7* 3.66* 11.8* 33.6* 92 32.1* 35.1* 13.1 239 BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2132-4-2**] 06:25AM 239 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2132-4-2**] 10:58AM 100 25* 1.1 140 4.31 106 20* 18 SLIGHT HEMOLYSIS 1 HEMOLYSIS FALSELY INCREASES THIS RESULT ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2132-3-31**] 03:31PM 65* 64* 263* 64 0.5 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2132-4-2**] 10:58AM 8.8 3.2 1.9 SLIGHT HEMOLYSIS PITUITARY TSH [**2132-3-31**] 03:31PM <0.02* [**2132-3-31**] 05:40AM <0.02* ADDED TSH [**2132-3-31**] 9:35AM THYROID T4 Free T4 [**2132-4-1**] 09:45AM 7.9 1.5 RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2132-4-1**] 9:01 AM FINDINGS: There is no significant interval change in the appearance of the present noncontrast head CT scan compared to the prior [**Hospital3 **] study of [**2131-11-11**], as well as the outside study from [**Hospital3 417**] Hospital. There is no sign for the presence of a visible intracranial mass lesion. Both studies show slightly asymmetric atrophy of the cerebellum, more evident in the region of the right cerebellar hemisphere. Images of the cerebellum, at this time, are moderately degraded by patient motion. In any case, visualization of the MR- described cavernous hemangioma would be extremely difficult, given its reported small size and typically limited visibility on a noncontrast head CT scan. The surrounding osseous and soft tissue structures show no additional abnormalities. CONCLUSION: No interval change from prior study of [**2131-11-11**]. In view of the questions you have raised in the history, kindly forward the original report of the [**Hospital3 417**] Hospital CT scan for our independent review. CTA CHEST W&W/O C &RECONS [**2132-4-3**] 8:11 AM CT ANGIOGRAM FINDINGS: The main right and left, lobar and proximal segmental pulmonary arteries are widely patent and appear normal, no evidence of acute pulmonary embolus. At the peripheral segmental level the contrast opacification is slightly suboptimal. Normal heart size and central pulmonary arterial vasculature. Normal caliber thoracic aorta. Patient is status post right upper lobectomy. Small right posterior basal pleural effusion. Partial atelectasis of the medial segment of the right middle lobe. Patchy consolidation in the posterior aspect of the right lower lobe also patchy airspace consolidation in the posterior portion of left lower lobe. There is associated increased ground-glass attenuation in these areas more marked on the left lung. Differential possibilities include aspirational pneumonia. Although the appearances were asymmetric, worse on the left side, asymmetric pulmonary oedema is also a consideration. However, the nondependent interlobular septae in the right lung do not appear thickened at present. Minor area of residual localized pneumothorax in the central medial thorax. No bone lesions demonstrated. In the arterial phase scan, there is an ill-defined area of hypodensity in the posteromedial aspect of segment VII (series 4, image 100) which remains unchanged in size compared to prior CT of [**2131-11-12**]. CONCLUSION: 1. No acute pulmonary embolus demonstrated. 2. Extensive patchy consolidation in the left lung and posterior aspect of the remaining right lower lobe with associated ground-glass attenuation in those areas. Differential considerations include aspiration pneumonia possibly with some associated and asymmetric pulmonary edema. Small localized right posterior basal pleural effusion. CHEST (PA & LAT) [**2132-4-8**] 11:02 AM The patient is status post partial resection of the right lung with volume loss and a persistent small right apical pneumothorax. The heart is normal in size. There are bibasilar areas of consolidation, left greater than right, which appear worsened in the interval. Small right pleural effusion is without change. IMPRESSION: 1. Evolving bibasilar pneumonia. 2. Small right apical pneumothorax. Bronchial lavage [**2132-4-4**]: ATYPICAL. Rare isolated atypical cells, can not exclude malignancy. Neutrophils, histiocytes and red blood cells. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 111709**],[**Known firstname **] [**2069-7-1**] 62 Male [**Numeric Identifier 111710**] [**Numeric Identifier 111711**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd SPECIMEN SUBMITTED: PARIETAL PLEURA (FS), RIGHT. UPPER LOBE WEDGE (FS), BRONCHIAL MARGIN, LEVEL 10 HILAR, AND LEVEL 11 INTER LOBAR. Procedure date Tissue received Report Date Diagnosed by [**2132-3-28**] [**2132-3-28**] [**2132-4-4**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/vf Previous biopsies: [**Numeric Identifier 111712**] 4 R/L LOWER PARATRACHEAL,2 R UPPER PARATRACHEAL,7 DIAGNOSIS: I. Parietal pleura (A): Fragments of lung and pleura with focal fibrosis. Note: By immunohistochemistry, the aggregates of cells present are negative for cytokeratin cocktail (AE1/AE3, CAM5.2), S-100, HMB-45, and MART-1. Calretinin is weakly positive in the mesothelial cells present. II. Right upper lobe, wedge resection (B-J): Malignant melanoma (1.0 cm), see note. Note: Sections show a monotypic population of atypical spindled and epithelioid cells with prominent nucleoli, arranged in nodules and small nests. By immunohistochemistry, these cells are positive for S-100 and MART-1; they are negative for cytokeratin cocktail, 34BE12, synaptophysin, chromogranin and TTF1. This immunophenotype supports the diagnosis of malignant melanoma. III. Lung, right upper lobectomy (K-R): 1. Bronchial and vascular margins with no malignancy. 2. Lung parenchyma with emphysematous changes and vascular congestion; no malignancy identified. 3. Pleural fibrosis. IV. Lymph node, level 9, pulmonary ligament (S): Two lymph nodes with no malignancy identified (0/2). V. Lymph node, level 10, hilar (T): One lymph node with no malignancy identified (0/1). VI. Lymph node, level 11, interlobar (U): One lymph node with no malignancy identified (0/1). VII. Lymph node, level 12, lobar (V): One lymph node with no malignancy identified (0/1). Clinical: Right upper lobe nodule. Gross: The specimen is received in seven parts each labeled with the patient's name, "[**Known lastname **], [**Known firstname 3075**]" and the medical record number. Part 1 is received fresh in the OR and consists of two fibrofatty fragments measuring 0.7 x 0.4 x 0.3 cm in aggregate. The specimen is inked and submitted entirely for frozen section and carries a frozen section diagnosis by Dr. [**Last Name (STitle) 10165**] of: "Parietal pleura, focal cellular spindle/epithelial proliferation, FDPPS". The specimen is submitted entirely in A Part 2 is received fresh in the OR and consists of an unoriented lung wedge of spongy grey tissue measuring 5.3 x 2.5 x 1.2 cm. The margin is inked in [**Location (un) 2452**] and the rest in black and the specimen is noted to be previously incised by the surgeon for microbiology. The specimen is serially sectioned to show a [**Doctor Last Name 352**] well-circumscribed nodule measuring 1.0 x 0.9 x 0.9 cm approximately 1.3 cm from the staple line, but does not involve the overlying visceral pleura. A portion of the specimen is frozen and carries a frozen section diagnosis by [**Doctor Last Name 10165**] of: "Right upper lobe wedge, spindle/epithelioid tumor, FDPPS". The frozen section remnant is submitted entirely in B. The staple line is cut away from the remainder of the specimen. The specimen is serially sectioned and submitted entirely in cassettes C-J with the nodule in E-H. Part 3 is additionally labeled "bronchial margin" and is received fresh in the OR and consists of a lung lobectomy specimen measuring 16.0 x 8.0 x 2.5 cm. The bronchial margin is identified and submitted en face for frozen section and carries a frozen section diagnosis by Dr. [**Last Name (STitle) 7108**] of: "Bronchial margin, negative for malignancy". The bronchial margin frozen section is submitted entirely in K. On the pleural and inferior surface of the specimen approximately 5.5 cm away from the bronchial resection margin is a pleural nodule that is tan-[**Doctor Last Name 352**] in color that measures 3.5 x 2.0 cm and is inked entirely in black. The specimen is serially sectioned and represented as follows: L = multiple sections of pleural nodule, M = representation of unremarkable lung adjacent to pleural nodule, N-P = additional sections of bronchus and vascular resection margins, Q = multiple areas suggestive of lymph nodes, R = unattached small free floating piece of dark [**Doctor Last Name 352**] tissue contained with lung specimen. Part 4 is additionally labeled "level 9 pulmonary ligament". The specimen consists of two small soft specimens of red and dark [**Doctor Last Name 352**] tissue measuring 0.6 x 0.4 x 0.4 cm in aggregate. The specimen is submitted entirely in cassette S. Part 5 is additionally labeled "level 10 hilar". The specimen consists of multiple pieces of soft pink, red and [**Doctor Last Name 352**] tissue measuring 1.0 x 0.6 x 0.4 cm in aggregate. The specimen is submitted entirely in T. Part 6 is additionally labeled "level 11 interlobar". The specimen consists of multiple fragments of soft dark red and [**Doctor Last Name 352**] tissue measuring 1.3 x 0.6 x 0.4 cm in aggregate. The specimen is submitted entirely in cassette U. Part 7 is additionally labeled "level 12 lobar". The specimen consists of a single piece of dark red and [**Doctor Last Name 352**] tissue measuring 0.7 x 0.5 x 0.3 cm. The specimen is submitted entirely in V. Brief Hospital Course: 62 M s/p RUL lobectomy [**3-27**] for RUL nodule. Patient tolerated procedure fairly well, slow to wake post procedure, pain control w/ dilaudid/bup epidural. On arrival to PACU extubated, pt unarrousable to verbal stimuli; CT x2right to suction. PACU course sig for continued lethergy, epidural decreased with improvement in mental status- awake to verbal and tactile stimuli, speech slurred, VSS. Transferred to floor after 5 hour PACU course in stable condition per PACU protocol. POD#1--[**3-29**] HLIV/Reg diet/CT to waterseal, blakes to bulb- not holding suction overnight.Neuro- drowsy, arrousable, slurred speech, LE tremors( baseline), A&Ox2-3, sitter 1:1> hx falls at home; no falls in house. POD#2--[**3-30**]: [**Doctor Last Name 406**] chest tubes x2 bulbs placed to pleuravac to suction b/c of + leak, bulbs not holding suction. BS congested, dim BS bilat, course bilat at bases; 98%=2L POD#3--[**3-31**] brief Afib, TSH < 0.02, CT to water seal: Neuro status- confusion, worse memory and language per family report; Neuro consult obtained.> 62 yo man with a rapidly dementing illness over the past year, previously was working as a PhD in chemistry, all thought to be secondary to paraneoplastic process. Some tremor episodes somewhat suspicious for seizure. PE:easily distracted, paucity of speech with poor naming, difficult to engage in activities and amotivational. + ataxia on right (may be related to right CBL hemangioma), + cogwheeling on the left. Very unsteady gait. +asterixis. Dx: beclouded dementia; Plan: toxic and metabolic w/u; pna (by CXRY)tx w/ levofloxacin x10d; monitor O2 sats- O2, nebs, CPT; T4= baseline-see below; d/c all sedating meds (trazodone) done; EEG done- pending;CT- head (given hx falls- r/o SDH)- negative-NO SDH, has right CBL atrophy .Staffed with Dr. [**First Name (STitle) 6817**]. POD#4--[**4-1**] one Chest Tube was dc, CT head was neg, CXR: expanded L consolidationeffusion; Swallow-thins/pureed w/ supervision only. Epid cap&flag -to be d/c, foley out, T4 7.9 Free T4 1.5 (in normal range). POD#5--[**4-2**]- 2nd Chest Tube was dc, CXR-sm R apical ptx. Physical Exam more alert. D/C sedative rx per Neuro (trazadone/benedryl);Rapid afib- dilt drip started. POD#6--[**4-3**] desaturation episode in a.m, transfer to ICU: re-intubated. Bronch: diffuse alveolar bleeding, Methylprednisolone x 1, WBC 20 POD#7--[**4-4**] WBC 15, extubated, bradycardic episode- cardiology consulted-amio gtt started; no anticoag, no pacer. POD#8--[**4-5**] stable, transferred out of unit. levaquin dc'd POD#9--[**4-6**] Card rec to keep Amio 400 [**Hospital1 **], no need for IV Hep. ANCA Neg. POD#10--[**4-7**] cxr improved, wbc 9.9 POD#11--[**4-8**] No sitter, CxR better POD#12--Dispo planing. Medications on Admission: asa 325', gemfibrozil 600", lisinopril 30', amlodipine 5', trazodone 25 qhs, synthroid 175, CACO3 500"', Vit D, buspirone 30', trifluoperazine 4 qhs, fluoxetine 160', colace, tylenol Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 8. Trifluoperazine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 9. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: syncope, dementia, thyroid CAncer s/p thyroidectomy, depression, hyperchol, s/p mediastinoscopy [**3-14**], laryngeal nerve palsy, Right upper lobe nodule Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 2347**]/ Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for: fever, shortness of breath, chest pain. Followup Instructions: Call Dr.[**Name (NI) 2347**]/ Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for an appointment in [**11-15**] days. The Cutaneous or [**Hospital 29684**] clinic at [**Hospital1 18**] will contact patient's daughter [**Name (NI) **] for a follow up appointment for w/u of melanoma Completed by:[**2132-4-10**]

Admission Date: [**2195-2-14**] Discharge Date: [**2195-3-9**] Date of Birth: [**2153-2-18**] Sex: F Service: MEDICINE Allergies: Iodine / Betadine Attending:[**First Name3 (LF) 2181**] Chief Complaint: Liver failure Major Surgical or Invasive Procedure: Patient was intubated on [**2195-2-21**] for hypoxia and bronchoscopy demonstrated thick blood clot in lower left lobe, with evidence of post-obstructive pneumonia past the blood clot. History of Present Illness: Ms. [**Known lastname **] is a 41yo female with PMH significant for hepatitis C and ETOH abuse who is being transferred from [**Hospital 1474**] Hospital for fulminant hepatic failure. Per patient, she presented to the OSH with N/V and epigastric pain. She describes a burning pain in her chest. She feels like she needs to burp but is unable to. She denies any hematemesis or hemoptysis. She also admits to significant tylenol use over the past 7 days to help relieve her pain. She thinks that she was taking approximately 20 tablets per day. Per boyfriend, she was taking 1000mg every 2 hours for 7 days. She denies a suicide attempt. She denies any fevers, chills, jaundice, abdominal distention, poor urine output, LE edema, or any other concerning symptoms. She does admit to poor PO intake. Her last alcoholic beverage was on [**Hospital 766**]. She drank approximately [**12-31**] gallon of hard liqour. No recent drug use. She noticed that her eyes were yellow today and also felt slightly confused. . Initial vitals at OSH were T 95 BP 138/78 AR 105 RR 20 O2 sat 99% RA. Preliminary labwork revealed fulminant hepatic failure, renal insufficiency, and lactic acidosis. She received a total of 4L NS. She was then loaded with Mucomyst 11,120mg IV over 60 minutes and then given 4100 over 4 hours. Past Medical History: 1)Hepatitis C: Diagnosed in [**2171**], has not received any treatment 2)Mitral valve prolapse Social History: Patient lives with boyfriend and 18yo son. Unemployed. Alcohol use since the age of 20. Consumes approximately [**12-31**] to 1 gallon of hard liquor. Smokes 1ppd. Occasional drug use. Per boyfriend, smoked cocaine several weeks ago. No IVDA. Family History: Mother and sister with hepatitis C. Physical Exam: Physical Exam: vitals T 97.9 BP 138/88 HR 96 RR 12 O2 sat 100% on 4L i/o 1.8 in/ 785cc out Gen: Patient awake and alert, appears flushed HEENT: MMM, +scleral icterus, yellow face Heart: distant hrt sounds, tachycardia, no m,r,g Lungs: CTAB, rhonchi throughout Abdomen: soft, tenderness to palpation in RUQ, negative [**Doctor Last Name 515**] sign, tenderness to palpation in epigastrum Extremities: No LE edema, 2+ DP/PT pulses bilaterally Neuro: No asterixis Pertinent Results: LFTS [**2195-2-14**] 01:20AM BLOOD ALT-1427* AST-7002* LD(LDH)-4595* AlkPhos-122* Amylase-58 TotBili-5.7* [**2195-2-14**] 05:48AM BLOOD ALT-1318* AST-6454* LD(LDH)-3970* AlkPhos-127* TotBili-5.9* [**2195-2-14**] 05:40PM BLOOD ALT-1076* AST-4926* LD(LDH)-2079* AlkPhos-132* TotBili-7.3* [**2195-2-15**] 04:54AM BLOOD ALT-868* AST-3418* LD(LDH)-893* AlkPhos-134* TotBili-7.8* [**2195-2-17**] 03:35AM BLOOD ALT-387* AST-716* AlkPhos-160* TotBili-12.9* [**2195-2-18**] 04:51AM BLOOD ALT-270* AST-288* LD(LDH)-354* AlkPhos-160* TotBili-14.2* [**2195-2-19**] 04:17AM BLOOD ALT-190* AST-196* LD(LDH)-344* AlkPhos-166* TotBili-14.4* [**2195-2-20**] 04:22AM BLOOD ALT-148* AST-158* LD(LDH)-341* AlkPhos-168* TotBili-14.7* [**2195-2-23**] 05:19AM BLOOD ALT-74* AST-177* LD(LDH)-338* AlkPhos-146* TotBili-12.8* [**2195-2-28**] 05:55AM BLOOD ALT-48* AST-115* LD(LDH)-259* AlkPhos-141* TotBili-9.4* [**2195-3-3**] 06:55AM BLOOD ALT-39 AST-84* LD(LDH)-227 AlkPhos-173* Amylase-30 TotBili-6.0* [**2195-3-7**] 05:13AM BLOOD ALT-39 AST-85* LD(LDH)-209 AlkPhos-167* TotBili-5.4* [**2195-3-9**] 06:00AM BLOOD ALT-34 AST-62* LD(LDH)-194 AlkPhos-149* TotBili-4.9* COAGS * [**2195-2-14**] 01:20AM BLOOD PT-37.7* PTT-52.7* INR(PT)-4.1* [**2195-2-14**] 01:20AM BLOOD Plt Ct-188 [**2195-2-14**] 05:48AM BLOOD PT-35.3* PTT-50.7* INR(PT)-3.7* [**2195-2-14**] 05:48AM BLOOD Plt Ct-191 [**2195-2-14**] 05:40PM BLOOD PT-28.6* PTT-50.2* INR(PT)-2.9* [**2195-2-16**] 03:55AM BLOOD PT-22.3* PTT-63.6* INR(PT)-2.1* [**2195-2-26**] 05:25AM BLOOD PT-14.7* PTT-33.0 INR(PT)-1.3* [**2195-3-9**] 06:00AM BLOOD PT-15.2* PTT-35.5* INR(PT)-1.3* [**2195-2-14**] 01:42AM BLOOD AFP-5.4 [**2195-2-14**] 01:42AM BLOOD HBsAg-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2195-3-4**] 07:00AM BLOOD T3-73* Free T4-1.2 [**2195-3-3**] 06:55AM BLOOD TSH-11* [**2195-2-14**] 01:20AM BLOOD Ammonia-175* [**2195-3-3**] 06:55AM BLOOD Ammonia-53* [**2195-2-27**] 06:20AM BLOOD VitB12-1549* Folate-18.1 CHEM 7 * [**2195-2-14**] 01:20AM BLOOD Glucose-137* UreaN-21* Creat-1.5* Na-133 K-4.5 Cl-93* HCO3-25 AnGap-20 [**2195-3-9**] 06:00AM BLOOD Glucose-112* UreaN-3* Creat-0.9 Na-134 K-3.5 Cl-104 HCO3-24 AnGap-10 CBC * [**2195-2-14**] 01:20AM BLOOD WBC-8.0 RBC-3.16* Hgb-12.4 Hct-33.8* MCV-107* MCH-39.4* MCHC-36.7* RDW-13.0 Plt Ct-188 [**2195-3-9**] 06:00AM BLOOD WBC-8.6 RBC-2.24* Hgb-8.4* Hct-26.2* MCV-117* MCH-37.7* MCHC-32.2 RDW-13.9 Plt Ct-261 CT HEAD [**2-17**] FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or acute territorial infarction. The ventricular system appears within normal limits. The sulci are slightly prominent for the patient's age. Soft tissues and bone structures appear unremarkable. The paranasal sinuses demonstrate bilateral ethmoidal mucosal thickening. The visualized aspect of the maxillary sinuses also demonstrates mucosal thickening. Fluid level is identified in the sphenoidal sinus. The mastoid air cells demonstrate normal aeration. . IMPRESSION: There is no evidence of hemorrhage, edema, or acute territorial infarction. . Mild prominence of the sulci for the patient's age. Bilateral ethmoidal mucosal thickening, there is also mucosal thickening in the visualized aspect of the maxillary sinuses and the sphenoidal sinus. TTE [**2-17**] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. 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. 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. There is no pericardial effusion. [**2195-2-19**] Abdominal US FINDINGS: The liver is heterogeneous and predominantly echogenic. There is a 2.1 x 1.6 x 2.1 cm well-circumscribed more echogenic lesion in the left hepatic lobe, without internal flow, compatible with a hemangioma. There is no intrahepatic biliary ductal dilatation. The common duct measures 3.3 mm. The spleen is not enlarged at 11.8 cm. The main portal vein is patent, with hepatopetal flow. . The gallbladder demonstrates moderate wall thickening and pericholecystic fluid. However, it is not distended and contains no stones. There is no upper abdominal ascites. The distal abdominal aorta is obscured. The remainder demonstrates a normal caliber. The pancreas appears grossly unremarkable. Both kidneys demonstrated normal echogenicity, without hydronephrosis or calculi. The right kidney measures 14.3 cm and the left kidney measures 12.9 cm. . IMPRESSION: 1. Gallbladder wall thickening and pericholecystic fluid is believed to be related to liver disease rather than acute cholecystitis, given the absence of gallbladder distention. 2. Echogenic liver, compatible with fatty infiltration. Additional and more severe forms of liver disease including fibrosis cannot be excluded. 3. Hepatic hemangioma in the left lobe. CTA CHEST [**2-22**] CT CHEST WITH CONTRAST: There is partial collapse of the left lower lobe and superimposed patchy consolidations that do not enhance as well, suspicious for superimposed pneumonia. There is a small left pleural effusion. There is very mild atelectasis at the right base with a very small pleural effusion. The airways are otherwise clear, though limited by respiratory motion. . The patient is intubated with the endotracheal tube approximately 3.5 cm above the carina. NG tube is located in the stomach. The pulmonary arteries opacify without filling defects. . The heart and other great vessels of the mediastinum are unremarkable. There are multiple prominent but non-pathologically enlarged mediastinal and left hilar lymph nodes, likely reactive. No pathologic axillary adenopathy is present. . The visualized portions of the liver demonstrate diffuse fatty infiltration of the liver. No suspicious lesions are identified in the bones but note is made of multiple healed left posterior rib fractures. . IMPRESSION: 1. Partial left lower lobe collapse with superimposed pneumonia. 2. No evidence for pulmonary embolism. 3. Fatty liver. [**2195-2-27**] CT CHEST w/o constrast CT OF THE CHEST WITHOUT IV CONTRAST: There are several mildly prominent paratracheal lymph nodes, which are unchanged. All measure less than 10 mm in shortest axis dimension. A discretely identifiable left hilar lymph node of 5 mm in width (2:28) is also unchanged. Bilateral hilar lymph nodes visualized on the recent CT are difficult to distinctly identify without intravenous contrast, but the right hilar contour appears similar. . There has been progressive atelectasis of the left lower lobe, which is now fully collapsed with near occlusion of the distal left lower lobe bronchus. A small left-sided pleural effusion is somewhat larger than before, and a tiny right-sided pleural effusion with minimal associated atelectasis has also increased somewhat. . There are several new poorly defined nodules in the right upper lobe (3:22, 30, 31, and 34) and an apical nodule has grown. . The patient has been extubated. A nasogastric tube enters the stomach. Otherwise, limited views of the upper abdomen are unremarkable. BONE WINDOWS: There are no suspicious lytic or blastic lesions. . IMPRESSION: 1. New ill-defined nodules in the right upper lobe, suggestive of invasive fungal infection, as suspected clinically. 2. Progressive atelectasis of the left lower lobe, now fully collapsed. 3. Larger, but small pleural effusions, with new trace ascites. [**2195-3-8**] CT CHEST w/o contrast CT CHEST WITHOUT CONTRAST: There are several prominent mediastinal and hilar lymph nodes that do not meet CT size criteria for enlargement. Heart size is normal. . Partial collapse of the left lower lobe is improved since [**2195-2-27**]. Bilateral simple layering pleural effusions, left greater than right, have slightly increased in size since [**2195-2-27**]. Several nodules in the right upper lobe have decreased in size since [**2195-2-27**] (4:111,155). Patchy opacity in the right lower lobe may represent atelectasis or infiltrate, and if infiltrative, represents incresed infectuous burden in the right lower lobe. . Bone windows demonstrate no suspicious lytic or blastic lesions. . Although this exam was not optimized for subdiaphrahmatic diagnosis, the imaged abdominal organs are unremarkable . IMPRESSION: 1. Ill-defined nodules in the right upper lobe are moderately decreased in size since [**2195-2-27**] although right lower lobe has patchy opacities that may represent atelectasis or infiltrate are more prominent since that time. 2. Partial atelectasis of the left lower lobe has improved since [**2195-2-27**]. 3. Small bilateral pleural effusions, slightly larger than on [**2195-2-27**] [**2195-3-7**] MRI ABD w/ and w/o contrast FINDINGS: Bilateral pleural effusions and lower lobe atelectasis are noted and better evaluated on the recent chest CT of [**3-8**], [**2194**] and [**2195-2-27**]. There is mild loss of signal intensity on out-of-phase images in comparison with in-phase images throughout the liver consistent with fatty infiltration. Heterogeneous enhancement throughout the hepatic parenchyma suggests the possibility of underlying cirrhosis although the hepatic contour is not nodular. In segment III (100:80; 4:27), a 1.9 X 1.8 cm nodule is seen which corresponds with the echogenic focus on ultrasound of [**2195-2-19**]. The lesion is mildly hyperintense to hepatic parenchyma on T2-weighted images and contains a linear band of precontrast T1 hyperintensity centrally. There is minimal enhancement on post-gadolinium images and no evidence of peripheral rim enhancement. No other focal hepatic lesions are identified. The portal vein is patent, and there is no biliary ductal dilation. The gallbladder is nondistended with mural edema. There is splenomegaly (14 cm). Mildly enlarged periportal lymph nodes are present up to 8 mm in diameter. The pancreas, adrenal glands and kidneys appear unremarkable. There is no ascites. Image marrow signal appears within normal limits. Multiplanar reformations provided multiple perspectives for the dynamic series with kinetic information. IMPRESSION: 1. A 1.8 cm nodule in segment III of the liver, corresponding to the echogenic focus seen on ultrasound, has indeterminate features. Infectious etiology is considered, and given hepatic risk factors hepatocellular carcinoma with atypical appearance cannot be excluded. Atypical or thrombosed hemangioma is possible, but continued surveillance in short-term (three months) with MRI is recommended. 2. Fatty infiltration of the liver and features consistent with cirrhosis. Mild splenomegaly. 3. Gallbladder edema consistent with underlying liver disease. Brief Hospital Course: Ms. [**Known lastname **] is a 41 year old F who was transferred to [**Hospital 18**] hospital MICU from an OSH for unintentional tylenol overdose 1gm q 2 hours x 7day, w/ liter of vodka a day for greater than a month, noted to have developed fulminant hepatic failure. Patients hepatic failure was complicated by hypoxic respiratory failure requiring intubation. Patient was treated empirically for a hospital aquired pneumonia. She underwent bronchoscopy and was found to have a large aspergillus bronchus cast. She was treated with caspofungin for likely invasive fungal disease. She was then transitioned to PO voriconazoles as an outpatient. Patient was noted to have a persistently collapsed left lower lobe of her lung. Despite this her respiratory status continued to improve during hospital stay until she was successfully weaned off of supplemental oxygen. Patient was encephalopathic during most of her hospital stay, but cleared mentally by discharge. Pt was also noted to have VRE in her urine, but this was thought to be an asymptomatic colonization. Patients hepatic function continued to improve during her hospital course. She was also noted to have hepatitis C. Of note a 1.9 x1.8cm mass was found in patients liver on ultrasound. This was confirmed on MRI. The mass was felt to be either a hemangioma or an atypical hepatocellular carcinoma. Follow up was recommended. During stay patient was also treated for a gluteal skin infection/cellulitis. The issues of substance abuse were addressed with the patient. Patient was recommended to a substance abuse program by social work. Pt was willing to participate in AA, but felt that she did not need an inpatient substance abuse program. She was told that she could absolutely not have another drink of alcohol and that she should avoid the use of tylenol in the future. . # Hepatic failure: Patient presented to OSH with markedly elevated LFTs, elevated INR consistent with fulminant liver failure. A CT abd/pelvis did not reveal cirrhosis but did reveal a mass in her liver, as she did have a history of hepatitis C and significant ETOH abuse. This was a likely subacute event of liver failure as patient was on tylenol over the past 1-2 weeks superimposed on underlying liver disease. Her tylenol level was initially 21. She was loaded with N-acetylcysteine at OSH for presumed Tylenol intoxication so toxicology and liver were both involved. She was maintained on N-acetylcysteine infusion until her coagulation normalized. Her coagulation factors and LFTs were monitered daily and trended down towards normal. She had an ultrasound which demonstrated a likely hemangioma in the liver and alpha feto-protein was low. Serologies were also checked demonstrating that patient had Hepatitis C with no evidence of other hepititidies and HIV was negative. Blood cultures on [**2195-2-22**] were negative for growth. . # Mental status changes: Patient had difficulty with mental status during hospital course. Initially felt to be due to hepatic encephalopathy from liver failure above, as ammonia level was elevated, as well as from alcohol withdrawl as patient noted to have DTs. She was treated with lactulose and rifaximin for hepatic encephalopathy, and with IV valium for treatment of alcohol withdrawl. It was felt as though the valium she received for her alcohol withdrawl was slow to clear given her liver failure, so her mental status was monitered closely. Lactulose and rifaximin continued and titrated to stool output. She improved to baseline at discharge. Patient was discharged on lactulose. . # Respiratory failure: Patient intubated on [**2195-2-21**] for hypoxia initially of unknown etiology. She underwent bronchoscopy on day of intubation that demonstrated thick blood clot in LLL, with evidence of post-obstructive pneumonia past the blood clot. She underwent CTA which was negative for PE, but again showed evidence of post-obstructive pneumonia. BAL washings during bronchoscopy were sent for culture and for cytology. Cultures were negative, cytology was negative for malignant cells, predominantly blood with a few bronchial cells and macrophages. Vanc/Zosyn were discontinued on [**2195-2-24**]. She was successfully extubated on [**2-24**]. Chest CT on [**2195-2-27**] showed new nodules in the right upper lobe suggestive of invasive fungal infection. CT also showed fully collapsed atelectasis of the left lower lobe. Prior blood clot found on bronchoscopy was found to be mixed clot and aspergillus. Patient was begun on IV caspofungin as fungal disease was felt to be invasive (however this was debated). Patient had a second bronchoscopy in order to try to reopen collapsed left lower lobe of lung. LLL remained collapse on imaging. Pt was transitioned to oral voriconazole at discharge for a 21 day course. She was scheduled for weekly LFTs. patient is due for repeat CT in 8 weeks. Repeat bronchoscopy, pulm and ID follow up as is indicated in discharge planning below. . # Liver mass: Patient was noted to have a mass in liver on CT scan at OSH. Concerned about an underlying malignancy given history of underlying liver disease. AFP checked and was normal at 5.4. RUQ U/S demonstrated likely hemangioma. MRI suggested cirrhosis, and noted a 1.9 X 1.8 cm nodule. The interpretation of the MRI was that the nodule could be of infectious etiology, an atypical hepatocellular carcinoma or a thrombosed hemangioma. Radiology recommended repeat MRI in 3 months. This was indicated to patient. . # Acute renal failure: Patient presented with Cr~1.8 to OSH. Improved to 1.5 on admission. This ARF resolved during hospital course with IVF hydration. Then on [**2-23**] patient developed an elevation in Cr again to 1.8. This was in the setting of receiving large dye load for a CT scan. Felt that patient had developed a contrast nephropathy. Cr was 0.9 at d/c. . # Anion gap acidosis: Patient presents with mildly elevated anion gap~15 in the setting of renal failure and high lactate. Elevated lactate may be secondary to underlying liver disease (decreasing metabolism of lactate) which is improving in the setting of hydration. Acidosis and elevated lactate resolved after initial IVF hydration. . # Epigastric pain: Patient presented to OSH with burning epigastric pain. History suggests underlying gastritis vs. PUD. She was maintained on protonix 40mg IV daily, with plans to re-address upon clearance of above issues. C.diff toxin on [**2195-2-27**] and [**2195-2-28**] were negative, stool cultures on [**2195-2-26**] was negative for Salmonella, Campylobacter, and Enteric gram negatives. All blood cultures were negative. . # Substance abuse: She has a history of significant alcohol abuse. She also smokes and has a history of drug use. Initial tox screen was unremarkable. She was treated for alcohol withdrawl as above. Also given her high risk behavior, hepatitis serologies and HIV were sent, which returned positive for known Hep C only. Social work saw her upon resolution of mental status issues and recommended her for rehab. She refused rehab and was willing to attend AA as an outpatient. Patient was discharged on thiamine and folic acid. . #Smoking Cessation was encouraged. Pt was discharged w/ nicotine patch. . #VRE colonized urine: Urine culture on [**2-22**] had VRE, changed foley on floor. Repeat UA, on [**1-/2116**] was negative. VRE precautions while inpatient. . # Hospital Acquired PNA: Patient received 7 days of Abx cipro/vanc. . # Buttock Cellulitis: Treated w/ a 7 day course Vanc/cipro. #Hypernatremia: treated with IV fluid boluses . #FEN: Patient received TF while her mental status was altered. She had transient hypernatremia which was treated with free water boluses. She was eventually transitioned back to a low sodium diet. . # Follow up as described in discharge worksheet. Medications on Admission: Medications on transfer: Mucomyst Protonix Zofran Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day: Blood pressure control. Disp:*60 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day. Disp:*1 1* Refills:*2* 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*2700 ML(s)* Refills:*2* 8. 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* 9. Voriconazole 50 mg Tablet Sig: Six (6) Tablet PO Q12H (every 12 hours) for 21 days: 300mg twice a day. Disp:*360 Tablet(s)* Refills:*2* 10. Outpatient Lab Work Liver function panel, electrolyte panel, please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] from ID [**Telephone/Fax (1) 432**] 11. CT Scan CT scan of the chest for [**2195-3-24**]. No contrast. 12. CT scan CT chest w/o contrast. [**2195-5-20**] 13. MRI/MRA liver MRI/MRA of liver on [**5-21**] Discharge Disposition: Home Discharge Diagnosis: Primary 1. Fulminant hepatic failure 2. Mental status changes Secondary 3. Aspergillus pneumonia 3. Respiratory failure 4. Liver mass 5. Acute renal failure 6. Anion gap acidosis 7. Epigastric pain 8. Substance abuse 9. Leukocytosis 10. Hypernatremia Discharge Condition: Stable. Discharge Instructions: You were admitted to the [**Hospital1 69**] because of fulminant hepatic failure due to unintentional tylenol overdose 1gm q 2 hours x 7day, w/ liter of vodka a day resulting in fulminant hepatic failure. This was complicated by respiratory failure that required intubation, but you were extubated, with continued hepatic encephalopathy, colonized Vancomycin resistent E.Coli in your urine, and a bronchoscopy and removal of a fungus ball. . You were found to have an fungal pneumonia. For this fungal pneumonia you need to complete 3 more weeks of antifungal therapy. We want you to have a repeat chest CT done on [**3-18**]. This can be done at the [**Hospital Ward Name **] of [**Hospital1 18**]. . You will then need a repeat CT again 8 weeks from now and a repeat bronchoscopy to make sure that you have cleared the fungal pneumonia. . You will take voriconazole 300mg twice a day for 21 days. Please get your liver funtion checked on [**2195-3-14**]. . During your hospital stay you were also treated for a bacterial pneumonia and a cellulitis. . We also found you to have a mass in your liver. You had an MRI during your hospital stay, but it is unclear if this mass is a tumor or just a vessel. As a result we want you to get a repeat MRI of your liver in 3 months. . If you experience worsening jaundice, nausea, vomiting, dizziness/lightheadedness, loss of consciousness, abdominal pain, fever greater than 101.5 degrees F, or any other symptoms that concern you, please go to the nearest Emergency Room or call your primary care physician [**Name Initial (PRE) 2227**]. Followup Instructions: Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in [**Hospital **] clinic. You have an appointment scheduled with him for [**2195-3-27**] at 930am in the basement of the [**Hospital Unit Name **], [**Street Address(2) **]. . Please have your liver function tests faxed to Dr. [**First Name (STitle) 1075**] at [**Telephone/Fax (1) 432**]. . Please follow up with Dr. [**Last Name (STitle) **] from the department of Interventional Pulmonary medicine. You will need to call [**Telephone/Fax (1) 3020**] to schedule a follow up appointment. . Please call [**Telephone/Fax (1) 3020**] to get a follow-up bronchoscopy during this period of time. . Please follow up with your new primary care physician at [**Hospital1 18**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**4-1**] at 3pm on the [**Location (un) **] of the [**Hospital Ward Name 23**] building [**Hospital1 18**] [**Hospital Ward Name 516**]. If you have to call to change this visit call [**Telephone/Fax (1) 250**]. . Please follow up with Dr.[**Last Name (STitle) **] [**Name (STitle) 766**], [**5-4**], at 930pm, in [**Doctor First Name **] the [**Location (un) **]. Please call [**Telephone/Fax (1) 2422**] if you must change this appointment.

Admission Date: [**2178-2-9**] Discharge Date: [**2178-2-17**] Date of Birth: [**2105-9-27**] Sex: M Service: MEDICINE Allergies: Sulfonamides / A.C.E Inhibitors / Angiotensin Receptor Antagonist / Keflex Attending:[**First Name3 (LF) 2167**] Chief Complaint: change in mental status Major Surgical or Invasive Procedure: Intubation Central Venous Catheter placement Thoracentesis Bronchoscopy History of Present Illness: Pt is a 72 yo M myelofibrosis, h/o c.diff, h/o delirium who presented to ED for AMS, fever. On the day of presentation, pt was received his regularly scheduled Interferon for myelofibrosis, then started to complain of nausea, vomiting, and diarrhea, as well as shortness of breath. He was then found to be nonresponsive at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **], where he resides, thus brought to the ED. Pt denied any chest pain/pressure. Per family, pt may have eaten an old [**Location (un) 6002**]. In the ED, he was initially 98% on RA, then became hypoxic to 82%. He was placed on 100% non-rebreather with O2 sats in low 90s. Ohter vs were: 105rectal 92 98/45, 32, 86%RA 92?NRB, lactate 4.8 (ua negative, CXR with bilateral hazziness but no specific infiltrate). Patient was given tylenol, 6L NS, vanc/dex/zosyn/ceftriaxone. Repeat VS were 100.8, 60, 101/38, 95% 15L FMask. . On admission to the MICU pt was alert and oriented to self and place only. He was somewhat combative, trying to pull off the mask. He was hypoxic to low 90s on nonrebreather, and ABG was 7.26/44/98. Anesthesia was called and intubated the patient uneventfully. Arterial line was placed in the left wrist. RIJ was placed. He required Dopamine and Levophed to maintain his MAP>60. EP was called to increase his V-pacing to 90 to increase cardiac output. Past Medical History: Idiopathic myelofibrosis - Anemia associated with CKD & Fe deficiency - PVD with recurrent LE venous stasis ulcers - PAF s/p [**Location (un) 4448**] - CHF (EF 45% in [**4-10**]) - HTN - Hyperlipidemia - Hypothyroidism - BPH - Depression - H/o chronic C. diff - Diverticulitis - recurrent delirium Social History: Currently lives in the [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Retired trial lawyer. History of tobacco usage but quit smoking in [**2151**], history of heavy alcohol usage and quit in [**2151**]. Married but currently seperated. Has 9 children. Family History: MI - father who died at 56y CAD, Parkinson's disease, renal failure - brother AS - mother EtOH abuse - mother, brother Bipolar d/o - daughter Physical Exam: ICU Admission EXAM: Vitals: T94.2axillary 98.6rectal 60HR, 93/46, 90-92% on NRB General: Alert, oriented x 2 (self and place). Diaphoretic HEENT: Sclera slightly icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Coarse crackles bilaterally CV: V-paced at 60. Normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, mildly distended, quite tender to palpation diffusely, most in LLQ. Ext: Warm, well perfused, 2+ pulses radial and femoral, non-palpable DP and PT, no clubbing, cyanosis or edema Pertinent Results: Pleural Fluid Chemistry Protein 1.6 Glucose 109 LD(LDH): 96 Pleural Fluid WBC 30 RBC 14 Poly 40 Lymph 11 Mono 28 [**2178-2-8**] 10:10PM PT-18.9* PTT-29.3 INR(PT)-1.7* [**2178-2-8**] 10:10PM PLT SMR-NORMAL PLT COUNT-427# [**2178-2-8**] 10:10PM WBC-21.7*# RBC-4.85 HGB-13.0* HCT-43.9 MCV-91 MCH-26.9* MCHC-29.7* RDW-18.0* [**2178-2-8**] 10:10PM NEUTS-67 BANDS-3 LYMPHS-12* MONOS-7 EOS-3 BASOS-1 ATYPS-0 METAS-5* MYELOS-2* NUC RBCS-4* [**2178-2-8**] 10:10PM ALBUMIN-3.9 CALCIUM-9.7 PHOSPHATE-2.9 MAGNESIUM-1.9 [**2178-2-8**] 10:10PM cTropnT-0.10* [**2178-2-8**] 10:10PM CK-MB-2 [**2178-2-8**] 10:10PM GLUCOSE-138* UREA N-27* CREAT-1.6* SODIUM-134 POTASSIUM-6.1* CHLORIDE-98 TOTAL CO2-23 ANION GAP-19 [**2178-2-8**] 10:20PM HGB-13.9* calcHCT-42 [**2178-2-8**] 10:30PM URINE [**Year/Month/Day 3143**]-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG [**2178-2-8**] 10:30PM URINE RBC-0-2 WBC-[**2-5**] BACTERIA-MANY YEAST-NONE EPI-[**5-13**] [**2178-2-9**] 12:48AM CK-MB-5 proBNP-[**Numeric Identifier **]* [**2178-2-9**] 12:48AM cTropnT-0.19* [**2178-2-9**] 12:48AM CK(CPK)-206* [**2178-2-9**] 12:48AM GLUCOSE-116* UREA N-27* CREAT-1.4* SODIUM-138 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-18* ANION GAP-16 [**2178-2-9**] 12:54AM LACTATE-3.0* [**2178-2-9**] 01:48AM HGB-11.8* calcHCT-35 O2 SAT-97 [**2178-2-9**] 01:48AM LACTATE-2.1* [**2178-2-9**] 01:48AM TYPE-ART PO2-98 PCO2-44 PH-7.26* TOTAL CO2-21 BASE XS--6 [**2178-2-9**] 01:55AM PT-21.3* PTT-34.9 INR(PT)-2.0* [**2178-2-9**] 01:55AM PLT COUNT-371 . CXR [**2-8**]: Perihilar opacities reflecting airspace pulmonary edema. Likely right pleural effusion. CT Head [**2-9**]: No evidence of mass lesion. No acute intracranial process. CT Torso [**2-9**]: 1. Large right pleural effusion which is causing compressive atelectasis of the posterior right upper and right lower lobes. 2. New moderate left pleural effusion causing compressive atelectasis of the posterior left upper lobe and complete atelectasis of the left lower lobe. 3. Cecal and ascending colonic wall thickening, consistent with colitis. 4. Colonic diverticulosis without evidence of diverticulitis. 5. Unchanged ascites. CXR [**2-13**]: Endotracheal tube and nasogastric tube have been removed. The left PICC line is now seen extending to at least the cavoatrial junction. The distal tip is not well seen. Right pleural effusion has decreased slightly, now moderate. Left lower lobe collapse or effusion persists. Cardiac size is top normal in size. Dense retrocardiac opacity persists. Aortic arch calcifications and [**Month/Year (2) 4448**] are unchanged. All microbiologic data no growth to date. C diff negative x 3. Sputum culture negative. Echo The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated with mild global hypokinesis and septal dysnchrony (LVEF = 40 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.3 cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild to moderate pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion. CXR [**2-16**] post R thoracentesis FINDINGS: Interval decrease in right pleural effusion following thoracentesis, with residual small to moderate effusion remaining and no evidence of pneumothorax. Associated improvement in parenchymal opacity at the right lung base. Previously noted left pleural effusion is difficult to assess due to exclusion of left costophrenic sulcus from the radiograph, but there is at least a small residual left effusion remaining as well as persistent left retrocardiac opacification. Brief Hospital Course: # Respiratory failure: In the [**Name (NI) **], Pt was hypoxic to low 90s on non-rebreather, likely due to septic shock. Differential diagnosis at first included pneumonia, pulmonary edema from CHF, and ARDS. CXR showed diffuse haziness bilaterally and chronic pleural effusion R>L. He was intubated and sedated on admission and ventilator settings were per ARDSnet protocol. He was given multiple antibiotics on admission (see below), which would cover pneumonia. He underwent bronchoscopy which showed scant secretions and normal anatomy. BAL fluid was sent for gram stain and cultures, which were negative. Urine legionella antigen was also negative. At the time of transfer to the floor, he was continued on ceftriaxone for presumed pneumonia even though cultures were negative. The patient was transitioned to Precedex on [**2-11**] due to intolerance of fentanyl/versed. This intolerance should be noted for future reference. He was weaned from the ventilator and extubated on [**2-12**], and on transfer to the floor, was maintaining his O2 saturation on room air. Due to persistant dyspnea, Mr. [**Known lastname **] [**Last Name (Titles) 106221**] thoracentesis, which resulted in significant improvement in his resporatory distress. # Septic shock/fever: Unclear source. Admission differential diagnosis included meningitis (altered mental status, high fevers), C. diff (pt has h/o C. diff colitis, currently has abdominal pain and high WBC count), and pneumonia. Vancomycin/Zosyn/Ceftriaxone/Decadron given in the ED; Ampicillin (Listeria), Acyclovir (HSV), and Flagyl (pt h/o C. diff) given on admission to ICU. Although stool cultures were negative for c.diff, given the patient's history and CT findings consistent w/ colitis, he was treated with po vancomycin for c.diff. He was also treated with ceftriaxone for presumed pneumonia. Plan is for a total of a 10 day course of ceftriaxone with vancomycin to continue for 2 additional weeks thereafter. He received stress dose steroids for 48 hours given his inappropriate cortisol stim. They were stopped as his clinical condition improved. It could be conceivable that his symptoms were from a viral syndrome or possibly related to his interferon treatment. IFN was held while hospitalized and should not be restarted without the input of Dr. [**Last Name (STitle) **] & Dr. [**First Name (STitle) **] of hematology # Cardiac: On day of admission, Troponins trended 0.10->0.19->0.26. Differential included demand ischemia and ACS. Cardiac cath 3 years ago at [**Hospital1 112**] showed no flow limiting lesions per patient. He was given 325mg ASA but heparin was not started due to high INR. He was continued on ASA 81 mg. His echo showed an EF of 40%. After aggressive hydration in ICU, Mr. [**Known lastname **] was diuresed with IV lasix. He was also continued on beta blockers. Due to ACE-I allergy (anaphylaxis), hydralazine was started. . # Change in Mental Status: Pt has tendency to become delirious during acute illnesses. MS gradually cleared during admission. His head CT on admission did not show any evidence of mass lesion or acute intracranial process . # Idiopathic Myelofibrosis: Pt was continued on hydroxyurea but interferon was held as per Hem Onc recs. Pt will see them post discharge at which time the decision regarding restarting IFN will be made. . # PAF with [**Known lastname 4448**]: Pt was seen by EP and they adjusted [**Known lastname 4448**] settings to increase v-pacing to 90. Settings subsequently decreased to 70 post-extubation. . # HTN: Continued metoprolol. Started on hydralazine. . # Elevated liver enzymes: Likely related to hypoperfusion of the liver; trended down throughout hospital course but have not fully returned to [**Location 213**]. . # Hypothyroidism: Continued levothyroxine . # Bleeding after heparin injection subQ: Pt had subcutaneous [**Location **] oozing after heparin shots. Hence heparin was held. Pt was given compression dressing and the bleeding stopped. . # FEN: Swallow eval showed that pt has mild to moderate dysphagia. Hence he was started on soft (dysphagia) diet and nectar thick liquids. Thin liquids were removed from his diet. He will need repeat swallow eval in [**6-12**] days. . # PPX: Heparin was held due to subcutaneous [**Date Range **] oozing and pt was given pnumoboots for DVT ppx. He was also on H2 blockers. . # Code: full . # Coommunication: With wife [**Name (NI) **] who is HCP. ([**Telephone/Fax (1) 106217**]) Medications on Admission: - Levothyroxine 125mcg daily - Toprol XL 25mg daily - Seroquel 25 mg Tablet - [**1-6**] Tablet(s) by mouth twice daily. 50 mg in am, 75 mg at bedtime. - Allopurinol 100mg daily - Simvastatin 10mg daily - Pentoxifylline 400mg TID - Danazol 200mg [**Hospital1 **] - Hydroxyurea 500mg alternating with 1000mg every other day - Albuterol prn 100mg Daily - Cymbalta 60mg daily - Lasix 40mg vs 80mg QOD - Vit C 500 mg Tablet - 1 Tablet(s) by mouth daily - Vit B - Vit D3 (400 for 7 weeks - ending [**2177-12-25**]) - MVI - Fe 325mg Daily - ASA 81mg daily - [**Month/Day/Year **], colace, fleets, bisacodyl, MOM - epogen [**2168**] [**Name2 (NI) **],W,F - ALBUTEROL SULFATE - 1 vial neb Every 4 hours PRN - FAMOTIDINE - 20 mg Tablet daily - INTERFERON ALFA-2B [INTRON A] - 6 million unit/mL Solution - 3.0 million units subcutaneously Every Monday, Wednesday, and Friday - LIDOCAINE [LIDODERM] - (Prescribed by Other Provider) - 5 % (700 mg/patch) Adhesive Patch, Medicated - Apply to lower back for 12 hours on, 12 hours off. - OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth q 6 hrs as needed for pain - PROCHLORPERAZINE MALEATE - (Prescribed by Other Provider) - 5 mg Tablet - One Tablet(s) by mouth twice a day as needed for nausea - TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - One half Tablet(s) by mouth at hs as needed for insomnia - ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet - Two Tablet(s) by mouth Every 6 hours as needed for fever, pain - B COMPLEX VITAMINS [VITAMIN B COMPLEX] - (OTC) - Capsule - 1 Capsule(s) by mouth daily . Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks. 3. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 7. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): last day = [**2-19**]. 11. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: [**4-12**] MLs PO Q6H (every 6 hours) as needed for cough. 13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation. 15. 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: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Discharge Diagnosis: septic shock pneumonia pleural effusions Discharge Condition: fair. AFVSS Discharge Instructions: You were admitted to the hospital with very low [**Last Name (NamePattern1) **] pressure and difficulty breathing. We never found the source of your illness, but have treated you for a presumed diagnosis of pneumonia and C diff colitis. Thankfully, after intensive medical care in the ICU you improved. You will need to finish a 14 day course of oral vancomycin and finish a 10 day course of ceftriaxone (another antibiotic). Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] will need to decide at your next appointment whether to continue with the interferon treatments. We also drained fluid from your lung (a thoracentesis) which helped your shortness of breath. If you have fever >100.4, diarrhea, difficulty breathing, loss of consciousness or any other concerns then please seek medical attention. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2178-3-5**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2178-3-5**] 10:00 Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2178-5-13**] 10:00 Completed by:[**2178-2-17**]

Admission Date: [**2125-2-1**] Discharge Date: [**2125-2-19**] Service: MEDICINE Allergies: Ultram Attending:[**First Name3 (LF) 2160**] Chief Complaint: Hematuria, cough, abdominal pain Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: 85 F h/o stage 0 CLL, not requring tx previously, presents to ED for persistent cough/abdominal pain, and hematuria. . Pt notes about 2 months of increasing fatigue, nightsweats, decreased appetite, and increasing left side abdominal pain (intermittent, no relation to food, BM, sharp, no diarrhea, constipation, melena). She was seen by PCP [**2125-1-9**], felt to have viral URI, symptoms persisted, and seen again [**2125-1-23**] with persistent cough (intermittently productive, yellow-white), single episode of hematuria (clear red, not clot), and LLQ abdominal pain, treated with azithromycin, and abdominal US obtained which revealed new splenomegaly with new 1.5-cm echogenic area. On [**1-31**], pt noted recurrent episode of "strong blood in urine." Describes clear red +clots, +feeling incomplete voiding, no suprapubic pain, no CVA tenderness. Also notes transient R LE shooting pain last night which has resolved. Pt presented to the ED with VS: 98.1 79 113/69 16 100%RA. In the ED, CXR with LUL collapse, CT ABD/PELVIS with multiple new metastasis, and new mass in bladder. Also RLL PE. UA +hematuria, + UTI. pt given levo, flagyl, morphine 2mg x3 for pain. BP then noted to drop to 70/37, pt received total 2L IVF, although timing unclear, with BP improved to 102/55s (?dehyration vs sepsis vs morphine). No central line placed. CT head obtained in anticipation of possible anticoagulation. Past Medical History: - CLL - referred to heme/onc (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]), for anemia, leukocytosis, found on [**2123-6-3**] flow cytometry confirmed B-cell chronic lymphocytic leukemia, stage 0, asymptomatic (no LAD, thrombocytopenia, splenomegaly), so no plan for treatment as of [**10-12**]. - htn - asthma - hyperlipidemia - OA - left hip, knee, previously on vioxx. - tah/bso [**1-6**] fibroids. - glucose intolerance (not on meds, a1c 6.1->5.5) - glaucoma - cancer screening: colonoscopy on [**2123-5-26**] showed 2 adenomatous polyps, one in the transverse colon and the other in the descending colon. Annual mammographies have been negative. Social History: - deniess tobacco, denies alcohol, IVDU. - she lives with her husband. They have 2 children, 1 son and 1 daughter, in their 50s and 60s, respectively. - Worked as a pharmacist in [**Location (un) 3155**], [**Location (un) 3156**]. She was 80 miles from the Chernobyl accident in [**2102**], leaving on the 3rd day of the radiation exposure, although she's not certain if she was in fact exposed to radiation. 3 months later, she returned to her residence. Some of her co-workers had thyroid concerns after the Chernobyl accident. She moved to the U.S. in [**2108**]. Family History: No family history of hematologic or oncologic dyscrasias. Both parents died of strokes. A sister, her only sibling, had "pancreatic" obstruction, not cancer related, and died at age 64. The patient's daughter had breast cancer at age 54. Physical Exam: VS: 97.3 97 116/56 26 96%2L GEN: NAD HEENT: PERRLA, sclera anicteric, OP clear, MMM, no carotid bruits. 8-10 cm JVD. left cervical 1cm LN, right axillary 1-2cm LN against chest wall. CV: regular, nl s1, s2, no r/g. 3/6 SEM. PULM: decreased BS L base, otherwise good air movement through. ABD: soft, NT, + BS, +splenomegaly, ~5inches from CV angle. EXT: warm, 2+ dp/radial pulses BL. trace B LE edema. NEURO: alert & oriented x 3, CN II-XII grossly intact. Pertinent Results: SPECIMEN SUBMITTED: urine for immunophenotyping Procedure date Tissue received Report Date Diagnosed by [**2125-2-9**] [**2125-2-9**] [**2125-2-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/cma?????? Previous biopsies: [**Numeric Identifier 3158**] CYTOSPIN [**Numeric Identifier 3159**] Cell blocks from catheterized urine; three cell blocks [**-6/3303**] CATARACT RT. EYE. [**-5/2577**] Peripheral blood for immunophenotyping. (and more) DIAGNOSIS FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens: 3, 5, 10, 19, 20, 23, 38, 45. RESULTS: Three-color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. Lymphocytes comprise <1% of total analyzed events. B-cells are scant in number precluding evaluation of clonality. Approximately 77% of total analyzed events show dim CD45 and high side scatter, representing neutrophils. INTERPRETATION Non-diagnostic study. Clonality could not be assessed in this case due to insufficient numbers of B-cells. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells. If clinically indicated, we recommend a repeat specimen (fresh) be submitted directly to the flow cytometry laboratory. AP AND LATERAL CHEST [**2125-2-8**]: COMPARISON: [**2125-2-5**]. INDICATION: Metastatic cancer. Bilateral small to moderate pleural effusions are present, with slight improvement on the left. Cardiomediastinal contours are unchanged. Bibasilar areas of atelectasis adjacent to the effusions are also without change. IMPRESSION: Bilateral small to moderate pleural effusions with slight improvement on the left. Cytology Report URINE/INSTRUMENTATION Procedure Date of [**2125-2-7**] REPORT APPROVED DATE: [**2125-2-12**] SPECIMEN RECEIVED: [**2125-2-8**] 08-[**Numeric Identifier 3160**] URINE/INSTRUMENTATION SPECIMEN DESCRIPTION: Received 60 ml brown fluid Prepared 1 ThinPrep slide. Catheter urine. CLINICAL DATA: Bladder tumor and CLL. PREVIOUS BIOPSIES: [**2125-2-5**] 08-[**Numeric Identifier 3161**] URINE/INSTRUMENTATION [**2125-2-5**] 08-[**Numeric Identifier 3162**] URINE/VOIDED [**2125-2-5**] 08-[**Numeric Identifier 3163**] URINE/VOIDED [**2125-2-2**] 08-[**Numeric Identifier 3164**] URINE/INSTRUMENTATION [**2125-2-2**] 08-[**Numeric Identifier 3165**] URINE/INSTRUMENTATION [**2117-10-1**] 00-[**Numeric Identifier 3166**] PAP [**2115-4-16**] 98-[**Numeric Identifier 3167**] PAP 96-[**Numeric Identifier 3168**] PAP 93-[**Numeric Identifier 3169**] URINE 93-[**Numeric Identifier 3170**] URINE 93-[**Numeric Identifier 3171**] URINE REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DIAGNOSIS: Urine: ATYPICAL. Atypical but very degenerated urothelial cells, cannot exclude urothelial dysplasia/neoplasia. A few squamous cells, histiocytes, scattered lymphocytes, and many red blood cells. Urine cytology: DIAGNOSIS: A. Cell block, "[**2125-2-2**]": Blood and rare atypical but markedly degenerated urothelial cells and a few lymphoid cells, see note. B. Cell block, "[**2125-2-3**]": Blood and rare atypical but markedly degenerated urothelial cells and a few possible lymphoid cells, see note. C. Cell block, "[**2125-2-4**]": Insufficient material for diagnosis. Portable AP chest dated [**2125-2-5**] is compared to the chest CT from [**2125-2-2**] and chest radiograph of [**2125-2-1**]. Patient respiratory motion degrades the image. The heart is normal in size; however, there is marked opacification of the left heart border and retrocardiac region which may represent atelectasis/consolidation and pleural effusion. The right lung is grossly clear, but there is probably a small right pleural effusion. There is no pneumothorax. IMPRESSION: 1. Patient respiratory motion degrades the quality of the image. 2. Left lower lobe opacification likely represents atelectasis/consolidation plus effusion. Cytology Report URINE/VOIDED Procedure Date of [**2125-2-3**] REPORT APPROVED DATE: [**2125-2-8**] SPECIMEN RECEIVED: [**2125-2-5**] 08-[**Numeric Identifier 3162**] URINE/VOIDED SPECIMEN DESCRIPTION: Received 200 ml. brown fluid. Prepared one ThinPrep slide. 6 specimens collected on [**2125-2-3**]. CLINICAL DATA: 85 year old female with known CLL and new large bladder mass with peritoneal mets, diff between CLL and TCC. PREVIOUS BIOPSIES: [**2125-2-5**] 08-[**Numeric Identifier 3163**] URINE/VOIDED [**2125-2-2**] 08-[**Numeric Identifier 3164**] URINE/INSTRUMENTATION [**2125-2-2**] 08-[**Numeric Identifier 3165**] URINE/INSTRUMENTATION [**2117-10-1**] 00-[**Numeric Identifier 3166**] PAP [**2115-4-16**] 98-[**Numeric Identifier 3167**] PAP 96-[**Numeric Identifier 3168**] PAP 93-[**Numeric Identifier 3169**] URINE 93-[**Numeric Identifier 3170**] URINE 93-[**Numeric Identifier 3171**] URINE REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3172**] DIAGNOSIS: SUSPICIOUS. Atypical but markedly degenerated urothelial cells and scattered atypical lymphoid cells present. Squamous cells, anucleate squames, red blood cells, crystals. ECHO: Conclusions The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular function with mild left ventricular outflow tract obstruction. No significant valvular disease. NONCONTRAST CT, (has had recent dye load), please evaluate l [**Hospital 93**] MEDICAL CONDITION: 85 year old woman with CLL admitted with multiple abdominal mets, and LLL obstruction [**1-6**] hilar LAD on CT abdomen. REASON FOR THIS EXAMINATION: NONCONTRAST CT, (has had recent dye load), please evaluate lymphadenopathy, LLL collapse, infiltrate. CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: 85-year-old woman with chronic lymphocytic leukemia, admitted with abdominal metastases and left lower lobe obstruction secondary to hilar lymphadenopathy on the abdomen CT. Question lymphadenopathy, left lower lobe collapse and infiltrate. At the request of the referring physician, [**Name10 (NameIs) 3173**] contrast was not administered because of a recent dye load. COMPARISONS: Limited comparison to a recent CT of the abdomen from [**2125-2-1**] which depicted the lung bases. TECHNIQUE: Axial CT images of the chest were obtained without [**Year (4 digits) 3173**] contrast, and coronal and limited sagittal reformatted images, including the spine, were also performed. CT OF THE CHEST WITHOUT IV CONTRAST: The patient was inadvertently imaged during submaximal inspiration/partial expiration; there is apparently slightly greater than 50% narrowing of the anteroposterior dimension of the mid trachea, an appearance suggestive of tracheomalacia. A coarse calcification is noted the right lobe of the thyroid. There are calcifications along the right, the left anterior descending, and the left circumflex coronary arteries. The pulmonary arteries cannot be assessed for filling defects. There is only trace pericardial fluid but a small-to- moderate left- sided pleural effusion of low density is somewhat larger. Although the left anteromedial basal segment appears spared, all other portions of the left lower lobe are collapsed, likely due to post-obstructive atelectasis. The overall degree of atelectasis has progressed since the prior day. A large subcarinal mass of 51 x 26 mm in axial dimensions (2a:27) is now fully visualized, although not as well depicted without [**Year (4 digits) 3173**] contrast. It can be seen to extend to the carina and also abuts the posteromedial aspects of each mainstem bronchus. A large mass along the right infrahilar region and adjacent portion of the lower left mediastinum measures 61 x 37 mm (2c:74), but was better depicted with contrast. The mass likely obstructs one or more descending basal segmental airways, but its precise origin is not fully clear. There are multiple enlarged mediastinal lymph nodes. The largest is a paraaortic node measuring 12 mm in shortest axis dimension. There is marked lymphadenopathy in the left axilla. The largest node (2A:97) measures 30 x 23 mm in axial dimensions. There are also several slightly prominent right hilar lymph nodes, but these are not over 8 mm in diameter. A small right-sided pleural effusion with associated atelectasis appears unchanged. Two calcified granulomas are noted in the right lung. Limited views of the upper abdomen again depict multiple masses, marked lymphadenopathy, a right adrenal mass, and marked splenomegaly. There are also gallstones and a new small amount of ascites. This appearance was better depicted on the prior CT of the abdomen. BONE WINDOWS: There are no suspicious lytic or blastic lesions. IMPRESSION: 1. Subcarinal nodal mass. 2. Mass in the left infrahilar region with post- obstructive atelectasis, which has progressed to near left lower lobe collapse. 3. Marked left axillary lymphadenopathy, amenable to biopsy. 4. Somewhat larger bilateral pleural effusions. 5. Collapsibility of the trachea suggesting tracheomalacia. 6. Coronary artery calcifications. 7. Multiple abnormal masses in the upper abdomen, better depicted on the recent abdominal CT. The only new finding is trace ascites. 8. Known pulmonary embolism not visualized given the lack of contrast administration. The extent of pulmonary emboli, accordingly, cannot be assessed. CT PELVIS W/CONTRAST [**2125-2-1**] 4:14 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: eval for diverticulitis, signs of C-diff Field of view: 45 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 85 yo F w/ CLL and climbing WBC, fatigue, cough, T 99, LLQ pain, recent Azithro REASON FOR THIS EXAMINATION: eval for diverticulitis, signs of C-diff CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: History of CLL with leukocytosis, left upper quadrant pain, and cough. Additional history from the online medical record indicates that there is hematuria. TECHNIQUE: Contrast-enhanced MDCT of the abdomen and pelvis displayed in multiplanar collimation. COMPARISON: [**2118-3-23**]. CT ABDOMEN WITH CONTRAST: There is a large 5.6 x 3.2 cm mass in the inferior mediastinum at the G-E junction. There is a large 4.2 x 1.9 cm subcarinal mass that compressess the esophagus. The most superior slice also suggests an additional visualization of a left hilar node, which is compressing the superior segment bronchus of the left lower lobe resulting in postobstructive collapse. There is additional atelectasis at the left base with a moderate left-sided pleural effusion. There is a trace pericardial fluid. A nonocclusive pulmonary embolism is present in the visualized portions the right lower lobe pulmonary artery, partially visualized on this study. Widespread metastatic disease is identified, with a large, 5.9 x 3.7 cm heterogenous mass in the left upper quadrant, overlying the spleen, with a small amount of associated ascites. Innumerable additional omental, peritoneal, mesenteric, and retroperitoneal soft tissue nodules/masses consistent with metastases are also noted. There is an enlarged 2.7 cm mass/node in the gastrohepatic space. Multiple metastatic deposits are noted about and within the right adrenal gland. The spleen is markedly enlarged measuring 19 cm in long axis and contains multiple sub- centimeter hypoattenuating, indeterminate lesions. There is no free air or free fluid. The small bowel loops appear normal. Multiple hypodense lesions are present in the kidneys, all probably simple or dense cysts. No lesions are identified in the liver. There is no intrahepatic biliary ductal dilation. The gallbladder and pancreas appear normal. CT PELVIS WITH CONTRAST: There is a large lobulated mass within the right superior lateral wall of the bladder measuring 6.0 x 2.9 cm. There are multiple markedly enlarged lymph nodes along the right external iliac, right common iliac, and left paraaortic lymph node distributions. The rectum, colon and uterus appear normal. The ovaries are not identified without definite adenexal mass. BONE WINDOWS: No suspicious lesions are identified. Sclerosis is noted at the pubic symphysis. IMPRESSION: 1. Widely metastatic disease with innumerable peritoneal implants, including a large left upper quadrant mass, and bulky iliac and retroperitoneal lymph nodes. Lobulated mass within the bladder wall. While a primary bladder malignancy remains a consideration, other primary neoplasms (such as lung or ovarian) with implants on the bladder should also be considered. 2. Mediastinal adenopathy with likely left hilar adenopathy (partially visualized) causing post- obstructive collapse of the superior segment of the left upper lobe. 3. Nonocclusive pulmonary embolism of the right lower lobe pulmonary artery. 4. Massive splenomegaly with multiple indeterminate 1-cm lesions, either metastases or small foci of infarction secondary to splenomegaly. [**Numeric Identifier 3174**] INTERUP IVC [**2125-2-1**] 4:14 PM Reason: please place IVC filter. Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 85 year old woman with CLL, multiple new abdominal masses, new bladder mass, with RLL PE, with concern for anticoagulation given hematuria. REASON FOR THIS EXAMINATION: please place IVC filter. PROCEDURE: IVC filter placement. INDICATION: 85-year-old woman with CLL, multiple new abdominal masses, and with new bladder mass. Patient has now presented with right lower lobe pulmonary embolism and with concern for anticoagulation given hematuria. IVC filter placement was requested. RADIOLOGISTS: This procedure was performed by Dr. [**First Name (STitle) 1022**] and Dr. [**First Name (STitle) 3175**], the attending radiologist, who was present and supervising throughout the entire procedure. PROCEDURE AND FINDINGS: After explaining the risks and benefits of the procedure, an informed consent was obtained from the patient. The patient was placed supine on the angiographic table and the right groin was prepped and draped in standard sterile fashion. A preprocedure timeout was performed. After injection of local anesthesia with 1% lidocaine and using ultrasound guidance, access was gained into right femoral vein with a 19-gauge needle. A 0.035 Bentson guidewire was advanced into the IVC under fluoroscopic guidance and the needle was exchanged for a 5 French Omniflush catheter. Using Omniflush catheter and guidewire, access was gained into left common iliac vein and IVC venogram was obtained. IVC venogram demonstrated no thrombosis in left iliac, IVC, and both renal veins were noted at L2 level. Based on these venographic findings, it was decided to place IVC filter at L3 level. A 5 French catheter was removed and guidewire advanced into the upper IVC under fluoroscopic guidance. A 7 French delivery catheter was advanced over the wire into the IVC. A G2 IVC filter was advanced through the catheter, and it was deployed in the immediate infrarenal IVC at L3 level. Final abdominal x- ray demonstrated proper location and position of IVC filter in infrarenal IVC. Vascular catheter was removed and manual compression was held until hemostasis was achieved. The patient tolerated the procedure well and there were no immediate complications. IMPRESSION: Patent IVC and single renal veins at L2 level. Successful G2 IVC filter deployment in immediate infrarenal IVC. Brief Hospital Course: 85 y/o russian woman with history of Stage 0 CLL presented with cough, abd pain, and hematuria, found to have LUL collapse secondary to LAD, multiple abd mets, and new bladder mass. Metastatic cancer of unknown primary Presented with hematuria, found to have new bladder mass on CT scan, in addition to peritoneal and lung mass. Urology consult service followed, recommended urine cytology for diagnosis. 3-way foley placed and clots ultimately cleared and urine returned to regular color. Per urology, biopsy of mass not advisable given risk of procedure (bleeding, poor functional status). Instead, urine cytology collected (multiple samples), which were not diagnostic by pathology. ASA was held. Patient was transfused with 1U PRBCs. Given inability to obtain a diagnosis, and extent of metastatic cancer (as well as unliklihood it is progressive CLL or transformation), comfort/palliative care was recommended. Her oncologist Dr. [**Last Name (STitle) **], and primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] were instrumental in decision-making and recommendations for goals of care and prognosis. Mrs. [**Known lastname 3176**] was very clear in her desire to pursue comfort measures only. The main symptoms were pain and dyspnea both were treated with oxycontin and oxycodone. On day of discharge, oxycontin was increased to 20 mg [**Hospital1 **]. She did not want to take morphine secondary to previous side effects. Palliative care team was involved as well and they recommended starting ritalin, dexamethasone as well. Constipation - on senna, colace and lactulose. Please give a dose of lactulose when patient arrives at rehab today([**2125-2-19**]) as pt had not had a bowel movement in 2 days. LLL collapse/possible post-obstructive pneumonia: was treated for pneumonia with antibiotics that were stopped when patient requested they be discontinued. O2 continued for comfort. Pulmonary embolism: IVC filter placed [**2-1**]. Systemic anticoagulation deferred in setting of hematuria. Leg edema is likely from IVC filter and abdominal metastases compressing on the venous return. Leg elevation recommended. CLL/hemolytic anemia: The patient's labs showed evidence of a hemolytic anemia. Prednisone was not administered given stable hematocrit and risk of steroids with unknown malignancy, on recommendations of Dr. [**Last Name (STitle) **]. (However, eventually dexamethasone was started per palliative care recommendations.) Celexa, klonapin continued at home doses. Son, [**Name (NI) **] ([**Name2 (NI) 3177**] Kopelev h-[**Telephone/Fax (1) 3178**], cell [**Telephone/Fax (1) 3179**].) is the proxy and aware of all issues. constant communication was maintained with him during the hospital stay. Patient will be discharged to rehab with hospice support. Medications on Admission: ALBUTEROL 17 GM--Take 2 puff twice a day as needed AMBIEN 10MG--One by mouth at bedtime as needed ASPIRIN 81 MG--One by mouth every day ATENOLOL 25 mg--1. tablet(s) by mouth once a day Atorvastatin 10 mg--0.5 tablet(s) by mouth once a day CLONAZEPAM 0.5 mg--one tablet(s) by mouth every evening as needed COSOPT 0.5 %-2 %--1 gtt os twice a day COZAAR 50 mg--1 tablet(s) by mouth once a day Citalopram 20 mg--0.5 tablet(s) by mouth at bedtime Flovent HFA 110 mcg/Actuation--take 2 puffs twice a day HYDROCHLOROTHIAZIDE 12.5MG--Take one by mouth daily LORATADINE 10 mg--1 tablet(s) by mouth once a day as needed for congestion, ear discomfort NITROGLYCERIN 0.3 mg--11 tablet(s) sublingually for chest pain; repeat x 1 after 5 minutes PHYSICAL THERAPY FOR LEFT KNEE OSTEOARTHRITIS--Evaluation and treatment; injection therapy RANITIDINE HCL 150 mg--1 tablet(s) by mouth daily Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): hold if somnolent. 5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed for wheezing. 6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 10. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal QDAY (). 11. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every twelve (12) hours. 12. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ml PO once a day as needed for constipation: Give if no stool for 2 days. . 13. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO 2 PM (). 14. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 15. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day) as needed for nausea. 17. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q2H (every 2 hours) as needed for dyspnea or pain. 18. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q3H (every 3 hours): patient may refuse if she is not in discomfort from pain or dyspnea. Do not wake patient up if sleeping to give medication. . 19. Senna 8.6 mg Capsule Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Metastases from unknown primary malignancy Symptoms of pain, dyspnea, leg edema - possibly related to wodespread cancer History of CLL, autoimmune hemolytic anemia Pulmonary embolism Discharge Condition: fair, going for ongoing hospice care Discharge Instructions: You are being discharged to extended care facility for further care. Hospice care will be provided at the facility. They can be in touch with your primary care physician, [**Name10 (NameIs) **] [**Last Name (STitle) **] and/or the palliative care team here at [**Hospital1 18**] for further recommendations for your care. Followup Instructions: The facility - [**Hospital1 599**] of [**Location (un) 55**] will care for your further hospice needs. They can be in touch with your primary care physician, [**Name10 (NameIs) **] [**Last Name (STitle) **] and/or the palliative care team here at [**Hospital1 18**] for further recommendations for your care.

Admission Date: [**2106-7-11**] Discharge Date: [**2106-7-14**] Service: NMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5868**] Chief Complaint: Left arm weakness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 87 year old RH woman with a history of PAF not on anti-coagulation now presenting with new onset left arm weakness. The history as per the patient and her husband is that they were eating dinner this morning at around 9:30 am when the patient felt the sudden onset of "terrible lightheadedness". The husband put down the newspaper and looked over at his wife to see her left arm hanging off the chair. He went over to her, lifted the arm into the air and asked her to keep it raised. It fell to the ground. He became concerned and called for the [**Hospital3 **] facility nurse who examined the patient and activated EMS after discovering similar findings. In the ambulance, she began moving her left arm a little more but it still was significantly weak. She denied any headache, visual problems, loss of consciousness, extremity shaking, or numbness/tingling. Past Medical History: Paroxysmal atrial fibrillation Anxiety Depression GERD Past history of Sciatica At least one ER visit within past 2 years for "syncope" Social History: She lives with husband at [**Hospital3 **] facility. She requires assistance with ADL's such as bathing, cooking. At baseline, walks with walker in the home. No recent alcohol or tobacco use. Family History: No family history of seizures or strokes. Physical Exam: Vitals T:97.8 BP:110/70 P:70 RR:16 Sat:99% on 2L General: Elderly woman in no acute distress. Head, neck, lungs, cardaic, abdominal and extremity exam were normal except for 1+ pre-tibial edema. Neurologic Examination: Mental Status: Awake and alert, cooperative with exam, normal affect; she is oriented to person, place, month and president. Attention: able to say months of year backward and forward. Language: Fluent, no dysarthria, no paraphasic errors, naming intact; fund of knowledge normal. Registration: [**1-20**] items, and recalls [**12-22**] with prompting at 5 minutes; she has no apraxia and no neglect Cranial Nerves: Visual fields are full to confrontation. Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Extraocular movements intact, no nystagmus. Facial sensation intact; facial movement decreased on left with decreased left NLF; Hearing decreased to finger rub bilaterally. Tongue midline, no fasciculations. Sternocleidomastoid and trapezius normal bilaterally. Motor: Normal bulk and tone bilaterally; no tremor. D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Left 3 3 4 4 3 4 4 3 3 4 3 3 4 4 3 Sensation: intact to light touch, pin prick, temperature (cold), vibration, and proprioception; extinction to DSS on left. Reflexes: B T Br Pa Pl Right 2 2 2 2 1 Left 2 2 2 2+ 1 Some crossed adductor activity at left patellar; grasp reflex absent; toes were equivocal on both sides Coodination: mild ataxia on right FNF and unable to perform on left secondary to weakness. Pertinent Results: Laboratory results: CBC, CHEM-7, U/A all within normal limits. HEAD CT/CTA ([**7-11**]): No evidence of acute intracranial hemorrhage. Questionably asymmetrical left ventricular dilatation. Left vertebral artery is occluded just below the skull base. The nature and duration of this finding is unknown. Flow is present in the other major branches of the circle of [**Location (un) 431**]. No evidence of large territorial infarct or enhancing lesion. Brief Hospital Course: In the emergency department, her systolic blood pressure was in 100s. A CT of head was consistent with chronic microvascular disease without hemorrhage; CT with angiography demonstrated calcifications of the ICAs and L vertebral artery occlusion. Clinically, she had an ischemic stroke in right cerebral hemisphere. Therefore, pt was admitted to the Neuro ICU for pressors to elevate her blood pressure. However, she refused central line, arterial line and Neo-Synephrine for BP maintenance. She did agree to aspirin, and she was started on heparin as well for her paroxysmal atrial fibrillation, which was the likely etiology of her stroke. She initially refused warfarin. As her blood pressure increased, her symptoms gradually improved and she was transferred to the floor. TTE demonstrated no significant sources of thrombus and carotid duplex u/s demonstrated <40% flows bilaterally (as per tech at bedside; pending final read). On [**7-13**], following discussion with pt and PCP, [**Name10 (NameIs) **] accepted anticoagulation with warfarin and aspirin was discontinued. Her exam demonstrated mild improvement to her weakness. However, she continues to have some left-sided weakness, and PT/OT evaluation recommended a short stay at an acute rehabilitation facility. Medications on Admission: Seroquel Prilosec Ambien Discharge Medications: 1. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 2. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Sotalol HCl 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Five Hundred (500) Units Intravenous ASDIR (AS DIRECTED): Adjust dosage for goal PTT 40-60. Discharge Disposition: Extended Care Facility: [**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 1110**] Discharge Diagnosis: Right Cerebral Infarct Paroxysmal Atrial Fibrillation Gastroesophageal Reflux Disease Sciatica Anxiety Depression Discharge Condition: Good, with persistent left arm and leg weakness. Discharge Instructions: Please follow-up with your Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) **] in [**11-20**] weeks. Call [**Telephone/Fax (1) 8506**] to schedule an appointment. Please schedule an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the Stroke Service at [**Telephone/Fax (1) 1694**] in [**2-23**] weeks. If you notice any worsening weakness, difficulty swallowing, changes in your vision, sudden headache, tingling, numbness or any other concerning symptom, please call your PCP immediately or come to the Emergency Department for evaluation. Take all medicines as prescribed. We have started you on a new medicine called coumadin to help thin your blood and try to prevent another stroke. Followup Instructions: Please schedule an appointment with your Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 8506**]. She will follow your INR after you get out of rehabilitation. Please schedule an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] / Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the Stroke Service at [**Telephone/Fax (1) 1694**].

Admission Date: [**2131-12-17**] Discharge Date: [**2131-12-24**] Date of Birth: [**2103-10-28**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11415**] Chief Complaint: fall off roof from 20 feet Major Surgical or Invasive Procedure: [**2131-12-17**]: 1. Closed treatment left elbow dislocation. 2. Closed treatment radial head fracture. 3. Irrigation and debridement down to and inclusive of bone of all open tibia and fibula fracture. 4. Open reduction and internal fixation of fibula fracture, right lower extremity. 5. Internal fixation right distal tibia pilon fracture. 6. Intramedullary nailing of the hip fracture with TFN (trochanteric fixation) nail 11 x 170 x 130. [**2131-12-19**]: 1. Open reduction and internal fixation of articular fracture of the distal humerus, at the capitellum. 2. Open reduction and internal fixation of coronoid process of the proximal ulna. 3. Open reduction and internal fixation of radial head fracture. 4. Repair of lateral ligamentous complex with local tissue. History of Present Illness: Mr. [**Known lastname 58468**] is a 28 year old right hand dominant Portugese speaking construction worker who fell off a 20 foot roof. He had immediate right leg and hip pain as well as left elbow pain, and an open wound on his left leg. He denies LOC. Left elbow fracture/dislocation was reduced and splinted in ED. Past Medical History: None Social History: Construction worker. Denies tob/EtOH/drugs. Family History: Non-contributory Physical Exam: On discharge: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Extremities: LUE: splint in place c/d/i, Sensation intact to light touch, Neurovascular intact distally, Capillary refill brisk RLE: Incision: intact, no swelling/erythema/drainage Dressing: clean/dry/intact External fixator: pin sites clean/dry/intact, Sensation intact to light touch, neurovascular intact distally, capillary refill brisk, motor intact Pertinent Results: [**2131-12-17**] 04:37PM BLOOD WBC-11.9* RBC-4.82 Hgb-13.1* Hct-40.7 MCV-85 MCH-27.3 MCHC-32.3 RDW-13.4 Plt Ct-263 [**2131-12-17**] 10:49PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2131-12-17**] 04:37PM BLOOD PT-14.9* PTT-24.6 INR(PT)-1.3* [**2131-12-17**] 10:49PM BLOOD Glucose-159* UreaN-13 Creat-1.0 Na-140 K-4.1 Cl-105 HCO3-25 AnGap-14 [**2131-12-17**] 10:49PM BLOOD Calcium-8.3* Phos-3.2 Mg-1.5* [**2131-12-17**] 04:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2131-12-20**] 07:45AM BLOOD WBC-12.9* RBC-2.31*# Hgb-6.5*# Hct-19.4* MCV-84 MCH-27.9 MCHC-33.3 RDW-12.9 Plt Ct-219 [**2131-12-20**] 07:45AM BLOOD Glucose-121* UreaN-8 Creat-0.7 Na-140 K-4.0 Cl-103 HCO3-30 AnGap-11 [**2131-12-17**] CT LUE: IMPRESSION: 1. Displaced fracture fragments arising off the coronoid process and radial head as described. 2. Minimally displaced capitellum fracture. 3. Loose body situated between the ulna and trochlea. [**2131-12-17**] CT RLE: IMPRESSION: 1. Markedly comminuted distal tibial fracture extending through the plafond with disruption of the ankle mortise and multiple loose fragments. 2. Overriding comminuted distal fibular fracture with proximal fragment extending to the skin surface. 3. Impaction fracture of the superior-medial talus. Brief Hospital Course: Mr. [**Known lastname **] presented to the Emergency Department complaining of a 20 foot fall from a roof. He was evaluated by the Trauma surgery service and found to have only orthopaedic injuries. The Orthopaedics department evaluated the patient who was found to have a right intertrochanteric hip fracture, a right open tibia and fibula distal pilon fracture, a left elbow dislocation, and a left radial head fracture. He was admitted, consented, and taken directly to the Operating room for emergent surgery on his open fracture. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any complication. Post-operatively, he was transferred to the TSICU for observation overnight. He was stable overnight and was transferred to the floor on [**2131-12-18**]. On [**2131-12-19**], he was again prepped and brought to the operating room for managment of his elbow injury. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any complication. Post-operatively, he was transferred to the PACU and floor for further recovery. On the floor, he remained hemodynamically stable with his pain well controlled. On [**2131-12-20**] he was transfused with 2 units of packed red blood cells due to acute blood loss anemia with appropriate rise in hct. He progressed with physical therapy to improve his strength and mobility. He was discharged in stable condition. Medications on Admission: None Discharge Medications: 1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO Qhs as needed for Constipation. Disp:*60 Tablet(s)* Refills:*6* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*6* 3. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily) for 4 weeks. Disp:*28 injection* Refills:*0* 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 6. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 2 weeks. Disp:*56 Capsule(s)* Refills:*0* 7. Wheelchair 1 wheelchair with elevated and removable leg rests and removable arm rests. Dx: R pilon fx, R IT frx, L elbow frx dislocation 8. Slideboard Use as directed 9. commode use as directed Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: 1. Right intertrochanteric hip fracture. 2. Right open tibia and fibula distal pilon fracture. 3. Left elbow dislocation. 4. Left radial head fracture. 5. Acute blood loss 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: If you experience any shortness of breath, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. You may not bear weight on your right leg and your left arm. Please use your crutches/walker for ambulation and your arm sling for comfort. Please resume all of the medications you took prior to your hospital admission. Take all medication as prescribed by your doctor. You have been prescribed a narcotic pain medication. Please take only as directed and do not drive or operate any machinery while taking this medication. There is a 72 hour (Monday through Friday, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on Saturdays, Sundays, or holidays. Please plan accordingly. * Continue your Lovenox injections as prescribed to help prevent blood clots. Please finish all of this medication. Feel free to call our office with any questions or concerns. Physical Therapy: Activity: Activity as tolerated Right lower extremity: Non weight bearing Left upper extremity: Non weight bearing Treatments Frequency: Pin care: Daily with 1/2 strength hydrogen peroxidoe and normal saline Keep incisions clean and dry Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1005**] (leg/ankle) next Tuesday, please call [**Telephone/Fax (1) 1228**] Please follow up with Dr. [**Last Name (STitle) **] (elbow) in [**10-2**] days. please call [**Telephone/Fax (1) 1228**] to make this appoitment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]

Admission Date: [**2177-1-11**] Discharge Date: [**2177-1-16**] Date of Birth: [**2142-3-23**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 54353**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 34 year old female who complains of SOB. 31 wks pregnant with shorntess of breath and fever to 101.2. Productive cough with greenish sputum. Patient started on steroids and nebulizer for reactive airways a couple days ago. Not improving. She also has pleuritic pressure across chest but not pain. No hemoptysis. Patient has noticed wheezing. Notes that she has been sleeping upright for the past week or so. Patient denies hx of GERD. . In the ED inital vitals were, 8 98.1 120 129/99 28 94% RA. Labs were notable for WBC of 11.6, hct of 35. Exam is notable for gravid patient. CXR showed: low lung volume, question volume overload, focal opacity in RML, question PNA. Cardiac size is top normal. EKG is sinus tach with non-specific ST changes. Recieved Albuterol x 3, Azithromycin, CeftriaXONE 1g, Magnesium Sulfate. RR is still in the upper 40s. She is A/O x3, experienced an episode of epistaxis while at the ED. Echo and BNP are ordered. EKG showed question of S1Q3T3 pattern, ED decided to CTA the patient. Vitals: HR 123, BP 149/88, RR 35, Sat 94% face tent 10L. . On arrival to the ICU, patient tachypneic and sinus tachycardia. 92% off of facemask. Pt kept on 8L humidified air mask. Received atrovent and seen by OB. LENIs pending. . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness. Denies chest pain, 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: URI ? Liver disease Vit D deficiency Asthma Social History: - Tobacco: smoked [**12-9**] pack per day for 20 years - Alcohol: none current - Illicits: denies Family History: none Physical Exam: Admission Physical Exam: General: Alert, oriented, uncomfortable and breathing rapidly HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no rales, rhonchi. + wheeze throughout CV: Distant heart sounds. Regular 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. Gravid uterus, S>D GU: no foley Ext: warm, well perfused, 2+ pulses, edema b/l in lower extremities Pertinent Results: Admission Labs: [**2177-1-11**] 09:15PM BLOOD WBC-11.3* RBC-4.38 Hgb-11.7* Hct-35.8* MCV-82 MCH-26.8* MCHC-32.8 RDW-16.5* Plt Ct-237 [**2177-1-11**] 09:15PM BLOOD Neuts-75.8* Lymphs-16.9* Monos-6.6 Eos-0.5 Baso-0.2 [**2177-1-11**] 09:26PM BLOOD PT-10.4 PTT-26.9 INR(PT)-1.0 [**2177-1-11**] 09:15PM BLOOD Glucose-101* UreaN-9 Creat-0.5 Na-136 K-5.0 Cl-102 HCO3-23 AnGap-16 [**2177-1-11**] 09:15PM BLOOD ALT-27 AST-58* AlkPhos-92 TotBili-0.2 [**2177-1-11**] 09:15PM BLOOD Lipase-19 [**2177-1-11**] 09:15PM BLOOD proBNP-7 [**2177-1-11**] 09:15PM BLOOD Albumin-3.6 UricAcd-4.0 [**2177-1-11**] 09:25PM BLOOD Lactate-1.6 CTA Chest Prelim Read: limited study for segmental and subsegmental branches, however no central PE seen. multifocal opacities concerning for pneumonia Brief Hospital Course: The patient was admitted to the ICU for pneumonia, shortness of breath, possible PE . # respiratory distress: likely due to anxiety, pna, potential PE. Considering fever, cough w/ sputum and CXR, likely that there si some component of PNA vs. reactive airways. Also, pt is prothrombotic considering not active, pregnant and smoker. PE a possibility, yet CTA did not demonstrate any large filling defect. Treated wtih antibiotics for likely pna and also prednisone/nebs for reactive airways. Reassuring that patient's saturations remain relatively stable off of O2 (95 --> 93). - f/u final CTA of chest -- wet read demonstrates no e/o central PE, but not good study for segmental / sub-segmental. will get LENIs - continue azithromycin and ceftraixone - continue prednisone 50mg qd - continue atrovent standing q6hrs, hold on albuterol for now considering sinus tachycardia - continue moist O2 - ABG . # Pregnancy: OB came and assessed patient and fetus. No fetal abnormalities at this moment. [**Name2 (NI) **] check 24hr urine for pre-eclampsia. - [**Hospital1 **] L&D fetal monitoring . # FEN: IVF prn, replete electrolytes, regular diet # Prophylaxis: Pneumoboots, heparin sc # Access: peripherals # Communication: Patient HCP: [**Name (NI) **], husband [**0-0-**] # Code: Full (discussed with patient) During the hospital stay she had: BP elevations, started initially on labetalol but moved to nifedipine with improvment. Diabetes worsened on steroids, insulin begun On hospital day 3 influenza swab returned positive for Influenza A. She was started on Tamiflu, azithromycin continued but other antibiotics stopped. Breathing significantly improved and she was transferred to the OB service on [**2177-1-14**]. Over the following 2 days, symptoms improved so that she was breathing comfortably with no supplemental oxygen. BPs improved on Nifedipine Glucoses controlled with insulin Fetal testing reassuring with NSTs reactive twice daily. Repeat ultrasound on [**1-15**] reassuring. Urine 24 hour testing 600+ mg protein/24 hours, supporting a diagnosis of mild preeclampsia Urine testing showed 10-100K e.coli and enterococcus, uncertain if this was contaminant. Patient refused straight cath but repeat urine culture (clean catch) pending at the time of discharge. Patient requested discharge on [**1-23**] and [**1-16**] and was discharged to home on [**1-16**] for outpatient follow-up Medications on Admission: - Zyrtec 10 mg Tab Oral 1 Tablet(s) Once Daily - Prenatal Multivitamins 28 mg iron-800 mcg Tab Oral 1 Tablet(s) Once Daily - Prednisone 50 mg Tab Oral 1 Tablet(s) Once Daily - Albuterol sulfate -- Unknown Strength 1 Syrup(s) Every [**3-14**] hrs, as needed - Ventolin HFA 90 mcg/actuation Aerosol Inhaler Inhalation [**12-9**] HFA Aerosol Inhaler(s) Every 4-6 hrs, as needed Discharge Medications: 1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: one more dose only. Disp:*1 Tablet(s)* Refills:*0* 2. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). Disp:*60 Tablet Extended Release(s)* Refills:*2* 3. oseltamivir 75 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): for 3 more days. Disp:*6 Capsule(s)* Refills:*0* 4. insulin syringe-needle U-100 [**12-9**] mL 29 x [**12-9**] Syringe Sig: One (1) syringe injection Miscellaneous three times a day. Disp:*90 syringeinjection* Refills:*2* 5. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous once a day: dose as directed. Disp:*1 vial* Refills:*2* 6. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous three times a day: dose as directed. Disp:*1 vial* Refills:*2* 7. Blood Pressure Cuff Misc Sig: One (1) Miscellaneous twice a day: Need extra-large cuff, patient arm 21 inches diameter. Disp:*1 cuff* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Influenza pneumonia with respiratory compromise Dehydration Pregnancy induced hypertension, mild Gestational diabetes Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Limited activity, increase rest Check BP twice daily Limited activity, increase rest Check BP twice daily Followup Instructions: Follow-up in office twice weekly Follow-up with endocrine

Admission Date: [**2170-3-26**] Discharge Date: [**2170-4-1**] Date of Birth: [**2111-3-25**] Sex: M Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: This is a 59 year old male with a history of coronary artery disease status post multiple stents, hypertension, hyperlipidemia, and diabetes mellitus type 2, who presents with an episode of choking sensation, discomfort with radiation from the stomach to the chest, worse with exertion. It started the evening prior to admission. It was relieved with two sublingual Nitroglycerin and the chest discomfort recurred with nausea and diaphoresis with a mild headache. He took two aspirin and went to sleep. Later that morning, the patient noted a left sided chest discomfort which had returned and presented to the Emergency Department. He was given sublingual Nitroglycerin which relieved the pain. The patient was started on a heparin drip. He had already taken his beta blocker and aspirin at home. The patient noted episodes exactly the same of this prior anginal episode denied. PAST MEDICAL HISTORY: 1. Coronary artery disease status post right coronary artery stents in [**2164**], [**2169**]. Status post left circumflex in [**2165**] and [**2168**]. Cardiac catheterization in [**12/2169**] showed left anterior descending, proximal and medial 80 to 90% stenosed, D1 90% stenosed and left circumflex stents patent; obtuse marginal 90%, right coronary artery mid 95%. PTC and stented. The ERCA stent patent. Ejection fraction 44%. 2. Posterior basilar hypokinesis. Anterior lateral inferior hypokinesis. 3. Hypertension. 4. Hyperlipidemia. 5. Diabetes mellitus. ALLERGIES: The patient has no known drug allergies. MEDICATIONS AT HOME: 1. Toprol XL 150. 2. Plavix 75. 3. Cozaar 25. 4. Glucotrol 10 twice a day. 5. Prilosec 20. 6. Lipitor 10. 7. Aspirin. 8. Flogard 1. SOCIAL HISTORY: The patient had quit smoking 35 years ago and used only occasional alcohol. LABORATORY: On admission the patient's white blood cell count was 8.3, hematocrit 40.7, platelets 164. Electrolytes were within normal limits. CK 49, troponin less than 0.3. Chest x-ray showed no congestive heart failure, no infiltrates. Stress test on [**2170-2-27**], Stress MIBI showed moderate partially reversible defects involving inferior and lateral walls, improved when compared to [**2169-12-4**] which was stress test prior to the second right coronary artery stent. PHYSICAL EXAMINATION: On examination, the patient was afebrile, vital signs were stable. Regular rate and rhythm. Clear to auscultation. HOSPITAL COURSE: The patient underwent a catheterization on [**2170-3-26**] which showed LMCA mild ostial plaquing, left anterior descending proximal eccentric 80 to 90%, mid-serial 80% and apical 90%. High diagonal ramus diffuse disease to 80 to 90%. D2 small with diffuse disease 80 to 90%. L6 single large bifurcating along with diminutive arteriovenous groove circumflex. Obtuse marginal one upper pole diffuse disease to 60%, obtuse marginal one lower pole diffuse disease to 80 to 90% in multiple places. Right coronary artery diffuse mild disease with mild in-stent restenosis. Patent ductus arteriosus diffusely diseased to 50%. The patient underwent coronary artery bypass graft times four with a left internal mammary artery to left anterior descending, saphenous vein graft to right coronary artery, saphenous vein graft to the obtuse marginal and saphenous vein graft to the diagonal on [**2170-3-28**]. The patient tolerated the procedure without complications. He was extubated on postoperative day one and transferred to the Floor where he continued to do well with only minimal sternal drainage overnight on postoperative day number three, but the incision which was monitored continued, but was very minimal. The patient was felt to be ready for discharge on postoperative day number four. He was on a regular diet, ambulating well, had good p.o. and pain control. DISCHARGE STATUS: The patient was to be sent home with Visiting Nurses Association for dressing changes and wound checks. DISCHARGE INSTRUCTIONS: 1. The patient to follow-up with Dr. [**Last Name (STitle) **] in four weeks. 2. To follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1683**], in one to two weeks. 3. The patient to see Cardiologist in two to three weeks. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg twice a day. 2. Ibuprofen 400 mg q. six hours p.r.n. 3. Glipizide 10 mg twice a day. 4. Atorvastatin 10 mg q. day. 5. Plavix 75 mg q. day. 6. Percocet one to two tablets p.o. q. four to six hours p.r.n. 7. Tylenol 650 mg q. four hours p.r.n. 8. Aspirin 325 mg q. day. 9. Zantac 150 mg twice a day and to follow-up with cardiac surgeon. 10. Lasix 20 mg twice a day times seven days. 11. Potassium chloride 20 mEq twice a day times seven days. 12. Colace 100 mg twice a day. 13. Milk of Magnesia 30 ml q. h.s. p.r.n. 14. Insulin sliding scale as needed. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSES: Status post coronary artery bypass graft times four. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 5915**] MEDQUIST36 D: [**2170-4-1**] 12:58 T: [**2170-4-1**] 16:50 JOB#: [**Job Number 25052**] cc:[**Location (un) 25053**]

Admission Date: [**2120-10-4**] Discharge Date: [**2120-10-23**] Date of Birth: [**2059-2-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: 61 yo man w/ h/o rectal CA and HTN who presents c/o diarrhea x 5 days (started on [**9-30**]). Patient reports persistent, non-bloody, watery diarrhea every 10-30 minutes. Denies abdominal pain, fever, chills, N/V, cough, rash, dysuria, sick contacts, or recent travel. No recent medication changes, no antibiotics recently. Has not eaten in restaraunts recently. H/o similar diarrhea in the past which he says was due to chemo. . In the ED, patient's lactate was initially 4.0 and he was tachycardic at 110. Normotensive at 124/80. Apparently, he refused central line (sepsis protocol). Received IVF through peripheral IV, and repeat lactate was 2.4. His HR also stabilized in the 80's. BP remained normal. While in the ED, he spiked to 101.3 so he was given Cefepime, vanco, and flagyl. CT of the abdomen and he was admitted to OMED for further observation. . Past Medical History: 1. Rectal metastatic adenocarcinoma with A lytic lesion in T11 dx in [**2120-3-22**], CEA was elevated at 329--->1207 ([**2120-8-20**]). s/p 13 XRT therapies. Treated with Avastin (bevacizumab), 5FU, and Leucovorin. Last treatment [**2120-9-25**]. Oncologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 2. Hypertension Social History: Originally from [**Location (un) 6847**], moved to USA about 30 years ago. Married. Former restaurant worker, not working presently. Has a 35 pack year smoking history, quit ~[**2118**]. Rarely drinks alcohol. Family History: Non-contributory Physical Exam: VS: T=98.6 (Tm=101.3); BP=155/82; HR=88; RR=11; O2=98% (RA) GEN: elderly asian man, NAD HEENT: PERRL OU, MMM, OP clear, no icterus NECK: no JVD CV: RRR, NL S1/S2, no murmurs appreciated on exam, no S3/S4 heard RESP: CTA, no W/R/R ABD: NABS, soft, NT, ND, no masses EXT: no edema RECTAL: guaiac negative per ED NEURO: A&Ox3, CN II-XII intact bilat, motor/sensory exam intact bilat Pertinent Results: GLUCOSE-153 UREA N-16 CREAT-0.7 SODIUM-135 POTASSIUM-3.0 CHLORIDE-107 TOTAL CO2-20 ANION GAP-11 CALCIUM-6.9 PHOSPHATE-1.4 MAGNESIUM-2.3 . WBC-1.2 RBC-4.07 HGB-11.8 HCT-33.0 MCV-81 MCH-29.0 MCHC-35.7 RDW-18.3 PLT COUNT-153 . PT-15.6 PTT-27.9 INR(PT)-1.7 . GRAN CT-780 . LACTATE-1.7 . URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 Brief Hospital Course: 61 y/o male with metastatic rectal ca diagnosed [**3-26**] s/p xrt (last [**6-25**]) and chemo (last [**2120-9-25**]) who was admitted with diarrhea, fever, and neutropenia who developed hypoxemia, lactic acidosis, and confusion. Since his admission, the patient's diarrhea and fevers had progressively improved on cefepime, vancomycin, and metronidazole as well as Lomotil. Since then his course has been complicated by a steadily declining hematocrit (33 to 25 over the admission), worsening thrombocytopenia, and a new coagulopathy (INR up to 5.4). On [**10-12**], he was noted to be hypoxemic and had chest x-ray showing only a distended stomach and a CTA with no PE (but also a distended stomach and known liver mets). ABG was 7.44/25/63 then 7.32/21/84 that afternoon. His oxygen requirement waxed and waned, from mid 80's on room air to mid 90's on room air. His hypoxemia persisted and the patient became increasingly tired, confused, and tachypneic. A repeat ABG was 7.3/19/75 but his lactate had climbed from 3.5 to 8.0. He was transferred to the ICU at which time he was fatigued and appeared disoriented. In this setting, he denied pain (including abdominal) as well as dyspnea despite obvious tachypnea and mild accessory muscle use. He was started on IVF with 3 amps bicarb, lactate trended down, acidosis resolving. CT abdomen showed SBO with no obvious cut off for obstruction a NGT placed and medical management recommeneded by surgery. Primary oncologist Dr. [**Last Name (STitle) **] continued to follow. In the ICU he was found to have guiaic positive NGT secretions. He was transfused PRBCs for a dropping HCT. In addition he was noted to have an elevated INR for which he was treated with FFP. He was evaluated by surgery who felt him to be a poor surgical candidate. For his confusion a CT of his head was performed which was negative for bleed or other change. His hypoxia resolved and was felt to be due to aspiration initially. He was treated with TPN given his poor nutritional status. He was treated with octroetide per surgery recs with no improvement. On [**2120-10-18**] a family meeting was held at which time it was decided that the goal of care was maximal comfort. At that meeting it was decided to continue with fluids and analgesia but to limit other medications and TPN. The family will provide Chinese herbs and prayer. . # GI: Diarrhea was believed to be chemo-induced diarrhea. The patient was covered with cefepime, vancomycin, and flagyl given neutropenic fever. The CT of abdomen on admission did not show any inflammatory processes in the abdomen. The patient was given supportive care with IVF and Lomotil once obtained stool samples for cultures which were negative and his diarrhea improved with lomotil. However, patient became acidotic and CT abdomen was repeated and revealed SBO. NGT was placed and surgey was consulted but did not feel that the patient was a good surgical candidate. Patient was continued on medical management. Octreotide was added to his regimen to help to relieve obstruction. His lactate continued to trend down and NGT outout began to slow. Patient denied any abdominal pain. However, while in the ICU he developed bloody stools in the setting of coagulopathy. This was felt to be likely secondary to his rectal cancer. He was tranfused pRBCs and FFP. After several bloody stools and rectal tube placement his bloody bowel movements slowed, his coags improved and his hematocrit was stable. . Coagulopathy: Likely DIC secondary to cancer. He devloped GI bleed as mentioned above and was transfused several units of FFP and pRBCs and 1 unit of platelets. By tranfer from the ICU his HCT and INR was stable but platelets were 34. The patient and family did not want any further transfusions as their goal was comfort and this would require daily monitoring of his CBC and coags. . # NEUTROPENIC FEVER: The patient was started on cefepime, vanco, and flagyl on admission. He had some fevers early in his hospitalization but remained afebrile for the rest of his admission. He because hypoxic and acidotic and a CT chest was otained which revealed likely aspiration/pneumonia. He was continue on his antibiotics to complete a 14 day course and received daily neupogen injections. By the 11th day of his antibiotic course he was no longer neutropenic. His neupogen was discontinued and he remained afebrile. # AG METABOLIC ACIDOSIS: concerning for lactic acidosis [**1-24**] to hypovolemia. Patient refused central line/sepsis protocol in ED. He was hemodynamically stable on transfer to the floor. Lactate normalized after IVF. Then the patient continued to have non-anion gap acidosis [**1-24**] to diarrhea. ABG was obtained and the patient appropriately compensated with decreased CO2 (25) with normal pH 7.4-7.44. He then became more hypoxic and acidotc and was tranferred to the ICU. In the ICU it was discoved that he had an extremely dilated stomach and SBO. It was felt that the lactic acidosis ,may have been secondary to the extreme distension of his stomach given the rapid decline in his lactate on decompression with NGT. His gap closed and his lactate conitnued to tened down. . # RECTAL CANCER: Last chemotherapy was last avastin/5FU on [**9-25**]. Given that he did not tolerate this well, no further chemotherapy was planned. He also developed what is believed to be lower GI bleed, SBO and DIC during admission all which were thaough to be related to his metastatic disease. Due to his poor prognosis and worsening medical condition a family meeting was held and the family and patient agreed that comfort was the most important goal at this point. He was continued on IVF and the NGGT was kept in place to prevent worsening pain from his SBO. It was decided that no further blood products would be given. . FEN: Patient was actively hydrated in the setting of diarrhea and acidosis. He was continued on IVF given his SBO. Given his poor prognosis and that comfort was the goal, he was not started on TPN, but rather hydrated with IVF in the setting of SBO. Medications on Admission: 1. Aspirin 325 mg PO DAILY 2. Atenolol 50 mg PO once a day. 3. Buspirone 4. Compazine prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 7. Morphine 2 mg/mL Syringe Sig: [**12-24**] Injection Q4H (every 4 hours) as needed. 8. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: Metastatic rectal cancer. Small bowel obstruction. Hypertension. Discharge Condition: Stable. He is appropriate and interactive. The goal of care is comfort. Discharge Instructions: Please take all medications as prescribed. The goal of care is comfort. Followup Instructions: You have the following follow-up appointments Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2120-10-30**] 10:00 Provider: [**Name Initial (NameIs) 4426**] 22 Date/Time:[**2120-10-30**] 10:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2120-10-30**] 10:30 Completed by:[**2120-10-23**]

Admission Date: [**2114-10-22**] Discharge Date: [**2114-10-27**] Date of Birth: [**2053-9-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Upper back/shoulder discomfort for the last 6-9 months. Worsening fatigue. Major Surgical or Invasive Procedure: [**2114-10-22**] 1. Coronary artery bypass grafting times 5: Left internal mammary artery to the left anterior descending coronary; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the third obtuse marginal coronary artery; as well as reversed saphenous vein graft from the aorta to the posterior descending coronary artery. 2. Endoscopic left greater saphenous vein harvesting. History of Present Illness: 61 year old gentleman with a history of diabetes who had a recent acute episode of unstable angina with negative enzymes. He underwent a stress test which revealed an inferior wall defect with EKG changes and was subsequently admitted for a cardiac catheterization. This revealed severe three vessel disease. Given the severity of his disease, He has been referred for surgical revascularization. Past Medical History: Coronary Artery Disease Hypertension Dyslipidemia Diabetes mellitus type II (Diagnosed 10 years ago) Chronic Renal insufficiency Gout Past Surgical History: Cholecystectomy Appendectomy Social History: Occupation: Currently laid off. Sales for 30+ years. Last Dental Exam: every 6 months Lives with wife in [**Name (NI) 487**], MA Race: Hispanic Tobacco: never ETOH: social Family History: No premature coronary disease. Brother died of hemorrhagic stroke at age 56. Physical Exam: : 65 Resp: 18 O2 sat: 100% RA B/P Right: 194/88 Left: General:WDWN 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 - none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema- none Varicosities: None [x] Neuro: Grossly intact 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: none Left: none Pertinent Results: [**2114-10-22**] 07:39AM HGB-11.6* calcHCT-35 [**2114-10-22**] 07:39AM GLUCOSE-222* LACTATE-0.9 NA+-138 K+-4.7 CL--107 [**2114-10-22**] 12:09PM WBC-8.1 RBC-2.66*# HGB-7.3*# HCT-22.1*# MCV-83 MCH-27.5 MCHC-33.2 RDW-15.3 [**2114-10-22**] 01:32PM UREA N-38* CREAT-1.6* CHLORIDE-119* TOTAL CO2-21* [**2114-10-22**] 10:12PM BLOOD ALT-21 AST-45* AlkPhos-41 Amylase-53 TotBili-0.3 [**Hospital 93**] MEDICAL CONDITION: 61 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate PTX left - please do xray in afternoon [**10-25**] Preliminary Report !! PFI !! 1. Left apical pneumothorax, smaller since yesterday's examination. 2. Right IJ central venous catheter, unchanged. 3. Left basilar subsegmental atelectasis with small pleural effusion, as before. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] PFI entered: [**Doctor First Name **] [**2114-10-25**] 5:44 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Intraoperative TEE for CABG Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.4 cm <= 5.2 cm Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. 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: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. AORTA: Focal calcifications in aortic root. Normal ascending aorta 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. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. 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. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Suboptimal image quality. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE BYPASS 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. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal with normal free wall contractility. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal biventricular systolic function. Thoracic aorta intact. No significant change from the pre-bypass 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 [**Last Name (NamePattern4) **] [**2114-10-22**] 14:36 Brief Hospital Course: Mr [**Known lastname 1071**] was a same day admission to the operating room on [**10-22**] at which time he had coronary artery bypass grafting. Please see OR report for details. In summary he had CABG x5 with Left internal mammary artery to the left anterior descending coronary; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the third obtuse marginal coronary artery; as well as reversed saphenous vein graft from the aorta to the posterior descending coronary artery. Endoscopic left greater saphenous vein harvesting. His bypass time was 115 minutes with a crossclamp of 96 minutes. He tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition. He did well in the immediate post-op course, woke neurologically intact and was extubated on the operative day. He remained hemodynamically stable and was transferred from the ICU to the stepdown floor on POD1. All tubes, lines and drains were removed according to cardiac surgery protocols. He was noted to have a transient rise in his serum creatinine from his baseline 2.0 to 2.6 which resolved over the next 36 hours. The remainder of his post-op course was relatively uneventful. Over the next several days his activity level was advanced with the assistance of nursing and physical therapy. His medications were titrated to effect and on POD 5 he was discharged home with visiting nurses. Medications on Admission: Simvastatin 40 qd Benicar 40 qd Aspirin 325 qd Atenolol 25 qd Allopurinol 100 qd Doxazosin 4 qd Lantus Insulin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 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:*0* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous once a day: as per pcp. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 12. Potassium Chloride 25 mEq Packet Sig: One (1) PO every other day for 3 days. Disp:*3 Potassium Chloride (Oral) 25 mEq Packet* Refills:*0* 13. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Coronary artery disease s/p cabg Post operative atrial fibrillation Hyperkalemia Hypertension Chronic renal insufficiency (2.0-2.2) Gout Diabetes mellitus type 2 Dyslipidemia Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming Monitor wounds for infection and report any redness, warmth, swelling, tenderness or drainage Please take temperature each evening and Report any fever 100.5 or greater 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 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) 914**] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr [**Last Name (STitle) 29065**] in [**12-29**] weeks Cardiologist: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] in [**1-30**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2114-10-27**]

Admission Date: [**2104-8-9**] Discharge Date: [**2104-8-20**] Date of Birth: [**2035-1-17**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Sulfonamides Attending:[**First Name3 (LF) 3016**] Chief Complaint: right upper extremity weakness, dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 69 yo F with DM, COPD, metastatic breast CA s/p cycle 1 of adriamycin/cytoxan [**5-29**] awaiting 2nd cycle who was recently seen in [**Hospital **] clinic and noted to have persistent RUE weakness. MRI C spine showed mets to C5-C7 causing moderate compression of cord. She was admitted on [**8-9**] for spine eval and treatment. She was started on steroids. Pt triggered on [**8-10**] afternoon for hypotension, low UOP, and hypoxia. Pt refused interventions. Started on broad abx and reportedly stabilized. . Tonight she was noted to be hypoxic to 85% on 6L. She was "difficult to arouse." O2 sats improved with NRB. VBG showed 7.44/47/47 w lactate 1.0. Review of prior admit suggested that she became altered almost nightly until rx with BiPAP which successfully treated her sx. This was tried on the floor but patient became hypoxic and did not tolerate mask. She is admitted to ICU for w/u and rx with BiPAP. . Currently, she reports that she wants to be left alone. She denies any CP, SOB, abd pain. . Of note, she was hypoxic during her previous admission in [**Month (only) 116**]/[**Month (only) **]. At that point, the etiology was unclear. It was thought [**2-23**] lymphangitic spread of tumor. Also considered PE (although CTA neg) and tamponade (although echo not c/w hd sig tamponade). Also considered fluid overload and she seemed to improve somewhat with diuresis. It was ultimately thought that sleep apnea was large contributor. She was treated w BiPap nightly with significant improvement in mental status. Past Medical History: 1. Diabetes. followed at [**Last Name (un) **] Diabetes Center. Her last hemoglobin A1c was 6.0 in 05/[**2104**]. 2. Hypercholesterolemia/?hypertension 3. Schizoaffective disorder. The patient is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] and is on Clozaril with q 1 month CBCs 4. COPD/Asthma. The patient is maintained on Advair and albuterol for this. She does state that she uses her albuterol approximately one time per day. Her last pulmonary function tests were in [**2096**]. 5. h/o Falls 6. Back pain 7. ? Severe sleep apnea: as documented above and per recent d/c summary. Improved with BiPAP in the unit last month. . Breast Ca history: - dx [**2104-6-9**] w dyspnea, hypoxia, falls w right breast mass - [**6-17**]: cytoxan, adriamycin, neupogen, emend, steroids Social History: Has been residing at [**Hospital 100**] Rehab since her last hospitalization. Health Care proxy is [**Name (NI) **] [**Name (NI) **]. She does not smoke but notes that her mother smoked heavily.(HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 105120**]). Family History: The patient's grandmother had coronary artery disease. Her parent's died of cervical cancer and stroke. Physical Exam: VS: 96.8 HR 97 94/43 20 100% NRB and 94% on 60% FiO2 Manual BP 126/60 w pulsus of [**6-29**] Gen: sleepy but arousable. Neuro: AAO to person, place, situation, time. Does fall asleep mid-sentence. localizes to voice, withdraws/localizes to pain. - cn: PERRLA, EOMI although limited by lack of cooperativity. face symmetric. - motor: 3/5 strength RUEx, [**5-26**] LUEx. lower ex limited by effort although at least [**3-26**] bilat. - toes equiv bilat. 1+ ankle and knee bilat Heent; Dry MM, JVP flat Cards: RRR no MGR Lungs: no rales, CTAB Abd: obese, mildly tender diffusely. No rebound or guarding Ext: edema throughout Pertinent Results: EKG [**8-10**]: NSR NA NI, TW flattening V5-V6. no apprec right heart strain other than small Q in III. . 140 102 12 ---------------< 178 3.8 31 0.5 . WBC: 11 - stable HCT: 27 - stable PLT: 526 - stable PT: 16.0 PTT: 34.3 INR: 1.4 . VBG: 7.44/47/47 lactate 1 . ABG on arrival to unit: [**Unit Number **].39/53/114/33 . CXR: my read: linear atelectasis right mid lung but no evidence of PNA. Stable widening of mediastinum. . MRI Brain prelim: Multiple intracranial metastases, many of which are leptomeningeal. Right frontal epidural metastasis. Multiple bone metastases. . [**8-9**] MRI C-spine w/o contrast: (PRELIM): Metastatic disease involving C5-C7 vertebral bodies with vertebral collapse and retropulsion and epidural component causing moderate compression on the cord. . TTE [**8-11**]: Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Small, hyperdynamic left ventricle with normal regional systolic function. Trivial pericardial effusion without tamponade. Compared with the prior study (images reviewed) of [**2104-6-17**], the pericardial effusion is smaller. The other findings are similar. [**2104-8-9**] 12:50PM GLUCOSE-234* UREA N-11 CREAT-0.6 SODIUM-140 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-31 ANION GAP-11 [**2104-8-9**] 12:50PM estGFR-Using this [**2104-8-9**] 12:50PM ALT(SGPT)-14 AST(SGOT)-26 LD(LDH)-285* ALK PHOS-186* TOT BILI-0.3 [**2104-8-9**] 12:50PM WBC-9.3 RBC-3.44* HGB-8.9* HCT-28.9* MCV-84 MCH-25.8* MCHC-30.7* RDW-22.7* [**2104-8-9**] 12:50PM NEUTS-82.6* LYMPHS-6.9* MONOS-6.0 EOS-4.1* BASOS-0.4 [**2104-8-9**] 12:50PM PLT COUNT-623* [**2104-8-9**] 12:50PM PT-15.4* PTT-32.1 INR(PT)-1.4* Brief Hospital Course: # Metastatic breast cancer: with C5-7 cord compression, right upper extremity weakness improving on steroids. Also found to have brain metastases and the patient has been treated with Decadron. After extensive discussion with Ms. [**Known lastname 5655**], her HCP and her outpatient psychiatrist, further chemotherapy or radiation was refused. She was determined to have capacity to make this decision and understands the risk of paralysis without treatment. She will be discharged to maximize functional status and control symptoms. . # Resp failure/hypoxia: intermittent and likely related to obstructive sleep apnea. Ms [**Known lastname 5655**] refused all interventions, including BiPAP/CPAP and occassionally oxygen. She was treated with an 8 day course of antibiotics for health care associated pneumonia with improvement in her pulmonary status. She was maintained on nebulizer treatments and was on 4L O2 nasal canula at discharge. # Altered ms: underlying psychiatric illness with intermittent hypoxia related to obstructive sleep apnea and brain metastases. She waxed and waned through the hospitalization, but was at our observed baseline at discharge. Her outpatient dose of clozapine was continued initially however the patient had periods of agitation during her admission and the clozapine was held. Her agitation was treated with ativan and zydis as needed. The clozapine was not restarted on discharge. # Hypotension: The patients home dose of lisinopril was held second to her hypotension on admission. Her blood pressure remained in the 130/60-70s so the lisinopril was not restarted. She may need to be monitored for hypertension and be re-evaluated by her primary physician when lisinopril can be restarted safely. # ID: For her cough with productive sputum, the patient completed a course of vancomycin and zosyn. Her cough improved and she remained afebrile for the duration of her admission. At discharge she was complaining of dysuria and frequency, but was unable to provide a urine sample. She will be empirically treated with a 7 day course of ciprofloxacin (history of pan-sensitive e.coli in the past) # DM: Outpatient doses of NPH were continued including a sliding scale insulin as needed. #Seizure: the day prior to discharge, she had new onset complex partial seizure manifested as left lateral eye gaze with blinking and incontinence. The seizure activity was stopped with 2mg IV ativan. She was started on Keppra 500 mg [**Hospital1 **] without any recurrence of seizure activity. Medications on Admission: Albuterol IH q 4-6 hours prn aspirin 81 mg daily Clozapine 125mg qAM, 100mg qPM SC heparin advair 250-50 [**Hospital1 **] ibuprofen 600 mg tid lisinopril 10 mg daily ondansetron 4mg q8 prn oxycodone 5 mg q4 hours prn pioglitazone 45 mg daily spiriva 1 puff daily acetaminophen prn bisacodyl prn docusate sodium [**Hospital1 **] NPH 75 units q AM, 34 units in PM omeprazole 20 mg daily vitamin D 800mg daily vancomycin 1g IV q 12 metronidazole 500 PO TID Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**1-23**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 2. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**1-23**] Adhesive Patch, Medicateds Topical DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**1-23**] Inhalation Q4H (every 4 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 13. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**4-27**] hours as needed for pain. 14. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day. 15. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Seventy Five (75) Units Subcutaneous qAM. 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Five (35) Units Subcutaneous qPM. 18. Cipro 250 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Metastatic breast cancer-brain, bone C5-C7 spinal cord compression [**Hospital 77965**] Healthcare associated pneumonia Diabetes mellitus Hypertension Schizoaffective disorder with paranoia Discharge Condition: Stable, refusing further intervention for metastatic breast cancer and spinal cord compression. Goals of care are symptom control and maximization of function. Discharge Instructions: You were admitted with arm weakness and were found to have breast cancer spread to your bones and brain. You were treated with steroids, but declined further chemotherapy or radiation therapy. You will be discharged to a rehabilitation facility to help maximize your function and control your symptoms. You understand the potential for paralysis with untreated spinal cord compression. . Please call your doctor or return to the ED if you develop chest pain, shortness of breath, inability to tolerate your medications or any other concerning symptom. Followup Instructions: Please follow up with your doctors at the [**Hospital3 **] facility. [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]

Admission Date: [**2173-6-14**] Discharge Date: [**2173-6-17**] Date of Birth: [**2126-10-2**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 443**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 46-yo-man w/ active cocaine use presents w/ LE edema. 10 days ago, he developed b/l LE edema that has gotten progressively worse until now. Three days ago, he developed dyspnea on exertion when climbing stairs, assoc w/ 2-pillow orthopnea and PND. He denies any recent chest pain, palpitations, headache, confusion, weakness, numbness, abd pain, or hematuria. No recent viral syndromes or URIs. He does admit to cocaine use last night. Today, his wife convinced him to present to the ED for evaluation. . In the ED, his BP was 230/170. BNP was elevated at 7500. CXR revealed evidence of cardiomegaly and pulm edema. He was treated w/ ASA 325 mg, lasix 10 mg IV, and hydralazine 10 mg IV x 2. He responded well to lasix w/ good UOP, but diastolic BP remained elevated at 170, prompting initiation of nitroprusside gtt. He is now admitted to the CCU for further care. Past Medical History: none Social History: significant for current tobacco use. Drinks 3-4 beers a few times weekly, no h/o withdrawal symptoms, seizures or DTs. Snorts cocaine 1-2 times monthly. Never injected drugs. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T , BP 181/122, HR 84, RR 12, O2 98% 2L/m Gen: lying flat in bed, pleasant and conversational, NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear w/ MMM. Neck: Supple with JVP of 8 cm. CV: reg s1, loud s2, + 2/6 systolic murmur radiating to axilla, no s3/s4/r Pulm: CTA b/l w/ no crackles or wheezing Abd: obese, +BS, soft, NTND. Ext: warm, 2+ DP b/l, 2+ pitting edema to knees b/l Neuro: a/o x 3, CN 2-12 intact Pertinent Results: [**2173-6-14**] 05:30PM WBC-7.7 RBC-5.00 HGB-15.0 HCT-42.8 MCV-86 MCH-30.0 MCHC-35.0 RDW-14.6 [**2173-6-14**] 05:30PM PLT COUNT-315 [**2173-6-14**] 05:30PM CK-MB-4 proBNP-7489* [**2173-6-14**] 05:30PM cTropnT-0.02* [**2173-6-14**] 05:30PM ALT(SGPT)-77* AST(SGOT)-60* CK(CPK)-195* ALK PHOS-104 AMYLASE-100 TOT BILI-0.4 . EKG demonstrated NSR at 87 bpm, nl axis, nl int, LVH w/ strain pattern, no ischemic changes. . CXR: Moderate to severe enlargement of the cardiac silhouette, and particularly the left atrium accompanied by pulmonary vascular congestion and mild pulmonary edema consistent with heart failure. . Conclusions: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy with mild cavity dilation and severe global hypokinesis. No left ventricular thrombus is seen. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with severe free wall hypokinesis. The aortic valve leaflets (3) are minimally thickened. No aortic stenosis or aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Moderate symmetric eft ventricular hypertrophy with severe global biventricular hypokinesis c/w diffuse process (toxin, metabolic, cannot exclude myocarditis; in the absence of LVH on ECG, an infiltrative process should also be considered). Mild mitral regurgitation. Moderate pulmonary arterial hypertension. Very small circumferential pericardial effusion. Possible abnormality on the aortic valve as described above without aortic regurgitation. . If clinically indicated a TEE would be better able to define an abnormality of the aortic valve. . . Brief Hospital Course: 46-yo-man w/ cocaine abuse presents w/ LE edema and DOE likely from diastolic heart failure in the setting of cocaine use complicated by hypertensive urgency. . Hypertensive urgency: BP 230/170 on presentation, most likely from chronic HTN exacerbated by cocaine use. No signs of end-organ damage at present except for elevated creatinine, which is more likely a chronic problem. The patient was started on labetalol and Lisinopril. His blood pressure was taken down from 230 systolic to approx 160 systolic/100 diastolic on discharge. His lower extremity edema improved with diuresis. An echo performed on admission showed an LF EF of 25%. It is hoped with good blood pressure control and use of an ACE-I with follow up in addition to cocaine abstaining will improved his cardiac function. . Renal Failure: creatinine on admission was 1.6 Likely acute hypertensive nephropathy plus probalbe long-standing hypertensive disease. discharged on ACE-I. . Substance Use: Social work saw patient and counceled him regarding substance abuse. . Discharged with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], cardiology follow up as well as scheduled appointment with a new PCP @ [**Street Address(1) 11615**] Health Center. Medications on Admission: none Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: - hypertensive emergency - ARF - mild transaminitis likely [**2-19**] etoh and cocaine abuse - cocaine abuse - lower extremity edema improved Discharge Condition: well Discharge Instructions: You came in with hypertensive emergency. You were treated with medications to improve your blood pressure. Notably you were discharged on: 1. Lisinopril 20mg daily 2. HCTZ 25mg daily 3. Labetalol 400mg [**Hospital1 **] 4. ASA 162mg daily . It is extremely important for you to take these medications. It is very important that you followup with your cardiology. . Please return to the ED if you experience SOB, chest pain, fevers, chills, dizziness, decreased urine output. It is also very important that you abstain from cocaine use. Followup Instructions: Please see Dr. [**Last Name (STitle) 171**] on Monday [**2173-6-21**] at 10:00 in [**Hospital Ward Name 23**] 7th. It is extremely important for you to keep this appointment. . You have a Primary Care Physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11616**] on [**6-25**] @ 1:45 pm. Please arrive 1 hour prior to the appointment to complete the Free Care Application there. You need to bring a picture ID, proof of citizenship, proof of address. The Clinci phone number is [**Telephone/Fax (1) 7976**] . Please followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] on [**7-12**] at 10:30am. His number is ([**Telephone/Fax (1) 11617**]. His secretary can help you clarify your insurance.

Admission Date: [**2103-6-27**] Discharge Date: [**2103-7-5**] Date of Birth: [**2077-7-23**] Sex: F Service: MEDICINE Allergies: Aspirin / Latex Attending:[**First Name3 (LF) 1377**] Chief Complaint: Acetaminophen overdose Major Surgical or Invasive Procedure: Intubation R IJ placement History of Present Illness: 25yo F with recent Tylenol overdose/suicidal attempt (d/ced on [**6-11**]) presents to [**Hospital1 18**] after taking 100 tabs of acetaminophen last night at 9 PM. [**Name (NI) 1094**] boyfriend recently committed suicide (cocaine overdose), and it was the precipitating cause of her recent SI. At her last admission, her INR had peaked to 8.9 with ALT 8230 and AST 7684. She was on Liver Transplant service for possible liver transplant, but she was delisted as she improved clinically. After d/c from the hospital, pt stayed at psych facility and followed up with Liver. On [**6-20**], INR 1.2, AST 48, ALT 105, TB 1.2 at the liver clinic. Yesterday, pt went to her boyfriend's grave and missed him so much to the point that she decided to end her life with Tylenol overdose. She wrote a suicide/goodbye note (in chart) and wrote on her left arm "let me die" with a pen. She states that she was vomiting white materials last night. She states her mother called her today around 2pm and she sounded "out of it"; when her mother asked about this, she admitted to the overdose and her mother called 911 and she was brought here. . Currently, denies any n/v, abdominal pain. She just states she doesn't want to live. Past Medical History: Depression with suicide attempt Tylenol overdose Social History: lives alone in [**Location 1268**] (lived with her boyfriend). Boyfriend died recently. No alcohol/drug use. Social worker at [**Name2 (NI) **] for Little Wanderers and clinician for BEST but has not yet returned to work. Family History: Noncontributory Physical Exam: PE: T 96.5, 144/46, 96, 20, 98% on RA GEN: obese, depressed, rare eye contact, tearful when talking about boyfriend. [**Name (NI) 4459**]: slight scleral icterus, EOMI, pupils dilated, PERRL. NECK: No JVD, no neck LAD CV: RRR, without any m/r/g. PULM: CTA bilaterally, no wheezes, rhonchi, crackles ABD: soft, NT, ND, +BS EXT: No edema, 2+ DP NEURO: AOx3, no asterixis, no focal deficits. Moving all extremities. SKIN: No ecchymoses, petichiae Pertinent Results: 138 104 7 / 262 AGap=15 ------------ 3.0 22 0.8 \ Ca: 8.0 Mg: 2.0 P: 1.9 D ALT: 1472 AP: 59 Tbili: 2.4 Alb: AST: 3012 Serum Acetmnphn 43.0 92 5.8 \ 13.3 / 213 ------ 40.1 PT: 26.5 PTT: 37.5 INR: 2.7 . RUQ ultrasound: 1. Normal liver echotexture without ascites. 2. Normal portal vein Doppler. 3. Cholelithiasis. . Head CT: FINDINGS: There is no evidence of intracranial hemorrhage, shift of midline structures, mass effect, hydrocephalus, or acute major vascular territorial infarct. The attenuation values of the [**Doctor Last Name 352**] and white matter appear normal. Osseous structures and soft tissues appear unremarkable. There is mild mucosal thickening bilaterally involving the maxillary sinuses (left greater than right). IMPRESSION: Unremarkable head CT. Brief Hospital Course: A/P: 25yo F with previous SI/Tylenol OD now presents with a repeat Tylenol overdose. . # Hepatic failure/Tylenol overdose. The patient presented 16 hours after ingestion and therefore did not receive activated charcoal. She received Mucomyst load and then maintenance dosing. The patient was initially communicative without any signs of encephalopathy. LFTs/coags/CBC/chem 10 were monitored q6h initially which showed trending up LFTs and coags but no chemistry abnormalities. 12 hours after admission, however, on the morning of [**6-28**], pt rapidly developed mental status change accompanied by n/v then later seizure. Pt was given 2mg iv Ativan which resolved seizure and was urgently intubated for airway protection and a central line was placed. Stat neuro consult and head CT was obtained with was negative for cerebral edema or bleed. For presumed cerebral edema, hypertonic saline was administered to keep Na 145-155 and Keppra was started for seizure. Pt did not further seizures afterward. Her AST and ALT peaked at [**2038**] and 3413, respectively on [**6-28**]. Her INR peaked at 3.3 on [**6-29**]. Then all LFTs and coags trended down. Her Mucomyst IV gtt was stopped on [**7-3**] and she was transferred to the floor for further management. Her Keppra was subsequently discontinued per neurology recommendations. She did not have any further seizure activity on the floor, and daily neurological exams were normal. Patietn did have episodes of visual hallucinations and disorientation on arrival to the floor, which were thought to be c/w delirium. Her mental status cleared by time of transfer. . # Respiratory: Pt was urgently intubated for airway protection after episode of seizure on [**2103-6-28**]. Subsequent CXRs were unremarkable for aspiration PNA. Pt was extubated on [**2103-7-1**], and steadily improved. She was breathing room air at time of transfer to [**Hospital1 **] 4. . # Depression/SI: Psych was consulted in ED, and continued to follow patient during her admission. Held all lexapro/ativan/ambien given liver failure. Pt had 1:1 sitter during her stay. She continued to be depressed. She was transferred to [**Hospital1 **] 4 for further inpatient psychiatric care. . # FEN: Clears initially but didn't really tolerated. After intubation, tube feeding was started per nutrition recs. Patient was then extubated, and her tube feed was removed. She was able to tolerate a regular diet, but continued to have a poor appetite, thought to be from her continued depression. There were no witnessed problems with swallowing. . # PPX: Patient had pneumoboots. . # ACCESS: Patient's peripheral IV and central line were removed prior to transfer. . # COMM: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Name (NI) 957**] (mother-health care proxy) [**Telephone/Fax (1) 73166**] (c) [**Telephone/Fax (1) 73167**] (h) 2nd person [**Name (NI) **] [**Name (NI) 73168**] (friend but 2nd HCP according to mother [**Doctor First Name **] [**Telephone/Fax (1) 73169**] Medications on Admission: 1. ativan 1mg qhs prn 2. lexapro 10mg qd 3. ambien 10mg qhs 4. [**Doctor First Name **]/prn Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for neck pain. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: Tylenol overdose/intoxication . Depression with suicidality Discharge Condition: Stable Discharge Instructions: You were admitted due to intentional tylenol overdose. All measures of injury from this (including to your liver) are improving. Please have your blood drawn in 1 week to monitor for continued improvement in your liver injury. . You must receive psychiatric care at the [**Hospital3 **] Deaconness inpatient psychiatric [**Hospital1 **]. Upon discharge you should follow-up with your primary care physician as well as your liver doctor for further care. . Take all medications as prescribed. You may take lorazepam as needed for anxiety and/or nausea. You may take oxycodone as needed for neck pain. Please take pantoprazole daily. Followup Instructions: You must receive psychiatric care at the [**Hospital3 **] Deaconness inpatient psychiatric [**Hospital1 **]. Upon discharge you should follow-up with your primary care physician as well as your liver doctor for further care. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

Admission Date: [**2180-10-30**] Discharge Date: [**2180-11-9**] Date of Birth: [**2101-3-29**] Sex: F Service: MEDICINE Allergies: Plavix Attending:[**First Name3 (LF) 443**] Chief Complaint: n/v, OSH transfer for emergent ERCP for cholangitis Major Surgical or Invasive Procedure: ERCP and sphincterotomy Repeat ERCP IR embolization History of Present Illness: 79 yo F CAD s/p PTC in 89, 99, 00, PCI with DES in [**2171**], and a negative adenosine exercise stress in [**3-3**] mild small inferior defect with medical management, developed 3 days of epigastric pain, N/V, went to [**Hospital1 **], choledocolithiasis, large CBD stone, WBC 20K, mildly elevtaed ALP, TBili LFTs WNL, thrombocytopenia and concern for possible DIC. Transferred here for emergent ERCP with schinterotomy which successfully removed large CBD stone. In GI suite pt received dilaudid 1mg, clonidine 0.2 mg, nitro 0.4 mg sl. One hour after the procedure, she was found to have [**10-2**] CP (although on floor she states it was abdominal pain and neck discomfort), N/V, and EKG with ST depressions in I, II, V3-V5. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for chest/epigastric pain and baseline dyspnea on exertion but she denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY (per pt and derived from OSH records): 1. CARDIAC RISK FACTORS: - Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: -RCA angioplasty in [**2157**] -RCA angioplasty in [**2158**] -Left Circumflex angioplasty in [**2167**] -LAD DES in [**2171**] @[**Hospital1 112**] - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - TAH/BSO at age 18 (unclear why) -Cholecystectomy at age 40 -Lumbar laminectomy -Tonsillectomy -chronic low back pain -GERD -Hiatal hernia -Diverticulosis -IBS -COPD on 2L home O2 -Anemia -Previous falls -CKD -Lyme disease in [**2165**] Social History: Divorced, lives alone, Retired local nursing home administrator, prior smoker, but quit 20 years ago. Denies excessive alcohol and other recreational drugs Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. -Father died of multiple myeloma at age 76. Mother died at 84 from pancreatic cancer. -Sister had two vessel CABG at age 56. -Brother with angioplasty at age 59. -Adult son and daughter with CAD or other medical issues Physical Exam: Admission Physical Exam: VS: 98 ??????F, 79, 178/73, 27, 93% GENERAL: Nauseated and uncomfortable. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 2 cm above sternal angle. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, mild [**Hospital1 **]-basilar crackles. ABDOMEN: Tenderness at RUQ, abdomen otherwise soft, No HSM EXTREMITIES: Trace BLE edema. No femoral bruits. 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+ . Discharge Physical Exam: Vitals - Tm/Tc:98.6/ HR:72-90 BP:116-159/63-80 RR:18 02 sat: 98- 100% 2L GENERAL: AOx3. Mood, affect appropriate. HEENT: Sclera anicteric. NECK: Supple with no JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. CTAB. ABDOMEN: Tenderness at RUQ, abdomen distended, No HSM, pos BS. NO BM for 3 days. EXTREMITIES: Trace BLE edema in foot. Mod TTP of LE and feet bilat. No open areas or obvious source of pain. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 1+/1+ DP/PT bilat Pertinent Results: Admission labs: [**2180-10-30**] 10:05PM BLOOD WBC-19.6* RBC-3.71* Hgb-10.4* Hct-30.8* MCV-83 MCH-27.9 MCHC-33.6 RDW-14.8 Plt Ct-309 [**2180-10-31**] 04:17AM BLOOD WBC-14.0* RBC-3.86* Hgb-10.5* Hct-31.6* MCV-82 MCH-27.3 MCHC-33.3 RDW-14.8 Plt Ct-327 [**2180-10-30**] 10:05PM BLOOD PT-23.3* PTT-23.5 INR(PT)-2.2* [**2180-10-31**] 04:17AM BLOOD PT-23.9* PTT-23.9 INR(PT)-2.2* [**2180-10-30**] 10:05PM BLOOD Glucose-123* UreaN-24* Creat-1.1 Na-139 K-3.0* Cl-101 HCO3-19* AnGap-22* [**2180-10-31**] 04:17AM BLOOD Glucose-154* UreaN-21* Creat-1.1 Na-137 K-3.5 Cl-99 HCO3-24 AnGap-18 [**2180-10-31**] 02:45PM BLOOD Glucose-128* UreaN-25* Creat-1.1 Na-138 K-3.8 Cl-104 HCO3-24 AnGap-14 [**2180-10-30**] 10:05PM BLOOD ALT-60* AST-182* LD(LDH)-330* CK(CPK)-69 AlkPhos-174* TotBili-1.3 [**2180-10-31**] 04:17AM BLOOD CK(CPK)-58 [**2180-10-31**] 02:45PM BLOOD CK(CPK)-35 [**2180-10-30**] 10:05PM BLOOD CK-MB-5 cTropnT-0.02* [**2180-10-31**] 04:17AM BLOOD CK-MB-4 cTropnT-0.02* [**2180-10-30**] 10:05PM BLOOD Albumin-3.8 Calcium-7.9* Phos-3.0 Mg-1.1* [**2180-10-31**] 04:17AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8 [**2180-10-31**] 02:45PM BLOOD Calcium-7.6* Phos-2.2* Mg-1.5* . Discharge labs: [**2180-11-6**] 04:24AM BLOOD WBC-9.1 RBC-3.26* Hgb-9.8* Hct-27.5* MCV-84 MCH-29.9 MCHC-35.4* RDW-13.5 Plt Ct-243 [**2180-11-6**] 02:00PM BLOOD WBC-9.0 RBC-3.37* Hgb-10.0* Hct-28.6* MCV-85 MCH-29.5 MCHC-34.9 RDW-13.6 Plt Ct-249 [**2180-11-7**] 06:35AM BLOOD WBC-9.1 RBC-3.36* Hgb-9.9* Hct-29.1* MCV-87 MCH-29.5 MCHC-34.0 RDW-13.6 Plt Ct-280 [**2180-11-2**] 04:14AM BLOOD PT-14.5* INR(PT)-1.3* [**2180-11-3**] 04:05AM BLOOD PT-17.1* INR(PT)-1.5* [**2180-11-5**] 04:07AM BLOOD Glucose-73 UreaN-29* Creat-1.1 Na-138 K-4.4 Cl-102 HCO3-24 AnGap-16 [**2180-11-6**] 04:24AM BLOOD Glucose-96 UreaN-25* Creat-1.1 Na-138 K-3.9 Cl-104 HCO3-26 AnGap-12 [**2180-11-7**] 06:35AM BLOOD Glucose-105* UreaN-23* Creat-1.1 Na-141 K-4.6 Cl-107 HCO3-30 AnGap-9 [**2180-11-2**] 04:14AM BLOOD ALT-37 AST-72* LD(LDH)-334* CK(CPK)-606* AlkPhos-94 TotBili-0.4 [**2180-11-5**] 04:07AM BLOOD Calcium-8.1* Phos-5.1* Mg-2.1 [**2180-11-6**] 04:24AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.8 [**2180-11-7**] 06:35AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.7 . lipase trend: . [**2180-10-30**] 10:05PM BLOOD Lipase-4700* [**2180-10-31**] 04:17AM BLOOD Lipase-2430* [**2180-11-1**] 04:24AM BLOOD Lipase-683* [**2180-11-2**] 04:14AM BLOOD Lipase-147* . CE trend: [**2180-10-30**] 10:05PM BLOOD CK-MB-5 cTropnT-0.02* [**2180-10-31**] 04:17AM BLOOD CK-MB-4 cTropnT-0.02* [**2180-10-31**] 02:45PM BLOOD CK-MB-3 cTropnT-0.01 [**2180-11-1**] 04:24AM BLOOD CK-MB-4 cTropnT-0.02* [**2180-11-1**] 01:35PM BLOOD CK-MB-6 cTropnT-0.05* [**2180-11-2**] 05:30PM BLOOD CK-MB-72* MB Indx-14.1* cTropnT-2.87* . Crit trend: [**2180-11-3**] 02:00PM BLOOD WBC-16.5* RBC-3.89* Hgb-11.4* Hct-32.4* MCV-83 MCH-29.4 MCHC-35.3* RDW-14.1 Plt Ct-130* [**2180-11-3**] 08:57PM BLOOD WBC-16.0* RBC-3.11* Hgb-9.2* Hct-26.0* MCV-84 MCH-29.4 MCHC-35.2* RDW-14.2 Plt Ct-224# [**2180-11-4**] 02:02AM BLOOD WBC-13.8* RBC-3.29* Hgb-10.0* Hct-27.9* MCV-85 MCH-30.4 MCHC-36.0* RDW-13.9 Plt Ct-185 [**2180-11-4**] 10:26AM BLOOD WBC-13.8* RBC-3.93* Hgb-12.1 Hct-33.3* MCV-85 MCH-30.7 MCHC-36.3* RDW-13.8 Plt Ct-183 [**2180-11-4**] 03:22PM BLOOD Hct-32.6* [**2180-11-4**] 10:01PM BLOOD Hct-31.4* [**2180-11-5**] 04:07AM BLOOD WBC-10.8 RBC-3.96* Hgb-11.7* Hct-33.6* MCV-85 MCH-29.5 MCHC-34.7 RDW-13.8 Plt Ct-208 [**2180-11-5**] 10:45AM BLOOD Hct-29.1* [**2180-11-5**] 03:16PM BLOOD Hct-27.4* [**2180-11-5**] 08:00PM BLOOD Hct-27.8* [**2180-11-6**] 04:24AM BLOOD WBC-9.1 RBC-3.26* Hgb-9.8* Hct-27.5* MCV-84 MCH-29.9 MCHC-35.4* RDW-13.5 Plt Ct-243 [**2180-11-6**] 02:00PM BLOOD WBC-9.0 RBC-3.37* Hgb-10.0* Hct-28.6* MCV-85 MCH-29.5 MCHC-34.9 RDW-13.6 Plt Ct-249 [**2180-11-7**] 06:35AM BLOOD WBC-9.1 RBC-3.36* Hgb-9.9* Hct-29.1* MCV-87 MCH-29.5 MCHC-34.0 RDW-13.6 Plt Ct-280 . MICRO/PATH: . CDiff Antigen [**11-2**]: Negative . IMAGING/STUDIES: . Abdominal XR [**10-30**]: IMPRESSION: 1. No evidence of obstruction, ileus, or free air. 2. Pneumobilia, consistent with a recent ERCP. . CT Abd/Pelvis [**11-1**]: IMPRESSION: 1. Minimal stranding about the pancreatic head could reflect pancreatitis. 2. Small bilateral pleural effusions. . CXR Portable [**11-4**]: Heart size is upper limits of normal. Prominent pericardial fat is seen on the CT scan. There is blunting of the left CP angles, consistent with known pleural effusion as seen on the prior CT scan. There is likely atelectasis at the lung bases. There are no signs for overt pulmonary edema or focal consolidation. . Interventional Radiology Procedure [**11-4**]: IMPRESSION: Successful prophylactic coil embolization of the GDA, as described above. . Brief Hospital Course: 79F with hx of severe CAD s/p DES in LAD in [**2171**], COPD on 2LNC at home transferred from OSH for emergent ERCP for choledocolithiasis who developed chest pain post-procedure with ST depressions on EKG. Course further complicated by post ERCP pancreatitis, GI bleeding now s/p IR embolization, as well as NSTEMI, with trop of 2.87. . ACTIVE DIAGNOSES: . # CAD/NSTEMI: Pt with report of severe chest pain with worsened ST depression in lateral leads post ERCP. First set of enzymes an hour after development of chest pain negative and on transfer to the CCU, she was chest pain free. The patient was initially continued on her ASA, statin, beta blocker, and lisinopril. The patient was on ticlodopine as a home medication because of an allergy to plavix. However, during the hospitalization, the patient refused her ticlodopine secondary to it making her nauseous. The patient complained on intermittent chest pain during the admission; EKGs during periods of pain were unchanged from priors, and CE were initially negative. However, during one episode the patient was found to have an elevated troponin, 0.80 first, then up to 2.87, with CK-MB 94 and 72, respectively. EKGs remained unchanged from priors. Because of this troponin bump in the setting of the patient refusing her ticlodopine, the patient was started on Prasugrel daily. However, the prasugrel, as well as other antiplatelets, were soon held, as the patient developed a GI bleed. Once the bleed resolved (see below), the patient was restarted on aspirin only. Upon discharge, she was on a beta blocker and ACE, as well. . # HTN Urgency: Pt with asymptomatic HTN as high as the 190's in the unit with widened pulse pressure, likely exacerbated in the setting of N/V and pain. While on the floor the patient had intermittent episodes of elevated blood pressures (180s-190s), usually in conjunction with abdominal pain. Given the concern for ischemia, the patient's pressures were aggressively controlled and she was initially on a Nitro drip. The patient's home clonidine was titrated off her medication list, and Nifedipine was also stopped. The patient was stabilized on a regimen of Carvedilol 25 mg [**Hospital1 **], Captopril 50 mg TID, and Imdur 60 mg daily. During episodes of elevated blood pressures, a Nitro drip was also used to help maintain pressures. Upon discharge, the patient's blood pressures were well controlled on Carvedilol, Captopril, and Imdur. . # GIB s/p ERCP: The patient developed a GI bleed in the post ERCP period, with downtrending crits. She was transfused PRBC to maintain crit >30, given her CAD history, as well as development of troponin increase and evidence of end organ ischemia. The patient started having maroon colored liquid bowel movements. She was never hemodynamically unstable; ERCP was made aware and an emergent EGD was done. The patient was bleeding from her sphincterotomy site, epinephrine was injected, and hemostasis achieved. However, a second source of bleeding was seen, as well. Epi was injected and coagulation was also attempted, but the vessel kept oozing. A clip could not be placed because of technical difficulties with the side viewing ERCP scope. IR was made notified and the patient's crits and vitals were monitored closely. Because of a ~6 point crit drop, IR was contact[**Name (NI) **] and the patient underwent embolization. The procedure went well and a coil was placed in a vessel. S/p procedure, the patient's crits and vitals were stable. No further evidence of GIB seen. During this period, all antiplatelets were held; however, after her vitals and crit were stabilized, the patient was restarted on ASA 325 daily. Overall she required 8 units of blood. All other antiplatelet agents, including Prasugrel, were stopped. During this episode, the patient's beta blockers were also held and the patient's blood pressure was controlled with Captopril and Imdur. Once her UGIB resolved, her beta blockers were restarted. . # Choledocolithiasis: The patient was initially transferred to [**Hospital1 18**] for emergent ERCP for cholangitis. She had a white count of 20K, moderately elevated alk phosphate and transaminitis. The patient was found to have a CBD stone and a sphincterotomy was performed; was also found to have mild dilatation of the biliary tree. She was started on Zosyn, and later switched to Unasyn the morning after the procedure, and was later transitioned to PO Augmentin and completed a total 10 day course of antibiotics. . # Post-ERCP panceatitis: The patient developed epigastric pain post procedure, and found to have a lipase ~4000. She was kept NPO and given IV morphine for pain control. The patient was hydrated with 200cc NS/hour, with careful monitoring of her volume status on her exam, given her cardiac history. ERCP continued to follow the patient while in the CCU. Her lipase started trending down and the patient's pain control regimen was transitioned from IV to PO Dilaudid, in addition, to keeping her on her home pain regimen for chronic back pain. The patient's nausea was treated with zofran and phenergan, as needed. By discharge she was weaned to her home chronic pain regimen of PO oxycodone and fentanyl patch. . # Elevated INR/Mild thrombocytopenia: Pt with INR of 2.2 despite not being on anticoagulation. This was assessed as being related to nutritional deficiency. She was given PO vitamin K and her INR improved. . CHRONIC DIAGNOSES: . #COPD: Pt on 2LNC at home baseline without any home medications. She was given iptratropium nebs PRN and was maintained on her home oxygen. . # CKD: Baseline Cr of 1.1 which remained stable during this admission . TRANSITIONAL ISSUES: #We determined that this patient likely no longer needs a second anti-platelet [**Doctor Last Name 360**] in addition to her aspirin. Additionally, it seems that as an outpatient she was poorly compliant with ticlid. This information was communicated in advance to her outpatient cardiologist. Cardiology: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 28181**] [**Name8 (MD) 81956**] MD [**First Name8 (NamePattern2) **] [**Hospital1 **] MA (Medical Group) Phone: ([**Telephone/Fax (1) 72499**]. She was switched to atorvastatin 80mg while in house given her troponin leak and concern for ACS but given her current insurance situation she was discharged on her home simvastatin 80mg. This can be addressed in the outpatient setting. Medications on Admission: -Home O2 2LNC -Ticlid 250mg [**Hospital1 **] -Metoprolol tartrate 150mg [**Hospital1 **] -Nifedipine XL 90mg PO daily -Lisinopril 20mg PO daily -Clonidine 0.1mg QAM, 0.2mg QPM -Aspirin 325 mg PO daily -Simvastatin 80mg PO daily -Fenofibrate 67mg PO daily -Omeprazole 20mg [**Hospital1 **] -Vitamin B12 Daily -Folic acid Daily -Fentanyl 50mcg patch Q72hrs -Oxycodone 15mg Q4-6hrs PRN -Compazine 10mg PO PRN -Aranesp SubQ once monthly - Celexa 40 mg daily Discharge Medications: 1. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cyanocobalamin (vitamin B-12) 50 mcg Tablet Sig: One (1) Tablet PO once a day. 6. nystatin 100,000 unit Tablet Sig: One (1) Tablet Vaginal HS (at bedtime) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 7. fenofibrate Oral 8. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 10. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. oxycodone 15 mg Tablet Sig: One (1) Tablet PO every [**3-29**] hours as needed for pain. 12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Perdiem Overnight Relief 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 15. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Outpatient Lab Work Please check Chem-7 and CBC on Monday [**11-13**] and call results to Dr. [**Last Name (STitle) 21454**] at Phone: [**Telephone/Fax (1) 13553**] Fax: [**Telephone/Fax (1) 26813**] 17. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Gallstone pancreatitis Non ST Elevation myocardial infarction Hypertension Anemia Emphysema Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). *Consider pain clinic management for Mrs. [**Known lastname **] given her chronic pain and requiring high doses of Oxycodone and Fentanyl Discharge Instructions: You were admitted to the hospital with gallstone pancreatitis (stone in your bile duct causing pancreatitis). This was removed and the duct was widened. Your blood pressure was low and it was found that you had some bleeding from the procedure site, this was fixed and your blood count has been stable after 4 units of blood. You were on antibiotics after the procedure and nystatin cream to treat vaginitis. You needed additional pain medicine but you are now back on your home doses of oxycodone and fentenyl. You had a heart attack after the procedure but are recovering well and your echocardiogram did not show any decrease in your heart function. . We made the following changes to your medicines: 1. STOP taking Ticlid, nifedipine, metoprolol and clonidine 2. START taking Imdur to prevent further chest pain 3. START taking carvedilol instead of the metoprolol to slow your heart rate, this medicine lowers your blood pressure as well. 4. START taking nystatin tablets intravaginally to treat the vaginitis, you only need 5 more days of this medicine 5. INCREASE the aspirin to 325 mg daily because of your heart attack 6. INCREASE the Lisinopril to 40 mg daily. 7. RESTART the compazine as needed for nausea. Followup Instructions: Name: [**Last Name (LF) **], [**First Name3 (LF) **] NP for Dr. [**Last Name (STitle) 21454**] Location: FAMILY MEDICINE ASSOCIATES Address: [**Street Address(2) 84438**], [**Location (un) **],[**Numeric Identifier 84439**] Phone: [**Telephone/Fax (1) 13553**] Appointment: TUESDAY [**11-14**] AT 1:15PM Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2180-11-22**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], 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 Name: [**Location (un) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Location: THE MEDICAL GROUP Address: [**First Name8 (NamePattern2) 15488**] [**Hospital1 420**], [**Numeric Identifier 26668**] Phone: [**Telephone/Fax (1) 10508**] **We are working on a follow up appointment with Dr. [**Last Name (STitle) 81956**] within 1 month. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above.** Completed by:[**2180-11-11**]

Admission Date: [**2178-3-7**] Discharge Date: [**2178-3-10**] Date of Birth: [**2158-7-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: None History of Present Illness: 19 yo male s/p motor vehicle crash, non-restrained, ejected, passenger fatality. Presents with Grade III liver laceration; Grade II renal laceration ;and right iliac crest fracture. Past Medical History: Denies Family History: Noncontributory Pertinent Results: [**2178-3-7**] 10:44AM GLUCOSE-92 UREA N-10 CREAT-0.9 SODIUM-139 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13 [**2178-3-7**] 10:44AM ALT(SGPT)-368* AST(SGOT)-343* ALK PHOS-88 TOT BILI-0.5 [**2178-3-7**] 10:44AM CALCIUM-8.8 PHOSPHATE-4.2 MAGNESIUM-1.9 [**2178-3-7**] 10:44AM PT-14.5* PTT-26.8 INR(PT)-1.3* [**2178-3-7**] 07:14AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2178-3-7**] 07:14AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2178-3-7**] 07:14AM WBC-21.5* RBC-4.62 HGB-13.3* HCT-41.3 MCV-89 MCH-28.7 MCHC-32.1 RDW-12.9 [**2178-3-7**] 07:14AM PLT COUNT-354 [**2178-3-7**] 07:14AM PT-13.8* PTT-24.3 INR(PT)-1.2* [**2178-3-7**] CT Chest/Abd/Pelvis IMPRESSION: 1. There is a liver laceration (AAST Grade 3) and associated hemoperitoneum. 2. Small right kidney laceration (likely AAST Grade 2) with associated hemorrhage. 3. Minimally displaced and angulated fracture of the right iliac. 4. Increased pelvic fluid with a hematocrit level in the pelvis. CT C-spine [**2178-3-7**] IMPRESSION: No fracture or malalignment of the cervical spine. MRI shoulder [**2178-3-9**] IMPRESSION: 1. No fracture. 2. Grade 1 acromioclavicular joint injury (sprain). [**2178-3-7**] THREE VIEWS, LEFT WRIST AND HAND: There is no evidence of fracture, dislocation, or radiopaque foreign body. Bony mineralization is normal. The soft tissues are unremarkable without radiopaque foreign body. THREE VIEWS, LEFT ELBOW: There is no evidence of fracture or dislocation. Bony mineralization is normal. The soft tissues are unremarkable without radiopaque foreign body. IMPRESSION: No fracture or dislocation. Brief Hospital Course: He was admitted to the Trauma Service and transferred to the Trauma ICU for close monitoring given his multiple injuries. Serial hematocrits were followed and remained stable (discharge hematocrit was 32). Orthopedic Spine surgery was consulted for concern for cervical spine injury; he was cleared clinically and radiographically and the collar was removed. Orthopedics was consulted for the pelvic fracture and for concern for possible shoulder injury. Both injuries were managed non operatively; he was cleared for weight bearing as tolerated. A right shoulder MRI showed that there were no fractures, rather it revealed only a sprain. It was recommended that Lovenox be initiated once injuries from his injured spleen and kidney were stabilized. His pain was controlled with Vicodin prn and he was also started on a bowel regimen. Social work was also consulted for coping given that there was a passenger fatality at scene and also because of + BAL. He was evaluated by Physical therapy and was cleared for discharge to home with his family. Instructions for follow up were provided. Medications on Admission: None Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 3. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: s/p Motor vehicle crash Grade II kidney laceration Grade III liver laceration Right iliac crest fracture Discharge Condition: Hemodynamcially stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: DO NOT participate in any contact sports or other activity that may cause injury to your abdominal area for at least the next 4-6 weeks because of your liver laceration. Go to the nearest Emergency room if you suddenly become lightheaded, dizzy, feel as though you are going to pass out as these may be signs of internal bleeding from your liver injury. Return to the Emergecny room as mentioned about and also for any fevers, chills, shortnes of breath, chest pain, abdominal pain, blood in your urine, nausea, vomiting, diarrhea and/or any other symtpoms that are concerning to you. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma surgery for follow up of your liver laceration. call [**Telephone/Fax (1) 6429**] for an appointment. Follow up in 2 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics in 2 weeks. call [**Telephone/Fax (1) 1228**] for an appointment. Completed by:[**2178-3-20**]

Admission Date: [**2137-9-25**] Discharge Date: [**2137-10-9**] Date of Birth: [**2073-6-5**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 3326**] Chief Complaint: s/p cath for NSTEMI, Vfib arrest, GIB Major Surgical or Invasive Procedure: endotracheal intubation central line placement CVVH cardiac catheterization History of Present Illness: HPI: 64yo woman with DM, HTN, ESRD on [**Hospital 58910**] transferred to the CCU service from the MICU s/p cardiac catheterization. The patient was in her home the day prior to admission cooking when she felt like she was going to pass out and then lost consciousness. EMS came and found her to have a v-fib arrest. They defibrillated 7 times in the field and brought her to [**Hospital 63273**] Hospital [**Telephone/Fax (2) 63274**]). Here she was shocked three more times. She was found to be hyperkalemic with an EKG showing widened QRS and peaked T waves. At the OSH, she was treated with insulin, glucose, and bicarb for hyperkalemia (6.5) and was started on an amiodarone drip. . She was transferred to [**Hospital1 18**] hemodynamically stable and intubated. Here, she was found to have a K of 7, and was treated with bicarb, Ca, insulin and glucose. She was dialyzed yesterday night with improvement in her K to 4.4 and resolution of her EKG changes. She was started on levophed for hypotension and was noted to have an elevated WBC with a left shift. She was also noted to have an elevation in cardiac enzymes (CK 1440->1348, MB 27-23, MBI 1.9-1.7, Trop 0.39) and new [**Last Name (LF) **], [**First Name3 (LF) **] cardiology was consulted. . Cardiology recommended that she go for an urgent cardiac catheterization. At cath, she was noted to have 3+ MR< LVEF of 40%, and severe inferior hypokinesis. She had a 90% mid-LAD lesion, a 70% LCx lesion at the ramus, and a 100% proximal RCA lesion. She had two stents placed to the mid-LAD, but during the procedure she vomited coffee-ground emesis and the catheterization was terminated. She had an OGT placed but she chewed it and it was removed. She was admitted to the CCU service. . Notably, she has a history of GIB in the past per her husband. [**Name (NI) **] does not know any details, but said that this occurred while she was on heparin and prevented her from getting a renal tx at the time. She apparently did not need hospitalization for this and the etiology was never discovered, per the husband. Past Medical History: h/o GIB in the past, as above DM not on insulin since [**5-19**] infection ESRD secondary to PCKD, with HD qMWF s/p renal transplant several years ago HTN, not medically treated since [**5-19**] infection h/o line infection [**5-19**] Social History: Married with children Physical Exam: On arrival in MICU: Afebrile SBP 80s-100s on pressors RR10, 100% O2 on CMV at 40% FiO2 Gen: Intubated, sedated, nonresponsive HEENT: mmm, OP benign, PERRL CV: RRR systolic murmur Resp: coarse breath sounds bilaterally anteriorly Abd: obese, NABS, soft, nondistended Ext: edematous, warm. Left subclavian dialysis catheter, R forearm fistula (maturing), left radial arterial line, left femoral line Skin: no rash Nro: Intubated and sedated. Not following commands. See Neuro note for complete exam when patient awake (prior to intubation) Pertinent Results: **SELECTED STUDIES** SPINE MRI: IMPRESSION: Endplate irregularity and enhancement at T7-8 level is suggestive of discitis. However, in the absence of soft tissue changes or abscess, the findings are not specific. Dual energy gallium/bone scan would be helpful for further evaluation. Other changes as above. MRI HEAD ([**10-6**]): IMPRESSION: 1. Limited study consisting only of DWI and FLAIR sequences. The signal abnormality involving both medial temporal lobes, insula bilaterally, and cingulate gyri appears to have progressed, and demonstrates abnormal signal on diffusion-weighted imaging. 2. New high signal intensity in the CSF overlying the right parietal lobe, incompletely assessed. A focal area of non-herpetic meningitis cannot be excluded. CXR: ([**10-7**]): A single portable chest radiograph again demonstrates an endotracheal tube with its tip at the clavicular heads. A left-sided central venous catheter is present with its tip in the IVC. No right-sided central venous catheter is evident. No pneumothorax. A nasogastric tube is present with its tip in the stomach. Right hilar contour is unchanged from previous study of [**2137-10-4**]. Retrocardiac opacity and mild pulmonary edema remain unchanged. CAROTID US ([**10-7**]): IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis. UE US ([**10-7**]): 1) No evidence of deep venous thrombosis or collection. Abd/pelvic CT ([**10-7**]): IMPRESSION: 1. No evidence for abscess. 2. Right kidney complex hyperdense lesion likely consistent with renal cell carcinoma and less likely a complex hemorrhagic cyst. 3. Mild intrahepatic ductal dilatation. 4. Right lung nodule. 5. Splenic infarct. ECHO ([**10-8**]): Conclusions: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. 4. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. 5. No obvious evidence of endocarditis seen. 6. Compared with the findings of the prior study of [**2137-9-25**], there has been no significant change. EEG ([**10-8**]): IMPRESSION: Abnormal EEG due to overall slowing suggestive of a diffuse moderate encephalopathy with superimposed bursts and runs of sharp and slow, spike and slow discharges suggesting marked increase to irritability overall. Brief Hospital Course: * Hypotension - The hypotension could have been from infection, cardiogenic shock, or medications; there were no signs of hemorrhage/volume depletion or neurogenic compromise. The patient remained persistantly hypotensive on levophed during her 2 week stay in the MICU, with the addition of vasopressin and continued hypotension. She received antibiotics and antivrials to treat possible infections; her MRI was suggestive of HSV encephalitis although CSF cultures were negative, and only one set of sputum cultures ([**9-28**]) were positive, with no positive blood cultures. An abdominal CT showed no source of infection, there was no pneumonia seen on chest x-rays and no sign of thrombophlebitis on US. Her LFTs showed no suggestion of hepatic or biliary infection. ECHOs showed good cardiac function, making cardiogenic shock unlikely. After two weeks of no improvement in her overall status, family discussions about goals of care and code status were initiated. From the first conversation, her family (husband and children) were adamant that she would not have wanted continued mechanical support and probably would not have wanted admission in the first place. She was made DNR/DNI and, after continued discussions, CMO with withdrawal of pressor support and antibiotics. After a time of extreme hypotension (SBPs 20s) and bradycardia, and after further discussion with her family, the ventilator was turned off and she passed away. Her family declined an autopsy and the ME declined the case. . * Mental Status changes: After her first extubation in the CCU the patient was noted to have an asymmetric neuro exam, with concern for CVA but head CT negative. An MRI was suggestive of temporal lobe enhancement suggesting HSV encephalitis and the patient was maintained on acyclovir. An LP yielded no organisms in culture. EEG showed severe encephalopathy without seizure. After her reintubation in the CCU prior to transfer to the MICU, the patient never regained a normal mental status. . * NSTEMI - On arrival in the MICU, the patient was s/p cath, able to get stents in LAD before termination. Pt only on Reopro, which was stopped, ASA and plavix. No heparin. ASA and plavix were continued. Repeat ECHOs showed good EF (>55%) and no abnormalities to explain the patient's persistant hypotension. . * GI Bleed - The patient had a h/o GIB, and was on multiple meds for cath that were anticoagulants, so the GIB not surprising. NG lavage cleared. She received blood transfusion at the time and had no reoccurrance of bleeding, with a stable hematocrit. . * Vfib arrest- The etiology is most likely ischemic given h/o chest pain prior to event. This acidosis probably caused hyperkalemia as well, as pt's K was very high. There were no more episodes of vfib or arrythmia during admission and the patient received stents with ECHOs showing good function. Electrolytes were monitored daily. . *Renal failure/hyperkalemia - She was followed by the renal team and maintained on CVVH as her blood pressure permitted. . *DM - She was monitored closely and treated with an insulin drip. . *Prophylaxis: - no sc heparin as initial GI bleeding; pneumatic boots, PPI, bowel regimen *Communication - with husband [**Name (NI) **] [**Name (NI) 42632**] ([**Telephone/Fax (1) 63275**]), daughter [**Name (NI) **] [**Name (NI) 22807**] ([**Telephone/Fax (1) 63276**](H), [**Telephone/Fax (1) 63277**](C)) Medications on Admission: ASA 81mg protonix lidoderm patch SSI + NPH Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Persistant hypotension status-post Ventricular fibrillation arrest Encephalopathy with concern for herpes encephalitis Polycystic kidney disease Diabetes GI bleeding Hypertenion End-stage renal disease on hemodialysis Discharge Condition: Expired

Admission Date: [**2114-9-15**] Discharge Date: [**2114-9-28**] Date of Birth: [**2037-6-3**] Sex: F Service: MEDICINE Allergies: Meropenem Attending:[**First Name3 (LF) 3561**] Chief Complaint: OSH transfer for hydronephrosis Major Surgical or Invasive Procedure: [**2114-9-15**] IR guided percutaneous nephrostomy tube [**2114-9-15**] Endotracheal intubation [**2114-9-23**] Extubation [**2114-9-23**] Cervical biopsy [**2114-9-28**] endotracheal intubation History of Present Illness: 77 YO F w HTN who was transferred from an OSH for multiple issues. The patient reports being in her usual state of health until the morning of her date of presentation when she awoke with an episode of nonbloody, loose stool. She felt generally poor so she didnt answer her phone and was later found by family member with blood in perineal area which was later localized to her vagina. EMS was called and she was tachy to 130s, SBP in 80s. Hcts 27-28 at [**Hospital3 **], got 2u pRBCs along with ceftriaxone, may have flashed, got lasix. Underwent Ct C/A/P which showed right hydroureter and hydronephrosis. Transferred to [**Hospital1 18**]. . In the ED, initial vs were: 101.7 135 88/57 40 97% on 4l. Initial c/f need to intubate for airway protection but held off and patient's mental status improved. She was seen by gyn due to vag bleed with high suspicion for cervical cancer. Urinalysis was + for u/a. Fem CVL was placed. She was started on phenylephrine 1.5mg/kg, and given an unclear amount of fluid along with vanc, flagyl, and azithro. Labs were notable for creat 2.0 along with elevated CK and trop. Cards was consulted but ED resident did not speak with cards fellow. EKG reportedly without acute ST segment changes. IR and urology were consulted for hydro and the patient was taken to IR for urgent nephrostomy tube placement. . VS prior to transfer: 73 115/50 21 97% on 4L NC. Upon arrival to the floor, the patient denied any ongoing complaints. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Hypertension Murmur of unknown etiology Social History: The patient lives at the [**Location (un) 87405**] which has both independent and [**Hospital3 **] facilities. Her sister lives in the same apartment complex. She denies tobacco. She used to drink occasional wine but denies any recent alcohol use. She does not use illicit drugs. She does not work. She has no children. Family History: Denies any family history of diabetes or malignancy. Physical Exam: Vitals: T: afebrile BP: 120/60 P: 69 R: 18 O2: 100% General: Alert, oriented, no acute distress HEENT: Sclera possibly slightly icteric, MMM, oropharynx dry Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: 3/6 systolic murmur, loudest at the LUSB, no radiation to the carotids, RRR Abdomen: soft, obese non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with urine and sediment Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, mild chronic venous dermatitis, poor foot hygeine Pertinent Results: [**2114-9-14**] 10:00PM URINE GRANULAR-0-2 HYALINE-0-2 [**2114-9-14**] 10:00PM URINE RBC-[**4-13**]* WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0 [**2114-9-14**] 10:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2114-9-14**] 10:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013 [**2114-9-14**] 10:00PM PT-14.8* PTT-25.7 INR(PT)-1.3* [**2114-9-14**] 10:00PM PLT COUNT-185 [**2114-9-14**] 10:00PM NEUTS-94.4* LYMPHS-3.4* MONOS-1.6* EOS-0.3 BASOS-0.3 [**2114-9-14**] 10:00PM WBC-18.0* RBC-5.14 HGB-11.6* HCT-36.5 MCV-71* MCH-22.6* MCHC-31.8 RDW-20.6* [**2114-9-14**] 10:00PM CK-MB-28* MB INDX-3.6 cTropnT-0.44* [**2114-9-14**] 10:00PM CK(CPK)-780* [**2114-9-14**] 10:00PM GLUCOSE-107* UREA N-39* CREAT-2.0* SODIUM-148* POTASSIUM-3.6 CHLORIDE-110* TOTAL CO2-21* ANION GAP-21* [**2114-9-14**] 10:18PM HGB-12.1 calcHCT-36 [**2114-9-14**] 10:18PM LACTATE-2.2* [**2114-9-15**] 06:21AM FIBRINOGE-802* [**2114-9-15**] 06:21AM PT-15.4* PTT-26.3 INR(PT)-1.4* [**2114-9-15**] 06:21AM PLT COUNT-189 [**2114-9-15**] 06:21AM NEUTS-92.4* LYMPHS-5.0* MONOS-2.1 EOS-0.2 BASOS-0.3 [**2114-9-15**] 06:21AM WBC-27.0* RBC-4.87 HGB-11.0* HCT-35.1* MCV-72* MCH-22.5* MCHC-31.2 RDW-21.2* [**2114-9-15**] 06:21AM TSH-1.4 [**2114-9-15**] 06:21AM ALBUMIN-2.8* CALCIUM-7.5* PHOSPHATE-4.7* MAGNESIUM-2.2 [**2114-9-15**] 06:21AM CK-MB-26* MB INDX-4.7 cTropnT-0.47* [**2114-9-15**] 06:21AM ALT(SGPT)-44* AST(SGOT)-107* CK(CPK)-557* ALK PHOS-129* TOT BILI-0.7 [**2114-9-15**] 06:21AM GLUCOSE-175* UREA N-42* CREAT-1.8* SODIUM-151* POTASSIUM-3.3 CHLORIDE-116* TOTAL CO2-20* ANION GAP-18 [**2114-9-15**] 07:53AM URINE HOURS-RANDOM UREA N-451 CREAT-120 SODIUM-70 POTASSIUM-56 CHLORIDE-70 [**2114-9-15**] 08:26AM LACTATE-1.9 [**2114-9-15**] 08:26AM TYPE-[**Last Name (un) **] PO2-95 PCO2-41 PH-7.35 TOTAL CO2-24 BASE XS--2 [**2114-9-15**] 02:58PM PLT SMR-NORMAL PLT COUNT-180 [**2114-9-15**] 02:58PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-OCCASIONAL BURR-OCCASIONAL [**2114-9-15**] 02:58PM NEUTS-80* BANDS-1 LYMPHS-10* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2114-9-15**] 02:58PM WBC-24.3* RBC-4.77 HGB-10.8* HCT-34.8* MCV-73* MCH-22.5* MCHC-30.9* RDW-21.5* [**2114-9-15**] 02:58PM CALCIUM-7.2* PHOSPHATE-1.5*# MAGNESIUM-1.9 [**2114-9-15**] 02:58PM CK-MB-22* MB INDX-5.9 cTropnT-0.50* [**2114-9-15**] 02:58PM CK(CPK)-370* [**2114-9-15**] 02:58PM GLUCOSE-168* UREA N-32* CREAT-1.5* SODIUM-147* POTASSIUM-3.4 CHLORIDE-113* TOTAL CO2-20* ANION GAP-17 [**2114-9-15**] 03:59PM LACTATE-3.3* [**2114-9-15**] 06:30PM URINE OSMOLAL-631 [**2114-9-15**] 09:25PM LACTATE-2.9* . MICRO: . [**2114-9-15**] Blood cx: STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. [**2114-9-15**] Blood cx: NEGATIVE [**2114-9-17**] Blood cx: NEGATIVE [**2114-9-18**] Blood cx: NEGATIVE [**2114-9-21**] Blood cx: NGTD . [**2114-9-15**] Urine cx: NEGATIVE [**2114-9-17**] Urine cx: NEGATIVE . [**2114-9-21**] Sputum: GRAM STAIN (Final [**2114-9-21**]): [**12-3**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2114-9-23**]): RARE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. . [**2114-9-23**] Sputum: pending . [**2114-9-21**] C. diff toxin: NEGATIVE . [**2114-9-21**] C. diff toxin: NEGATIVE . IMAGING: . [**2114-9-14**] CT Abd and Chest w/o contrast: 1. Right hydronephrosis and hydroureter, without definite etiology. 2. Calcified pleural plaques, suggesting previous asbestos exposure. 3. Degenerative changes in the spine. . [**2114-9-15**] Pelvic Ultrasound: 1. Markedly limited pelvic ultrasound and nondiagnostic transvaginal exam due to inability to insert the transvaginal probe. 2. Fluid in the endocervical canal compatible with vaginal bleeding, recommend MRI for further evaluation when clinically feasible. 3. Possible posterior bladder wall thickening can be better evaluated when MRI is obtained. . [**2114-9-16**] Doppler Ultrasound BLE: No deep venous thrombus in either lower extremity. The posterior tibial and peroneal veins in the left calf are not well imaged. . [**2114-9-17**] ECHO: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild to moderate global left ventricular hypokinesis (LVEF = 40%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The estimated cardiac index is borderline low (2.0-2.5L/min/m2). Right ventricular chamber size is normal with mild global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve is bicuspid with moderately thickened leaflets. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. . IMPRESSION: Bicuspid aortic valve with critical aortic valve stenosis. Moderate aortic regurgitation. Moderate-severe mitral regurgitation. Moderate to severe tricuspid regurgitation. Pulmonary artery systolic hypertension. . PATHOLOGY: [**2114-9-23**] Cervical biopsy: Squamous carcinoma, at least in-situ (see note). Note: There is extensive fragmentation and necrosis and evaluation for invasion is limited Brief Hospital Course: #Uroseptic shock - Treated empirically with vanc/zosyn. Supported with vasopressors from [**9-17**] to [**9-21**]. No organism isolated. Zosyn changed to cipro/[**Last Name (un) 2830**] on [**9-21**] b/c of initial concern for VAP (did not pan out). Meropenem discontinued in favor of cefepime when a rash developed. Cipro monotherapy began [**9-23**] to complete 14 day course for complicated UTI. . #Respiratory failure - Intubated [**9-17**] in the setting of unstable tachycardia and flash pulmonary edema. Treated with antibiotics and diuresis and extubated uneventfully on [**9-23**]. . #Atrial fibrillation - DCCV on [**9-17**] and [**9-20**] for AFib with RVR with conversion to sinus rhythm. Started heparin [**9-24**]. Discontinued on [**9-27**] given hematuria. . #Acute kidney injury - Secondary to shock, with peak Cr 2.0 ([**9-14**]), improved with fluid resuscitation. Then Cr up to 1.8 ([**9-21**]) due to acute on chronic systolic CHF which improved with diuresis. . #Aortic stenosis - [**Location (un) 109**] 0.5cm2 by TTE. Cardiology offerred valvulplasty if patient were to undergo aggressive management of cervical cancer. . #Hydronephrosis - Secondary to bulky metastatic disease. Perc nephrostomy placed [**9-15**] and readjustment for malpositioning on [**9-16**]. . #Rash - Likely contact dermatitis based on distribution over dorsal surfaces and back. . #Cervical SCC - Biopsy [**9-23**] showed squamous carcinoma, at least in-situ (evaluation for invasion is limited) due to extensive fragmentation and necrosis. Plan per gyn-onc was to offer palliative treatment following resolution of acute issues given extent of disease. . #Recurrent Respiratory Failure- patient had acute onset dyspnea consistent with flash pulm edema on [**9-27**], with respiratory status temporarily stabilized with non-invasive mechanical ventilation. She then experienced another episode of a. fib with RVR and flash pulm edema overnight [**Date range (1) 6231**]. She required endotracheal intubation. Following intubation, patient had persistent hypotension with profound lactic acidosis. Patient's family was called to her bedside on morning of [**2114-9-28**], and decision was made to withdraw life-sustaining measures. Patient passed away shortly thereafter. Medications on Admission: Lisinopril Calcium Vitamin D Effexor Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

Admission Date: [**2143-12-7**] Discharge Date: [**2143-12-12**] Date of Birth: [**2081-6-5**] Sex: F Service: NEUROSURGERY Allergies: Erythromycin Base Attending:[**First Name3 (LF) 1271**] Chief Complaint: s/p fall with head trauma Major Surgical or Invasive Procedure: Left craniotomy for left frontal mass resection History of Present Illness: 62 year old female wiht head trauma s/p fall in shower complaining of right upper and lower extremity weakness times five days Past Medical History: Right eye gloucoma/cataract HTN SLE Fibromyalgia Social History: noncontributory Family History: noncontributory Physical Exam: expired [**2143-12-12**] @1802 Pertinent Results: [**2143-12-7**] 03:00AM WBC-12.9* RBC-4.09* HGB-13.7 HCT-37.9 MCV-93 MCH-33.6* MCHC-36.3* RDW-12.6 [**2143-12-7**] 03:00AM ALBUMIN-4.2 CALCIUM-10.2 [**2143-12-7**] 03:00AM LIPASE-34 [**2143-12-7**] 03:00AM ALT(SGPT)-11 AST(SGOT)-16 LD(LDH)-154 ALK PHOS-90 AMYLASE-52 TOT BILI-0.4 [**2143-12-7**] 07:05AM FIBRINOGE-433* [**2143-12-7**] 07:05AM PT-13.5* PTT-27.2 INR(PT)-1.2 [**2143-12-7**] 07:05AM PLT COUNT-218 [**2143-12-7**] 07:05AM GLUCOSE-165* UREA N-21* CREAT-1.0 SODIUM-142 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-18 Brief Hospital Course: Patient was admitted [**2143-12-12**] after severeal days of right upper and lower extremity weakness ultimately leading to lost of balance and head trauma s/p fall in shower. Head Ct in outside hospital revealex left frontal mass confirmed by repat CT in [**Hospital1 18**]. Dilantin loading dose 1gm to be followed by 100mg TID was initiated. Additionally Decadron 4mg Q6 hours along with MRI of the Head with and without contrast, Chest/Abdominal/Pelvic CT, bone scan, ESR, CRP, CEA ere added for work up. MRI revealed Left frontal lobe mass along the medial aspect of the brain suggestive of a primary neoplasm glioblastoma appears more likely than oligodendroglioma. Pateint was preop and consented for resection of frontal lobe mass. Procedure was peformed [**2143-12-10**] without complication and transfered to PACU. Please see operative report for details. Postoperative day 2 [**2143-12-12**] @ 1802 patient expired after suffering an episode of pulseless electrical activity (PEA). Family was notified and refused option of autopsy for death evaluation. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2143-12-12**]

Admission Date: [**2192-7-5**] Discharge Date: [**2192-7-16**] Date of Birth: [**2116-8-4**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: 1) Diffuse abdomenal pain 2) Admitted for cardiac catherization of renal artery stenosi Major Surgical or Invasive Procedure: Exploratory Laporatomy with right colectomy Cardiac catheterization with stenting of LAD History of Present Illness: THE FIRST HALF OF THE HISTORY AND PHYSICAL AS WELL AS THE BRIEF HOSPITAL COURSE WAS DONE BY THE ADMITING CARDIOLOGY TEAM AND THE SECOND WAS DONE BY THE SURGERY TEAM, RESPECTIVELY: 75 yo F with HTN, Hyperlipidemia, DM, h/o CVA in [**2186**], AFib, breast cancer s/p radiation and lumpectomy initally admitted to [**Hospital 1474**] Hospital for CHF and a SBP of 240. She ruled out for MI at that time. She was trasferred to [**Hospital1 18**] for evaluation of Renal Artery Stenosis seen on MRI on [**2192-6-21**]. She underwent cardiac cath on [**2192-7-5**] showing single vessel CAD. The LMCA was free of disease. The LAD had severe proximal calcium with an 80% stenosis in the mid vessel. The LAD was stented with a drug-eluding stent. The LCX had a 50% stenosis in the mid vessel. The RCA had moderate diffuse disease with a 40% proximal stenosis. Selective angiography of the renal arteries showed a 50% stenosis of the left and a 20-30% stenosis of the right renal artery. . She is being transferred from CMI to [**Hospital Unit Name **] for acute on chronic renal insufficiency, increasing CK-MB post procedure, and intermittent Aflutter with poor conduction seen on telemetry. Her ACEI, Diuretic, and Dig are currently being held. An EP consult was obtained. Her BP is being controlled BP with hydralazine. . Currently pt denies CP/SOB/N/V/belly pain. . Surgery was consult for her abdomenal pain. Past Medical History: HTN CVA [**2186**] with residual right sided weakness NIDDM s/p Appendectomy and hysterectomy Breast cancer [**2186**] s/p right lumpectomy and radiation AFib Social History: Lives with husband. [**Name (NI) **] 6 children. Quit tob [**1-11**]. Denies EtOH or drug use. Family History: Denies FH of heart disease. Physical Exam: BP 168/89 (152-181/39-55), HR 51 (50-64), RR 20, 91% RA, Wt 62.7 kg, I/O 600/900 . Gen: well appearing female in NAD HEENT: MMM, anicteric Neck: no JVD, b/l carotid bruits CV: irregularly irregular, III/VI systolic murmer at LUSB radiating throughout chest and into carotids Lungs: rhonchi right base o/w clear Abd: soft, NT/ND, pos BS, no abd bruit Groin: small right hematoma, no bruit Ext: no edema, weak DP/PT pulses Neuro: A&Ox3 Pertinent Results: [**2192-7-12**] 03:47AM BLOOD PT-17.1* PTT-34.9 INR(PT)-1.9 [**2192-7-10**] 10:11AM BLOOD PT-18.9* PTT-32.3 INR(PT)-2.4 [**2192-7-9**] 06:00AM BLOOD PT-22.9* PTT-33.9 INR(PT)-3.5 [**2192-7-12**] 03:47AM BLOOD LD(LDH)-239 CK(CPK)-941* [**2192-7-10**] 03:31AM BLOOD WBC-21.6*# RBC-3.45* Hgb-10.1* Hct-28.7* MCV-83 MCH-29.2 MCHC-35.1* RDW-15.7* Plt Ct-291 Brief Hospital Course: 75 yo F with HTN, PAF, h/o CVA, mild RAS, CAD s/p drug-eluding stent of LAD on [**7-5**] now with increasing Cr post procedure and episode of AFlutter. . 1. CAD s/p drug-eluding stent to LAD. Currently chest pain free. Initial bump in CK-MB post procedure now trending down. Will continue to follow. groin site with bruit but no hematoma or ooze. evaluated with femoral ultrasound which was negative. . 2. Rhythm. h/o PAF with Aflutter noted on tele. Awaiting EP consult. Restarted on Coumadin. Goal INR 1.5-2.0. Continue Amiodarone. d/c digoxin . 3. Acute on Chronic Renal Insufficiency likely secondary to dye load from cath. Baseline Cr unclear. [**Name2 (NI) **] diurectic and ACEI for now and continue to monitor Cr. Worsening renal function most likely from contrast nephropathy. Hydrated and monitored for fluid overload treated with lasix. Had echocardiogram on [**7-6**] which revealed.... . 4. DM. Continue on outpt regimen of Glyburide with ISS. . 5. HTN. Continue outpt regimen of Amlodipine and Metoprolol with hydralazine while holding ACEI and diuretic. . 6. Hyperlipidemia. Continue statin. . 7. PPX. Ranitidine, INR 1.4 on coumadin Because of her abdomenal pain, Surgery was consulted. A CT of the abdomen was obtained showing marked thickening of the right colon and proximal transverse colon indicating grangrenous bowel. A decision was made to take the patient immediately to the operating room for an exploratory laporotomy. Intra-operatively, the patient was found to have ischemic bowel with gangrene and a right colectomy was performed. She tolerated the procedure well and was transferred to the surgical intensive care unit. The she was intubated and sedated and closely monitorred by both the ICU team and the primary team, as well as other consulting services to optimize her recovery. She slowly recovered over the course of a few days and was extubated. She soon became strong enough to be transferred to the surgical floor were she began to tolerate regular meals, pass flatus, and have good urine output. She also started to work with the physical therapist to regain he straingth. Eventually, she was able to be close to her baseline and was in a good enough condition to be discharged home with services. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): For refills please call Dr. [**Last Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*5* 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q5MIN () as needed for chest pain: If 3rd tab needed seek medical attention. Disp:*100 Tablet, Sublingual(s)* Refills:*0* 4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. 10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 14. Warfarin Sodium 2 mg Tablet Sig: Two (2) Tablet PO ONCE (once) for 1 doses. 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*80 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: NECROTIC CECUM Discharge Condition: FAIR Discharge Instructions: PLEASE GO TO THE CALL OR GO TO THE ER IF SUDDEN PAIN IN ABDOMEN, NAUSE/VOMITING, FEVER, OR ABDOMENAL DISTENTION. TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS CAREFULLY. FOLLOW WITH [**First Name8 (NamePattern2) **] [**Doctor Last Name **] IN [**1-8**] WEEKS (SEE BELOW) AND DOCTOR [**Date Range **]/[**Hospital **] CLINIC WITHIN A WEEK. [**Month (only) **] SHOWER. DO NOT SCRUB WOUND, PAD DRY. STRIPS WILL FALL OFF ON ITS OWN IN ABOUT 4 DAYS. Followup Instructions: DR. [**Last Name (STitle) **]([**Telephone/Fax (1) 2300**] ([**Telephone/Fax (1) 2300**] IN [**1-8**] WEEKS AND DR. [**Last Name (STitle) **] Completed by:[**2192-9-13**]

Admission Date: [**2147-12-8**] Discharge Date: [**2147-12-20**] Date of Birth: [**2084-3-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: SOB Major Surgical or Invasive Procedure: [**Female First Name (un) 576**] vs pleurex? History of Present Illness: 63 YO F w metastatic breast ca recently on gemcitabine, AFIB on coumadin s/p recent admission for SOB found to have malignant pleural effusion requiring thoracentesis who presented to the ED for worsening sob since discharge on [**11-30**] along with chills but no fevers. Since discharge on [**11-30**], the patient received oxygen as well as a neb machine at home but was unable to control her symptoms at home. . Upon arrival to the ED, she triggered for an o2 sat of 80% on RA. She improved to the high 90s-100% with 5-6L NC. Exam was notable for a chronically ill, non-toxic appearing woman. Labs were notable for WBC 18.2 with predominance of neutrophils, hct 29.1, creat 1.2. CXR was c/w bilateral pleural effusions and a possible infiltrate. Blood cultures were drawn and she was given tylenol, levaquin and vancomycin given her recent hospitalization due to c/f HAP. Prior to transfer to the floor, her vs were 98.2 84 104/65 24 98% on 3L. . Upon arrival to the floor, she reports feeling much improved. She has no additional complaints. Past Medical History: Past Oncologic History: Breast cancer - per patient, diagnosed 15 years ago and has received multiple rounds of chemotherapy, including adriamycin and taxol in the past. Most recently on gemcitabine. Oncologist is Dr. [**First Name4 (NamePattern1) 24592**] [**Last Name (NamePattern1) 4726**] at [**Location (un) 2274**]. Has mets to bone, lung, and liver. Neg head MRI recently per patient. Prior right sided talc pleurodesis. . Other Past Medical History: Cardiomyopathy/heart failure - likely secondary to adriamycin Depression hyperthyroidism AF with aberrency on coumadin Social History: She lives with her husband in [**Name (NI) 1468**]; previously worked as an assistant in a store. She does not drink alcohol, smoke, or use drugs. Family History: Mother with afib. Physical Exam: VS: afebrile 110/80 100 96% on 2.5L GEN: AOx3, NAD although clearly tachypneic, unable to complete a sentence; pulsus 6 HEENT: PERRLA. MMM. no LAD. neck supple. JVP not visable. Cards: heart sounds regular. S1/S2 normal. no murmurs/gallops/rubs. Pulm: Dullness to percussion in bilateral lower lobes, wheezy throughout Abd: soft, NT, +BS. no rebound/guarding. neg HSM. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Pertinent Results: [**2147-12-8**] 10:57PM PT-39.1* PTT-37.9* INR(PT)-4.1* [**2147-12-8**] 05:35PM GLUCOSE-161* UREA N-18 CREAT-1.2* SODIUM-137 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14 [**2147-12-8**] 05:35PM estGFR-Using this [**2147-12-8**] 05:35PM proBNP-3806* [**2147-12-8**] 05:35PM VIT B12-347 FOLATE-GREATER TH [**2147-12-8**] 05:35PM WBC-18.2*# RBC-2.86* HGB-9.2* HCT-29.1* MCV-102*# MCH-32.1* MCHC-31.6 RDW-21.3* [**2147-12-8**] 05:35PM NEUTS-97.3* LYMPHS-1.7* MONOS-0.7* EOS-0.2 BASOS-0.1 [**2147-12-8**] 05:35PM PLT COUNT-544*# Brief Hospital Course: 63 YO F w metastatic breast cancer p/w reaccumulated pleural effusion and dyspnea s/p pluerex catheter placement on the left. The patient's respiratory status worsened upon transfer to the intensive care unit and she was intubated. Goals of care discussion were ongoing and it was understood that the patient did not want to ventilated for a prolonged period. The patient was actively treated with antibiotics and also received pulse dose steroids for multiple days. There were no improvement in her symptoms. Pt respiratory condition worsened and she became more and more dependent on the ventilator. After 5 days on the ventilator, the family had another discussion with the primary team. It was understood that Ms [**Known lastname 87502**] was not going to improve in the short term and it was against her wishes to be ventilator dependent for a prolonged period of time. The patient was terminally extubated and she passed away on [**2147-12-20**]. Medications on Admission: aspirin 81 mg Tablet warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). potassium chloride 10 mEq Tablet Sustained Release methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY fluoxetine 10 mg Capsule Sig: Four (4) Capsule PO DAILY folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day. fluticasone-salmeterol 100-50 mcg/dose Disk [**Hospital1 **] metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for neb furosemide 20 mg Tablet daily Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Admission Date: [**2201-2-3**] Discharge Date: [**2201-2-14**] Date of Birth: [**2141-7-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: angina, dyspnea on exertion Major Surgical or Invasive Procedure: aortic valve replacement [**2201-2-3**] (27mm St. [**Male First Name (un) 923**] mechanical valve) History of Present Illness: 59 yo male with history of bicuspid AV/AI followed by serial echos. Pt. now with exertional angina and SOB. Cath revealed nl cors. and 3+ AI. Referred for AVR. Past Medical History: aortic insufficiency bicuspid aortic valve borderline elevated lipids diverticulosis asthma prior documentation of abd. bruit (w/u unremarkable per pt) Social History: high school teacher never used tobacco rare ETOH use lives with wife Family History: non-contributory Physical Exam: 5'[**01**]" 200# NAD skin unremarkable PERRL EOMI anicteric sclera no bruits neck supple CTAB RRR 2/6 murmur soft, NT, ND, + BS extrems warm, well-perfused, no edema or varicosities noted neuro grossly intact 2+ bil. fems/DPs/radials Pertinent Results: Conclusions PRE-CPB:1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. 3. Right ventricular chamber size and free wall motion are normal. 4. 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. 5. The aortic valve is bicuspid. The annulus measures 25 mm. The ST junction is mildly effaced. There is no aortic valve stenosis. Mild to moderate ([**12-26**]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] were notified in person of the results. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician ?????? [**2194**] CareGroup IS. All rights reserved. [**2201-2-6**] 07:00AM BLOOD WBC-8.6 RBC-3.71* Hgb-11.4* Hct-31.9* MCV-86 MCH-30.7 MCHC-35.7* RDW-14.0 Plt Ct-107* [**2201-2-7**] 09:10AM BLOOD PT-18.2* PTT-31.2 INR(PT)-1.7* [**2201-2-6**] 07:00AM BLOOD Glucose-106* UreaN-20 Creat-1.2 Na-138 K-4.4 Cl-101 HCO3-30 AnGap-11 Brief Hospital Course: Admitted [**2-3**] and underwent AVR with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated that afternoon and transferred to the floor on POD #1 to begin increasing his activity level. His chest tubes and pacing wires were removed. Coumadin and heparin were started for his mechanical valve. He was seen in consultation by physical therapy. Early on POD #7, he developed tachycardia and hypotension acutely.Given IVF for resuscitation and beta blockade to control tachycardia. CXR done and echo showed pericardial effusion. Transferred back to the CVICU for monitoring. Central line placed and taken to the cath lab for pericardiocentesis and drain placement. Pericardial effusion drained succesfilly and drain removed on [**2-12**]. Pt transferred from the ICU on [**2-12**]. Coumadin [**2-12**] -[**2-14**] 7.5, 7.5, 10mg- INR [**2-14**] 1.8- per Dr. [**Name (NI) **] pt d/c'd to home on [**2-14**] on 7.5 mg coumadin. Next INR check [**2-15**]. Dr. [**Last Name (STitle) 8098**] following INR- confirmed w/ his office [**Doctor First Name **]. Medications on Admission: ASA 81 mg daily diovan 40 mg daily ProAir IH prn vitamins amitriptyline 10 mg -two tabs QHS Discharge Medications: 1. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose will change for goal INR [**1-27**]. Disp:*30 Tablet(s)* Refills:*2* 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN (). Disp:*30 Tablet(s)* Refills:*0* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*qs * Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Outpatient Lab Work INR check [**2-15**] with results called to Dr. [**Last Name (STitle) 8098**] [**Telephone/Fax (1) **] or faxed [**Telephone/Fax (1) 81573**] 14. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 1 months. Disp:*90 Tablet(s)* Refills:*0* 15. Pro-Air MDI PRN as directed. 16. Coumadin 5 mg Tablet Sig: 1 [**12-26**] Tablet PO once a day: as directed by Dr. [**Last Name (STitle) 8098**] Goal INR [**1-27**]. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: aortic insufficiency s/p AVR bicuspid aortic valve postop cardiac tamponade s/p pericardiocentesis borderline elevated lipids diverticulosis asthma prior doumentation of abd. bruit (w/u unremarkable per pt) Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incisions dry call for fever greater than 100.5, redness, drainage, or wieght gain of 2 pounds in 2 days no driving for one month or until off narcotic pain medication no lifting greater than 10 pounds for 10 weeks Dr.[**Last Name (STitle) 8098**] will follow your INR and dose your coumadin. your next INR will be checked on [**2-16**] at the coumadin clinic in Dr. [**Name (NI) 63433**] office. Followup Instructions: see Dr. [**First Name9 (NamePattern2) 81574**] [**Name (STitle) 10302**] (PCP) in [**12-26**] weeks ([**Telephone/Fax (1) 81575**]. see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] (cardiologist) in [**1-27**] weeks ([**Telephone/Fax (1) 81576**]. see Dr. [**First Name (STitle) **] [**Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 11763**] please call for all appts. INR should be drawn on [**2201-2-15**] and faxed to the office of Dr. [**Last Name (STitle) 8098**], attn:[**Doctor First Name **] L. at ([**Telephone/Fax (1) 81577**]. Plan confirmed with [**Doctor First Name **] on [**2-13**] at 1400. Completed by:[**2201-2-14**]

Admission Date: [**2150-5-5**] Discharge Date: [**2150-5-12**] Date of Birth: [**2102-11-16**] Sex: F Service: MEDICINE Allergies: Imuran / Remicade Attending:[**First Name3 (LF) 689**] Chief Complaint: transfered from OSH for BRBPR Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 47 yo F with breast cancer (in remission on herceptin), Crohn's disease, PE/DVT, factor V Leiden, who presented to [**Hospital1 4494**] with cc: of blood per rectum. Per OSH admission note, pt reports 4 weeks of inc abd cramping c/w Crohn's flare. GI doctor [**First Name (Titles) 18546**] [**Last Name (Titles) **] with some mild improvement. She had 4 bloody BMs at home preceeded by tenesumus and then came to OSH ED for eval. . In ED, HD stable. Six episodes of bloody stools, one with syncopal episode. Exam notable for guiac positive stool on rectal exam. While at OSH, recieved 2 u FFP for INR 3.5, with improvement ot 2.0. Also recieved 2 u PRBCS. [**Last Name (Titles) 2768**] was increased to 60 mg qd for Crohn's flare. Hct of 24. Past Medical History: 1. Crohn's disease, followed by Dr [**Last Name (STitle) 2987**] [**Name (STitle) 32027**] in [**2138**], started w/ iritis per OMR -failed imuran [**1-8**] fevers -sulfasalizine did not help sxs; asacol/colazol with little relief -c-scope [**2147**]: Internal hemorrhoids; Ulceration, granularity, friability and erythema in the entire colon compatible with known Crohn's colitis;Abnormal mucosa in the cecum; normal TI, bx c/w diagnosis -seen in [**2-9**] and was on asacol, [**Date Range **], remicaid on hold while recieving chemo 2. PE/DVT -s/p filter placement 3. Factor V Leiden 4. Breast cancer, stage II, HER-2 positive, ER/PR negative dx [**2-8**] -followed by Dr [**First Name (STitle) **] [**Name (STitle) 32028**] w/ cytoxan, adriamycin, taxol -currently on herceptin 5. Osteopenia [**1-8**] steroids 6. h/o GIB in [**6-10**] (see OMR) with syncope as presenting symptom 7. sleep apnea 8. h/o ovarian cysts Social History: Married, no EtOH, smoking, works on a horse farm Family History: Significant for father having coronary artery disease and coronary artery bypass graft in his late 60s. He also had pulmonary embolism postoperative after gallbladder surgery. Mother has breast cancer diagnosed in her late 70s. One sister with factor V Leiden Physical Exam: PE: VS: 97.4 (AF) HR 64 112/67 95-100% RA Gen: pleasant lady, NAD, drowsy s/p sedation for C-scope HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist, +conjunctival pallor Neck: no JVD, no cervical lymphadenopathy Chest: Clear to auscultation bilaterally CVS: Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd: Soft, nontender, nondistended, with normoactive bowel sounds, horizontal scar across low abdomen, s/p breast reconsruction on R Ext: 2+ DP pulses bilaterally, trace edema b/l Pertinent Results: [**2150-5-5**] 09:55PM BLOOD WBC-16.0*# RBC-3.54* Hgb-10.0* Hct-28.9* MCV-82# MCH-28.2# MCHC-34.5 RDW-16.6* Plt Ct-338 [**2150-5-12**] 05:20AM BLOOD WBC-11.1* RBC-3.80*# Hgb-10.9*# Hct-31.9*# MCV-84 MCH-28.6 MCHC-34.0 RDW-16.6* Plt Ct-430 [**2150-5-5**] 09:55PM BLOOD Neuts-88* Bands-5 Lymphs-4* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2150-5-5**] 09:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-1+ Ovalocy-1+ [**2150-5-5**] 09:55PM BLOOD PT-19.1* PTT-24.1 INR(PT)-1.8* [**2150-5-10**] 09:00PM BLOOD PT-12.6 PTT-59.3* INR(PT)-1.1 [**2150-5-12**] 08:45AM BLOOD PT-11.9 PTT-51.6* INR(PT)-1.0 [**2150-5-5**] 09:55PM BLOOD Ret Aut-2.0 [**2150-5-5**] 09:55PM BLOOD Glucose-108* UreaN-14 Creat-0.7 Na-141 K-4.3 Cl-105 HCO3-28 AnGap-12 [**2150-5-11**] 05:10AM BLOOD Glucose-85 UreaN-25* Creat-0.9 Na-140 K-4.1 Cl-102 HCO3-30 AnGap-12 [**2150-5-5**] 09:55PM BLOOD ALT-15 AST-11 LD(LDH)-156 AlkPhos-80 Amylase-73 TotBili-0.7 [**2150-5-5**] 09:55PM BLOOD Lipase-35 [**2150-5-5**] 09:55PM BLOOD Albumin-3.1* Calcium-8.2* Phos-4.8*# Mg-2.3 Iron-31 [**2150-5-6**] 04:05AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.5 [**2150-5-5**] 09:55PM BLOOD calTIBC-268 Ferritn-127 TRF-206 Brief Hospital Course: Ms. [**Known lastname 32025**] is a 47 yo lady with active Crohn's disease, breast cancer in remission, Factor V Leiden with h/o PE/DVT, who was admitted to the ICU from an OSH with LGIB in the setting of a Crohn's flare. ICU Course: In the ICU the pt was noted to be hemodynamically stable. She had bloody bowel movements while receiving bowel prep for a colonoscopy. Her colonoscopy was performed and showed friable inflamed mucosa c/w Crohn's dz. The patient was treated with IV steroids and Asacol without antibiotic coverage. Patient was then transferred to the medicine floor for further management. Her hospital course by problem is summarized below. . # Crohn's flare. Patient was followed by the GI team throughout her stay. She continued to have small bloody BMs likely secondary to her active disease and due to her need for ongoing anticoagulation (see below). The main challenge with controlling her disease was this need for anticoagulation. She was treated with IV steroids and then a [**Known lastname **] taper. She was continued on Asacol. She is to follow up with GI as an outpatient for ongoing management. Upon discharge she was hemodynamically stable for several days, tolerating POs and not having bloody bowel movements. . # H/o PE/DVT with Factor V Leiden. Patient is on Coumadin as an outpatient. On admission her INR was supratherapeutic likely exacerbating her GI bleed. Patient was treated with FFP in the ED for an INR of 3.5. Anticoagulants were thus held in the setting of her active bleed. After her colonoscopy and once she was not actively bleeding, a heparin gtt was started for short term anticoagulation since it was felt that her risk of thrombosis was high with her underlying disease. Initially her PTT was difficult to control and required frequent adjustments to her sliding scale however this later stabilized within the therapeutic range. Upon discharge, she was restarted on Coumadin with a Lovenox bridge. The patient has close follow up with hematology. . # Breast CA s/p mastectomy w/reconstruction. No active issues. . # Nutrition. Patient was initially NPO and then her diet was advanced slowly which she tolerated well without nausea, vomiting or worsening diarrhea. . # Prophylaxis: PPI, anticoagulation as above, ambulation. . Patient remained a full code. Medications on Admission: Herpceptin q 3 wks Coumadin 4 mg qd [**Known lastname 2768**] 40 mg qd Aasacol 1200 mg tid Discharge Medications: 1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): as directed by your hematologist. Disp:*qs qs* Refills:*2* 2. 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* 3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times a day). Disp:*270 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. [**Known lastname 2768**] 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): please continue until tappered by your Gastroenterologist. Disp:*90 Tablet(s)* Refills:*0* 5. Herceptin 440 mg Recon Soln Sig: per your oncologist Intravenous per your oncologist. Disp:*0 0* Refills:*0* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Disp:*60 Tablet, Chewable(s)* Refills:*2* 8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: as directed by your hematologist. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Lower GI bleed 2. Crohn's disease 3. Factor V Leiden with h/o PE/DVT 4. h/o Breast Cancer Discharge Condition: Good - no further blood per rectum, afebrile, no abdominal pain, Hct stable Discharge Instructions: Please take all of your medications as directed. Please make sure you have your INR checked in 2 days and report the results to the PCP. Please return to the hospital with any bleeding, black stool, fevers, chills, abdominal pain or any other complaints. Followup Instructions: You have the following appointments scheduled: 1. Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] GI (SB) Date/Time:[**2150-7-9**] 1:50 2. Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-9-16**] 1:00 3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20428**], MD Phone:[**Telephone/Fax (1) 2041**] Date/Time:[**2150-9-16**] 2:15 Please follow up with your Hematologist within 1 week. Completed by:[**2150-6-6**]

Admission Date: [**2128-8-27**] Discharge Date: [**2128-8-31**] Date of Birth: [**2052-9-12**] Sex: F Service: ACOVE HISTORY OF PRESENT ILLNESS: This is a 75-year-old female with history of metastatic cancer of suspected primary melanoma with baseline dementia, who presented to [**Hospital3 **] recently with a mental status change secondary to dehydration, urinary tract infection, and polypharmacy, who was discharged on [**8-23**], who returns to [**Hospital3 **] from [**Hospital **] Nursing Home with recurrence of mental status change. Patient was noted to have fevers, increasing slurred and garbled speech, intermittent rigors, and generalized change in her mental status. She was transferred to the Emergency Department for evaluation, where she was found to have a left lower lobe pneumonia by chest x-ray. In the Emergency Department, she was given one dose of ceftriaxone. Patient was found to be hypoxic with O2 saturations down to 91% on room air. She was continued on oxygen 3 liters nasal cannula. She was transiently hypotensive with mental status changes in the Emergency Department. Blood pressure did increase with IV fluids. A productive purulent cough was also noted in the Emergency Department. PAST MEDICAL HISTORY: 1. Left neck mass considered metastasis from an unknown primary thought to be malignant melanoma status post chemotherapy consisting of cisplatin in [**2128-3-6**]. Aspiration of this mass in [**2128-1-7**] showed a poorly differentiated tumor with large irregular hyperchromatic nuclei likely metastatic cancer and possibly melanoma. 2. History of hypertension. 3. History of melanoma insitu right back in [**2126**]. 4. History of squamous cell carcinoma of the right chin in [**2127**]. 5. History of basal cell carcinoma of the shoulder in [**2126**]. 6. Hyperlipidemia. 7. Depression. 8. Spinal stenosis. 9. Osteoarthritis. 10. Dementia. 11. Status post cholecystectomy. ALLERGIES: 1. Benadryl causes confusion. 2. Advil causes rash. MEDICATIONS ON ADMISSION: 1. Bactrim double strength one tablet 3x a day, last dose of the course [**2128-8-27**]. 2. Viscus lidocaine swish and swallow tid. 3. Nystatin swish and swallow qid. 4. Seroquel 25 mg po tid. 5. Ativan 0.5 mg po bid. 6. Oxycodone 5 mg po tid. 7. Mirtazapine 50 mg po q hs. 8. Colace 100 mg po bid. 9. Senna tablet one tablet po bid. 10. Trazodone 25 mg po at 2 pm and 6 pm. 11. Tylenol 500 mg q8h ongoing. SOCIAL HISTORY: Currently a resident at [**Hospital3 537**] in hospice care. Daughter is her health-care proxy. History of tobacco use. No alcohol use. FAMILY HISTORY: Breast cancer. PHYSICAL EXAM ON ADMISSION: Temperature 99.8, blood pressure 110/60, heart rate 90, respiratory rate 24, and 97% on 3 liters O2 saturation. On examination, the patient is somnolent, but arousable in no acute distress, alert and oriented times two. HEENT: Extraocular movements are intact. Pupils are equal, round, and reactive to light and accommodation. Oropharynx with evidence of slight thrush. Neck: Left neck mass, firm approximately 8 cm in diameter, fixed in the anterior portion of the left neck. Jugular venous pressure approximately 8 cm, otherwise neck is supple. Chest: Decreased breath sounds at the right base, bronchial breath sounds throughout. E:A changes noted in the right base. Cardiovascular: Hyperdynamic heart sounds regular, rate, and rhythm, normal S1, S2, no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended, no masses. Extremities: No clubbing, cyanosis, or edema. Poor skin turgor, [**2-8**] distal pulses bilaterally. Neurologic examination: The patient is alert and oriented times [**1-8**], nonlinear speech, flat nasolabial folds on the left face. Cranial nerves II through XII are grossly intact. LABORATORY DATA ON ADMISSION: White count 16.6, hematocrit 29.1, platelet count 475. Electrolytes: Sodium 133, potassium 4.5, chloride 96, bicarb 25, BUN 15, creatinine 1.1, glucose 137. ELECTROCARDIOGRAM: Sinus tachycardia, heart rate 120, normal axis. Q waves in II, III, and aVF consistent with an old inferior myocardial infarction. CHEST X-RAY: [**8-26**] suggestive of a right lower lobe pneumonia. OTHER LABORATORY DATA: ALT 11, AST 14, T bilirubin 0.6, amylase 84, lipase 138, albumin 3.5, alkaline phosphatase 85. ASSESSMENT AND PLAN: The patient is a 76-year-old female with dementia, metastatic cancer suspected melanoma as primary with DNR/[**Hospital 24351**] transferred from hospice care with recurrence of mental status change and found to have fever, mild hypoxia, transient hypotension, and evidence of a right lower lobe pneumonia by chest x-ray. HOSPITAL COURSE: 1. Hypotension: Responded to IV fluid administration. Was no longer a persistent issue following IV fluid administration and transfusion of 1 unit of packed red blood cells. 2. Right lower lobe pneumonia: Patient received ceftriaxone and Vancomycin on admission. Was ultimately continued on a regimen of Levaquin and Flagyl for a total course of 14 days. She is currently at day four of her regimen. Patient continues to have a mildly productive cough, but has been afebrile for the past 48 hours. Sputum culture was not obtained. Blood cultures from [**8-27**] show no growth to date. 3. Agitation/delirium: Patient was noted to be quite agitated and delirious upon admission. She did receive benzodiazepines in the Emergency Department and had been receiving two antidepressants and two antipsychotic medications. Her regimen was changed to include only Zyprexa [**Hospital1 **] and trazodone q hs. Patient did require a sitter throughout her admission, but had markedly improved agitation control and improved orientation while on Zyprexa, although restraints were necessary on the first night of the patient's stay. She has done well with a sitter throughout her hospital stay. We will continue q day dosing of Seroquel with consideration of taper in the future when she is oriented to a new environment. 4. Pain control: Patient is currently on a standing dose of oxycodone, and will be continued on a standing dose of OxyContin and oxycodone prn for breakthrough pain for control of her ongoing pain, which is suspected to contribute to her agitation at times. 5. Fluids, electrolytes, and nutrition: Speech and Swallow evaluation was refused by the patient's daughter. [**Name (NI) **] was continued on mechanical soft diet with thickened liquids. IV fluids were administered to bring the patient's blood pressure back to within normal limits initially and then for ongoing prevention of dehydration. Patient should continue adequate hydration to avoid mental status changes from dehydration. 6. Prophylaxis: The patient was continued on a proton-pump inhibitor, Protonix for prevention of gastritis as the patient has a history of gastritis. Also Heparin subcutaneous q8h was used to prevent deep venous thrombosis. 7. Code status: DNR/[**Hospital 24351**] hospice care. DISPOSITION: The patient will be transferred to a hospice facility to be specified in the subsequent discharge summary addendum. CONDITION ON DISCHARGE: Recovering from pneumonia and delirium. DISCHARGE MEDICATIONS: 1. Docusate 100 mg po bid. 2. Heparin subcutaneous 5,000 units q8h. 3. Acetaminophen 325 mg 1-2 tablets po q4-6h as needed for fever greater than 101 degrees. 4. Oxycodone 5 mg one po q8h. 5. Pantoprazole 40 mg po q24h. 6. Nystatin 5 mL swish and swallow qid prn thrush. 7. Aspirin 81 mg po q day. 8. Levofloxacin 250 mg po q day for nine days. 9. Metronidazole 500 mg po tid for nine days. 10. Olanzapine 5 mg po bid. 11. Trazodone 50 mg po q hs. 12. Seroquel 25 mg po q day. 13. Oxycodone 5 mg po q4h prn breakthrough pain. FOLLOW-UP PLANS: The patient is to followup with Dr. [**Last Name (STitle) 713**] on [**2128-9-2**]. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Transient hypotension. 3. Delirium. 4. Dementia. 5. Malignant neoplasm unspecified. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1589**], M.D. [**MD Number(1) 1590**] Dictated By:[**Last Name (NamePattern1) 1615**] MEDQUIST36 D: [**2128-8-31**] 13:03 T: [**2128-8-31**] 13:09 JOB#: [**Job Number 102016**] cc:[**Last Name (NamePattern4) 102017**]

Admission Date: [**2176-8-22**] Discharge Date: [**2176-8-25**] Date of Birth: [**2100-5-7**] Sex: M Service: MEDICINE Allergies: Percodan Attending:[**First Name3 (LF) 443**] Chief Complaint: direct admit for L carotid stenting Major Surgical or Invasive Procedure: L carotid stenting History of Present Illness: 76 y/o man with PMH sig for DM2, HTN, hyperlipidemia, CAD (s/p 2vCABG, s/p PTCA w/ RCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]), carotid stenosis (severe 80-99% on R, moderate 60-70% on left), thought to be [**2-10**] rad therapy for oropharyngeal cancer, now admitted for L carotid artery senting by Dr. [**Last Name (STitle) **]. . Prior to his R stent, the patient was having multiple TIAs with unilateral blurry vision and one episode of syncope. The patient underwent successful stenting of the right common and internal carotid artery on [**2176-7-9**]. Since his discharge, he has not had any dizziness, blurry vision, other visual disturbances, headache, shortness of breath. He does admit to feeling a generalized weakness and fatigue. Also, he has been diagnosed with anemia with his last colonscopy being in [**2171**] which was normal. . ROS: He denies any prior history of stroke, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . All of the other review of systems were negative except says his stools have been darker since he was started on the iron and he has had periodic epistaxis that are not profound and resolved on his own. In addition, the patient describes feeling depressed for several months. He sleeps more and has less energy. He takes part in fewer activities. However, he does feel hopeful for the future. . Past Medical History: Hypertension Hyperlipidemia Anemia of Chronic Disease Diabetes CAD: - [**2161**]: LAD and RCA PTCA - [**2163**]: 2 vessel CABG (LIMA-->LAD, SVG-->OM) (Dr. [**Last Name (STitle) 39668**] [**Hospital1 2025**]) Significant carotid artery disease per wife's report (records requested from [**Hospital1 2025**]) [**2156**] malignant tumor involving the tonsil, s/p radical neck surgery and radiation ([**Hospital1 2025**]) [**2167**] Hematuria related to kidney stone GERD Lap Cholecystectomy Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension Social History: Social History: Patient is married with two children. Lives with wife [**Name (NI) **] who is a nurse. He is retired and reviously worked for [**Company 2676**]. Smoking: 40pack-year (quit 25 yrs ago), ETOH: occasional,No drugs. Pt not very active anymore, but independent in daily activities. Family History: Mother with heart disease, passing away in her late 70??????s. Father with similar throat cancer. No family history of premature CAD, DM. Physical Exam: VS - T 97.8 HR 66 BP 173/59 recheck later 138/50 RR 20 O2sat100% Gen: WDWN middle aged male in NAD. Oriented x3. Mood depressed, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Evidence of previous tumor resection on the right, supple with no JVD, no LAD, +L carotid bruit CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 SEM over URSB, no r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, 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. Increased tympany on the LUQ. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, or xanthomas. Neuro: no aphasia, no recall difficulty, CN 2-12 intact B/L, strength 5/5 B/L upper and lower extremities, reflex 2+ throughout with negative Babinksi, coordination intact, fine motor intact, vibratory sensation decrease in B/L LE, light sensation intact B/L Upper and Lower Extremity. Non focal. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: ADMISSION LABS: [**2176-8-22**] 03:51PM GLUCOSE-181* UREA N-34* CREAT-1.6* SODIUM-139 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12 [**2176-8-22**] 03:51PM estGFR-Using this [**2176-8-22**] 03:51PM ALT(SGPT)-12 AST(SGOT)-16 LD(LDH)-162 ALK PHOS-52 TOT BILI-0.1 [**2176-8-22**] 03:51PM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-2.0 IRON-38* [**2176-8-22**] 03:51PM calTIBC-283 VIT B12-590 FOLATE-16.3 HAPTOGLOB-228* FERRITIN-23* TRF-218 [**2176-8-22**] 03:51PM TSH-3.1 [**2176-8-22**] 03:51PM WBC-4.1 RBC-3.04* HGB-9.0* HCT-27.0* MCV-89 MCH-29.8 MCHC-33.6 RDW-14.7 [**2176-8-22**] 03:51PM PLT COUNT-170 [**2176-8-22**] 03:51PM PT-12.7 PTT-26.9 INR(PT)-1.1 . . PERTINENT LABS/STUDIES: Hct: 27 -> 29.2 -> 29.3 Cr: 1.6 -> 1.3 -> 1.3 Glucose: 181 -> 116 -> 120 TIBC: 283 Vit B12: 590 Folate: 16.3 Hapto: 228 Ferritin: 23 TRF 218 TSH: 3.1 MICRO: Urine Cx: No growth Blood Cx x2: No growtn CTA +/- contrast of head ([**2176-7-8**]): Severe atherosclerotic disease in the bilateral carotid and right vertebral arteries. There is suggestion of an acute thrombus in the distal right cervical vertebral artery extending into the intradural portion. Recommend correlation with MRI to assess for acute ischemia. Atherosclerotic stenosis in bilateral cervical ICAs and common carotid arteries as detailed above. No significant abnormality in the intracranial circulation is seen. . Carotid Doppler U/S ([**2176-5-1**]) 1. B/l sig ICA stenoses which are severe on the right causing 80 to 99% luminal narrowing and moderate on the left where a 60 to 69% stenosis is present. 2. Suggestion of narrowing of the proximal CCA bilaterally, right greater than left. . Cardiac catheterization ([**2176-4-30**]): 1. Three vessel coronary artery disease. 2. Patent LIMA-->LAD and SVG-->OM with 20% proximal ulceration. 3. Stenting of RCA with Drug eluting stent. . ETT w/ echo ([**2176-4-9**]): ischemia of the septum and inferior wall. Abnormal septal motion. LVEF 51%. EKG demonstrated TWI in 1 avL, and V4-V6 with no significant change compared with prior dated 7/[**2176**]. TELEMETRY demonstrated:NSVT . . DISHCARGE LABS: [**2176-8-24**] 07:26AM BLOOD WBC-5.4 RBC-3.37* Hgb-9.8* Hct-29.3* MCV-87 MCH-29.1 MCHC-33.5 RDW-14.4 Plt Ct-160 [**2176-8-24**] 07:26AM BLOOD Plt Ct-160 [**2176-8-24**] 07:26AM BLOOD Glucose-120* UreaN-25* Creat-1.3* Na-139 K-4.4 Cl-105 HCO3-28 AnGap-10 [**2176-8-22**] 03:51PM BLOOD ALT-12 AST-16 LD(LDH)-162 AlkPhos-52 TotBili-0.1 [**2176-8-24**] 07:26AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.1 Brief Hospital Course: Patient is a 76 year-old man with a h/o type 2 Diabetes, HTN, hyperlipidemia, CAD, and carotid stenosis who presented for stenting of his left carotid artery. # Carotid stenosis: Patient underwent a stenting of his right carotid artery on [**2176-7-9**]. He returned to [**Hospital1 18**] for an elective stenting of his left carotid artery, which had a stenosis of 60-69%. Patient became hypotensive after the procedure and was admitted to the CCU. This episode was thought to be a vagal response, and the patient did not have any further episodes while in the CCU. The patient was restarted on his home regimen of Plavix and aspirin and did not have any acute events while in the hospital. . # Coronary Artery Disease: Patient has a significant history of CAD. He had a PTCA w/ a DES to the RCA in [**2176**] and a two-vessel CABG in [**2163**]. Patient had an ECG performed on this admission, which showed no significant interval changes since 7/[**2176**]. The patient did not have any symptoms or signs of ongoing ischemia during this admission. He was continued on his outpatient regimen of Plavix, Aspirin, Metoprolol, Imdur, and Valsartan, and he was monitored on tele for the duration of his hospital stay. . # Systolic Congestive Heart Failure: Patient had an ECHO performed in [**2176-4-9**] which showed ischemia of the septum and inferior wall, abnormal septal motion, and a LVEF of 51%. Patient did not appear volume overloaded on physical exam during this hospital stay, but he has a history of periodic lower extremity edema. He has been taking Lasix prn as an outpatient. On this admission, was monitored for signs of volume overload. It was recommended that the patient follow up with his cardiologist for a repeat ECHO as an outpatient to assess for interval change. . # Anemia- Patient's Hct was consistently low on this admission. Iron studies and hemolysis labs were sent, and the results were consistent with anemia of chronic disease. Patient was also found to have a new systolic ejection murmur on this admission, which may have been related to this anemia. Patient's stools were guiaiced on this admission, and they were consistently negative. Patient was transfused one unit of PRBCs before his carotid stent placement, and his Hct increased appropriately from 27.0 to 29.3. Patient was continued on his ferrous sulfate, and he had no other acute events while in the hospital. . # Diabetes: Patient has a history of type 2 diabetes, and he takes oral anti-glycemics as outpatient. His physical exam was consistent with peripheral neuropathy with decreased vibratory sensation in his lower extremities bilaterally. Patient was started on a regular insulin sliding scale while in the hospital, but he refused to take insulin injections. His blood sugars remained relatively well controlled, with a range of 100-180. Patient was discharged on his home regiment of oral anti-glycemics. . # Chronic Kidney Disease: Patient has a GFR of 53, which is consistent with stage 3 CKD. This is most likely due to diabetes. Patient had improvement in his BUN/Cr to 29/1.3 with hydration and Mucomyst. Patient had no acute events during this admission and was continued on Valsartan. . # Hypertension: Patient has a history of hypertension. He was continued on his home doses of Metoprolol, Valsartan, and HCTZ, and he had no acute events during this admission. . # Hyperlipidemia: Patient has a history of hyperlipidemia and was continued on his outpatient statin. . # Code: Full Code Medications on Admission: Plavix 75 mg daily Lasix 40 mg daily p.r.n.edema Amaryl 4 mg b.i.d. Imdur 60 mg q.h.s. metformin 500 mg b.i.d. metoprolol 25 mg q.h.s. Prilosec 20 mg daily Trental 400 mg t.i.d. Actos 15 mg daily Pravachol 40 mg q.h.s., losartan/hydrochlorothiazide 160/25 one tablet daily aspirin 325mg daily omega-3 fatty acids/vitamin E 1000 mg/5 unit capsule one capsule t.i.d. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 4 days. Disp:*16 Capsule(s)* Refills:*0* 10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for fluid overload. 12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 13. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Amaryl 4 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day. 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home With Service Facility: [**Hospital 39671**] Home Health Services of [**Location (un) **] Discharge Diagnosis: Primary: 1. carotid artery disease . Secondary: Hypertension Hyperlipidemia Anemia of Chronic Disease Diabetes CAD: - [**2161**]: LAD and RCA PTCA - [**2163**]: 2 vessel CABG (LIMA-->LAD, SVG-->OM) (Dr. [**Last Name (STitle) 39668**] [**Hospital1 2025**]) Significant carotid artery disease per wife's report (records requested from [**Hospital1 2025**]) [**2156**] malignant tumor involving the tonsil, s/p radical neck surgery and radiation ([**Hospital1 2025**]) [**2167**] Hematuria related to kidney stone GERD Lap Cholecystectomy Discharge Condition: Vital signs stable, ambulatory without dizziness, tolerating PO feeds and fluids. Discharge Instructions: You were admitted for a carotid artery stent, which was placed successfully in the cardiac catheterization lab. You were able to ambulate independently after the procedure. You were discharged to home in stable condition. You are advised to seek medical attention if you acquire chest pain, shortness of breath, dizziness, nausea, or vomiting, or any other concern that is out of the ordinary for you. You are advised not to swim for a duration of at least one week until you see your primary care physician. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2176-8-30**] 2:20 Completed by:[**2176-9-2**]

[** **] Date: [**2116-7-14**] Discharge Date: [**2116-7-23**] Service: ORTHOPAEDICS Allergies: Codeine / Versed / Colchicine / Lipitor Attending:[**First Name3 (LF) 8587**] Chief Complaint: Right Thigh Pain s/p Fall Major Surgical or Invasive Procedure: [**2116-7-15**]: s/p ORIF right hip History of Present Illness: The patient is a [**Age over 90 **] year old female with history of Hypertension, AFib, CVA to L insula [**12/2112**], diastolic CHF with last EF 55% in [**12/2115**], mild-moderate MR, minimal AS, pulm hypertension, and Amiodarone-induced hypothyroidism who was admitted after a fall and found to have R intertrochanteric femoral fracture. . Pt lives alone and was at home putting away dishes when she suffered an unwitnessed fall. Did not hit her head and denies LOC. She remembers all the events. Her R leg was seen to be shortened and externally rotated and Xray showed R intertrochanteric fracture. Ortho was consulted in the ED. . In the ED her vitals were: 98.6 70 138/97 98% on RA. Labs showing slight worsening of her Hct to 25.6 from baseline 27-29. Hyponatremic to 128 with concurrent hypochloremia to 94, HCO3 low at 20, and BUN/Cr at baseline 36/2.4. UA with mild sign of infxn but also with 3-5 Epi's. UCx pending. CXR without acute process. Of note, pt with h/o prolapsed uterus and Foley was placed. No head or neck scans were done in the ED. . EKG showing: AFib, no RVR, normal axis, normal QRS's, normal T waves. Slightly late R wave progression with clockwise transition. Except for rhythm, normal EKG. In the ED she got 2mg IV Morphine. Foley placed. 18g placed in R hand, 1L NS given. . Her cardiac ROS is negative for all symptoms. She endorses being able to do laundry in the basement and go up 2-3 flights of stairs without chest pain or shortness of breath on exertion. She is able to do all her ADL's without symptoms. No fatigue, lethargy, no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, palpitations. She denies any history of cardiac surgical interventions including AMI's, caths, or CABG. Past Medical History: Hypertension Atrial fibrillation, diagnosed [**2108**] c/b R arm thrombus s/p CVA to L insula [**12/2112**] w/ very mild right facial asymmetry and some attentional/memory problems Colonic GI bleed x 4 ([**2111**], [**2112**], [**2113**], [**2114**]) on Coumadin Diastolic Heart Failure (EF 70-75% in [**2112**]) Moderate Mitral regurgitation Moderate Aortic regurgitation Diverticulosis Gout Amiodarone-induced hypothyroidism, [**11/2115**] h/o E.Coli & VRE UTI, [**2112**] Right cataract surgery, [**2114**] Dyspepsia s/p R breast excision ([**5-/2112**]) atypical ductal hyperplasia s/p open appendectomy 40 years ago Social History: Patient lives alone in [**Location (un) 2312**] since the death of her husband 9 year ago. She has no children, but has a very supportive nephew and [**Name2 (NI) 802**] who visit her frequently and help her with her medications and appointments. She is retired, but previously worked as a "stitcher" for many years. Tobacco: Never EtOH: drank wine with dinner, quit after her stroke in [**2112**] Illicits: Never Contact [**Name (NI) 19447**]: HCP/Nephew: [**Name (NI) **] [**Name (NI) 19442**], MD [**Telephone/Fax (1) 19443**] Family History: No hx of colon cancer of GI bleeds. Females have a history of mitral valve prolapse. Mother died of CHF/diabetes. Father died of MI. Physical Exam: On [**Telephone/Fax (1) **]: Vital Stats: 97.6 153/67 66 17 97% RA General: Pleasant female in no distress, appears younger than [**Age over 90 **]yo. Conversant, appropriate, some discomfort from R leg pain Eyes: PERRLA, no scleral icterus, EOMI ENT: Mouth dry appearing, with dentures in, but no apparent lesions or trauma Carotid pulses easily palpable bilaterally. Prominent external jugular veins noted, but no HJ reflux Respiratory: CTAB anteriorly, deferred posterior exam, good air movement no accessory muscle use Cardiac: Grossly regular S1/S2 with AS type crescendo-decrescendo murmur through precordium but best at BUSB's, S2 is present. Bilateral radials are strong, bilateral DP's palpable Gastrointestinal: Abd soft, NT ND, benign, BS+ Extremities: Trace pitting edema around ankles but doesn't appear grossly volume overloaded. R leg is shorter and externally rotated Neurological: CN 2-12 intact, no grossy facial droop, BUE strength normal, deferred BLE exam, but sensation and pulses intact. Discharge: RLE: SILT sural/saph/tibial/sup fibular nerves Motor intact Compartments soft DP/PT pulses 2+ Pertinent Results: On [**Age over 90 **]: [**2116-7-14**] 08:20PM BLOOD WBC-7.1 RBC-3.04* Hgb-8.7* Hct-25.6* MCV-84 MCH-28.6 MCHC-34.0 RDW-15.4 Plt Ct-221 [**2116-7-14**] 08:20PM BLOOD Neuts-83.8* Lymphs-7.7* Monos-6.6 Eos-1.6 Baso-0.3 [**2116-7-14**] 08:20PM BLOOD PT-12.5 PTT-24.5 Plt Ct-221 INR(PT)-1.1 [**2116-7-14**] 08:20PM BLOOD Glucose-115* UreaN-36* Creat-2.4* Na-128* K-4.4 Cl-94* HCO3-20* AnGap-18 [**2116-7-14**] 08:20PM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8 Pertinent Labs during Hospital Course: [**2116-7-15**] 05:25AM BLOOD TSH-5.3* Free T4-1.6 On Discharge: Pertinent Imaging: [**2116-7-14**] AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT HIP: Comminuted right intertrochanteric proximal femoral fracture is demonstrated with varus angulation and mild lateral displacement of the distal fracture fragment. The hips demonstrate mild degenerative changes with joint space narrowing. The sacroiliac joints and pubic symphysis are not diastatic. There is diffuse demineralization of the osseous structures. Degenerative changes are also seen involving the lower lumbosacral spine. There are diffuse vascular calcifications. [**2116-7-14**] CXR: There is moderate enlargement of the cardiac silhouette. The mediastinal and hilar contours demonstrate unchanged tortuosity of the thoracic aorta with vascular calcifications. The pulmonary vascularity is not engorged. There are linear opacities within the left lung base and right mid lung field compatible with subsegmental atelectasis. There is no pneumothorax or pleural effusion. No focal consolidation is seen. Compression deformity of a low thoracic vertebral body is present but similar compared to the prior study. [**2116-7-15**] HIP RADIOGRAPH: Brief Hospital Course: Ms [**Known lastname 19444**] was admitted on [**2116-7-14**] for a right hip fracture. On [**Date Range **] she was found to be hyponatremic with concurrent hypochloremia and renal failure. She was seen and evaluated by the medical service who cleared her for surgery. On [**2116-7-15**] she underwent open reduction internal fixation of the right hip without complication. She was extubated and transferred to the recovery room in stable condition. In the recovery room she was transfused one unit of blood cells for post operative anemia. She was transferred to the floor and there were no overnight events on the night of surgery. She is being discharged in stable condition to rehabilitation facility. Medications on [**Date Range **]: AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1 (One) Tablet(s) by mouth once a day AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth once a day DONEPEZIL [ARICEPT] - 5 mg Tablet - 2 (Two) Tablet(s) by mouth once a day Start with 1 tablet once a day for 1 week and then increase to 2 tablets per day --> PT DOESN'T KNOW IF SHE'S TAKING OR NOT FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth daily OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 40 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily LEVOTHYROXINE 75 mcg daily MULTIVITAMIN - (OTC) - Tablet - one Tablet(s) by mouth daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous Q24H (every 24 hours) for 4 weeks. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Right intertrochanteric fracture Discharge Condition: AAO X 3 Ambulatng with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4650**] Discharge Instructions: Wound Care: -Keep Incision dry. -Do not soak the incision in a bath or pool. -Keep pin sites clean and dry. -Sutures/staples will be removed at your first post-operative visit. Activity: -Continue to be wbat your right leg. -You should not lift anything greater than 5 pounds. -Elevate rightleg to reduce swelling and pain. -Do not remove splint/brace. Keep splint/brace dry. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go to your local emergency room. Followup Instructions: Staples should be taken out in 2 weeks. Follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 19448**] in 2 months.. call [**Telephone/Fax (1) 9769**] to schedule appointment. Completed by:[**2116-7-17**]

Admission Date: [**2191-12-18**] Discharge Date: [**2191-12-26**] Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11415**] Chief Complaint: s/p fall with right leg pain Major Surgical or Invasive Procedure: History of Present Illness: Ms. [**Known lastname 76979**] is an 88 year old female who sustained a mechanical fall at home. She was taken to [**Hospital3 3583**] and was found to have a right distal femur fracture. She was then transferred to the [**Hospital1 18**] for further care. Past Medical History: PMH: 1. total R knee and hip replacement ~[**2155**] 2. hypertension 3. anxiety/insomnia - treated for years with klonopin/paxil 4. endometriosis 5. arthritis 6. paraoxysmal atrial fibrillation - pt reports hx of "irregular heartbeat," unsure of most recent episode. Has never been on aspirin, has been on "coumadin" for a duration >1 year, but pt unsure of indication. ***No history of cardiac issues - denies MI or heart failure. Had a stress test (per pt) > 10yrs prior, had to stop the test early bc "legs hurt," but denies chest pain or shortness of breath. ***Last colonoscopy >15yrs ago (per pt), was told it was normal. . PSH: 1. hysterectomy - >20yrs for ?endometriosis 2. appendectomy - >40yrs ago 3. other "female procedure' prior to hysterectomy, so "i could have children." Social History: Lives at independent living by herself, on [**Location (un) 448**]. Walks without the use of a walker or cane. Reports difficulty with balance over recent months, must use handrails to make steps. Active church goer. Continues to drive independently, buys groceries independently. Family History: n/a Physical Exam: Upon admission PE - T 98.7 BP 122/72 HR72 RR 16 100% Gen - NAD, A/Ox3, lying in bed, conversant, cooperative, intermittently repeated thoughts, but overall, very oriented. HEENT - no conjunctival pallor, no scleral icterus appreciated, MMM, no posterior pharyngeal erythema appreciated. NECK - no posterior/anterior LAD, no JVD appreciated. No carotid bruits appreciated bilaterally. No thyroid massess/nodules apprec. CV - RRR, S1+S2+S3-S4-, no murmurs or rubs appreciated. LUNGS - CTAB, good air movement bilaterally, no crackles appreciated, no wheezes appreciated ABD - NABS, soft, non-tender, non-distended. No organomegaly appreciated. Infraumbilical scars in place. Foley in place, draining urine. EXT - no lower extremity edema. 2+ palpable pulses bilaterally dorsalis pedis, posterior tibial, radial, ulnar, all 2+. R lower extremity with deformity R distal though, TTP, SILT, DP/SP/T, [**4-23**] [**Last Name (un) 938**]/FHL/GS/TA NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not do fundoscopy. Preserved sensation throughout. 1+ reflexes L4 on L. PSYCH - Listens, responds to questions appropriately, mildly anxious. Brief Hospital Course: Ms. [**Known lastname 76979**] presented to the [**Hospital1 18**] on [**2191-12-18**] via transfer from [**Hospital3 3583**]. She was evaluated by the orthopaedic surgery department and found to have a right distal femur fracture. She was admitted, consented for surgery, cleared for surgery by medicine. On [**2191-12-19**] she was taken to the operating room and underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 101**] plate to her right femur fracture. She tolerated the procedure well, was extubated, transferred to the recovery room, and then to the floor. On [**2191-12-20**] she was transfused with 2 units of packed red blood cells due to acute post operative anemia. She was seen by physical therapy to improve her strength and mobility. On the evening of [**2191-12-21**] the patient developed atrial fibrillation with heartrate up to the 170's that was not controlled with IV metoprolol and diltiazem. Thus, on [**2191-12-22**] the patient was transferred to the SICU. In the SICU the patient's atrial fibrillation was converted to normal sinus rhythm on a diltiazem drip and was subsequently maintained on oral atenolol with oral diltiazem as needed. She was also transfused with 2 units of packed red blood cells due to acute post operative anemia. On [**2191-12-23**] she was transferred out of the SICU onto the orthopaedic floor. The rest of her hospital stay was uneventful with her lab data and vital signs within normal limits and her pain controlled. She is being discharged today in stable condition. Medications on Admission: 1. klonopin qhs 2. atenolol 25mg qd (pt unsure of dose) 3. paxil qd (pt unsure of dose) 4. calcium qd (pt unsure of dose) Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: s/p fall Right distal femur fracture Acute post operative anemia Atrial fibriliation Discharge Condition: Stable Discharge Instructions: Continue to be touchdown weight bearing on your right leg Continue your lovenox injections for a total of 4 weeks after surgery You may resume your home medications as prescribed by your doctor If you notice any increased redness, draiange, or swelling, or if you have a temperature greater than 101.5 please call the office or come to the emergency department Physical Therapy: Activity: As tolerated Right lower extremity: Touchdown weight bearing [**Doctor Last Name **] Brace: Unlocked at all times, may take off for passive ROM to the knee and for daily care. Treatments Frequency: Staples/sutures out 14 days after surgery Dry sterile dressing daily or as needed for drainage or comfort Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedic clinic in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7962**] [**Telephone/Fax (1) 25562**] as your heart medication have been changed due to your A-fib [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]

Admission Date: [**2103-4-29**] Discharge Date: [**2103-5-4**] Date of Birth: [**2025-7-23**] Sex: F Service: NEUROSURGERY Allergies: Bactrim / Penicillins / Macrobid Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: diangnostic cerebral angiogram History of Present Illness: This is a 77 year old female patient who was lifting a ten pound bag of kitty litter when she had sudden onset of severe headache and a stiff neck.She went to bed in hopes that the headache would resolve but wokeup four hours later with the same headache. The patient went to an outside hospital where Head CT showed Subarachnoid hemorhage and she was transferred to [**Hospital1 18**] for further care. Her only complaint was of headache. At the time of admission she denied photophobia,motor weakness, sensory changes, speech difficulty, visual changes and nausea or vomiting. She is on coumadin for Afib and was given FFP and vitamin K at the OSH. Past Medical History: Coronary artery Disease, Carotid stenosis, Hypertension, Hyperlipidemia, Atrial fibrillation, Congestive Heart Failure Social History: No ETOH or tobacco use Family History: non contributory Physical Exam: PHYSICAL EXAM Day of admission [**2103-4-29**]: Hunt and [**Doctor Last Name 9381**]: Grade I [**Doctor Last Name **]: Grade II GCS 15 BP: 95/58 HR: 72 R 15 O2Sats 99% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-2mm EOMs Full Neck: Supple. No nuchal rigidity Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. 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, 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 [**4-19**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On the day of discharge [**5-4**] - Pt is pleasant and cooperative Neuro: AAOx3, PERRL, baseline tremors, gait unsteady, CN II-XII intact, PERRL, motor is full, sensory to light touch grossly intact Pertinent Results: [**2103-4-29**] 02:27PM CK(CPK)-75 [**2103-4-29**] 02:27PM cTropnT-<0.01 [**2103-4-29**] 02:27PM PT-16.1* PTT-26.2 INR(PT)-1.4* [**2103-4-29**] 09:04AM PT-17.6* PTT-27.5 INR(PT)-1.6* [**2103-4-29**] 04:08AM URINE HOURS-RANDOM [**2103-4-29**] 04:08AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2103-4-29**] 03:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2103-4-29**] 03:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2103-4-29**] 03:18AM GLUCOSE-133* UREA N-18 CREAT-0.7 SODIUM-144 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-16 [**2103-4-29**] 03:18AM estGFR-Using this [**2103-4-29**] 03:18AM CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-2.3 [**2103-4-29**] 03:18AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2103-4-29**] 03:18AM WBC-6.1 RBC-4.15* HGB-12.4 HCT-35.3* MCV-85 MCH-29.9 MCHC-35.1* RDW-14.6 [**2103-4-29**] 03:18AM NEUTS-75.5* LYMPHS-18.8 MONOS-4.0 EOS-1.1 BASOS-0.7 [**2103-4-29**] 03:18AM PLT COUNT-264 [**2103-4-29**] 03:18AM PT-21.7* PTT-29.1 INR(PT)-2.0*URINE CULTURE (Final [**2103-4-30**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. URINE CULTURE (Final [**2103-4-30**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. Interpeduncular fossa hemorrhage and perimesencephalic hemorrhage as seen on osh ct. No aneurysm or dissection of the intracranial arteries. Mild atherosclerotic irregularity. Diagnostic Cerebral Angiogram: [**2103-4-29**] Posterior communicating artery infundibulum [**5-3**] CT-angiogram - A small volume of intracranial hemorrhage persists, centered in the interpeduncular fossa, progressively decreased since [**0-0-0**]. A small right posterior communicating artery infundibulum is unchanged. There is no aneurysm or embolic filling defect. Brief Hospital Course: This is a 77 year old female who was lifting a ten pound bag of kitty litter when she had sudden onset of severe headache and a stiff neck. She went to bed in hopes that the headache would resolve but woke up four hours later with the same headache. She went to an outside hospital where head CT was consistent with sunarachnoid hemorhage and she was transferred to [**Hospital1 18**] for further care. On [**2103-4-29**] the patient was evaulated in the Emergency Department by our service and the patient's only complaint was of headache. The patient denied photophobia,motor weakness, sensory changes, speech difficulty, visual changes or nausea and vomiting. She was on coumadin for Atrial fibrillation and was given 4 units of FFP and vitamin K at the outside hospital prior to arrival. A CTA of the Head was performed which was consistent with an interpeduncular fossa hemorrhage and perimesencephalic hemorrhage as seen on outside hospital Head CT. No aneurysm or dissection of the intracranial arteries. Mild atherosclerotic irregularity. The patient was taken for a Diagnostic Cerebral Angiogram which revealed a Posterior communicating artery infundibulum. The patient was admitted to the Neurosurgical Intensive Care Unit for close neurological assement and monitoring. The keppra (seizure prophylaxis) was discontinued per Dr [**First Name (STitle) **]. The patient was bradycardic 1400 40s-50 for the rest of the day and hypotensive with systolic 93/51, but asymptomatic. Cardiac enzymes were negative and a EKG was within normal limits was. The patient was restarted on restarted Aspirin. On [**4-30**], The patient's Heart rate 60-70s. The patient was neurologically intact. The patient was alert and oriented to person, place, and time. She exhibited full strength and sensation without pronator drift. The femoral site was clean dry and intact without hematoma. The decision was made to keep the patient in the ICU for another few days to monitor for possible recurrence of brain hemorhage. The patient was deemed low risk for vasospasm and in consideration of her hypotension and cardiac history as well as home medication including calcium channel blocker Diltiazem, the Nimodipine was discontinued. Patient remained stable during her ICU course. She was transferred to floor in stable condition. She had an uncomplicated course. The patient's home dosing of Diltiazem was restarted on [**5-4**]. Her coumadin dose was restarted was dosed daily. Her last dose was 7.5mg scheduled for [**5-4**] (INR 1.1). She was evaluated by PT/OT and they recommended acute rehab. Now DOD, she is afebrile, VSS, and neurologically stable. She is tolerating a good oral diet and her pain is well controlled. She is set for d/c to acute rehab in stable condition and will f/u accordingly. Medications on Admission: Lipitor 40mg daily, Diltiazem 240mg po daily, ASA 162mg daily, Celexa 10mg daily, Advair, Coumadin Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 5. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 8. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 9. Coumadin 2.5 mg Tablet Sig: [**12-18**] Tablets PO at bedtime: until therapeutic. Discharge Disposition: Extended Care Facility: [**Hospital **] Nursing and rehab centre Discharge Diagnosis: Posterior communicating artery infundibulum Interpeduncular fossa and perimesencephalic subarachnoid hemorrhage hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Diagnostic Cerebral Angiogram Medications: ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin 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 or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room General Instructions for Sunarachnoid Hemorhage: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? 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. ?????? You were on a medication such as Coumadin (Warfarin)and Aspirin prior to your injury, you may safely resume taking your Coumadin on [**2103-5-2**]. You already restarted your Aspirin 162 mg po qd on [**2103-4-29**] CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in __4___weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. - Please follow up with your PCP [**Last Name (NamePattern4) **] [**12-17**] weeks upon discharge Completed by:[**2103-5-4**]

Admission Date: [**2193-9-21**] Discharge Date: [**2193-9-25**] Service: MEDICINE Allergies: Niacin / Lovastatin Attending:[**First Name3 (LF) 2610**] Chief Complaint: UTI Major Surgical or Invasive Procedure: na History of Present Illness: This is a 85 yo female resident of [**Hospital 100**] rehab with a history of COPD and dementia presenting with shortness of breath and UTI. . Apparently she has been lethargic and dyspneic over the last [**2-1**] weeks. At baseline she has dementia and doesnt communicate. History was obtained from her daughter. [**Name (NI) **] daughter she also has been experiencing fevers but she could not remember how high. She was also noted to be dehydrated. Her vitals at rehab were 97.8, 122/70, 92, 24, 94% on RA. She was brought in the ED on request of her relatives. . In the ED, initial vs were: 101.8 110 129/81 34 95. CXR showed RLL infiltration. Patient was given nebs and steroids; levo (750), vanc (1g) and ceftriaxone (1g); as well as nitrglycerin and rectal acetaminophen. She was noted to have distended abdomen and a Foley was placed with 2 Lt output. CT torsoe was concerning for left pyelonephritis. UA was positive for occ bacteria. She also received 2LT NS. Prior to transfer her vitals were 101.2 68-88 113/69 24 97% 4lt. . Review of sytems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. 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. Past Medical History: 1. COPD 2. Pulmonary nodules 3. ?CAD ?MI in [**2171**]; normal dipyridamole thallium in [**2173**]. 4. Osteoarthritis 5. Dementia 6. Cataracts. 7. Chronic back pain and hip pain 8. Hearing loss 9. Varicose veins 10. Heart murmur 11. Breast cancer in the left breast back in [**2183**] treated with radiation and tamoxifen, which was later changed to Arimidex. 12. Osteopenia with history of atraumatic vertebral fracture. 13. Abnormal endometrial, worked up by OB/GYN in the past. 14. Hypercholesterolemia. 15. Alzheimers disease. 16. Status post cholecystectomy in [**2164**]. 17. Status post umbilical hernia repair. 18. Rib fractures. 19. Actinic keratoses. 20. Posterior vitreous detachment. 21. Hypertension. 22. History of vertigo. 23. Headaches with negative workup in the past. Social History: no smoking or drinking Family History: NC Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2193-9-24**] 07:00AM BLOOD Glucose-122* UreaN-12 Creat-0.5 Na-145 K-3.9 Cl-107 HCO3-28 AnGap-14 [**2193-9-22**] BLOOD WBC-10.8 RBC-3.59* Hgb-10.1* Hct-32.4* MCV-90 MCH-28.2 MCHC-31.3 RDW-14.5 Plt Ct-143* [**2193-9-21**] BLOOD WBC-12.2* RBC-3.68* Hgb-10.5* Hct-32.9* MCV-89 MCH-28.6 MCHC-31.9 RDW-14.5 Plt Ct-134* [**2193-9-21**] BLOOD WBC-16.0*# RBC-4.21 Hgb-11.8* Hct-37.2 MCV-88 MCH-28.0 MCHC-31.7 RDW-14.5 Plt Ct-177 [**2193-9-21**] BLOOD Neuts-86.1* Lymphs-9.1* Monos-3.3 Eos-1.3 Baso-0.2 [**2193-9-22**] BLOOD Glucose-169* UreaN-37* Creat-1.0# Na-146* K-4.3 Cl-112* HCO3-28 AnGap-10 [**2193-9-21**] BLOOD Glucose-299* UreaN-60* Creat-2.2*# Na-140 K-4.8 Cl-105 HCO3-25 AnGap-15 [**2193-9-21**] BLOOD Glucose-298* UreaN-96* Creat-5.1*# Na-132* K-5.6* Cl-96 HCO3-21* AnGap-21* [**2193-9-22**] BLOOD Calcium-8.2* Phos-3.0 Mg-2.5 Micro: [**9-20**] U/A positive at [**Hospital 100**] Rehab per telephone report with Pt's nurse. [**9-21**] Urine Cx- No growth [**9-21**] Legionella antigen- negative [**9-21**] Blood Cx X 3- pnd [**9-21**] MRSA screen- negative . Images: CXR: RML atelectasis . CT chest/abdomen/pelvis: 1. Enlarged, edematous left kidney with perinephric stranding and fluid. 2-3 mm calculs near the left distal ureter appears vascular. No definite renal or ureteral stone identified. 2. Fluid in the mid-to-distal esophagus, placing the patient at risk for aspiration. 3. Unchanged L1 compression deformity from [**2190-10-31**]. 4. 2.5-cm left adnexal cyst. . ECHO 06 The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (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 ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis or regurgitation. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: 85 yo female resident of [**Hospital 100**] rehab with a history of COPD and dementia presenting with shortness of breath, lethargy and fever who was noted to have leukocytosis, CXR concerning for PNA, CT evidence of ureteral stone, renal failure, and urine retention. 1. Dyspnea, RML atelectasis: There was initial concern for a pneumonia or possible cardiac etiology such as CHF or CAD so a CXR was obtained that demonstrated a possible consolidation in the RML and a chest CT was ordered. The chest CT demonstrated only atelectasis in the RML and no acute lung processes and urine legionella was negative. Thus, this was most likely a COPD exacerbation and it was treated with albuterol nebs and ipratropium PRN. At discharge the pt's 02 sats were in the upper 90's on room air. 2. Fever, hydronephrosis: The patient had a U/A done while at [**Hospital 100**] Rehab that was positive for leukocyte esterase, RBCs, and WBCs and was emperically treated with 1g ceftriaxone IV. Thus, upon her arrival to the [**Hospital1 18**] the following day, her U/A and urine cx were negative. Mrs.[**Doctor Last Name 93601**] abdomen was noted to be distended and a foley was placed that drained around 2 L of urine. She began spiking high fevers so she was treated with IV vanco/levo/ceftriaxone in the ED and admitted to the ICU with concern for pyelonephritis. She received fluids and supplemental 02. Her temperature returned to [**Location 213**] and her 02 requirement declined. Urology and IR were consulted, but opted not to perform a procedure given her rapid clinical improvement. She was then transferred to the medicine floor and her urine output was maintained. 3. Renal failure/urinary retention: Mrs.[**Known lastname 93602**] initial CR was 5.1 and she was hyperkalemic upon presentation to the ED, most likely from her bladder distention. Upon receiving a foley catheter and supplemental fluids, she produced a good amount of urine and her Cr and potassium levels returned to [**Location 213**]. She was also given kayexalate to expedite the process. On [**9-24**] her foley was removed and she was incontinent following monring, however did not void on own subsequently, retaining up to 1L of urine in bladder. Thus, a Foley catheter was reinserted and the patient was discharged with it in place. The retention could be due to unresolved constipation or perhaps neurogrnic causes, which can later be considered with a Urology follow-up. Medications on Admission: albuterol QID prn aricept 5mg atorvastatin 10 celebrex 100 [**Hospital1 **] flovent hfa 4p [**Hospital1 **] ipratropium IH [**Hospital1 **] prn lisinopril 5 mg loratadine 10 nameda 5 [**Hospital1 **] omeprazole 40 mg proair HFA prn ranitidine 15 [**Hospital1 **] seroquel 50 [**Hospital1 **] Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**2-1**] Inhalation Q4H (every 4 hours) as needed for wheezing. 3. Ipratropium Bromide 0.02 % Solution Sig: [**2-1**] Inhalation Q6H (every 6 hours) as needed for wheezi. 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for constipation. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Tablet, Delayed Release (E.C.)(s) 11. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed for Constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: UTI Discharge Condition: Good Discharge Instructions: You were admitted to the [**Hospital1 18**] for fever, acute renal failure, and treatment of a urinary tract infection. You were also found to be constipated and to have a full bladder when you came to the hospital, which likely caused your acute renal failure. You were given a foley catheter to help empty your bladder and laxatives to help you have a bowel movement. You were also given fluids and your renal function returned to [**Location 213**]. You were also treated with antibiotics and your fever returned to [**Location 213**]. You were then discharged back to the [**Hospital1 10151**] Center to finish the course of antibiotics. . Changes to your medications: 1. Take 1 double strength Bactrim (trimethoprim-sulfamethoxazole) tablet every 12 hours for the next five days (final day of treatment [**9-29**]). . Seek immediate medical attention if you have fevers, are unable to urinate on your own, pain with urination, changes in your mental status, have abdominal or flank pain or any other concerning symptoms. Followup Instructions: Please follow-up with your primary care doctor within two weeks. Completed by:[**2193-9-25**]

Admission Date: [**2124-8-18**] Discharge Date: [**2124-8-28**] Date of Birth: [**2046-8-3**] Sex: M Service: CARDIOTHORACIC Allergies: Latex Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: Coronary artery bypass grafts x 3(LIMA-LAD, SVG-RCA,SVG-Cx) History of Present Illness: This 78 year old white male was being evaluated for claudication and revascularization of his left leg. During this workup he was found to have an abnormal stress test and a catheterization revealed significant double vessel disease. he was referrred for coronary revascularization, but had been given Plavix. He was admitted and begun on Heparin to allow clearance of the Plavix. Past Medical History: Peripheral vascular disease chronic renal insufficiency s/p right carotid endarterectomy hyperlipidemia hypertension renal artery stenosis Social History: Ex-smoker having quit 25 years ago. Retired engineer. Lives at home with his wife, Drinks 3-4 [**Name2 (NI) 17963**] a week. Family History: No family history of early coronary artery disease or peripheral vascular disease. Physical Exam: T 97.8 BP 139/68 HR 72 RR 20 96% RA 70.4 KG Neuro: non-focal Pulmonary: Lungs clear to auscultation bilaterally Cardiac: regular rate and rhythm. Sternal incision: sternum stable. No erythema or drainage. Abdomen: soft and nontender without rebound or guarding. Normoactive bowel sounds Extremities: warm with 1+ edema Pertinent Results: Date of Birth: [**2046-8-3**] Sex: M Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6477**] PREOPERATIVE DIAGNOSIS: Coronary artery disease. POSTOPERATIVE DIAGNOSIS: Coronary artery disease. PROCEDURE PERFORMED: Coronary artery bypass grafting x3: Left internal mammary artery grafted to the left anterior descending with reverse saphenous vein graft to the posterior descending artery and reverse saphenous vein graft to first diagonal branch. ASSISTANT: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 80112**], MD ANESTHESIA: General endotracheal anesthesia. CLINICAL NOTE: Mr. [**Known firstname 1726**] [**Known lastname **] is a 78-year-old male with symptoms of chest tightness, shortness of breath, status post right carotid endarterectomy, and known with peripheral vascular disease with claudication and hypertension. He underwent catheterization that showed severe 2-vessel disease presenting for revascularization. DESCRIPTION OF PROCEDURE: After adequate anesthesia was achieved and with the patient supine, he was prepped and draped in the usual sterile manner. Median sternotomy was performed through which the pericardium was exposed. The left internal mammary artery was taken down to the level of the left subclavian vein and divided distally after heparin was given. Saphenous vein was harvested from the right lower extremity using endoscopic vein harvesting system and prepared in the usual fashion. The pericardium was exposed. The patient was then heparinized. The ascending aorta was cannulated with a soft-flow ascending aortic cannula. Three stage venous cannula was placed through the right atrial appendage. Retrograde coronary sinus cannula was placed through the right atrial wall. He was placed on bypass and the aorta was crossclamped. The heart was arrested with cold antegrade blood cardioplegia followed by multiple retrograde doses. The posterior descending artery was a small vessel but was grafted to a segment of vein in end-to-side fashion with running 7-0 Prolene. The first diagonal branch of the LAD was a good size branch that was similarly grafted. The left anterior descending artery was grafted to the mammary artery in end-to-side fashion with a good size left internal mammary artery. With the crossclamp in place, the 2 main grafts were fashioned to the ascending aorta. Two punch aortotomies with running 6-0 Prolene. Warm cardioplegia was given retrograde. The crossclamp was released with the patient's head down while de-airing the root. The grafts were de-aired and open to flow. Epicardial pacing wires were placed. He was weaned off bypass, decannulated after protamine administration and once the field was dry, 1 left pleural and 2 mediastinal tubes were left in place. The sternotomy was closed with heavy steel wires and the presternal layers were closed with Vicryl sutures. The skin was closed with subcuticular closure. Dry dressing was applied. He tolerated the procedure well and left the OR in stable condition. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern4) 80113**] [**Last Name (LF) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2046-8-3**] Age (years): 78 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraop TEE for CABG ICD-9 Codes: 402.90, 786.05, 786.51, 440.0 Test Information Date/Time: [**2124-8-22**] at 13:21 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm Aorta - Ascending: 2.4 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - LVOT diam: 1.7 cm Aortic Valve - Pressure Half Time: 143 ms Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV cavity size. Moderate regional LV systolic dysfunction. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Simple atheroma in aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). Mild to moderate ([**11-24**]+) AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) 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. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: 1. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 2. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with anterior, antero-septal and antero-lateral hypokinesis. 3. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild to moderate ([**11-24**]+) aortic regurgitation is seen. 5. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being AV paced. 1. Biventricular function is unchanged. 2. Aorta is intact post decannulation. 3. Other findings are unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2124-8-22**] 14:20 [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2124-8-26**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80114**] Reason: f/u atx, effusion [**Hospital 93**] MEDICAL CONDITION: 78 year old man with s/p cabg REASON FOR THIS EXAMINATION: f/u atx, effusion Provisional Findings Impression: JRld SAT [**2124-8-26**] 8:33 PM Increased bibasilar atelectasis more so in the left. Increased bilateral pleural effusions more so in the left. Final Report REASON FOR EXAM: Status post CABG, assess pleural effusion. Comparison is made with prior study performed [**2124-8-23**]. Bibasilar atelectasis worse in the left side have increased. Small bilateral pleural effusions worse in the left side have also increased. There is no CHF. Cardiomediastinal silhouette is unchanged. Sternal wires are aligned. DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Approved: SUN [**2124-8-27**] 2:22 PM Brief Hospital Course: 78 year old male who was transferred to [**Hospital1 18**] on [**2124-8-18**] for CABG. He was being evaluated prior to Left fem-[**Doctor Last Name **] bypass. He had failed a persantine-ett and cath showed severe ostial LAD disease and 60% RCA disease. He was brought to the OR with Dr [**Last Name (STitle) **] on [**2124-8-22**] for 3-vessesl CAD (LIMA-LAD, SVG-D1, SVG-PDA). Please see operative report for full details. Post-operatively he was transferred to the CVICU for invasive monitoring. Patient was noted to be in a junctional rhythm on POD 3 and nodal blocking agents were held. As a result, he was NOT restarted on beta blockers. He was transferred to the step down floor on post-op day 4. He remained in sinus rhythm from post-op day 4 to discharge. He was evaluated by PT and cleared to be discharged to home. Medications on Admission: Lisinopril 20mg/D,Plavix 75mg/D,ASA81,Zocor 20mg/D, ToprolXL 25mg/D 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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 5. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO Q12H (every 12 hours) for 5 days. Disp:*20 Packet(s)* Refills:*0* 6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Please take this as long as you take the narcotic pain medicine. Disp:*60 Capsule(s)* Refills:*0* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 11485**] VNA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafting hypertension peripheral vascular disease s/p right carotid endarterectomy hyperlipidemia chronic renal insufficiency renal artery stenosis Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any fever greater than 100.5 report any redness or drainage from incisions take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr [**Last Name (STitle) **] [**Last Name (STitle) **] [**12-26**] weeks Dr [**Last Name (STitle) 17025**] 2 weeks Completed by:[**2124-8-28**]

Admission Date: [**2182-2-14**] Discharge Date: [**2182-2-19**] Date of Birth: [**2145-10-30**] Sex: M Service: MEDICINE Allergies: Bactrim DS / Levaquin / Vancomycin Hcl / Dilantin Kapseal / Keflex / Ciprofloxacin / Baclofen Attending:[**First Name3 (LF) 1990**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation History of Present Illness: 36 yo M with h/o T12 paraplegia, CKD, and polysubstance abuse who presents with altered mental status and overdose. Per history from his mother, blood pressures had been running 150s-160s at home on his new dose of amlodipine 7.5 mg PO daily prescribed by his PCP [**Last Name (NamePattern4) **] 12/[**2181**]. She also reported that he was slightly more depressed than usual and had not been going out as frequently. Patient was in his usual state of health today until after he ate dinner. His mother heard gurgling and went to his room and subsequently found him with acutely altered mental status, gurgling and moaning, very angry, but able to name the president. Mother reports that his previous declines from UTIs have been similar in their acuity. She called EMS to take him to the ED. Pt received Narcan 2 mg IM x1 prior to arrival at ED with little change in mental status. Pinpoint pupils noted. Per previous discharge summaries, patient has been positive on toxicology screens for benzos, opiates, and cocaine in the past. Per mother, metoprolol is available at home, but she keeps it locked up. . In the ED, VS were 96.4 48 177/104 100% on NRB Labs sig for initial FS of 130, lactate of 2.0, trop-T of < 0.01, WBC of 11.5, and normal LFTs. Toxicology screen positive for benzos, opiates, and cocaine. Patient triggered for altered mental status and was intubated for altered mental status (described as yelling garbled, unintepretable sounds) with Rocuronium and Etomidate (succinylcholine not used as can prolong effects of cocaine if used for intubation). Patient also received Atropine 1 mg IV x1, and Cefepime/Linezolid for broad UTI/meningitis coverage. LP could not be performed b/c patient has rods in his back and would require an IR guided LP. CXR negative for aspiration event, Head CT negative for acute intracranial bleed. Cardiology and toxicology were consulted. EKG with junctional bradycardia. Cardiology thought no need for pacer given lack of hypotension. Toxicology thought this could appear to be a mixed ingestion, but did not think it was a beta-blocker or CCB overdose, recommended serial FS, supportive care, and did not recommend glucagon at this time. VS on transfer were: [**Telephone/Fax (2) 101746**] 100% on AC FiO2 40% 500 x 15 PEEP 5. . On the floor, patient is intubated and sedated. IV hydralazine 10 mg x1 was given with good effect on his blood pressure and heart rate (HR up to 55, SBP down to 150/80). Past Medical History: - T12 paraplegia secondary to MVA in [**2165**] - chronic kidney disease, with baseline creatinine of [**2-28**] - history of MRSA decubitus ulcers - chronic indwelling foley - recurrent urinary tract infections growing pseudomonas, e. coli, and enterococcus - seizure disorder (last episode in [**2176**]) - history of c. diff colitis - osteomyelitis in the right hip - chronic back pain - anxiety Social History: As per prior discharge summary, patient lives with his mother, who is primary caretaker. [**Name (NI) **] a girlfriend, with whom he always stays. Unemployed. Former heavy alcohol use, quit over 1.5 years prior. Occasional prior marijuana. No tobacco use. No other illicits. Cocaine positive on toxicology screens in the past admissions. Family History: Maternal great aunt: DM. Maternal uncle: colon cancer. HTN. Physical Exam: Initial exam: VS: [**Telephone/Fax (2) 101747**] 100% on AC 500 x 16 FiO2 40% PEEP 5 GA: intubated; biting at tube and fighting restraints; intermittently following commands (squeezing hand) HEENT: pinpoint pupils minimally reactive to light CARDIAC: bradycardic. no m/g/r PULM: CTAB no wheezes GI: soft +BS no g/rt GU: foley Neuro: intermittenly following commands; 2+ reflexes bilaterally (biceps, achilles,plantar); babinski's downgoing BL. EXTREMITIES: wwp, +dry skin and warm, pulses 2+, bounding; moving all extremities with excellent grip strength bilaterally Discharge: VS: 99.5 126/100 80 18 100% RA GA: NAD HEENT: NCAT, PERRLA CARDIAC: RRR, nl s1s2 no m/g/r PULM: CTAB no wheezes GI: soft +BS no g/rt GU: foley in place EXTREMITIES: wwp, pulses 2+ Pertinent Results: Admission labs: [**2182-2-14**] 09:46PM LACTATE-2.0 [**2182-2-14**] 08:34PM GLUCOSE-117* UREA N-22* CREAT-2.9* SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18 [**2182-2-14**] 08:34PM ALT(SGPT)-14 AST(SGOT)-24 CK(CPK)-88 ALK PHOS-107 TOT BILI-0.3 [**2182-2-14**] 08:34PM LIPASE-54 [**2182-2-14**] 08:34PM cTropnT-<0.01 [**2182-2-14**] 08:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2182-2-14**] 08:34PM WBC-11.5* RBC-5.27# HGB-15.7 HCT-45.4 MCV-86 MCH-29.8 MCHC-34.6 RDW-13.6 [**2182-2-14**] 08:34PM NEUTS-67.1 LYMPHS-26.5 MONOS-3.3 EOS-2.3 BASOS-0.7 [**2182-2-14**] 08:34PM PLT COUNT-259 [**2182-2-14**] 08:34PM PT-13.5* PTT-31.5 INR(PT)-1.2* [**2182-2-14**] 08:16PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [**2182-2-14**] 08:16PM URINE BLOOD-TR NITRITE-POS PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD Discharge labs: [**2182-2-19**] 06:10AM BLOOD WBC-7.0 RBC-4.55* Hgb-13.5* Hct-40.5 MCV-89 MCH-29.6 MCHC-33.2 RDW-13.6 Plt Ct-212 [**2182-2-19**] 06:10AM BLOOD Plt Ct-212 [**2182-2-19**] 06:10AM BLOOD Glucose-94 UreaN-30* Creat-2.3* Na-139 K-4.9 Cl-106 HCO3-25 AnGap-13 [**2182-2-15**] 05:31AM BLOOD CK(CPK)-50 [**2182-2-16**] 08:53PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG Micro: [**2182-2-16**] 8:53 pm URINE Source: Catheter. **FINAL REPORT [**2182-2-18**]** URINE CULTURE (Final [**2182-2-18**]): NO GROWTH. [**2182-2-14**] 8:27 pm URINE Site: NOT SPECIFIED **FINAL REPORT [**2182-2-16**]** URINE CULTURE (Final [**2182-2-16**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. Imaging: Head CT ([**2182-2-14**]) - no acute intracranial process Renal u/s: 1. No renal obstruction or son[**Name (NI) 493**] findings of pyelonephritis/renal abscess. 2. Unchanged thickened bladder likely related to underlying neurogenic bladder. Brief Hospital Course: 36 yo M with T12 paraplegia, CKD, and polysubstance abuse who presents with altered mental status and overdose. . # Altered mental status: Patient admitted to the MICU with altered mental status, likely in the setting of toxic/metabolic etiology such as medication/drug overdose. Ct head showed no acute process. Patient with positive toxicology screens for opiates, benzos, and cocaine (and has been in past admission as well), and is only medically prescribed oxycodone, percocet, and klonopin. Of note, Oxycodone should only show up in GC/MS toxicology send-out, not in the first pass urine toxicology screen peformed in the ED, indicating patient may have been taking other narcotics other than his prescribed oxycodone. Per toxicology, symptoms are not consistent with a pure toxidrome, therefore there are likely multiple substances on board. Psychiatry was consulted, and they felt that patient was not actively suicidal, that this overdose was a mistake. He was given an outpatient psychiatry referral and was also provided with substance abuse resources by social work. . # Respiratory Failure: Intubated for airway protection in the setting of altered mental status. CXR appears clear and shows no evidence of PNA or aspiration. Excellent oxygenation noted on admission ABG. Pt was successfully extubated on HD #2. . # Bradycardia: EKG demonstrates sinus bradycardia and with a junctional rhythm. No evidence of hypotension. [**Month (only) 116**] be combined ingestion of benzos/opiates resulting in bradycardia. Definite concern for [**Location (un) **] Reflex in the setting of hypertension, as pt's HR improved with lowering of blood pressure with hydralazine. Discussed with cardiology unofficially, no pacer currently required for bradycardia given no evidence of hypotension. Bradycardia improved over the course of his MICU stay, no events of bradycardia on the floor. Was monitored on tele. # Hypertension: Likely in setting of cocaine overdose versus medication non-compliance. Has hypertension with baseline SBPs in 150s as outpatient, so well above his current baseline. Likely non-compliant with home medications as well. Treated as hypertensive emergency given altered mental status with IV hydralazine 5 mg IV q6H goal SBP > 150. B-blockers were held in the MICU given concern for cocaine use. Was restarted on amlodipine (home medication) while on medical floor with improvement in BP, did not require any PRN. . # Possible Overdose: Patient with positive toxicology screen, history of polysubstance abuse and positive tox screens for opiates, benzos, and cocaine in the past. Per mother, patient has been more depressed recently. Seen by psychiatry as soon as he was extubated; they felt that there was no acute danger of suicide. Pt was also seen by social work in the MICU. . #. Chronic Kidney Disease: baseline Cre at 2.9. Medications were renally dosed. . # ?UTI: pt with UA suggestive UTI on admission, also with altered mental status c/w prior UTIs so was initially started on cefepime. Urine culture came back no growth, a repeat UA was checked which also was c/w UTI (however pt with chronic foley), no growth on cx. Pt with flank pain (not tenderness; pt without sensation below T12) and possible UTI, so renal u/s was done to r/o abscess, pyelo, which was negative. Cefepime was dc'ed after 5 days, was given a 2 day course of nitrofurantoin (allergies to keflex, bactrim, cipro) to complete total 7 day course. He will f/u with PCP. . #. Seizure disorder: continued Keppra (dosed IV while NPO). Medications on Admission: 1. Docusate sodium 100 mg po BID 2. Senna 8.6 mg po BID 3. Bisacodyl 10 mg PR qhs prn constipation 4. Levetiracetam 500 mg po BID 5. Tolterodine 2 mg po prn bladder spasms 6. Pantoprazole 40 mg po BID 7. Oxycodone 60 mg SR po q8 8. Clonazepam 1 mg po qhs 9. Ferrous sulfate 300 mg po BID 10. Sevelamer HCl 800 mg po TID with meals 11. Ambien 5 mg 1-2 tablets po qhs prn insomnia 12. fluticasone 50 mcg/Actuation Spray one inhalations [**Hospital1 **] 13. Oxycodone-acetaminophen 5-325 mg po q4 prn pain 15. Amlodipine 7.5 mg PO daily (started [**12/2181**] by PCP) 16. Renagel Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. tolterodine 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for bladder spasm. 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 9. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 11. sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 13. fluticasone 50 mcg/Actuation Disk with Device Sig: One (1) Inhalation twice a day. 14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 15. alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 16. nitrofurantoin macrocrystal 100 mg Capsule Sig: One (1) Capsule PO twice a day for 2 days. Disp:*4 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Substance abuse/Overdose Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were seen in the hospital for an overdose, for which you were medically managed and found to be stable after leaving the intensive care unit. One of the social workers saw you here and provided you with information for follow up treatment. You were also seen by the psychiatrists here who believe you would benefit from seeing a psychiatrist as well, and gave you information to set up an appointment with one of the doctors [**First Name (Titles) **] [**Hospital3 **]. You also had symptoms suggestive of a urinary tract infection for which you were treated with a course of intravenous antibiotics. Please take oral antibiotics for two more days at home. Changes to your medications: START taking nitrofurantoin 100 mg twice a day for two days (start tomorrow morning) Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: WEDNESDAY [**2182-2-27**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Please also make an appointment to see a psychiatrist, either one recommended by Dr. [**Last Name (STitle) 81147**], the psychiatrist who saw you here, or one closer to home. Please also follow up with a substance abuse treatment program, as this will be very important for helping you with your drug use. Completed by:[**2182-2-20**]

Admission Date: [**2162-4-5**] Discharge Date: [**2162-4-29**] Date of Birth: [**2105-6-15**] Sex: M Service: VASCULAR CHIEF COMPLAINT: Right leg pain. HISTORY OF PRESENT ILLNESS: This is a 56 year old white male with known peripheral vascular disease status post right fem-[**Doctor Last Name **] in [**2155**] for questionable popliteal aneurysm, who presents to the emergency room with right calf pain since [**70**]:30 p.m. on the day of admission while making deliveries. He had not experienced this before and tried analgesics without relief and at this point called EMS. There is no clear history of claudication, but describes right knee pain when carrying packages long distances. Can walk one city block without pain, but does admit to numbness and tingling. PAST MEDICAL HISTORY: Hypertension. PAST SURGICAL HISTORY: Inguinal hernia repair. Right fem-PT bypass in 12/97 with right fasciotomy. ALLERGIES: No known drug allergies. MEDICATIONS: Atenolol 50 mg q.d. SOCIAL HISTORY: Alcohol abuse. Former smoker. PHYSICAL EXAMINATION: Vital signs 97.1, 70, 16, 210/111, O2 sat 94% in room air. General appearance was an alert, obese male in mild distress and diaphoretic. HEENT exam was unremarkable. On chest exam lungs were clear bilaterally. Heart had regular rate and rhythm. Abdominal exam was obese, soft, nontender. There were no masses. He had good rectal tone and heme negative. On extremity exam the left lower extremity was warm with palpable pulses. The right extremity was cool to mid-thigh with mottling. Toes were blue. There was sensation and he could weakly wiggle his toes. Pulse exam showed radial pulses 2+ bilaterally, carotids 2+ bilaterally without bruits. Femoral pulses were 2+ bilaterally. Right [**Doctor Last Name **], DP and PT were absent. There was no graft pulse. Left [**Doctor Last Name **], DP and PT were palpable. LABORATORY DATA: On admission CBC with white count 6.4, hematocrit 48.5. BUN 7, creatinine 0.7. EKG normal sinus rhythm with V rate of 74, T wave changes in 1 and 3. HOSPITAL COURSE: The patient was initially elevated in the emergency room and he was begun on heparin 5000 bolus and continuous at 1500 units per hour with serial coags and dosing adjusted accordingly. Patient's chest x-ray was unremarkable. He was begun on a prophylactic alcohol withdrawal program. On [**2162-4-6**] patient underwent an urgent exploration of the right SFA, popliteal artery and PT with thrombectomy of the right femoral-PT vein graft. The patient tolerated the procedure well. He returned to the O.R. later that day and underwent right BKA. On postoperative check patient was extubated in the PACU. He remained hemodynamically stable. Postoperative hematocrit was 34.7, platelet count 50. This was serially monitored. He was continued on a PCA and around-the-clock Ativan for DT prophylaxis. Enzymes were cycled. Total CK was [**Numeric Identifier 105032**], troponin 0.3. Patient remained stable and was transferred to the VICU for continued monitoring and care. He was continued on perioperative Kefzol while lines were in place. The patient had liver enzymes done on admission which were abnormal. He underwent an ultrasound of the liver which showed fatty infiltration. T-max on postoperative day one was 101.5. Hematocrit remained stable at 33.9. Platelet count was 51. BUN 8, creatinine 0.6. He was continued on Dilaudid PCA. Atenolol was resumed. Diet was advanced as tolerated. GI was requested to see patient in regard to his elevated LFTs. HIT level was sent because of his thrombocytopenia. Patient's heparin was discontinued with improvement in his platelet count. Physical therapy began post BKA exercises. On postoperative day two the resident was called to see patient for t-max of 102.5. Lung exam was unremarkable. He was tachycardiac with a heart rate of 112. The incisions were clean, dry and intact. Chest x-ray showed atelectasis with effusions. Urinalysis was 3 to 5 RBC, no WBC. Blood and urine cultures were obtained which were no growth and finalized. Patient's HIT was positive. Blood cultures and urine cultures were negative and finalized. HIT was positive. Heparin was discontinued. He remained febrile on postoperative day two. Total white count was 12.7. Total CK was [**Numeric Identifier 38254**]. This was reflective of his ischemia. Patient continually remained confused with tachycardia and febrile. GI felt that his mental status changes were secondary to hepatic encephalopathy and DTs. Lactulose was begun. Ultrasound of the liver was obtained. The patient was transferred to the intensive care unit for respiratory support. Patient was intubated and sedated. Patient's ammonia level was 67. An Ativan drip was begun. Lactulose was continued. His antihypertensives were continued. Total CK was elevated, but this was secondary to rhabdomyolysis. Diminished urinary output secondary to myoglobulinuria. He remained NPO with NG in place. They felt his elevated HIT was secondary to splenic sequestration. He was continued on IV fluids D5 half normal saline. On postoperative day three white count was 9.7. Coags were normal. BUN 15, creatinine 0.6. Liver AST 246, ALT 34, alkaline phos 74, t-bili 3.3, amylase 54, lipase 55. Patient remained in the SICU intubated and TPN was begun. Patient underwent IVC filter placement without complications. The patient did have an episode of diminished cardiac output, etiology undetermined. EKG showed no changes. CKMBs were not elevated. Patient was continued on beta blockade, remained NPO. He was making adequate urine. A second set of blood cultures grew one out of four gram positive cocci. Vancomycin was added to patient's antibiotic regimen. This was on [**2162-4-10**]. Levofloxacin was started on [**2162-4-8**]. White count remained stable at 7.6. Patient's central line was changed on [**2162-4-12**]. Chest x-ray was unremarkable. On postoperative day six he continued with fever spike to 102.7, defervesced to 99.1. Total white count remained stable at 7.1. Patient's liver functions ALT and AST showed improvement. Alkaline phos remained stable. Total bili continued to rise. Albumin was 2.3, amylase 110. Cultures on the 14th of the CVL tip, blood and urine on [**4-11**] and blood on [**4-10**] were no growth. Chest x-ray showed bilateral effusions. Ativan wean was begun. TPN was placed on tube feeds which were advanced. On postoperative day seven antibiotics were changed to vancomycin and Zosyn. Tube feed was advanced. TPN rate was decreased. Diuresis was continued. A CPAP trial was initiated. White count was 9.2, up from 7.1. Stump cultures grew 4+ gram positive cocci, 1+ gram negative rods and 1+ gram positive rods. Blood, urine and sputum cultures were no growth. Chest x-ray continued to show bibasilar opacifications and effusions. Diuresis was continued. Patient continued to be followed by the GI service. His white count stabilized at 9.2. CKs on postoperative day seven began to show a downward trend along with ALT and AST. Total bili peaked at 5.4 and began to show a downward trend. The patient remained on CPAP with pressure support. On postoperative day eight patient continued on vanco and Zosyn. The stump wound was opened by Dr. [**Last Name (STitle) **] to allow for drainage. Tube feeds were advanced to goal. He continued to run t-max in the 101 to 100.9 range. White count continued to remain unremarkable at 7.5. Blood cultures taken on [**4-13**] showed no growth. Wound cultures grew moderate coag negative staph on the 14th. CVL tip grew greater than 15 colonies of staph. Patient underwent bedside excisional debridement of the stump wound on [**4-14**]. He felt that patient's tissue was nonviable and would require AKA, but would monitor the wound and decide the following day whether or not to take him back to surgery. The patient returned to the operating room on [**2162-4-15**] and underwent revision of right AKA that was left open. A VAC dressing was placed. Patient was transferred to the SICU for continued monitoring and care. He remained intubated. Hematocrit remained stable at 28.5 post debridement. KUB showed the NG in the appropriate place. Antibiotics were continued. On postoperative days 10 and one patient required a transfusion of packed red blood cells and FFP for hematocrit of 26.5 and PTT of 28.6. He remained intubated, continued on tube feeds. He continued to run low grade temps of 101. Patient was extubated on postoperative days 11 and two. Post transfusion hematocrit was 27.4 after one unit of packed red blood cells. The patient began to defervesce over the next 48 hours on postoperative days 10 and two. White count remained stable at 8.3. Cath cultures were no growth. Blood cultures were no growth, but not finalized. Sputum cultures were negative. VAC dressing was changed for the first time on [**2162-4-18**]. Patient was transferred to the VICU on [**2162-4-19**]. Patient underwent a speech and swallowing evaluation at the bedside on [**2162-4-20**]. There were no signs or symptoms of aspiration. There were no signs or symptoms of dysphagia noted. While they felt silent aspiration could not be ruled out at the bedside exam, patient had no suspicious neurologic history to suggest risk for being a silent aspirator. Recommendations were to advance diet to regular consistency solids and thin liquids, sit patient upright for meals. The patient's VAC was changed again with conscious sedation on [**2162-4-22**]. Patient was evaluated by physical therapy who felt he would require rehabilitation prior to being discharged to home. Patient was transferred to the regular nursing floor on postoperative days 16 and seven. He continued to progress. Patient continued to remain afebrile. Antibiotics were discontinued. The VAC was discontinued and normal saline wet to dry dressings were begun. Case management was requested to see patient regarding discharge planning. The remaining hospital stay was uneventful. The patient was transferred to [**Location 1268**] VA for continued care. At the time of transfer patient was tolerating a regular diet with Boost t.i.d. Recommendations were to continue to have patient be in an upright position while eating. Dressings were normal saline wet to dry dressings b.i.d. to open AKA stump site. DISCHARGE MEDICATIONS: 1. Albuterol metered dose inhaler one to two puffs q.six hours p.r.n. 2. Ipratropium bromide metered dose inhaler two puffs q.four to six hours p.r.n. 3. Sarna lotion t.i.d. p.r.n. 4. Allopurinol 2 mg h.s. 5. Colace 100 mg b.i.d. 6. Dulcolax suppository h.s. p.r.n. 7. Atenolol 50 mg q.d. 8. Tylenol #3 one to two tablets q.four to six hours p.r.n. pain. 9. Hydromorphone 0.5 to 2 mg IV q.six hours p.r.n. pain for dressing changes only. 10. Nitroglycerin 2%, 1 inch q.six hours if systolic blood pressure greater than 140. DISCHARGE DIAGNOSES: 1. Acute right leg ischemia, status post exploration of right SFA, popliteal artery and posterior tibial artery with thrombectomy of right fem-PT bypass graft. 2. Gangrenous right foot, status post right BKA. 3. Ischemic wound changes, status post right AKA. 4. Liver disease secondary to cirrhosis with encephalopathy. 5. Corrected DTs secondary to history of alcohol abuse. 6. Corrected thrombocytopenia with positive HIT 7. Rhabdomyolysis with myoglobulinuria, corrected. 8. Status post IVC filter placement. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2162-4-27**] 11:02 T: [**2162-4-27**] 11:00 JOB#: [**Job Number 105033**]

Admission Date: [**2165-3-20**] Discharge Date: [**2165-3-28**] Date of Birth: [**2092-10-23**] Sex: M Service: MEDICINE Allergies: Albuterol Attending:[**First Name3 (LF) 2024**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: This is a 72 year old male with PMH significant for cutaneous SCC metastatic to left axilla and lung, s/p resection ([**2162**]), adjuvant XRT, chemotherapy (most recently on phase I protocol of Torisel and Neratinib), atrial fibrillation on coumadin, hypertension, and dyslipidemia who presents from clinic with two days of shortness of breath and weakness. Patient was seen in clinic for C5D15 of Torisel and Neratinib, which has been on hold since [**3-9**] secondary to grade 2 mucositis. There he was complaining of shortness of breath and weakness. His VS in clinic were notable for T 99.8, O2 79% on transferring to bed which increased to 89% w/ deep breathing on RA and 94% on 3L nc. Patient states that his shortness of breath started two days ago. He endorses a light non-productive cough at night. He denies any fevers, chills, chest pain, nausea, vomiting, diarrhea, or abdominal pain. He has baseline mucositis with throat pain. In the ED, initial vs were: 99, 112/77, 75, 28, 97% on 4L. His exam was notable for tachypnea despite breathing mid 90s on 4L nc. A rectal temp was 101.4. Labs were notable for 91% PMNs, but no leukocytosis (WBC 5.6), and a subtherapeutic INR 1.3. CXR was concerning for RLL infiltrates. CTA was negative for PE but evident for new right pleural effusion and RLL consolidation. CT head was negative for acute bleed. Blood cx were drawn and patient received iv vanc and zosyn, tylenol, and 1L NS. In the ED, his patient and wife expressed that should his respiratory status decompensate he is agreeable to intubation. He was transferred for further monitor of his hypoxia. On the floor, patient stated breathing much improved. Review of sytems: (+) Per HPI (-) 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: -HTN -Hyperlipidemia -Severe, extended course of shingles -Urinary retention, frquently self-catheterizes -A. Fib on coumadin -UTIs -Gout -Right inguinal hernia repair at [**Hospital1 18**] in [**2154**]-[**2155**] -Repair of "broken nose." -Right knee anterior meniscal tear with fluid drainage and cortisone injection in [**6-1**] -Enlarged prostate (biopsy negative) -Hiatal hernia -14-year history of skin cancers, including "a dozen" basal cell cancers, one SCC of the chin, and one "0.8 mm deep" melanoma of the left forearm ([**5-1**]) . Oncology History: Initially presented in [**2162**] with a left anterior chest lesion. -On [**2162-10-14**], he underwent surgical resection of squamous cell carcinoma with an advancement flap. Specimen measured 3.4 x 2.5 cm and extended to a depth of 1.1 cm. Pathology- moderately differentiated squamous cell carcinoma with focal lymphatic and perineural invasion. -[**5-/2163**], he developed swelling involving the left axilla. On [**2163-7-11**], FNA of this lymphadenopathy was positive for malignant cells consistent with metastatic squamous cell cancer. -[**2163-8-5**], complete axillary lymph node dissection, [**2-18**] lymph nodes were involved with metastatic squamous cell carcinoma measuring up to 3.9 cm in greatest dimension with foci of extracapsular extension. [**8-/2163**], Adjuvant radiation therapy to the left axilla- 5094 cGy to the left axilla with left chest wall boost of 3000 cGy, completed on [**2163-9-19**]. -[**1-/2164**], bilateral small pulmonary nodules which increased in size; [**2164-3-25**]-biopsy confirmed metastatic squamous cell cancer. In [**4-/2164**], the patient received carboplatin at an AUC of 5 combined with paclitaxel 175 mg/m2. He completed four cycles and subsequently was treated with capecitabine and most recently six cycles of single [**Doctor Last Name 360**] gemcitabine completed on [**2164-10-11**]. - Currently on phase I protocol #09-066. Cycle 5 day 15 of his drugs were held in the setting of grade II mucositis and thrush. Social History: Patient lives at home with his wife. [**Name (NI) **] is a retired investment banker. He endorses drinking [**1-26**] glasses of wine weekly. He denies a history of smoking or illicit drug use. Family History: Mother deceased CVA. Father deceased MI. Sister deceased from renal failure r/t DM. Physical Exam: General: Elderly caucasion male, speaking in full sentences HEENT: Sclera anicteric, oropharynx w/ mucositis, mmm Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregularly irregular, tachycardic, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Alert and oriented x3, CN2-12 intact, [**5-29**] plantar/dorsiflexion, moving all extremities . on discharge: no foley Pertinent Results: Admission Labs: [**2165-3-20**] 11:22AM BLOOD WBC-5.6 RBC-3.85* Hgb-10.1* Hct-30.6* MCV-80* MCH-26.3* MCHC-33.1 RDW-18.2* Plt Ct-212 [**2165-3-20**] 11:22AM BLOOD Neuts-91.0* Lymphs-6.2* Monos-2.1 Eos-0.7 Baso-0.1 [**2165-3-20**] 11:40AM BLOOD PT-14.6* PTT-28.1 INR(PT)-1.3* [**2165-3-20**] 11:22AM BLOOD Glucose-126* UreaN-15 Creat-0.7 Na-135 K-4.3 Cl-100 HCO3-25 AnGap-14 [**2165-3-20**] 11:22AM BLOOD ALT-46* AST-33 LD(LDH)-222 AlkPhos-73 TotBili-0.4 [**2165-3-20**] 11:22AM BLOOD TotProt-6.0* Albumin-2.9* Globuln-3.1 Calcium-8.5 Phos-2.8 Mg-1.9 [**2165-3-20**] 12:58PM BLOOD Glucose-113* Lactate-1.2 [**2165-3-20**] 09:34PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.033 [**2165-3-20**] 09:34PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG [**2165-3-20**] 09:34PM URINE RBC-4* WBC-189* Bacteri-FEW Yeast-NONE Epi-0 Microbiology: Urine culture x 2 negative MRSA screen negative Urine Legionella antigen negative Respiratory viral screen x 2 - no virus cultured Blood cultures - NGTD EKGs: [**2165-3-20**] Atrial fibrillation, average ventricular rate 82. Moderate baseline artifact. Compared to the previous tracing of [**2164-10-25**] the rate has slowed from 135 to 82 and the rhythm has changed from atrial flutter with 2:1 block to atrial fibrillation. In addition, the current tracing has regression of the ST-T wave changes noted in leads II, III, aVF and V3-V6 at that time. Imaging: [**2165-3-20**] AP CXR - IMPRESSION: Increased pulmonary edema, cannot exclude bibasilar consolidation. Known pulmonary metastases. [**2165-3-20**] CT HEAD - prelim - no acute bleed or sig change from prior [**2165-3-20**] CTA Chest - IMPRESSION: 1. No definite evidence of pulmonary embolism, slightly limited by respiratory motion. 2. Interval increase in size of multiple bilateral pulmonary metastases. 3. Increase in mediastinal adenopathy. 4. Right basilar pleural thickening and nodularity with a new moderate right pleural effusion, associated with atelectasis and consolidation of the right lower lobe. 5. Patchy opacities in the right middle and left upper lobes, may be infectious or inflammatory. [**2165-3-21**] Transthoracic ECHO - The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-26**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Mild to moderate mitral regurgitation. Moderate pulmonary hypertension. Substantial biatrial dilatation. Brief Hospital Course: Mr. [**Known lastname 3501**] is a 72 year old male with SCC metastatic to left axilla and lung, a fib, HTN, HLD, who presented with shortness of breath and weakness. # Hypoxia, shortness of breath - Most likely secondary to pleural effusion and pneumonia. CTA was negative for PE and patient is therapeutic on coumadin for afib. He was also treated for healthcare associated pneumonia with vancomycin, zosyn, and levofloxacin starting on [**3-23**] for a 10 day course that was transitioned to augmentin alone after his levofloxacin dose on [**2165-3-28**]. His shortness of breath improved, however, he remained hypoxic on room air. A thoracentesis was done and showed an exudative effusion. Pleural fluid was sent for cytology and this was pending at the time of discharge, gram stain had 4+ PMNs, no organisms. PENDING AT THE TIME OF DISCHARGE: PLEURAL FLUID CULTURES AND CYTOLOGY . # Atrial fibrillation/atrial flutter - On admission the patient was placed on shorter acting forms of metoprolol and diltiazem due to concern for possible sepsis and hypotension. The patient intermittantly had heart rates of up to 150 that responded to his usual medications. Pt was discharged on prior diltiazem SR dose and metoprolol tartrate 37.5 [**Hospital1 **] was increased to toprol 150 daily. Pt's coumadin was held in preparation for thoracentesis but restarted without bridge after thoracentesis was completed. . # Mucositis and Thrush: Secondary to chemotherapy and improved significantly with course of fluconazole. Pt was discharged on magic mouthwash (Maalox/Diphenhydramine/Lidocaine). . # Metastatic SCC: Cutaneous squamous cell carcinoma, with metastasis to left axilla (s/p left axillary dissection) and pulmonary nodules. Patient is s/p resection, XRT, and currently undergoing phase I clinical trial treatment with Torisel and Neratinib (though this has been held since [**3-9**] given mucositis). Per his oncologist, pt may resume this regimen on discharge. THis is to be discussed further c pt's oncologist as outpt. Pt recieved oxycodone for pain, ativan for anxiety and magic mouthwash for mucositis. . # HTN: well controlled on diltiazem and metoprolol . # Hyperlipidemia: Continued home statin . # Gout: Continued allopurinol . Full code Medications on Admission: Acetaminophen-Codeine 300 mg-30 mg [**1-26**] Tablet(s) q 4-6 prn Allopurinol 300 mg daily Chlorhexidine Gluconate 0.12 % Mouthwash 15mL [**Hospital1 **] Dexamethasone 0.5 mg/5 mL Elixir one teaspoon daily Diltiazem 180 mg SR daily Kaopectate/Benadryl/Visc Xylocaine 5mL QID prn Lorazepam 1-2 mg prn Metoprolol 37.5 mg [**Hospital1 **] Nystatin 4 ml QID Percocet 5 mg-325 mg [**1-26**] Tablet(s) Q4h prn Simvastatin 40 mg daily Warfarin 2.5 mg daily Ergocalciferol (Vitamin D2) 400 unit daily Multivitamin Psyllium [Metamucil] Ranitidine HCl 150 mg [**Hospital1 **] Discharge Medications: 1. Home Oxygen Home Oxygen 3L continuous via nasal cannula pulse oximetry for portability 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety, insomnia. 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) 15 mL Mucous membrane twice a day. 5. Dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO once a day: elixir. 6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily) as needed for constipation. 14. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: One (1) 30mL Mucous membrane every six (6) hours as needed for heartburn. Disp:*1 bottle* Refills:*0* 15. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:*6 Tablet(s)* Refills:*0* 16. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0* 17. Outpatient Lab Work Please check PT/INR on Friday [**2165-3-29**], Monday [**2165-4-1**] and Wednesday [**2165-4-3**]. Please call results in to Dr [**Last Name (STitle) 6457**] at [**Telephone/Fax (1) 7318**]. PLease ask if any dose adjustment is necessary in pt's coumadin. After [**2165-4-3**] please discuss with Dr [**Last Name (STitle) 6457**] whether it would be ok to space INR checks out to once a week (every wednesday). 18. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: primary: bacterial pneumonia, atrial fibrillation with rapid ventricular response Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to [**Hospital1 **] Hospital because of shortness of breath and low oxygen in your blood. We thought this was from pneumonia and treated you with antibiotics. You also had a lot of fluid around your lungs that could be from pneumonia or from your cancer. We drained the fluid and your breathing got better. We are still waiting to hear from pathology about the final results from the fluid. Dr [**Last Name (STitle) **] can tell you more about the fluid next time you see her. When you get home please continue your regular medicines. The following changes have been made to your medications: STOP your metoprolol tartrate (lopressor) START metoprolol succinate (toprol) 150 mg once a day START the antibiotic augmentin for 3 more days . Please continue to get your coumadin level checked, as you have been. Since you are on the antibiotics you should get your coumadin level checked frequently. Followup Instructions: You have the following appointments scheduled: Provider: [**Name Initial (NameIs) 455**] 3-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2165-4-3**] 8:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7634**], MD Phone:[**Telephone/Fax (1) 447**] Date/Time:[**2165-4-3**] 8:30 Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2165-4-10**] 8:30 Completed by:[**2165-3-28**]

Admission Date: [**2149-10-21**] Discharge Date: [**2149-10-27**] Date of Birth: [**2085-5-16**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest Discomfort Major Surgical or Invasive Procedure: s/p Redo-Sternotomy/Coronary Artery Bypass Graft x 2 on [**2149-10-21**] History of Present Illness: Mr. [**Known lastname **] is a 64 yo male with significant cardiac past medical history who was experiencing chest discomfort with minimal activity. He had a positive exercise tolerance test and was referred for a cardiac cath. On cath he had a patent LIMA but occluded native and vein graft vessels. He was then referred for redo bypass surgery. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 [**2138**] Hypercholesterolemia Hypertension Diabetes Mellitus Factor VII Deficiency s/p Colectomy Social History: Live alone Quit 15 yrs ago after 3ppd x 30years, Occ. Pipe 1 drink ETOH/day Family History: Mother and Father both with CAD Physical Exam: General: NAD, Lying supine after cath HEENT: EOMI, PERRL, NC/AT Skin: Well healed MSI, L GSV harvest ankle to thigh Heart: RRR, +S1S2 -c/r/m/g Lungs: CTAB -w/r/r Abd: Soft NT/ND, +BS Ext: cool, decreased pp, -varicosisties Neuro: A&O x 3, non-focal, MAE Pertinent Results: [**2149-10-26**] 06:15AM BLOOD WBC-5.3 RBC-3.17* Hgb-10.0* Hct-27.0* MCV-85 MCH-31.4 MCHC-36.8* RDW-13.6 Plt Ct-233 [**2149-10-26**] 06:15AM BLOOD UreaN-19 Creat-0.9 K-4.2 [**2149-10-24**] 01:25PM BLOOD Glucose-119* UreaN-25* Creat-1.0 Na-138 K-3.9 Cl-103 HCO3-26 AnGap-13 [**2149-10-21**] 12:28PM BLOOD PT-17.3* PTT-31.5 INR(PT)-2.1 [**2149-10-24**] 11:41AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022 [**2149-10-24**] 11:41AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Brief Hospital Course: Patient was a same day admit and on [**2149-10-21**] he was brought directly to the operating room where he underwent a redo coronary artery bypass graft x 2. Please see op note for surgical details. Pt. tolerated the procedure well and was transferred to the CSRU in stable condition receiving Neo-Synephrine and Propofol. Later on op day pt was weaned from mechanical ventilation and sedation and was extubated. He was neurologically intact. By post-operative day one he was weaned from any Inotropes and diuretics and b-blockers were initiated per protocol. His chest tubes were removed on post op day 1 and epicardial pacing wires on day 2. He was transferred to the telemetry floor on post-op day 1. Patient had no post op complications and made a rather swift recovery. He cleared level 5 on post op day 3. He did however have a slight temperature and remained in the hospital until post op day six when he was discharged home with vna services and the appropriate follow-up appointments. Medications on Admission: Metformin, Glipizide, Lopid, Lipitor, ASA, Atenolol, Lisinprol Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. 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* 5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. 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. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease s/p Redo-Sternotomy/Coronary Artery Bypass Graft x 2 on [**2149-10-21**] Hypercholesterolemia Hypertension Diabetes Mellitus Factor VII Deficiency s/p Coronary Artery Bypass Graft x 3 [**2138**] Discharge Condition: good Discharge Instructions: Can take shower. Wash in incisions with warm water and gentle soap. Gently pat dry. Do no bath or swim. Do not apply lotions, creams, ointments, or powders to incisions. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. If you notice any sternal drainage or fever greater than 101 please contact office. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) 16004**] in [**11-17**] weeks Dr. [**Last Name (STitle) **] in [**12-19**] weeks Completed by:[**2149-10-27**]

Admission Date: [**2175-4-27**] Discharge Date: [**2175-5-3**] Date of Birth: [**2129-12-10**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5868**] Chief Complaint: HA and abnormal MRI Major Surgical or Invasive Procedure: None History of Present Illness: This is a 45 yo RH woman with h/o headaches who was transferred from [**Hospital3 2568**] for abnormal CT. She was in her usual state of health until Monday (4 days ago) when she awoke at 4am with terrible headache and vision changes. Her vision was blurry with red/blue lights, this lasted "all morning." Head pain is all over, throbbing, constant with nausea (no emesis), + photo/phonophobia, worse with leaning forward or having a BM, not relieved with multiple meds(motrin, darvan, methadone that she had taken in the past for LBP). The headache got better yesterday then got much worse in the evening and she became diaphoretic, thus she presented to [**Hospital3 **]. She denies any weakness, numbness, tingling, vertigo, trouble swallowing, facial droop, trouble getting around or doing activities, trouble with language, neck pain/stiffness. + tinnitus bilaterally since yesterday. No diplopia, voice changes or hiccups. No fever, + chills last night, no weight changes, rash, joint pain. At [**Hospital3 **], her BP was 220/118, she was given morphine 4mg x 3 doses, labetolol 10mg x 2 doses, reglan and zofran. Head CT was abnormal, transferred to [**Hospital1 18**] for neurosurgical evaluation. Nsurg saw patient, rec'd MRI, and decided she needed admission for a metastatic w/u given MRI showed ? mass in left occipital lobe and maybe elsewhere as well (?), thus neurology was consulted. Patient states that she has a h/o headaches that started around age 16, one sided and throbbing, but UNLIKE headache she currently has, + photo/phonophobia, + n/v, no aura. These headaches stopped [**2-11**] yrs ago. In our ED she was given labetolol 10mg, then started on a labetolol gtt. dilaudid 1mg, anzemet and decadron 10mg. Past Medical History: - HTN - headaches as above - 3 miscarriages around 2.5-3 months gestation - low back pain from lifting her mother once - s/p c section and tonsillectomy - hypothyroidism - GI ulcers, no h/o GI bleed and no h/o surgery required for ulcer - in reviewing medical information from [**Hospital3 **], ESR was 79 in [**2173**], patient does not know why or why this was checked. Social History: no tob/etoh/drugs, but does get 2nd hand smoke from her cousin whom she spends a lot of time with, currently going thru a divorce, has 3 kids (18, 15, 13 yo). Was an x-ray tech, but is currently on disability after lifting her mother and acquiring low back pain. Family History: dad died of liver cancer and had hepatitis, mom broke her ankle and then died of PE, sister died of a "migraine that had bleeding on autopsy" at age 30, brother alive with colon cancer dx'd at age 57, aunt with pancreatic cancer. Kids are healthy. No known aneurysms. Physical Exam: VITALS: BP 159/98 on labetolol gtt (was 220/118 at OSH), 98.9, 78, 98% RA GEN: obese pleasant woman, diaphoretic, nervous/anxious SKIN: no rash HEENT: NC/AT, anicteric sclera, mmm, no ocular bruits NECK: supple, no carotid bruits, no meningismus CHEST: normal respiratory pattern, CTA bilat BREAST: exam normal, no masses, no LAD axilla, no nipple discharge CV: regular rate and rhythm without murmurs ABD: soft, nontender, nondistended, +BS, no HSM EXTREM: no edema, wwp NEURO: Mental status: Patient is alert, awake, pleasant but anxious affect. Oriented to person, place, time. Good attention - spells world forwards and backwards. Language is fluent with good comprehension, repetition, naming intact, no dysarthria. No apraxia, agnosias, no neglect. Able to calculate, no left/right mismatch. Registration [**2-10**] objects. Recalls [**2-10**] objects after 3 minutes. Color vision is OK, no color anomia. Cranial Nerves: I: deferred II: Visual acuity: 20/25-1 right, 20/30-1 left without aids. Visual fields: full to left/right/upper/lower fields. Fundoscopic exam: discs flat, fundi clear, no hemorrhages or exudates. Pupils: 4->2 mm, consenual constriction to light. III, IV, VI: EOMS full, gaze conjugate. No nystagmus or ptosis. V: facial sensation intact over V1/2/3 to light touch and pin prick. VII: symmetric face VIII: hearing intact to finger rubs IX, X: Symmetric elevation of palate. [**Doctor First Name 81**]: shrug [**4-14**] bilaterally XII: tongue midline without atrophy or fasciculations. Sensory: Normal touch, vibration, proprioception, pinprick, temperature sensation. No extinction to double simultaneous stimulation. Motor: Normal bulk, tone. No fasciculations or drift. No adventitious movements. No asterixis. Full strength. Reflexes: [**Hospital1 **] BR Tri Pat Ach Toes RT: 2 2 2 2 2 mute LEFT: 2 2 2 2 2 mute Coordination: Normal finger-to-nose, heel-to-shin, RAMs. Gait: normal narrow based, normal tandem, no romberg Pertinent Results: [**2175-4-27**] 01:20AM BLOOD WBC-16.7* RBC-4.88 Hgb-16.1* Hct-46.0 MCV-94 MCH-33.0* MCHC-35.0 RDW-13.4 Plt Ct-340 [**2175-5-2**] 08:11AM BLOOD WBC-11.8* RBC-4.38 Hgb-14.2 Hct-42.2 MCV-97 MCH-32.5* MCHC-33.7 RDW-13.4 Plt Ct-321 [**2175-4-27**] 01:20AM BLOOD Neuts-77.4* Lymphs-17.5* Monos-3.0 Eos-1.7 Baso-0.3 [**2175-4-27**] 01:20AM BLOOD PT-11.3 PTT-22.3 INR(PT)-0.9 [**2175-4-29**] 06:16AM BLOOD Glucose-142* UreaN-33* Creat-0.8 Na-141 K-4.4 Cl-104 HCO3-24 AnGap-17 [**2175-4-28**] 04:00AM BLOOD Albumin-4.7 Calcium-10.2 Phos-2.6* Mg-2.4 ---- [**2175-4-27**] 01:20AM BLOOD TSH-12* [**2175-4-28**] 04:00AM BLOOD TSH-2.3 [**2175-4-29**] 06:16AM BLOOD TSH-0.89 [**2175-4-30**] 07:30AM BLOOD TSH-2.3 [**2175-4-28**] 04:00AM BLOOD T4-7.1 T3-57* calcTBG-1.06 TUptake-0.94 T4Index-6.7 Free T4-1.1 ---- [**2175-4-28**] 04:00AM BLOOD PTH-74* [**2175-4-28**] 04:00AM BLOOD Cortsol-2.8 [**2175-4-30**] 07:30AM BLOOD Cortsol-7.3 ----- MRA/V: FINDINGS: The arterial images are somewhat limited by motion artifact. The right vertebral artery appears to be dominant. The left is small and less well seen. The basilar artery is widely patent. The distal internal carotid arteries appear normal. The cerebral artery show good flow. The venous study is better in quality. There is good flow in the superior sagittal sinus. As expected, inferiorly with changing direction it decreases in signal intensity slightly but there is good flow throughout it. The deep venous system is normal. There is normal asymmetry of the transverse and sigmoid sinuses as well as the jugular veins. Normal cortical veins are seen. IMPRESSION: No evidence of dural venous sinus thrombosis. ----- CXR Normal ----- MRI head [**4-27**]: IMPRESSION: Focal area of signal abnormality within the occipital lobes, with gadolinium enhancement and restricted diffusion seen in the left occipital lobe. The primary diagnostic consideration, given the history of hypertension is posterior reversible leukoencephalopathy (PRES). Other considerations include demyelinating or metastatic disease. A followup MRI is recommended in three to four days to assess for reversibility, which if present would obviously favor PRES. ----- CSF cytology negative ----- MRA kidneys: IMPRESSION: 1. No renal artery stenosis. Normal appearance of the kidneys. 2. Fatty infiltration of the liver. ----- MRI repeat [**5-2**]: 1. Interval decrease in size of T2 and FLAIR hyperintensities with residual signal on the left greater than right. No definite signal abnormalities seen within the vermis. 2. Persistent focus of restricted diffusion, corresponding with enhancement at site of T2 and FLAIR hyperintensity within the left occipital lobe, raising the question of possible infarct which could be sequelae of posterior reversible leukoencephalopathy (PRES). Brief Hospital Course: The patient is a 45 year old woman with a week of a throbbing bilateral headache associated with photophobia/phonophobia that is atypical from her usual migraine. This is in the setting of exacerbated hypertension of unknown cause. No other medications started recently per patient. Her exam showed a woman who is diaphoretic and tremulous. Otherwise she is neurologically intact, with no evidence of increased ICP. She was initially extremely hypertensive on admission and placed on a labetalol drip. This was quickly weaned off and she was well controlled on oral BP meds. We started metoprolol and verapamil, both of which control blood pressure and can be used for migraine prophylaxis. Her MRI was consistent with a reversible posterior leukoencephalopathy, likely caused by her elevated BP. We could not entirely exclude the possibility of tumor, although we felt it was less likely. She had no venous sinus occlusion on MRV. The MRA was poor quality. A repeat MRI 5 days later showed interval improvement, making posterior leukoencephalopathy more likely. She also had an LP which was very normal, with no cells, normal protein/glucose, and no OCBs. This made infectious/inflammatory/demyelinating causes very unlikely. After this diagnosis was made and her BP was very well controlled on oral medications, her headache became the [**Last Name **] problem. [**Name (NI) **] headaches sounded like status migrainosus or a mixed headache type that was exacerbated by a hypertensive crisis. She was on a Dilaudid PCA initially. A solumedrol 1 gram IV dose was given which helped somewhat but didn't relieve the pain. The pain service was consulted and she was started on ibuprofen, neurontin, topamax, and PO dilaudid with variable results. She was also started on Klonopin for muscle relaxation. At this point, it was felt that her headaches were multifactorial. She was having migraine headaches which caused tension headaches, which caused reappearance of her migraine headaches. The above medications were meant to attempt to break that cycle. She was stable otherwise and felt she would better be able to break her headache cycle at home, so she was discharged with the above medications, with Percocet instead of dilaudid. She will follow-up in stroke clinic, and due to the enhancing lesion, in neurosurgery clinic with a follow-up MRI scan in [**3-16**] weeks to exclude the possibility of tumor. She can also follow-up in the pain clinic if needed depending on how her headache resolves. 2.Endocrine: The endocrine service was consulted due to concern for an endocrine source for her HTN. She had a high TSH initially, that quickly corrected. Her other thyroid studies were normal. We then considered pheochromocytoma and RAS. She had a renal artery MRA which was normal. Studies for pheo are pending. She also had PTH sent which returned elevated. Vitamin D, renin, aldosterone are currently pending, as are urine and plasma studies to rule out pheo. She will follow-up in endocrine clinic to address these test results and continue her work-up. 3.CV:She was sent home on metoprolol and verapamil for Bp control. These can be titrated as needed by her PCP. 4.Pain:As above, she was sent out with 1 week or pain medication to allow her to resolve her headache. She was also sent on a klonopin taper in order to avoid benzo withdrawl. She will follow-up as above. Medications on Admission: synthroid 0.125mg daily corgard 40mg daily Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 4. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) for 7 days. Disp:*42 Tablet(s)* Refills:*0* 5. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). Disp:*270 Capsule(s)* Refills:*2* 6. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Clonazepam 1 mg Tablet Sig: as directed Tablet PO TID (3 times a day) for as directed days: Take 1 tab three times a day for 1 week, then take 1 tab twice a day for 4 days, then 1 tab daily for 4 days, then stop. Disp:*33 Tablet(s)* Refills:*0* 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 7 days. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Posterior leukoencephalopathy-Hypertension related Migraine headache Tension-type headache HTN Discharge Condition: Stable. She continues to have a headache, but is otherwise at her baseline. Discharge Instructions: Please call your doctor or return to the ED if you have a worsening of your headache, weakness, numbness, tingling, visual or hearing changes, trouble speaking, imbalance, or falls. ----- Please take your medications as directed for headache relief. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10541**], MD Date/Time:[**2175-7-11**] 2:30 --- Please see your PCP [**Last Name (NamePattern4) **] [**12-12**] weeks in follow-up after hospitalization. --- Please follow-up with Dr [**Last Name (STitle) **] in [**3-16**] weeks. You should call his office at [**Telephone/Fax (1) 1669**] to arrange this. You will also need a repeat MRI and this will be arranged by his office as well. --- Please follow-up in neurology clinic with Dr [**Last Name (STitle) 4638**] and [**Doctor Last Name **] at [**Telephone/Fax (1) 2574**]. They will call you to arrange this appointment for 4-6 weeks from now. ---- Finally, please call the endocrine clinic at the number they gave you while in the hospital to make an outpatient appointment with Dr [**First Name (STitle) **] or Dr [**Last Name (STitle) 17033**].

Admission Date: [**2173-10-21**] Discharge Date: [**2173-10-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 86 year old female with a history of hypertension, hypercholesterolemia, and dementia who presents from [**Hospital3 **] with complaints of chest pain. The patient is a poor historian, providing varied details since presentation. [**Name (NI) **] unclear why she had come to the hospital. Endoreses having experineced chest pain, which she describes as daily, occuring with exercise. Says she infrequently gets with rest. Denies any SOB, DOE, or palpitations. She has no history of prior heart attack or being told she has a bad heart. No headaches, blurred vision, or focal motor,sensory abnormalities. In the ED, initial plan was to observe patient overnight with a ROMI, and a ETT in the morning. During her ED stay, patinet had an 16 beat run of NSVT, during which she was asymptomatic. Over the course of the day, patient's BP had been drifing upward, with systolic blood pressure rising from 155 to 264, and developed respiratory distress. Her O2 sats dropped to low 90s. She was initially given 5 mg of metoprolol x 2 without significant effect. She was begun on a nitro gtt, with reduction to SBP to 165. Additonally, she was begun on CPAP 10/5 and given 20mg IV lasix, to which she put out 500cc. She was successfully ween to 5L O2 NC and sent to the CCU for further care. The patient remained chest pain free throughout. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Has markedly swollon legs with venous stasis changes, which the patinet reports to be chronic for months to years. Per contact with pt's Alzheimer's facility, pt does not usually complain of chest pain. They report that prior to presenting to the [**Name (NI) **], pt had had a visitor after which she developed some agitation. There is no record of chest pain, rather emotional distress. Past Medical History: Hypertension Hyperlipidemia Dementia Social History: Patient is resident at springhouse [**Hospital3 **]. She has a durable limited power of attorney to Robiee [**Doctor Last Name **]. Never married, no children. Worked as a secretary. -Tobacco history: None -ETOH: None -Illicit drugs: None Family History: No family history of early MI, otherwise non-contributory. Physical Exam: VS: T=98.5 BP= 163/ 46 HR= 64 RR= 30 O2 sat= 100% on 5LNC GENERAL: Frail elderly female in NAD. Oriented x2. Mood, affect appropriate. Hard of hearing. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MM. No xanthalesma. NECK: Supple with JVP flat. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Patient tachypic, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ LE pre-tibial edema, with b/l erythema and skin breakdown. SKIN: LE stasis dermatitis with ulceration 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: [**2173-10-22**] 04:16AM BLOOD WBC-7.8 RBC-4.11* Hgb-12.2 Hct-35.5* MCV-86 MCH-29.7 MCHC-34.4 RDW-15.0 Plt Ct-131* [**2173-10-21**] 04:20PM BLOOD PT-13.9* PTT-25.0 INR(PT)-1.2* [**2173-10-22**] 04:16AM BLOOD Glucose-118* UreaN-12 Creat-0.8 Na-145 K-4.3 Cl-106 HCO3-32 AnGap-11 [**2173-10-22**] 04:16AM BLOOD CK(CPK)-41 [**2173-10-22**] 04:16AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2173-10-22**] 04:16AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.1 Cholest-PND [**2173-10-22**] 04:16AM BLOOD Triglyc-PND HDL-PND PA/LAT [**10-21**]: 1. Minimal bibasilar atelectasis. 2. Calcified structure in the left upper quadrant of uncertain etiology. ECHO [**10-22**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. 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. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Patient is an 86 year old female with a history of HTN, dyslipidemia, and dementia who presented with complaints of atypical chest pain, admitted with hypertensive emergency with flash pulmonary edema. # CORONARIES: The patient has no known history of significant coronary disease. EKG only with mild ST changes in setting of marked hypertension, and symptoms of pain atypcial for ACS event. Had mild troponin elevation on second set of cardiac markers, and flat CKs, thought to be most likely demand ischemia in setting of marked systolic hypertension. No mediastinal enlargement to suggest aortic dissection. Patient is a poor historian, describing daily exertional chest pain with exercise, but has varied answering to questions. On confirmation with pt's [**Hospital3 **] facility, she had not previously ever complained of chest pain. Pt was medically managed with aspirin, statin. Prior to discharge she was restarted on her outpt atenolol and added lisinopril 5mg for additional BP control. # PUMP: The patient has no known history of heart dysfunction, but did develop flash pulmonary edema in the setting of hypertensive emergency. Pt responded very well to lasix both symptomatically and on oxygen requirement. Pt did not require any additonal doses of lasix since arriving to the CCU. Echocardiogram showed moderate LVH, EF 75%, [**11-25**] TR, no wall motion abnormalities and increased PCW. # RHYTHM: No current or history of arrythmias # HYPERTENSIVE URGENCY: Pt with no history of significant systolic blood pressure elevation and only on atenolol 25mg daily preivously. In the emergency room, pt's SBP rose to 260 complicated by flash pulmonary edema. Pt received IV beta blockade and a nitroglycerin drip, which was able to be weaned off within several hours. Etiology of hypertension was thought to be mostly agitation and pt's BPs were well controlled with home dose of atenolol and the addition of lisinopril 5mg daily. Pt will need monitoring of electrolytes several days post discharge to evaluate effects of new medicaiton. # ACUTE PULMONARY EDEMA: Pt developed acute pulmonary edema in the setting of hypertensive emergency. Improvement with blood pressure control, diuresis, and CPAP, with thereafter good saturations and comfort on minimal O2. Pt did not require any additonal diuresis after arriving to the CCu. # DEMENTIA: Pt was continued on Zyprexa. Pt's code status was DNR/DNI throughout the hospitalization. Medications on Admission: Atenolol Lipitor ASA Exelon Zyprexa MVI Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Rivastigmine 4.6 mg/24 hour Patch 24 hr Sig: One (1) patch Transdermal once a day. Discharge Disposition: Extended Care Facility: Springhouse Discharge Diagnosis: Hypertensive Urgency Discharge Condition: Stable, SBP 120s-140s. Discharge Instructions: You were admitted for very high blood pressure, thought to be secondary to emotional distress. You blood pressure was well controlled while you were here with the addition of Lisinopril 5mg daily. We also made sure that you did not have a heart attack. The following changes were made to your medications: **ADD lisinopril 5mg by mouth daily Please call your doctor or return to the hospital if you experience any chest pain, shortness of breath, visual changes, nausea, vomiting, lightheadedness or any other concerning symptoms. Followup Instructions: Please see your primary care doctor in the next 1-2 weeks. Completed by:[**2173-10-22**]

Admission Date: [**2196-7-28**] Discharge Date: Date of Birth: [**2145-8-22**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old male with history of substance abuse, chronic back pain, hepatitis B and C with toxic megacolon, status post emergency colectomy and renal insufficiency. The patient presented for elective ileostomy takedown. PAST MEDICAL HISTORY: 1. Substance abuse, including cocaine, heroin, and alcohol. 2. Chronic back pain due to compression fracture. 3. Osteomyelitis. 4. Hepatitis B. 5. Hepatitis C. 6. Chronic obstructive pulmonary disease. 7. Hypertension. 8. Toxic megacolon. 9. Renal insufficiency. PAST SURGICAL HISTORY: Status post emergent subtotal colectomy with end ileostomy and mucous fistula [**2195-10-17**]. Status post open "chole." MEDICATIONS ON ADMISSION: 1. Albuterol 90 mcg two puffs q.i.d.p.r.n. 2. Aristocort 0.5% applied to rash b.i.d. 3. Doxepin 25 mg q.h.s. 4. Flovent 110 mcg two puffs q.d. 5. Linezolid 600 mg one tablet b.i.d. 6. Multivitamin one tablet q.d. 7. Neurontin 300 mg one tablet t.i.d. 8. Propanolol 40 mg one tablet b.i.d. 9. Protonix 40 mg one tablet q.d. 10. Rifampin 300 mg one tablet b.i.d. 11. Risperdal one tablet q.h.s. 12. Soma 350 mg one tablet t.i.d. 13. Ultram 50 mg one to two three times a day p.r.n. ALLERGIES: The patient is allergic to SULFONAMIDES. PHYSICAL EXAMINATION: Examination revealed the following: temperature 97.1, blood pressure 150/90, pulse 86, respiratory rate 18, oxygen saturation 99%, weight 157?????? pounds. LUNGS: Lungs were clear to auscultation. HEART: regular rate and rhythm, normal S1 and S2. ABDOMEN: Soft, nontender, nontender, bowel sounds present and hyperactive, significant were green-brown cecal material in colostomy bag. Discrete moderate tenderness in the mid and lower thoracic spine. NEUROLOGICAL: Unremarkable. HOSPITAL COURSE: The patient was taken to the operating room on [**2196-7-28**], where ileostomy takedown, ileocolonic anastomosis takedown of mucous fistula and lysis of adhesion was performed. The operation went without complications. The patient was transferred to PACU in stable condition. Postoperatively, the patient spiked fevers up to 102.6. Vital signs were stable. The patient was started on Cipro. On postoperative day #3, there was increased abdominal distention with increased erythema around the wound and slight serous disease. On postoperative day #4, discharge from the dressing turned green. There was increased distention, diffuse abdominal tenderness to palpation. The patient was taken to the operating room on [**2196-8-1**] for exploratory laparotomy, lysis of adhesions, and ileostomy and small bowel resection. The patient was found to have a small bowel perforation. The operation went to complication. The patient was transferred to the ICU in stable condition. In the ICU, the patient continued spiking fever up to 102.1. He has remained intubated. He was started on Vancomycin, Levofloxacin, and Flagyl. The patient required intermittent fluid bolus for hypertension. The patient was started on TPN on [**2196-8-4**]. On [**2196-8-5**], the blood pressure was stable enough to tolerate Lasix for diuresis. On [**2196-8-6**] the patient was stable enough and transferred to the floor. On the floor, the patient continued to have a low-grade fever. The patient started working with PT, ambulating and advancing the diet on [**2196-8-11**]. The diet was advanced slowly. The patient tolerated the diet well. On [**2196-8-16**], the patient was afebrile. Vital signs were stable. The patient finished the course of antibiotics. The wound is dry with good granulation tissue growing in small amount of fibrous discharge at the bottom. Pain is well controlled with medication. The patient is off TPN. The patient is tolerating good POs. The patient is ambulating. The patient has no concerns, nor active issues at this time. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is discharged home with VNA for wet-to-dry dressing changes, G-tube care. FOLLOW-UP CARE: The patient should follow up with Dr. [**Last Name (STitle) 468**] in seven to ten days. The patient should call the office for an appointment. MEDICATIONS: 1. Albuterol one puff to two puffs q.6h.p.r.n. 2. Ipratropium two puffs IH q.i.d. 3. Lacrilube one application OU p.r.n. 4. Artificial tears, one to three drops OU p.r.n. 5. Epoetin alfa 6000 units q.week. 6. Reglan 10 mg PO q.8h.p.r.n. 7. Percocet one to two tablets PO q.4h. to 6h. p.r.n for pain. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern4) 15509**] MEDQUIST36 D: [**2196-8-16**] 13:07 T: [**2196-8-16**] 13:31 JOB#: [**Job Number 18260**]

Admission Date: [**2177-1-5**] Discharge Date: [**2177-1-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14037**] Chief Complaint: AMS, hypothermia Major Surgical or Invasive Procedure: None History of Present Illness: 86yo man with h/o CAD, DM2, HTN, CRI, mild pancytopenia, admitted from NH after diarrhea x3d, weakness and falls x1d, found in the ED to have profound hypothermia to 87 degrees, bradycardia to 25 bpm, BP 90/palp, hypoxia to 88% on NRB. Was given atropine in ED with poor HR response; given warmed IVF and bear hugger with good temperature response. In ED, also received 2 units PRBCs for anemia, Vanc and Levaquin for possible sepsis. Was sent to the MICU for eval and treatment. Past Medical History: 1. CAD x/p CABG X 2 2. CHF (EF 60-65%), dry weight 134 lbs 3. CRF with baseline creatinine of 2.6-3.6 4. DMII 5. Anemia- [**5-21**] EGD negative and colonoscopy negative 6. GERD 7. HTN 8. OA 9. Spinal stenosis 10. pna tx [**8-21**] 11 thrombocytopenia Social History: Lives at [**Location **] [**Hospital3 **]. Son is HCP. [**Name (NI) **] tobacco. No EtOH. Family History: Noncontributory Physical Exam: On presentation to ED: Vitals: T87.8 oral (really), HR 20, BP 90/palp, RR 18, 88% on NRB Gen: ill-appearing, elderly, frail man HEENT: PERRL, EOMI, anicteric, R pupil surgical, L reactive Neck: supple, JVP flat CV: distant hs, brady, regular, no mgr Lungs: CTA b/l Abd: soft, nt nd, +bs, no organomegaly Rectal: guaiac negative per ED staff Ext: no LE edema, 1+ DP pulses Neuro: responding verbal commands, MAE Skin: cool, dry Pertinent Results: [**2177-1-5**] 12:20AM BLOOD WBC-1.6*# RBC-2.77* Hgb-9.2* Hct-26.2* MCV-94 MCH-33.1* MCHC-35.1* RDW-16.1* Plt Ct-21*# [**2177-1-5**] 06:50AM BLOOD WBC-2.5*# RBC-2.58* Hgb-8.2* Hct-23.8* MCV-92 MCH-31.7 MCHC-34.3 RDW-16.0* Plt Ct-38*# [**2177-1-5**] 08:40AM BLOOD WBC-2.8* RBC-2.54* Hgb-8.1* Hct-23.4* MCV-92 MCH-31.7 MCHC-34.4 RDW-16.5* Plt Ct-37* [**2177-1-5**] 07:42PM BLOOD WBC-4.0 RBC-2.63* Hgb-8.1* Hct-24.3* MCV-92 MCH-31.0 MCHC-33.6 RDW-16.5* Plt Ct-35* [**2177-1-6**] 05:10AM BLOOD WBC-4.9 RBC-3.36*# Hgb-10.6*# Hct-30.7*# MCV-92 MCH-31.5 MCHC-34.5 RDW-16.1* Plt Ct-50* [**2177-1-7**] 05:00AM BLOOD WBC-4.8 RBC-3.54* Hgb-11.0* Hct-32.4* MCV-91 MCH-31.1 MCHC-34.1 RDW-16.7* Plt Ct-44* [**2177-1-8**] 05:20AM BLOOD WBC-5.7 RBC-3.36* Hgb-10.8* Hct-30.4* MCV-91 MCH-32.1* MCHC-35.5* RDW-16.2* Plt Ct-52* [**2177-1-5**] 12:20AM BLOOD Neuts-85* Bands-0 Lymphs-11* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2177-1-6**] 05:10AM BLOOD Neuts-83.2* Lymphs-9.8* Monos-6.2 Eos-0.8 Baso-0 [**2177-1-5**] 12:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [**2177-1-5**] 12:20AM BLOOD PT-13.8* PTT-35.3* INR(PT)-1.2 [**2177-1-5**] 12:20AM BLOOD Plt Smr-VERY LOW Plt Ct-21*# [**2177-1-5**] 06:50AM BLOOD Plt Ct-38*# [**2177-1-5**] 08:40AM BLOOD Plt Ct-37* [**2177-1-5**] 07:42PM BLOOD Plt Ct-35* [**2177-1-6**] 05:10AM BLOOD Plt Ct-50* [**2177-1-7**] 05:00AM BLOOD Plt Ct-44* [**2177-1-8**] 05:20AM BLOOD Plt Ct-52* [**2177-1-5**] 12:20AM BLOOD Gran Ct-1240* [**2177-1-5**] 08:40AM BLOOD Ret Aut-1.7 [**2177-1-5**] 12:20AM BLOOD Glucose-199* UreaN-101* Creat-3.5* Na-142 K-5.8* Cl-114* HCO3-16* AnGap-18 [**2177-1-8**] 05:20AM BLOOD Glucose-40* UreaN-97* Creat-4.1* Na-144 K-4.5 Cl-110* HCO3-22 AnGap-17 [**2177-1-5**] 12:20AM BLOOD CK(CPK)-105 [**2177-1-5**] 06:50AM BLOOD ALT-33 AST-22 LD(LDH)-155 CK(CPK)-70 AlkPhos-80 Amylase-36 TotBili-0.3 [**2177-1-5**] 07:42PM BLOOD CK(CPK)-102 [**2177-1-6**] 05:10AM BLOOD ALT-39 AST-31 LD(LDH)-180 CK(CPK)-114 AlkPhos-84 Amylase-56 TotBili-0.5 [**2177-1-6**] 05:10AM BLOOD Lipase-25 [**2177-1-5**] 12:20AM BLOOD CK-MB-16* MB Indx-15.2* cTropnT-0.02* [**2177-1-6**] 05:10AM BLOOD CK-MB-12* MB Indx-10.5* cTropnT-0.07* [**2177-1-5**] 12:20AM BLOOD Calcium-8.0* Phos-5.8* Mg-2.5 [**2177-1-8**] 05:20AM BLOOD Calcium-8.8 Phos-5.4* Mg-2.0 [**2177-1-5**] 06:50AM BLOOD calTIBC-196* Ferritn-731* TRF-151* [**2177-1-5**] 06:50AM BLOOD TSH-9.0* [**2177-1-6**] 05:10AM BLOOD TSH-7.3* [**2177-1-6**] 05:10AM BLOOD T4-3.9* calcTBG-1.08 TUptake-0.93 T4Index-3.6* [**2177-1-5**] 06:50AM BLOOD Cortsol-22.5* [**2177-1-7**] 05:00AM BLOOD Cortsol-21.5* [**2177-1-7**] 05:50AM BLOOD Cortsol-41.0* [**2177-1-6**] 05:10AM BLOOD Vanco-12.2* [**2177-1-5**] 12:40AM BLOOD pO2-83* pCO2-49* pH-7.31* calHCO3-26 Base XS--2 Comment-NONE SPECI [**2177-1-8**] 11:17AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.015 [**2177-1-8**] 11:17AM URINE Blood-LGE Nitrite-POS Protein-100 Glucose-TR Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG [**2177-1-5**] 06:50AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2177-1-8**] 11:17AM URINE RBC-86* WBC-3 Bacteri-NONE Yeast-NONE Epi-0 [**2177-1-5**] 06:50AM URINE RBC->50 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 [**2177-1-8**] 11:17AM URINE Hours-RANDOM UreaN-582 Creat-47 Na-80 [**2177-1-8**] 11:17AM URINE Osmolal-431 [**2177-1-6**] 7:48 pm URINE **FINAL REPORT [**2177-1-7**]** URINE CULTURE (Final [**2177-1-7**]): NO GROWTH. [**2177-1-6**] 5:10 am BLOOD CULTURE Site: ARM AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): Brief Hospital Course: A/P: 86yo man with h/o CAD, DM2, HTN, CRI, pancytopenia, a/w hypothermia, bradycardia, profound pancytopenia, found to be hypothyroid. . 1. Hypothyroidism, Primary: patient was found to have TSH on admit of 9.0, repeat was still elevated at 7.3; T4 was low at 3.9, c/w primary hypothyroidism; pt was started on Synthroid 112mcg/day. [**Last Name (un) **] stim test was negative. Endocrine was consulted and did not feel many of his symptoms were secondary to hypothyroidism. They wanted to decrease his synthroid to 50 mcg, recheck his TSH in 1 week and then decrease again to 25 mcg. This should be done at rehab. 2. Bradycardia: thought likely [**2-19**] hypothyroidism, maintained on on tele, had episodes of brady down to 35s occassionally with longest pause 2.2 seconds. Cardiology evaluated while the patient was in the MICU, said that the patient did not require pacer but to continue to monitor for drops in pressure or symptoms, which patient did not have during his hospital stay; thought likely to resolve as Synthroid takes effect. Will need outpatient follow up. . 3. Hypotherm: also likely [**2-19**] hypothyroidism, will warm as needed for now. Did not improve with synthroid. On discharge has temp of 92.7, so there is likely a central cause for this of unknown etiology. The patient should be followed closely, if his temp drops farther, he should be rewarmed. 4. Pancytopenia: patient was noted on admission to have WBC 1.9 down from baseline 6.0, Hct 26.2 down from baseline 30, plts 21 down from baseline 90-100. Patient currently receiving Epogen ?5000 or 20,000 units/week, received at the VA, but not followed by a Hematologist. Has had fairly stable counts until [**2174**]. In [**11-19**] anemia began, and was thought to be [**2-19**] kidney disease. EGD and cspy in [**5-21**] were negative for bleed, iron studies were c/w anemia of chronic disease with low retic count 1.7%. Heme recommended increasing his Epo to 40,000 units per week, which was initiated while he was in house on the night prior to his discharge. Heme also noted that his peripheral smear contained strange-looking cells suspicious for myelodysplastic process. They do not feel that a BM biopsy would change his management, but plan to follow him in clinic. Of note, the patient's WBC count returned to the patient's normal range, his hct remained stable after receiving 2 units PRBCs. His plt count remains low but is slowly trending upwards. He has had no evid of bleeding but we are holding ASA given this significant risk (he has a h/o falls) . 5. Blood sugars: pt has h/o DM2, was started on RISS as glyburide was held, then patient became hyponatremic, possibly because of hypothyroidism; was on a D5W drip briefly, RISS adjusted to keep sugars in check; pt seems very sensative to insulin at bedtime when he is not eating, so this scale was decreased compared to his daytime dosing. If patient needs to be started on a oral hypoglycemic, he should not be restarted on his glyburide as it is renally cleared. Glipizide can be considered. . 6. ARF: pt's creatinine bumped to 4.1 from 3.5 on day prior to discharge; likely prerenal in setting of overdiuresis, net negative 1700 day prior. Rehydrated gently with 500cc, rechecked BUN and Cr afterwards with resolution. Baseline Cr 3.5. . 7. Constipation: possibly [**2-19**] hypothyroid, increased bowel regimen . 8. CAD: CEs flat, ASA held [**2-19**] low platelets; cont statin; holding BB [**2-19**] AVB, bradycardia. He should not be restarted on a beta blocker. . 9. CHF: patient was initially felt to be a bit overloaded [**2-19**] his CXR and his clinical presentation; this was thought to be due to a combination of bradycardia, anemia and possible infection; TTE showed LVH but no evid of worsening heart function with LVEF>55%. Pt was initially diuresed with Lasix 40mg IV as needed, then became overdry with bump in creatinine, was given some fluid back via NS boluses, and is being discharged euvolemic. . 10. ?LLL pna: thought to have evid of pna (?aspiration) on initial CXR, started Levaquin x 7days ( started on [**1-6**] to stop [**1-12**]). Needs 1 more day. . 11. HTN: continued prazosin, increased to 2 mg prasozin at night, also increased Hydralazine. We avoided ACEI given ARF/CRI, and avoided BB given profound bradycardia. . 12. Code: DNR/DNI 13. Communication: Son [**Name (NI) **] [**Name (NI) 18965**] Medications on Admission: ASA 325 qd protonix 40 qd lipitor 10 qd glyburide 2.5 qam iso mono 30 qd zoloft 50 qd MOM epogen ?20,000/week vs 5000/week prazosin 1mg qd Discharge Medications: 1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Prazosin HCl 1 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO QHS (once a day (at bedtime)) as needed. 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q8H (every 8 hours) as needed. 9. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday): per Heme recommendation patient should stay on this dose rather than return to his 5000 unit/week prior regimen. 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): especially important while on iron; please hold only for diarrhea. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q8H (every 8 hours) as needed. 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 5 days. 14. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Hydralazine HCl 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 17. Prazosin HCl 2 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 18. Outpatient Lab Work You should have TSH checked in 1 week. If improved, should have synthroid dose decreased to 25 mcg. 19. Insulin Continue insulin sliding scale. FS QID and insulin QID. 150-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units 351-400 10 units AT night, this sliding scale should be decreased by one unit. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: 1. Hypothyroidism, primary 2. Pancytopenia(anemia,leukopenia,thrombocytopenia), with dysmorphic blood cells 3. Bradycardia, thought secondary to hypothyroidism 4. Hypothermia, thought secondary to hypothyroidism 5. Constipation, thought secondary to hypothyroidism 6. Congestive heart failure exacerbation, likely related to bradycardia and possible pneumonia 7. Acute renal failure on top of chronic renal insufficiency, thought secondary to overdiuresis 8. Difficult to control sugars, thought secondary to diabetes mellitis plus hypothyroidism 9. Possible left lower lobe pneumonia, seen on chest X-ray Discharge Condition: Stable, still hypothermic Discharge Instructions: Please continue to take all medications as prescribed and to follow the plan laid out by your healthcare team. If you develop chest pain, shortness of breath, palpitations, confusion, dizziness, decreased urine or stool output, lightheadedness, loss of consciousness, please call or have someone else call 911 immediately to be brought to the nearest emergency room for evaluation and treatment. Followup Instructions: Please set up an appointment with Dr. [**Last Name (STitle) 5762**] upon discharge to be re-evaluated in the week after leaving the hospital. You will need to have labs drawn to check your renal (kidney) function and your thyroid function, and will also need to be seen regarding your congestive heart failure. You should also be seen by your eye doctor at [**Hospital 13128**].

Admission Date: [**2159-2-27**] Discharge Date: [**2159-3-29**] Service: HISTORY OF PRESENT ILLNESS: This gentleman was admitted directly to the Coronary Care Unit on [**2-27**], status post myocardial infarction with an anterolateral non-Q-wave myocardial infarction. PAST MEDICAL HISTORY: (Past medical as follows) 1. Coronary artery disease. 2. Myocardial infarction times two. 3. Peripheral vascular disease, status post bilateral carotid endarterectomy operations in the [**2147**]. 4. Status post angioplasty to the left lower extremity and the femoral artery in the [**2147**]. 5. Hypercholesterolemia. 6. History of lung cancer in [**2138**], status post left lower lobe resection. 7. Hypertension. 8. Status post gallbladder surgery in [**2140**]. 9. Status post appendectomy in [**2098**]. 10. Spinal stenoses, status post two surgeries in [**2148**] and [**2151**]. 11. Non-insulin-dependent diabetes mellitus, diet controlled. 12. Chronic renal insufficiency. 13. Chronic anemia, on Epogen. 14. Atrial fibrillation diagnosed in [**2158-10-30**]. 15. History of diverticulitis. 16. History of cataract surgery. ALLERGIES: His only drug allergy is ERYTHROMYCIN which produced anaphylaxis and hives. MEDICATIONS ON ADMISSION: Medications on admission were iron, Rocaltrol, amiodarone, Epogen, lovastatin, dipyridamole, calcium supplement, quinine, Norvasc, Proscar, furosemide, oral nitrates, aspirin, multivitamin, atenolol, [**Doctor First Name 233**] Ciel, albuterol, nitroglycerin p.r.n., and Plavix. HOSPITAL COURSE: This gentleman was admitted to the Coronary Care Unit directly after presenting at [**Hospital **] Hospital with severe chest pain. He had ultimately ruled in for a myocardial infarction and was transferred to [**Hospital1 346**] for management. He was followed closely by the Cardiology Service in preparation for cardiac catheterization. On [**2-27**], his laboratories were as follows: White blood cell count of 9.7, hematocrit of 30.2, platelet count of 257,000. Sodium of 145, potassium of 3.3, chloride of 102, bicarbonate of 29, blood urea nitrogen of 39, creatinine of 2.8 (which was near his baseline of middle 2s), and a blood sugar of 93. His PT was 13.4, with an INR of 1.3, and a PTT of 56.8. He had an abnormal electrocardiogram on admission with ST depressions throughout multiple leads. He was maintained in the Coronary Care Unit on a heparin drip and on a nitroglycerin drip; and Dr. [**Last Name (STitle) **] (his cardiologist) referred the patient to Dr. [**Last Name (STitle) **]. The patient was ultimately seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. His cardiac catheterization showed an output of 4.3, with an index of 2.5, a 90% left anterior descending artery lesion at the diagonal, a 95% circumflex lesion that was distally occluded 100%, and a 60% distal right coronary artery lesion. It also demonstrated severe iliac disease. The patient was also maintained on his beta blocker and remained in the Coronary Care Unit. The patient was transfused one unit of packed red blood cells for a hematocrit of 27, status post catheterization. He had some slight episodes of chest pressure that resolved spontaneously with no electrocardiogram changes. One day preoperatively, his creatinine dropped from 2.8 to 2.4. His white blood cell count remained stable at 8.8, and his enzymes continued to be cycled. His Plavix was discontinued in preparation for his bypass surgery. On [**3-1**], he underwent coronary artery bypass grafting by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**], off pump, with a left internal mammary artery to the left anterior descending artery, a vein graft to the posterior descending artery, and a vein graft to the obtuse marginal. He was transferred to the Cardiothoracic Intensive Care Unit in stable condition. Of note, also, vascular report for noninvasive carotid studies showed no significant studies on either right or left carotid arteries preoperatively. On postoperative day one, he was transfused 3 units of packed red blood cells. He was on an insulin drop at 2.5, and his Neo-Synephrine was slowly weaned off. He was hemodynamically stable with a blood pressure of 118/49 and in normal sinus rhythm at 79. His lungs were clear bilaterally. His sternum was stable. His incisions were clean, dry, and intact. His white blood cell count rose to 23.3. Sodium of 140, potassium of 4.8, chloride of 111, bicarbonate of 20, blood urea nitrogen 27, creatinine of 2. Neurologically, he was intact. He was followed by Dr. [**Last Name (STitle) **] of Cardiology. His ACE inhibitor was held for the time being while his creatinine was elevated. On postoperative day one, in the evening, he had a CT-guided left pleural space hematoma drained with a pigtail catheter with no residual pneumothorax. A portable transthoracic echocardiogram study was done that evening which showed that the ejection fraction was mildly depressed at 30% to 40%, but no significant pericardial effusion was seen. Please refer to the final report. On postoperative day two, the patient was confused overnight. He was on a dobutamine drip at 2.5 and an insulin drip at 2. He was in the 80s, in sinus rhythm with a good blood pressure with mixed venous of 63%. His index was 2.39 on dobutamine. His white blood cell count remained elevated at 20.2. His creatinine rose again to 2.5, with bicarbonate also depressed at 17. His sternum was stable. His incisions were clean, dry, and intact. His abdomen was mildly distended. The patient continued to be confused. He was started back on his amiodarone, Plavix, and aspirin as his dobutamine was weaned. He was seen by Case Management. He had some postoperative atrial fibrillation with some broad complex tachycardia that paroxysmal and then converted back to a narrow complex in atrial fibrillation, with a ventricular rate of about 90 to 100. He was already on intravenous amiodarone. On postoperative day three, he had a decreased cardiac index, so his dobutamine was increased. He also started Levaquin for his pulmonary status. He was awake. His lungs had coarse breath sounds. His incisions were otherwise clean, dry, and intact. He remained n.p.o. His dobutamine was dropped back down to 2.5. He was in atrial fibrillation in the 90s, with a blood pressure of 126/57, a temperature maximum of 100.6. In the morning, he was on amiodarone at 0.5, dobutamine at 5 (which was later weaned down), nitroglycerin at 1.5, and insulin at 3. His lactate was 2. His white blood cell count dropped to 14.6, and his creatinine rose from 2.5 to 2.7. He remained in the Cardiothoracic Intensive Care Unit. A Pulmonary consultation was obtained given his asthma, and chronic obstructive pulmonary disease, and lung cancer, and his somewhat declining respiratory status. His chest CT showed an interstitial pattern consistent with pulmonary edema and a patchy right upper lobe infiltrate. A small right pleural effusion, a small medial left pleural effusion, with two loculated anterior superior effusions, and a question of tracheomalacia. Dr. [**Last Name (STitle) **] of Pulmonary saw the patient and recommended continuing his nebulizers and given him some Solu-Medrol, as well as continuing his antibiotics of Levaquin, and pulmonary toilet. He recommended diuresing him as he was hemodynamically able to tolerate. He was seen daily by Cardiology and Pulmonary who continued to follow his respiratory status. On postoperative day four, he was in atrial fibrillation in the 90s, remained on dobutamine at 5, nitroglycerin at 5, insulin at 3, as well as his anticoagulation, antibiotics, and steroids. His white blood cell count rose slightly to 15.3. His hematocrit dropped to 25.7. His lactate leveled out at 1.7, and his creatinine rose slightly to 2.8. His mixed venous was 47%. Sputum which had been sent off showed some gram-negative rods in the stain. He continued with pulmonary toilet. His pulmonary artery catheter remained in place, and he continued on his antibiotics and steroids. A digoxin level was also checked. He was seen by the Otorhinolaryngology Service for dysphasia. He continued to have complaints of some shortness of breath. He continued with diuresis. On postoperative day five, he remained in atrial fibrillation in the 50s, with a good blood pressure. His Swan-Ganz catheter was changed over to central venous pressure. He was continued on his digoxin. He was also continued on antibiotics, remained in the Cardiothoracic Intensive Care Unit. He was seen by the Renal Service in consultation for his rise in creatinine of 3.1, and a white blood cell count of 17 with no plans for further diuresis at the moment. [**Name2 (NI) **] was continued with his anticoagulation. The Renal consultation suggested some tubular injury and suggested putting him on hydralazine and not continuing with diuresis at this time. On postoperative day six, his hydralazine was increased. He remained on Levaquin, heparin, amiodarone, digoxin, hydralazine, Imdur, albumin nebulizers, Atrovent, as well as his oral medications. Chest x-ray showed a question of a left lower lobe pneumonia which was unclear given the patient's history, and the patient was started on Coumadin for his atrial fibrillation. His white blood cell count rose to 19.5. He was followed daily by Renal and Otorhinolaryngology Services. He passed his swallowing test. He remained in atrial fibrillation on postoperative day seven. Additional laboratories that day showed a rise in white blood cell count to 22.4, ALT of 195, AST of 98, alkaline phosphatase of 50, and total bilirubin of 0.6. Heparin was discontinued, and the INR started to rise. He was also seen by Physical Therapy and transferred out to the floor on postoperative day eight. On postoperative day six, his Swan-Ganz catheter had been discontinued to a CVP. The patient was also put on air bed for a small area of a scrotal breakdown. He was screened by the Nutritional Team. His digoxin level was 4.5. His digoxin was held. His sternum looked dark and dusky with his stitches looking slightly dusky. His right leg was dry and clean, no erythema. Please refer to the Operative Note for the discussion of this gentleman's small area of herniation under his sternum. On postoperative day eight, his INR came back at 6.5. His Coumadin was held, and he was given 1 mg of vitamin K. He was seen daily by Renal. He continued with disorientation. He was followed by Otorhinolaryngology Service for more dysphasia. The patient had increased difficulty with swallowing, and it appeared that he aspirated slightly. He had some respiratory distress on the afternoon of [**3-9**]. He was transferred back to the Cardiothoracic Intensive Care Unit as his oxygen saturations dropped below 90%, while he was having respiratory distress. On postoperative day nine, he had an episode of ventricular tachycardia that lasted 20 seconds and continued in some respiratory distress. He was monitored for his digoxin level and his INR with daily dosing of Coumadin as we waited for his INR to drop. He was reintubated by Anesthesia for respiratory insufficiency and his inability to clear secretions on [**3-10**]. His creatinine rose to 2.9. His INR dropped back down to 2.1, and his white blood cell count rose to 20.7. He continued to be monitored for his acute renal failure and his respiratory status after reintubation. His afterload reduction continued with hydralazine. He was started on ceftazidime. He was alert and moving all extremities and following commands. He had a bronchoscopy done by Dr. [**Last Name (STitle) 39080**] which showed some minimal blood-tinged secretions bilaterally. He was seen again by the Clinical Nutrition Team. On postoperative day 10, again, he had a run of supraventricular tachycardia. He had a repeat echocardiogram which showed an ejection fraction of 30% to 40%, which was unchanged. He was transfuses 2 units of packed red blood cells, a Swan-Ganz catheter was re-placed. He was on an amiodarone drip at 0.5, a dopamine at 2.5, and a propofol drip at 40. He had a temperature maximum of 100. He remained ventricularly paced at 80 with an index of 2.7. His creatinine rose as did his white blood cell count to the 23 range. His lactate was 1.9. Blood cultures were sent off and were pending. Sputum was sent off and was pending. His respiratory status was adjusted on the ventilator. He was seen by Infectious Disease for his rise in white blood cell count. Blood cultures were sent off. Fungal cultures were sent off. His sputum came back with gram-negative rods. His antibiotics were changed. His creatinine stayed level in the 3 range. His lactate, which had risen to 4.5, came back down to 1.9. Additional blood cultures were drawn. His renal status was followed by the Renal attending. Multiple adjustments were made for his respiratory status, and his antibiotics and his renal function. He remained on ceftazidime, Diflucan, amiodarone, dopamine, propofol, and Epogen, as well as his oral anticoagulation therapy, and hydralazine for afterload reduction. He remained intubated on postoperative day 11 with coarse breath sounds. He continued to be followed by the Infectious Disease Service and Nutrition. He required A pacing with an underlying sinus bradycardia. He was continued on his amiodarone. His digoxin level remained elevated at 2.8 with accompanying bradycardia. He remained ventricularly paced on postoperative day 12. His creatinine started to come down to 2.5. His white blood cell count remained in the 20 range. Diuresis was stopped. Free water was given for management of his fluids and electrolytes. He was seen by Plastic Surgery given the increased drainage from his sternum and a question of infection in that area. They noted his mummified necrotic inferior aspect of his sternotomy incision, and they recommended eventual debridement and a chest CT to evaluate for substernal fluid collection. His metabolic support was done by the Nutrition Team. On postoperative day 13, he remained paced, intubated, and sedated. He also continued on his insulin and amiodarone drips, with a dopamine drip at 4, and a morphine drip at 4. He was seen by the Electrophysiology fellow given his atrial fibrillation, and slow ventricular response, and his increased digoxin level. The patient was paced with his pacing Swan during periods of bradycardia and recommended that since his blood pressure was stable, that Digibind was not indicated. The Renal Service continued to follow his electrolyte status in anticipation of his sternal debridement. He was also seen by the Infectious Disease team again. The CT of his chest showed large pleural effusions. He had some emesis, and there was a question of aspiration. There was bloody fluid suctioned. He remained ventricularly paced. His creatinine rose to 3.5. His white blood cell count rose to 18, with his blood urea nitrogen climbing now into the 90s. His electrocardiogram just showed the effect of digoxin and his old inferior myocardial infarction, and he remained in atrial fibrillation. Dr. [**Last Name (STitle) 13797**] of Plastic Surgery recommended surgical debridement by the Cardiothoracic team and a vac drain to be placed. Cultures of his sternum showed yeast. His sputum showed yeast. He continued on his antimicrobials and remained on the dopamine drip at 2. His creatinine rose to 3.6 with a blood urea nitrogen of 101. The patient had normal sinus rhythm at 55 and a stable blood pressure, but an increased P-R interval. His pacing Swan was still being used. He was seen by Dr. [**Last Name (STitle) **], and Infectious Disease, as well as the Renal Service. He had some blood via his G-tube and in his stool. On postoperative day 16, he received 2 units of fresh frozen plasma and he was transfused 2 units of packed red blood cells for a hematocrit of 21.9. His Plavix was held. He remained on double antibiotic therapy. On postoperative day 17, he had an episode of pulmonary edema. He was given 80 mg of intravenous Lasix. He remained on a nitroglycerin drip at 1, a dopamine drip at 2. He had first-degree atrioventricular heart block on his electrocardiogram in the 60s, with a blood pressure of 128/46. As of [**3-13**], his blood cultures were negative. His catheter tip from his central line was negative. His Plavix continued to be held. His total parenteral nutrition was held. Plastic Surgery suggested that there was an impaired vascular supply to the base of the sternum and recommended operative treatment, as soon as the patient could tolerate it. He continued to be maintained in the Intensive Care Unit. His creatinine rose to 4, with a blood urea nitrogen of 113. His white blood cell count came down to 8.6, with a hematocrit of 29.6, and an INR of 1.3. Infectious Disease team requested tissue be sent when the patient was debrided. The patient remained in sinus bradycardia with a blood pressure of 150 to 160/40 to 50, and remained stable, and did not require any pacing over the prior 48 hours. He was seen by Cardiothoracic Surgery, Dr. [**Last Name (STitle) 39081**] for evaluation for tracheostomy. He was continued on antibiotic therapy, and hydralazine for afterload reduction, on the ventilator, sedated. Neurologically, he was stable. His creatinine rose to 4.5, with a blood urea nitrogen of 120 on postoperative day 19. His chest tube remained in place. On postoperative day 19, he had a right subclavian triple lumen line placed for total parenteral nutrition and intravenous access. Suggestions were followed by Renal and Cardiology. He had some liquefaction of his necrotic skin around the area of his sternum. On postoperative day 21, he remained on pressure support, and CPAP, on Diflucan, and ceftazidime, with a blood urea nitrogen of 141, and a creatinine of 4.9 (that continued to rise). He was in sinus rhythm with first-degree atrioventricular heart block, at a rate of 63, with a blood pressure of 153/37. He was seen by the Cardiothoracic Intensive Care Unit resident and received hemodialysis as well as a tracheostomy and percutaneous endoscopic gastrostomy tube placement. He was being treated for his pneumonia. His sternal wound and his acute renal failure issues were being managed by Renal. He continued to have somewhat deteriorating renal function. He received a transfusion for a hematocrit of 27.5. He had a Quinton femoral catheter placed for hemodialysis by the Cardiothoracic Intensive Care Unit team. He continued to be monitored by the Cardiothoracic Intensive Care Unit staff. He had some tachypnea and some brief atrial fibrillation on postoperative day 22. He was awake and responsive. He had coarse breath sounds at his right base, but his abdomen was distended with decreased breath sounds. He had some trace peripheral edema. He remained a little bit more agitated and started a Dilaudid infusion. He was transfused 2 more units of packed red blood cells. He had increased abdominal distention that was tenderness to palpation. There was a question of ischemia, and it was recommended that there be a surgical evaluation. He was seen by Surgery, that went through the differential diagnoses. He blood urea nitrogen rose to 156, with a creatinine of 5.2. His amylase was 241. His upright chest x-ray showed no free air. His abdominal CT from [**3-14**] showed mild diffuse thickening of the sigmoid colon. He continued with hemodialysis. On [**3-24**], the patient was being turned and had an episode of pulseless ventricular tachycardia. He was defibrillated times one and given 1 mg of epinephrine intravenous push, with cardiopulmonary resuscitation, and then defibrillated at 300, and a 300-mg bolus of amiodarone. He was shocked times two at 350 joules and returned into supraventricular tachycardia with a heart rate of greater than 100 with a blood pressure of 200/90. The patient responded appropriately to a single question and then was sedated again. A chest and abdominal CT showed no collections or sources for infection. He was sedated but seemed to be responding appropriately. His abdomen was distended; it was soft and was tender in the left lower quadrant. Blood on stool on rectal examination. There was a high suspicion for ischemic bowel in spite of a negative finding on abdominal CT from the prior day. The patient was making about 1 liter of urine per day. The patient did not receive timely dialysis that day, on [**3-24**]. He respiratory status started to deteriorate. He had coarse breath sounds bilaterally. His left upper extremity became swollen and erythematous. His abdomen was softly distended. He had increased tachypnea. His FIO2 was increased to 100%, and he was requiring full respiratory support. His abdomen remained tender. On postoperative day 23, he had ventricular tachycardia, was paced. He received bicarbonate and epinephrine and had went back to spontaneous rhythm with blood pressure. He was moving all four extremities. He remained on his amiodarone drip. His creatinine remained elevated at 4.6 with a white blood cell count of 8.6, and he continued to deteriorate. He was seen by Dr. [**Last Name (STitle) 39081**] again on postoperative day 23. There appeared to be no sternal breakdown at the time of his cardiopulmonary resuscitation and compression, and his sternal debridement which had been planned was cancelled in lieu of his cardiac arrest (in lieu of his ventricular tachycardia arrest). The patient was reloaded with amiodarone and seen again by the Infectious Disease who noted his pulmonary interstitial edema, and his decreased bilateral effusions. He also noted a low attenuated lesion in the right lobe of the liver and extensive vascular calcifications. The patient was seen again by the Surgical Intensive Care Unit attending. The patient remained afebrile with a distended abdomen. He appeared to be rigorous with a normal temperature maximum. He had another episode of ventricular tachycardia. His amiodarone was increased. Surgery team was considering exploratory laparotomy for the question ischemic bowel despite the CT scan the day prior. He had another episode of ventricular tachycardia overnight. He was restarted on a dopamine drip as well as intravenous amiodarone. His dopamine was at 3, amiodarone was at 0.5. He remained triple antibiotic therapy as well as his Plavix. He remained sedated and ventricularly paced on dopamine support. His sternum was draining seropurulent drainage. Electrophysiology placed a pacing wire on postoperative day 24. The patient went back to the catheterization laboratory. Electrophysiology placed a pacing wire on postoperative day 24. His grafts were intact, and his native circumflex had a stent placed. He remained intubated and sedated. His abdomen remained soft, but somewhat distended. His blood urea nitrogen and creatinine remained elevated in the 140s and at 4.9. Renal saw him again to evaluate hemodialysis. His respiratory status continued to worsen with increasing acidosis. He remained on pressure support. His temperature was 94 (clearly hypothermic) with a blood pressure in the 80s/40s to 50s. He remained paced at a rate of 80. He was started on vancomycin and remained on a dopamine drip at 3. He remained sedated on propofol. The patient started continuous venovenous hemofiltration with systemic heparin. Again, on postoperative day 25, the patient tested positive for heparin-dependent antibodies. His continuous venovenous hemofiltration with heparin was discontinued, and it was reset using citrate. He was seen again by Infectious Disease for a change in antibiotic coverage. The left eye began to be asymmetric when compared with the right with a question of proptosis. His ceftazidime was changed to q.24h. His vancomycin was changed to q.24h., and he restarted his continuous venovenous hemofiltration. He remained intubated with a question of his neurologic stability, on triple antibiotic therapy. His dopamine was increased to 6, and he was on a morphine drip at 2. On postoperative day 25, he had two episodes of ventricular tachycardia. His creatinine dropped slightly to 3.8. His abdomen remained softly distended. His was grimacing to pain. His abdomen was tender. He continued with treatment for his acute renal failure. The patient continued to deteriorate requiring maximal respiratory support, grimacing only to pain. His family wanted to speak regarding his prognosis and a plan. He was seen by General Surgery on postoperative day 25 who noted his abdomen and said it was unlikely that it was ischemic bowel. A family meeting was scheduled for that day. The patient remained critically ill and was seen again by the Electrophysiology Service. He continued on amiodarone, and they recommended his temporary pacing wire could be discontinued. He had continuous venovenous hemofiltration again. His blood pressure was stable on dopamine at 6 and remained pressor dependent for his blood pressure in the 98 range to 100 range over 40 go 60, with a heart rate of 60 to 82, and a temperature maximum of 94 to 97.5. His potassium was 3.4 and was repleted slowly given his hemodialysis status. He had greenish purulent drainage continuing at the base of his sternal incision. The patient continued to deteriorate. Debridement was recommended as soon as the patient was stable enough to tolerate it. The patient was seen by the Ethics Support Service along with the family. The patient was made do not resuscitate on postoperative day 26. He continued on antibiotic therapy, and dopamine drip at 6.5, and a morphine drip at 3, as well as amiodarone. He continued to be stable on maximal support, and he had Renal managing his dialysis. He was also seen by the Metabolic Support Service. The patient appeared to be unresponsive except to deep pain. He was transfused. He was bradycardic. He was continued on a morphine drip and continuous venovenous hemofiltration. His creatinine dropped to 2.2. His sternal wound was necrotic, and he remained a do not resuscitate status in the Intensive Care Unit. His pupils became slightly unequal. He continued on support in the Intensive Care Unit with pressors. He had no response to pain on Ativan and morphine. He remained with his tracheostomy, and he was seen again by Infectious Disease as well as Cardiology Services, who recommended that his management (given his do not resuscitate status) be discussed with Cardiothoracic Surgery. On postoperative day 27, the patient had no change in his hemodynamics, but he was still requiring dopamine at 6.5 for pressor support, with a heart rate in the 50s. He remained on morphine. On postoperative day 27, he remained in atrial fibrillation and was continued on his dopamine, and morphine support, and full ventilatory support. On postoperative day 28, the patient remained stable and sedated, with atrial fibrillation in the 60s, with a blood pressure of 121/43, on a dopamine drip at 6.5, and a morphine drip of 3. He had no acute events overnight. His sternal wound was unchanged and remained necrotic. He continued on his support in the Intensive Care Unit. A family meeting was held again in the morning of [**3-29**]. The family continued to articulate an understanding of the patient's wishes, and the decision was made for withdrawal of care. Dr. [**Last Name (STitle) 1537**] was not in favor of this, but stated he found it reasonable and was amenable to do as the family wished. The family and pastor visited with the patient prior to withdrawal. The patient expired in the Cardiothoracic Surgical Intensive Care Unit at approximately 11:52 a.m. on [**2159-3-29**]. DISCHARGE DIAGNOSES: (Discharge diagnoses were as follows) 1. Status post coronary artery disease. 2. Status post off-pump coronary artery bypass graft times three. 3. Peripheral vascular disease with prior vascular surgeries as noted at the beginning of this dictation. 4. Hypercholesterolemia. 5. Status post lung cancer with left lower lobe resection. 6. Hypertension. 7. Non-insulin-dependent diabetes mellitus. 8. Chronic renal insufficiency. 9. Chronic anemia. 10. Atrial fibrillation. DISCHARGE DISPOSITION: Again, the patient expired in the Cardiothoracic Surgical Intensive Care Unit on [**2159-3-29**]. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 76**] MEDQUIST36 D: [**2159-5-8**] 13:17 T: [**2159-5-9**] 08:06 JOB#: [**Job Number 39082**]

Admission Date: [**2137-10-11**] Discharge Date: [**2137-10-16**] Date of Birth: [**2068-8-25**] Sex: F Service: NEUROLOGY Allergies: Amoxicillin Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: lower extremity weakness Major Surgical or Invasive Procedure: none History of Present Illness: 69 year-old female with history of AAA, HTN, HLD, ESRD on dialysis, SLE, questionable dx Multiple Sclerosis 40 years ago at [**Hospital1 112**] dx Dr [**First Name (STitle) 2617**], neuropathy, Neurogenic Bladder, chronic fecal incontinence, ESRD on HD presented initially with left chest pain and later was noted to have dense paraparesis in the legs. Per further discussion with the patient, she had been hypotensive on HD on [**10-10**] to 70s (her baseline hypitension) and had problems moving her legs initially and then at 3pm on [**10-10**] had not been able to move her legs. She has been bedbound following a leg fracture and had been on warfarin DVT prophylaxis stopped [**10-8**] due to problems with bruising and epistaxis. On examination at [**Hospital1 18**] patent had a flaccid paraparesis and only be able to just wiggle her toes bilaterally, sensory level to T8 anteriorly to pain/temp and T12/L1 posteriorly. Reflexes were absent in the legs and proprioception was decreased to the ankle on left and the knee on right. Patient had a SBP 70s in the ED but was mentating well A+Ox3. Transferred to the neuro ICU for pressors. CTA abdomen [**10-11**] revealed a stable large infrarenal AAA measuring 7.2 x 7.7 x 9.3 cm of which a large portion was thrombosed with no rupture or signs of impending rupture. Vascular Surgery had consulted regarding possible vascular cause for her weakness. Vascular Surgery did not find evidence of aortic dissection or impending aortic rupture. CTA legs showed extensive atherosclerotic plaque throughout the LE vasculature and bilateral popliteal aneurysms R>L. There was occlusion of the anterior tibial arteries at the origin on the right and at the mid calf on the left. Patient refused any surgical or endovascular intervention on her infrarenal AAA. MRI whole spine [**10-11**] revealed a completed anterior spinal artery infarct extending from T9 to conus. Patient was started on aspirin and was treated conservatively. Past Medical History: - ESRD on HD (hypertensive nephropathy) - Hypertension - AAA - Hyperlipidemia - Lupus - Multiple Sclerosis - Question of Atrial fibrillation - History of Staph Bacteremia - Anemia - History of cellulitis - Hypercalcemia - spinal stenosis - Hyperparathyroidism - s/p Open appendectomy - s/p CCY - Tessio catheter placement Social History: Social Hx: She lives with her husband. She is retired. 1ppd smoker x 30 years, quit 6-7 years ago. No ETOH or illicit drug use. Family History: Family Hx: Father deceased from MI. Mother deceased from unknown causes. Sister deceased from MI. Physical Exam: Physical Exam on Admission: Vitals: P: 86 R: 16 BP: 83/52 SaO2: 97% 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: lcta b/l Cardiac: RRR, S1S2, no murmurs appreciated Abdomen: soft, NT/ND, +BS Extremities: warm, Dopplerable pedal pulses Skin: Skin breakdown over sacrum, medial aspect right thigh erythematous Neurologic: Mental Status: Awake, alert, oriented to person, place and date. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Able to follow both midline and appendicular commands. No right-left confusion. Able to register 3 objects and recall [**11-26**] at 5 minutes ([**1-24**] with prompting). No evidence of apraxia or neglect Language: speech is clear, fluent, nondysarthric with intact naming, repetition and comprehension. Cranial Nerves: I: Olfaction not tested. II: PERRL 3mm and sluggishly reactive to light. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. 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: Normal bulk. LLE flacid. Tone difficult to assess RLE given history fracture. No pronator drift bilaterally, though she has difficulty maintaing left arm in this position (she attributes this to a left arm prosthesis). No adventitious movements, such as tremor, noted. No asterixis noted. Right leg externally rotated. Decreased rectal tone. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 4 5 4+ 5- 5 4 0 0 0 0 0 R 4- 5 4 5- 5 4- 0 0 0 0 0 There is trace wiggling of toes on left foot only. Sensory: Absent light touch and pinprick to feet and diminished up to ankles. Intact perianal pinprick sensation. No sensory level. Proprioception intact to large amplitude movements at left great toe, absent at right. Vibration absent entire RLE, up to knee LLE. Distal cold temp. loss b/l. DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 0 1 0 0 R 1 0 1 0 0 Plantar response was mute bilaterally. Coordination: No intention tremor or dysmetria on finger-nose, FNF. RAMs intact. Gait: deferred given LE plegia. Physical Exam on Discharge: Vitals: T 97.6 BP 125/75 HR 96 RR 20 O2 100% RA 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: CTAB Cardiac: RRR, S1S2, no murmurs appreciated Abdomen: soft, NT/ND, +BS Extremities: warm, 1+ LE edema Neurologic: Mental Status: Awake, alert, oriented to person, place and date. Able to relate history without difficulty. Speech fluent without dysarthria. Attentive, able to follow both midline and appendicular commands. No right-left confusion. No evidence of apraxia or neglect. Cranial Nerves: I: Olfaction not tested. II: PERRL. VFF to confrontation. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. 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: No pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted. Right leg externally rotated. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 4+ 5 4+ 4+ 5 4 0 0 0 0 2 R 4 5 4 4+ 5 4 0 0 0 0 1 Able to wiggle toes b/l and move ankles slightly L>R. Sensory: Diminished light touch and pinprick below knees b/l. Proprioception decreased at b/l great toes, intact at ankles. Sensory level to T8 anteriorly and T12/L1 posteriorly. DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 0 1 0 0 R 1 0 1 0 0 Plantar response was mute bilaterally. Coordination: No intention tremor or dysmetria on finger-nose, FNF. RAMs intact. Gait: deferred given LE plegia. Pertinent Results: [**2137-10-11**] 09:10AM %HbA1c-4.9 eAG-94 [**2137-10-11**] 12:44AM GLUCOSE-93 NA+-141 K+-4.4 [**2137-10-11**] 12:30AM GLUCOSE-97 UREA N-25* CREAT-2.9* SODIUM-142 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-26 ANION GAP-24* [**2137-10-11**] 12:30AM estGFR-Using this [**2137-10-11**] 12:30AM ALT(SGPT)-32 AST(SGOT)-40 CK(CPK)-125 [**2137-10-11**] 12:30AM CK-MB-6 cTropnT-0.21* [**2137-10-11**] 12:30AM CALCIUM-9.4 PHOSPHATE-5.2* MAGNESIUM-2.0 CHOLEST-170 [**2137-10-11**] 12:30AM VIT B12-850 [**2137-10-11**] 12:30AM TRIGLYCER-167* HDL CHOL-68 CHOL/HDL-2.5 LDL(CALC)-69 [**2137-10-11**] 12:30AM TSH-1.3 [**2137-10-11**] 12:30AM WBC-8.3 RBC-3.36* HGB-11.1* HCT-35.9* MCV-107* MCH-33.0* MCHC-31.0 RDW-16.5* [**2137-10-11**] 12:30AM NEUTS-70.4* LYMPHS-17.9* MONOS-6.5 EOS-4.3* BASOS-0.9 [**2137-10-11**] 12:30AM PLT COUNT-160 [**2137-10-11**] 12:30AM PT-15.3* PTT-24.0 INR(PT)-1.3* CTA chest/abd/pelvis: IMPRESSION: 1. 9.3 cm infrarenal abdominal aortic aneurysm extending into the bilateral common iliac arteries without evidence of rupture or acute dissection. 2. Densely calcified vasculature throughout the chest, abdomen, and pelvis with significant narrowing of aortic branch vessels and occlusion or near occlusion of the bilateral renal arteries and [**Female First Name (un) 899**]. Please note that the spinal arteries are not evaluated with this technique. 3. Symmetric opacification of the external iliac and common femoral arteries without evidence of occlusion. (please refer to separate dictation of lower extremity runoff completed on same date for lower extremity vasculature). 4. Compression deformity of the T4 and T12 vertebral body with ~50% loss of vertebral body height. No malalignment of the thoracolumbar spine. MR C/T/L spine: IMPRESSION: 1. Mild lower thoracic cord swelling with central [**Doctor Last Name 352**] matter hyperintensity extending from T9 to the conus, imaging findings are typical of spinal cord infarction. 2. Scoliotic deformity of the thoracic spine with multilevel degenerative changes as described above. 3. Known abdominal aortic aneurysm is partially imaged, better evaluated on prior abdominal CT scans. Brief Hospital Course: 69 year-old female with history of AAA, HTN, HLD, ESRD on dialysis, SLE, questionable dx Multiple Sclerosis 40 years ago at [**Hospital1 112**] dx by Dr [**First Name (STitle) 2617**], neuropathy, Neurogenic Bladder, chrnic fecal incontinence, ESRD on HD presented initially with left chest pain and later was noted to have dense paraparesis in teh legs. Per further discussion with the patient, she had been hypotensive on HD on [**10-10**] to 70s (has baseline hypotension) and had problems moving her legs initially and then at 3pm on [**10-10**] had not been able to move her legs. She has been bedbound following a leg fracture. She had been on warfarin DVT prophylaxis that was stopped [**10-8**] due to problems with bruising and epistaxis. On examination at [**Hospital1 18**] patent had a flaccid paraparesis and only able to just wiggle her toes bilaterally, sensory level to T8 anteriorly to pain/temp and T12/L1 posteriorly. Reflexes were absent in the legs and proprioception was decreased to the ankle on left and the knee on right. Patient had a SBP 70s in the ED but was mentating well A+Ox3. CTA abdomen [**10-11**] revealed a stable large infrarenal AAA measuring 7.2 x 7.7 x 9.3 cm of which a large portion was thrombosed with no rupture or signs of impending rupture. Vascular Surgery had consulted regarding possible vascular cause for her weakness. Vascular Surgery did not find evidence of aortic dissection or impending aortic rupture. CTA legs showed extensive atherosclerotic plaque throughout the LE vasculature and bilateral popliteal aneurysms R>L. There was occlusion of the anterior tibial arteries at the origin on the right and at the mid calf on the left. Patient refused any surgical or endovascular intervention on her infrarenal AAA. MRI whole spine [**10-11**] revealed a likely compeleted anterior spinal artery infarct extending from T9 to conus. Transferred to the neuro ICU for pressors. Patient was started on aspirin 325mg daily and was treated conservatively. PT/OT evaluated. On discusion, it was felt that no further imaging was needed. Renal were consulted and patient was continued on HD. On exam on [**10-12**], she improved slightly with increased strength in her toes bilaterally. On [**10-14**] she had mild improvment in toes and trace movement in quads on left. Her SBP was stable in the 100- 130's while off pressors. She was transferred to the floor on [**10-14**]. Her weakness continued to gradually improve during her admission. On [**10-15**] she had a transient episode of chest pressure/SOB - EKG and CM's were negative, CXR unchanged. She had HD later that day and felt that her symptoms improved. Her blood pressure remained stable from 100's - 130's. Her home antihypertensives were held throughout her admission. These will need to be restarted gradually once her blood pressure begins to rise about 140. **Goal SBP is 100-140.** Dermatology was consulted regarding acute on chronic itch and skin changes in her hands, arms and back. Given a close contact with scabies, she had already undergone permethrin cream rx. Dermatology recommended TAC ointment and Sarna lotion topical therapy. She also received another permethrin cream whole body skin application prior to discharge. She was seen by PT/OT who recommended rehab placement upon discharge. TRANSITIONAL CARE ISSUES: Patient will need close blood pressure monitoring. All of her home BP medications (Toprol XL 100mg Daily, Lisinopril 10mg PO Daily, Imdur 30mg QHS, Norvasc 10mg Daily) have been held during her hospitalization. Her goal SBP is 100-140. Her antihypertensives may be gradually restarted if her BP begins to rise above 140. Caution must be taken during dialysis to avoid hypotension. Patient will need intensive PT/OT for her severe lower extremity weakness. Medications on Admission: -Imodium 2mg -Toprol XL 100mg Daily -Plaquenil 200mg Daily -Lisinopril 10mg PO Daily -Zoloft 100mg Daily -Imdur 30mg QHS -Oxycodone 10mg prn -Norvasc 10mg Daily -PhosLo 3caps Daily Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for diarrhea. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for pain. 7. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to inguinal folds. 11. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for puritus. 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 14. clobetasol 0.05 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to scalp. 15. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to pruritic areas of back, arms, abdomen, and flanks. Please Avoid use on face, axilla, skin folds, or groin. 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Spinal cord infarct 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 1968**], You were admitted to [**Hospital1 69**] on [**2137-10-11**] for weakness in your legs. You were found to have a blood clot in your spinal cord which is likely causing your weakness. This may have been related to an episode of low blood pressure during dialysis. Your weakness has improved somewhat during your admission but you will need intensive rehabilitation in order to regain your strength. You should continue with your previous schedule of dialysis with close attention to your blood pressure to avoid it dropping too low again. We made the following changes to your medications: STARTED Aspirin 325mg daily STOPPED Toprol XL 100mg Daily, Lisinopril 10mg PO Daily, Imdur 30mg QHS, Norvasc 10mg Daily. These should be restarted gradually with close attention to your blood pressure. If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. It was a pleasure taking care of you during your hospital stay. Followup Instructions: The following appointment has been made for you in our stroke clinic: Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2137-11-15**] 3:30 You should also make an appointment to see your primary care doctor within 1-2 weeks.

Admission Date: [**2178-4-21**] Discharge Date: [**2178-4-28**] Date of Birth: [**2103-7-27**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2178-4-21**] - CABGx4 (Left internal mammary to the left anterior descending artery, vein graft to the diagonal artery, vein graft to the obtuse marginal artery, vein graft to the posterior descending artery) History of Present Illness: 74 yo female with history of coronary artery disease and angina. He underwent an ETT which was positive and subsequently underwent a cardiac catheterization which revealed severe three vessel disease. Given these findings, he is now admitted for surgical revascularization. Past Medical History: CAD : [**Hospital6 1597**] where she underwent angiography. She was told that a stent was not possible and a CABG was recommended. She preferred a conservative approach. A repeat exercise test was performed on medical therapy [**2171-8-14**] which was discontinued at 6 minutes, pulse 100, BP 162/80 with 1-[**Street Address(2) 33576**] depression in V3-5 and chest discomfort. Her EF was 0.45. She was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20391**] at the [**Hospital3 2358**] who felt that medical therapy was an appropriate choice. Hypercholesterolemia Breast CA s/p right lumpectomy followed by mastectomy without XRT . declined Tamoxifen because of clot rist. Cardiac Risk Factors: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension osteoporosis/osteopenia CATH:Cath (circa [**2171**]): - LV gram with EF 45% - LAD with 50-60% stenosis - Large diagonal with 90% stenosis - Totally occluded LCx filling by collaterals - 80% mid-PDA stenosis - Right dominant COMMENT: 3VD WITH LARGE TERRITORY IN JEOPARDY, AND MOD LV DYSFUNCTION. I WOULD SUGGEST CABG. Pacemaker/ICD:NA Social History: Retired teacher. Family History: One brother, age 72, is status post CABG and allegedly had his first infarction in his 30s. Physical Exam: T: 97.2 HR: 51 BP: 158/63 RR: 18 SaO2: 99% on RA Weight: 85kg General: WDWN, NAD, breathing comfortably on RA HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: RRR, s1s2 normal, no m/r/g, no JVD No carotid bruits Pulmonary: CTAB No RRW Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: warm, 2+ DP pulses, no edema Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves all extremities Pertinent Results: [**2178-4-27**] 07:30AM BLOOD WBC-9.3 RBC-3.22* Hgb-9.4* Hct-27.7* MCV-86 MCH-29.1 MCHC-33.9 RDW-14.6 Plt Ct-350# [**2178-4-21**] 01:08PM BLOOD PT-14.2* PTT-33.5 INR(PT)-1.3* [**2178-4-27**] 07:30AM BLOOD Glucose-142* UreaN-18 Creat-1.3* Na-138 K-4.4 Cl-97 HCO3-31 AnGap-14 RADIOLOGY Final Report CHEST (PA & LAT) [**2178-4-28**] 9:30 AM CHEST (PA & LAT) Reason: evaluate left effusion [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with s/p CABGx4 REASON FOR THIS EXAMINATION: evaluate left effusion EXAMINATION: PA and lateral chest. INDICATION: Left pleural effusion. PA and lateral views of the chest are obtained on [**2178-4-28**] and compared with the most recent study of [**2178-4-25**]. When compared with that study, there has been a decrease in size of the left pleural effusion. A small left pleural effusion remains. Bibasilar subsegmental atelectasis persists as does subsegmental atelectasis in the right middle lobe. Patient is status post recent thoracotomy. IMPRESSION: Decrease in size of the left-sided pleural effusion with a small residual effusion remaining. Bilateral subsegmental atelectasis. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Cardiology Report ECHO Study Date of [**2178-4-21**] PATIENT/TEST INFORMATION: Indication: cabg Status: Inpatient Date/Time: [**2178-4-21**] at 10:41 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 Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.3 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: 2.1 cm (nl <= 2.5 cm) Aortic Valve - Valve Area: *1.9 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: Normal LV wall thickness. Normal LV cavity size. LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - hypo; mid anteroseptal - hypo; mid inferoseptal - hypo; mid inferior - hypo; mid inferolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; remaining LV segments contract normally. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) 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 size is normal. Mid and distal LV segments are hypokinetic. Basal segments contract normally. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Preserved RV systolic fxn. Improved LV systolic fxn, especially seen in the mid-anterior wall. MR is now trace. No AI. Aorta intact. Other parameters as prebypass. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2178-4-21**] 11:43. Brief Hospital Course: Ms. [**Known lastname 33578**] was admitted to the [**Hospital1 18**] on [**2178-4-21**] for surgical management of her coronary artery disease. She was taken directly to the operating room where she underwent coronary artery bypass grafting to four vessels. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. She later awoke neurologically intact and was extubated. On postoperative day one she was transfused with packed red blood cells for postoperative anemia. Her pressors were later discontinued. Aspirin, beta blockade and a statin were resumed. Later on postoperative day two she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She had a short burst of atrial fibrillation for which her beta blockade was increased and her electrolytes were repleted. Ms. [**Known lastname 33578**] continued to make steady progress and was discharged home on [**2178-4-28**]. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Isosorbide 30mg twice daily Aspirin 325mg daily Folic acid 1mg daily Multivitamin Lisinopril 5mg daily Lipitor 40mg daily Atenolol 25mg twice daily Caltrate daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 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. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: CAD s/p CABG Hyperlipidemia HTN NSTEMI [**3-23**] Osteopenia/osteoporosis Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with cardiologist Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 4022**] Follow-up with Dr. [**First Name (STitle) **]. [**Last Name (un) 33579**]. [**Telephone/Fax (1) 33580**] in [**11-18**] weeks. Please call all providers for appointments. Completed by:[**2178-4-30**]

Admission Date: [**2123-5-31**] Discharge Date: [**2123-6-2**] Date of Birth: [**2096-7-10**] Sex: M Service: TRA HISTORY OF PRESENT ILLNESS: The patient is a 26 year old male, riding a bicycle, who was hit by a car. The patient hit the windshield of the car, breaking the windshield and had a brief loss of consciousness. The patient was initially evaluated at an outside hospital, upon which evaluation he was noted to have a subarachnoid hemorrhage on CAT scan of his head. Following this, his mental status was noted to deteriorate the patient was transferred to [**Hospital1 346**] for higher level of trauma care. On presentation to the [**Hospital1 69**] Emergency Room, the patient was complaining of neck and back pain. PAST MEDICAL HISTORY: Negative. PAST SURGICAL HISTORY: Right hip gunshot wound and a left chest stab wound. MEDICATIONS: None. ALLERGIES: None. SOCIAL HISTORY: Positive ETOH, positive tobacco. Positive opiates and positive cocaine. PHYSICAL EXAMINATION: On initial evaluation, the patient's temperature was 98.6; heart rate 92; blood pressure 118/76; respiratory rate of 12; saturating 100 percent on nasal cannula. pH was 7.33, PC02 of 45, P02 of 79, bicarbonate 25, base excess of 3. Venous oxygen saturation of 49 percent. His white count was 20.1; hematocrit of 41.5; platelets were 259. His sodium was 145; potassium of 3.9; 109; C02 of 25; ionized calcium 1.09; PT 12.6; PTT 21.6; INR of 1.0. His fibrinogen was 258. Amylase was 83. Ethanol level was 181. Urine toxicology was positive for benzodiazepine, opiates and cocaine. Urinalysis was significant for moderate blood and otherwise was negative. On examination, the patient was moving all extremities. He had a right posterior head scalp laceration, which had been stapled at the outside hospital. His pupils were 5 mm bilaterally and equally reactive to light. His tympanic membranes were clear bilaterally. His oropharynx was clear. Trachea was midline. His heart was regular rate and rhythm. Lungs were clear to auscultation bilaterally. Chest was without deformities or tenderness. Abdomen was soft, nontender, nondistended. His vital signs were stable. His flanks showed no deformities, CVA tenderness bilaterally. Back showed no deformities and no tenderness. Spine showed no deformity, no step-offs, no tenderness. Rectal and perineal examination was significant for good rectal tone and guaiac was negative. Perineum was atraumatic. Right upper extremity and left upper extremity showed no deformities. His right lower extremity had a small laceration which had also been stapled. The left lower extremity showed no deformities and his pulses were intact throughout. His GCS examination: The patient had no verbal response and was withdrawing to painful stimuli, giving him a GCS of 6 under sedation. Chest x-ray, plain film, was negative. CT of the head showed a small subarachnoid hemorrhage in the left frontal area and a small left lateral convex subdural hematoma. CT of the cervical spine was negative. CT of the chest showed a bilateral dependent lower lobe consolidations and a CT of the abdomen was negative. Right knee plain films were negative. ASSESSMENT: 1. Subarachnoid hemorrhage. 2. Subdural hemorrhage. 3. Bilateral lung consolidations. 4. Right posterior head laceration. 5. Right knee laceration. PLAN: Admit the patient to trauma, initially to the Intensive Care Unit. Sedate with Propofol and provide Morphine if needed. Monitor with an A line. The patient was on a ventilator on transfer. This was continued. The patient was provided with gastrointestinal prophylaxis in the form of Pepcid. Foley was placed. He was covered with insulin sliding scale for hyperglycemia. His C collar was kept in place to protect his cervical spine. Neurosurgery was consulted for the traumatic brain injury. Pneumo boots were provided for deep vein thrombosis prophylaxis. The patient was admitted to the Intensive Care Unit. Additionally, Dilantin was provided for seizure prophylaxis given the subarachnoid brain injury. Neurosurgery's recommendations were to keep the systolic blood pressure less than 150, to examine neurologic checks every one hour, continue the Dilantin and repeat the head CT the following day. HOSPITAL COURSE: The patient was able to follow commands and move all four extremities upon lightening his sedation later the day of admission and his ventilator was weaned. He was able to be extubated. Upon further evaluation of his head and face CT, the patient was found to have a left posterior lateral fracture of the maxillary sinus and plastic surgery was consulted for management. They recommended to keep the patient's head elevated and continue the neurosurgical precautions. The fracture was found to be non displaced and there was no indication for surgical repair. The patient was able to be extubated later on the day of admission. He was still complaining of right knee pain; however, there were no fractures on the films. His subarachnoid was stable on repeat head CT scan. The plan was to perform a magnetic resonance scan of the patient's right knee due to ligamentous or soft tissue injury per the Orthopedic service. However, on further evaluation, recommendation was changed to fit the patient for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] brace and follow-up with Dr. [**First Name (STitle) **], orthopedic attending, in two weeks. The patient's mental status improved and he was able to be transferred to the floor on hospital day number two. He was initially provided with a sitter and had no acute events. He was afebrile. Vital signs were stable. His cervical spine was cleared clinically and he was seen by physical therapy. He was ambulated by physical therapy with assistance. Later that evening, house staff was notified that the patient wanted to leave against medical advice. The patient had been seen by physical therapy earlier and due to an unsteady gait was urged to stay for further physical therapy evaluation the following day. The patient refused and the risks and possible consequences of leaving against medical advice were explained. The patient stated understanding and was able to explain the nature of leaving against medical advice back to the house staff evaluating the patient. His vital signs were stable at that time. His mental status was lucid and clear and there were no new medical interventions being planned. At that time, the patient was sent with some discharge orders. His disposition was to home. DISCHARGE INSTRUCTIONS: The patient was leaving against medical advice and, as such, the patient understood releasing the hospital and its employees of responsibilities of such consequences. The patient was instructed to keep the brace on his leg as explained. DISCHARGE DIAGNOSES: Left frontal subarachnoid hemorrhage. Facial fractures. Bilateral pulmonary contusions. Right knee strain. FOLLOW UP: Follow-up with Orthopedics, Dr. [**First Name (STitle) **], in two weeks. Telephone number [**Telephone/Fax (1) 1113**]. Follow-up with plastic surgery in 2 to 3 weeks, [**Telephone/Fax (1) 17687**]. Neurosurgery with CT of the head was scheduled for [**2123-7-2**] at 1:15 p.m. Phone number [**Telephone/Fax (1) 327**]. Trauma clinic follow-up in four weeks following scheduled CT scan, phone number [**Telephone/Fax (1) 2359**]. The patient had no major surgical or invasive procedures during this admission. DISCHARGE CONDITION: Against medical advice. DISCHARGE MEDICATIONS: 1. Albuterol two puffs inhalation q. Six hours. 2. Atrovent two puffs inhalation four times a day. 3. Percocet 5/325 mg one to two p.o. every four to six hours. 4. Dilantin 100 mg p.o. three times a day for five days. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**] Dictated By:[**Last Name (NamePattern1) 13138**] MEDQUIST36 D: [**2123-12-21**] 17:06:04 T: [**2123-12-21**] 18:13:03 Job#: [**Job Number 56175**]

Admission Date: [**2110-3-28**] Discharge Date: [**2110-4-1**] Date of Birth: [**2026-12-6**] Sex: F Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 3151**] Chief Complaint: Generalized tonic clonic seizure x2 Reason for MICU transfer: Seizure, PNA, CHF and r/o meningitis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 99188**] is an 83 year-old woman with HTN, DM, lupus, CKD and a history of seizure disorder who presents from home after two seizures. Patient reports first sizure around 5:30pm with generalized tonic clonic movements lasting about 4 minutes with a second seizure lasting a shorter duration. Per daughter, seizures in the past have been attributed to her lupus (?). Initial vitals in the ED were 96.7 33 160/84 16 100%RA. Pt was satting 90% on RA and was put on BiPAP at that time. Labs in the ED were notable for WBC 9.1 71.9%N, HCT 38.3 (b/l 33) proBNP 2626, Cr 2.4 (b/l 1.4-1.5), Glucose 208, Lactate 2.2 and TropT 0.02. K was 6.6. UA was notable for 6 WBC and few bacteria with nitr negative. CXR revealed pulmonary edema with suggestion of LUL consolidation c/f PNA. A head CT scan revealed no acute process. Given presenting complaint of seizures, meningitis was considered but LP was deferred. Neurology was consulted and advised emperic treatment for meningitis and starting keppra. The patient received 750mg IV levofloxacin originally out of c/f PNA. This was stopped in favor of azithromycin 500mg IV with the thought that this had less risk of lowering seizure threshold. For c/f meningitis, received 2g IV ceftriaxone, 2g IV ampicillin, 600mg IV acyclovir, 1g IV vancomycin. For seizures received 750mg IV levetiracetam. Also 10 units IV of regular insulin for hyperkalemia, and 650mg rectal tylenol. Prior to transfer pt was off Bipap. Vitals on transfer were On arrival to the MICU, patient appears comfortable although still requiring 10% nonrebreather but satting high 90s on this. Denies pain. States her breathing feels much improved. Past Medical History: - Fibular Fx and Tibial Fx s/p ORIF on [**2103-6-25**]. Fell on the stairs, no LOC. Head CT neg. - SLE - followed by Dr. [**Last Name (STitle) **] @ [**Hospital1 **] - Insulin dependent diabetes - followed by Dr. [**Last Name (STitle) 713**] @ [**Last Name (un) **] - HTN - Hypercholesterolemia - s/p MI in [**2077**] - Rheumatoid arthritis - Headaches - Osteoporosis - Cervical dysplasia - Bell palsy - Syphillis s/p penicillin Rx Social History: Former book-keeper at a furniture store in [**Country **]. Moved from [**Country **] in [**2069**]. Denies alcohol & tobacco use Family History: Mother - DM, CVA. Daughter - DM Physical Exam: Physical Exam on Admission: Vitals: 98.6 137/38 HR 49 98% on 100% NRB RR 16 GENERAL: pt resting comfortably on nonrebreather HEENT: Normocephalic, atraumatic, EOMs intact, sclerae and conjunctivae are noninjected. Oropharynx benign. No oral ulcers or thrush. NECK: No JVD, thyromegaly, or adenopathy. CARDIAC: slow rate. Revealed normal S1, S2. Harsh 2 or [**1-28**] systolic ejection murmur of left sternal border, radiating to the right upper sternal border. No rub or gallop. LUNGS: Clear to percussion and auscultation. ABDOMEN: Soft. No organomegaly or masses appreciated. EXTREMITIES: No clubbing, cyanosis, edema, rash, nodules, or purpura. Pertinent Results: Labs on Admission [**2110-3-27**] 11:00PM BLOOD WBC-9.1# RBC-4.11* Hgb-11.6* Hct-38.3 MCV-93 MCH-28.2 MCHC-30.2* RDW-13.9 Plt Ct-195 [**2110-3-27**] 11:00PM BLOOD Neuts-71.9* Lymphs-20.2 Monos-6.7 Eos-0.8 Baso-0.3 [**2110-3-27**] 11:00PM BLOOD PT-10.8 PTT-32.2 INR(PT)-1.0 [**2110-3-27**] 11:00PM BLOOD Glucose-208* UreaN-51* Creat-2.4* Na-135 K-6.6* Cl-101 HCO3-25 AnGap-16 [**2110-3-27**] 11:00PM BLOOD proBNP-2626* [**2110-3-27**] 11:00PM BLOOD cTropnT-0.02* [**2110-3-27**] 11:00PM BLOOD Calcium-8.7 Phos-5.4*# Mg-2.8* [**2110-3-29**] 05:42AM BLOOD Vanco-5.9* [**2110-3-27**] 11:21PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2110-3-27**] 11:21PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.0 Leuks-TR [**2110-3-27**] 11:21PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-1 [**2110-3-27**] 11:21PM URINE CastGr-36* [**2110-3-27**] 11:21PM URINE Mucous-RARE Microbiology: [**2110-3-29**] URINE Legionella Urinary Antigen -PENDING INPATIENT [**2110-3-28**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2110-3-28**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2110-3-28**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2110-3-28**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2110-3-27**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] Brief Hospital Course: 83 y/o F h/o HTN, DM, lupus, CKD and a history of seizure disorder presents with hypoxia after 2 sequential seizures. # HYPOXIA -> Patient reports that she occasionally has dyspnea at home. She has a known history of interstitial lung disease based on prior chest CTs. On presentation, she reported that her dyspnea was worse than her baseline. She was initially found to be febrile to 101, tachypneic to the 30s, with O2 sats in the low 90s. She was initially started on BiPap in the ED, and then transitioned to a 100% non-rebreather in the MICU. Differential for her hypoxia included pulmonary edema given known history of diastolic heart failure, pneumonia, interstitial lung disease. Her O2 supplement was weaned from NRB with antibiotics and additional lasix. Repeat echocardiogram suggested worsening diastolic heart failure. Chest CT was done after patient failed to notably improve after significant diuresis and showed LUL and LLL consolidations as well as chronic ILD. Patient was continued on IV ceftriaxone and azithromycin for presumed pneumonia. Other than consolidations on chest CT, there were no other overt signs of infection; patient remained afebrile, without elevations in her WBC count. However, she is chronically on steroids, which may have been masking a possible infection. Once weaned to 3L NC was called out of MICU. She continued to do well from respiratory perspective and was satting in the high 90s on 2L O2. At transfer, she continued on IV ceftriaxone and azithromycin, and had been diuresed a total of 3L. On the floor, her antibiotics were transitioned to PO cefpodoxime and azithromycin. She received one dose of lasix PO on the floor. She was felt to be euvolemic at that point (minimal crackles at bases, no JVD, no LE edema). She was taken off oxygen and was satting in the high 90s on room air. Pulmonary saw her and felt that the consolidations were most likely due to an aspiration pneumonitis, not pneumonia. Pulmonary recommended outpatient pulmonary follow-up for PFTs and follow-up of interstitial lung disease. She was discharged with one additional day of azithromycin and 3 more days of cefpodoxime. # SEIZURES -> She initially presented with seizures, possibly generalized tonic clonic seizure by description of the family, with history of provoked seizure and possible epilepsy, although unclear of the exact diagnosis. Patient was not on AED at home. She initially had drowsiness, thought to be post-ictal. Etiology of seizure likely multifactorial with underlying PNA on chest imaging, and acute kidney injury causing medication accumulation. LP was attempted but was unsuccessful. Her clinical presentation was not consistent with meningitis (no meningeal signs, not sensitive to light, full range of neck motion without pain, no c/o headache); meningitis antibiotics were discontinued. Her mental status improved over the course of her MICU stay. She was started on Keppra 750 mg [**Hospital1 **]. No further seizure activity was noted. Per neurology, patient should be maintained on keppra for seizure prophylaxis for at least two years if seizure free, and likely for life. # Acute renal failure on CKD. Creatinine increased to 2.4 from baseline of 1.4-1.5. Thought to be pre-renal in the setting of cardiac dysfunction, poor perfusion, and possibly decreased oral intake. Medications were adjusted based on renal function. Her cre improved with diuresis to 1.1. Once on the floor, she recieved her home dose of PO lasix, 20 mg, and subsequently had a bump in her cre to 1.3. Lasix was subsequently held given clinical euvolemia. Recommend restarting lasix upon discharge. # Bradycardia. Patient initially had HR in mid 50s. Appears this is her more recent baseline. Last ECG in [**Month (only) 116**] had HR of 59. Patient's metoprolol was held temporarily for 1 day and restarted on [**2110-3-29**]. On the floor, patient was noted to have episodes of bradycardia down to the 30s. Telemetry showed long pauses without p waves as well as some variable p wave morphology, possibly related to sick sinus syndrome. EKG showed long PR interval consistent with 1st degree AV block. Patient does report that she often feels dizzy at home, although not here in the hospital, which is concerning for symptomatic bradycardia. Metoprolol was held given low HR with good improvement. HR was in the 60-70s at discharge. Patient remained asymptomatic relative to bradycardia during her hospitalization. # Chest pain -> After several days on the floor, patient developed some new back pain as well as abdominal pain. EKG was done and showed prolonged PR interval consistent with first degree AV block but no ST changes. LFTs were normal. Felt to be most likely musculoskeletal. # Hypertension. BP on arrival 160 systolic. Likely [**12-26**] heightened anxiety/sensation of dyspnea. Possible BP has been further uncontrolled at home which could have caused flash pulmonary edema. However, given underlying infection and acute renal failure, her antihypertensives were held for a day with the exception of lasix to treat presumed pulmonary edema. Her amlodipine, enalapril, and metoprolol were restarted on [**2110-3-29**]. Metoprolol was subsequently discontinued on the floor due to bradycardia down to the 30s. # Diabetes, insulin dependent. Patient was initially NPO given mental status. As her mental status improved, she was restarted on home NPH with sliding scale. Blood sugars hovered in the mid-200s to 300s. Sliding scale was increased slightly with some improvement. # Lupus. Does not appear to be in acute flare. Hydroxychloroquine and prednisione were restarted on [**2110-3-28**]. Creatinine improved, therefore, hydroxychloroquine dosage was not changed as it can potentially lower seizure threshold in renal failure. # Anemia, chronic. Hct initially was up to 38.3, thought to be from hemoconcentration. It returned to her baseline around 33 by [**2110-3-29**]. Remained stable throughout hospitalization. # Elevated lactate 2.2. No anion gap. Could be elevated in the setting of seizure. Hemodynamically stable for the MICU stay. # Hyperkalemia. K of 6.6 on arrival. Received 10u IV insulin in ED with K down to 4.4. Resolved. ================================= Transitional issues 1. Outpatient follow-up for thyroid nodule found on chest CT 2. Follow-up with neurology for seizures 3. Follow-up with pulmonology regarding interstitial lung disease for PFTs Medications on Admission: - Amlodapine 10 mg daily - Enalapril 40 mg daily - Furosemide 20 mg dialy on Monday, Wednsday, and Friday - Hydroxychloroquine 200 mg daily - NPH 15 units QAM and 5 units QPM - Lidocaine 5 % Adhesive Patch PRN - Metoprolol succinate 50 mg daily - Prednisone 5 mg daily - Simvastatin 10 mg daily - Solifenacin 5 mg daily - Terazosin 2 mg QHS - Aspirin 81 mg daily - Calcium carbonate 1,250 mg daily - Cholecalciferol 1,000 unit daily - Colace 100mg [**Hospital1 **] Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Enalapril Maleate 40 mg PO DAILY 4. Hydroxychloroquine Sulfate 200 mg PO DAILY 5. PredniSONE 5 mg PO DAILY 6. Azithromycin 250 mg PO Q24H Duration: 3 Days RX *azithromycin 250 mg daily Disp #*1 Tablet Refills:*0 7. Cefpodoxime Proxetil 400 mg PO Q12H RX *cefpodoxime 200 mg twice a day Disp #*12 Tablet Refills:*0 8. NPH 15 Units Breakfast NPH 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. LeVETiracetam 750 mg PO BID RX *levetiracetam 750 mg twice a day Disp #*60 Tablet Refills:*2 10. Calcium Carbonate 1250 mg PO DAILY 11. Furosemide 20 mg PO M,W,F 12. Simvastatin 10 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Generalized Tonic Clonic Seizures secondary to infection Aspiration Pneumonitis Pneumonia Acute decompensation of chronic diastolic heart failure Bradycardia Acute on Chronic Kidney Disease Hyperkalemia 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 Ms. [**Last Name (Titles) 99189**], It was a pleasure participating in your care. You were admitted to the hospital because you had two seizures. You were seen by Neurology, who recommended that you take a daily medication to prevent seizures in the future. You had difficulty breathing when you came into the hospital. We did a CT scan of your chest and found some abnormal changes in your lungs. We also treated you with antibiotics because you may have an infection in your lungs. We recommend that you follow-up with your lung doctor (pulmonologist). We also saw that you had some fluid in your lungs. We gave you medication and helped remove the fluid from your lungs. This medication helped improve your breathing. Several times while you were in the hospital, you developed a very low heart rate. We stopped your medication, metoprolol, to help increase your heart rate. Please continue to take all your home medications as prescribed, except the following: 1. START taking Keppra (Levetiracetam) 750 mg twice daily 2. START taking Cefpodoxime 400 mg twice daily for 3 days 3. START taking Azithromycin 250 mg once daily for 1 days 4. STOP taking Metoprolol Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2110-4-9**] at 10:20 AM With: [**Doctor First Name **] FERN, RNC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2110-5-26**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage We are in the process of finding a neurology (seizure specialist) appointment for you. If someone does not call you with an appointment within the next several days, please discuss this further at your primary care appointment on [**4-9**].

Admission Date: [**2149-11-11**] Discharge Date: [**2149-11-17**] Date of Birth: [**2093-3-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Nausea Major Surgical or Invasive Procedure: none History of Present Illness: 55 yo M w/PMHx sx for IDDM, CAD, GERD, peripheral neuropathy and Charcot foot, and multiple prior hospital admissions for DKA (most recently [**Date range (1) 61439**]) presents to the ER with typical symptoms = 3 day hx of nausea, vomiting, abdominal pain, and decreased po intake. States he has not eaten well for the past 2 weeks and reports a 50lb weight loss. Has not taken insulin for the past 2-3 days, when questioned why he states "mental illness". He presented to the ED for treatment of his nausea, vomiting, and thirst. . Currently reporting n/v and abd pain. Denies f/c, cp, sob, d/c, melena, hematechezia, LUTS. . In the ED, glucose 1142, K 8.3, AG 45, HC03 <5. Insulin 7U IV given then 5 units/hr gtt started. He was give 5L NS. Also got 1gm CaGlu. Transferred to the MICU for management. Past Medical History: IDDM h/o diabetic foot ulcers, MRSA Charcot foot GERD CAD c EF 20-30%, MI [**3-6**] Peripheral neuropathy Multiple past admissions for DKA Social History: Worked as a painter for 5 years but lost his job 2 wks ago. Lives alone. Has two sisters. [**Name (NI) **] social support. Tobacco: 1 ppd for 30 years. +h/o EtOH [**1-5**] pint every other day but none in last two weeks. No h/o DTs. Frequent marijuana use. Family History: Mother c DM, CAD, CVA Father c rectal CA 2 sisters - healthy Physical Exam: Gen: uncomfortable, moaning frequently HEENT: NCAT. dry MM. Sclera nonicteric. No oral ulcers or lesions. Poor dentition. Neck: supple, No LAD. No JVD CV: RRR. No MRG. Lungs: Kussmal respirations, CTA b/l Abd: S/NT/ND +BS. No guarding or rebound. No HSM. Ext: 2+DP pulses. 2+radial pulses. Charcot foot on left with no fluctuance. No ulcers Skin: unkempt and dirty but no rashes Neuro: moaning and repetitive but alert and oriented x3. CN 2-12 intact. Pertinent Results: Admission labs: CBC: WBC-24.72*# Hct-44.0# Plt Ct-365# Diff: Neuts-85* Bands-8* Lymphs-4* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Coags: PT-14.4* PTT-25.6 INR(PT)-1.4 Chem10: Glucose-1142* UreaN-53* Creat-3.2*# Na-130* K-8.3* Cl-81* HCO3-LESS THAN 10 Calcium-8.9 Phos-15.6*# Mg-2.3 ABG: Type-ART pO2-157* pCO2-12* pH-6.94* calHCO3-3* Base XS--29 Card enzs: CK(CPK)-123 -> 148 -> 161 CK-MB-11* -> 10 -> 10 MB Indx-8.9* -> 6.8 -> 6.2 cTropnT-0.06* -> 0.03 -> 0.01 U/A: Blood-SM Nitrite-NEG Protein-TR Glucose-1000 Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Discharge labs: CBC: WBC-9.4 Hct-34.2* Plt Ct-207 Diff: Neuts-71* Bands-20* Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 Chem 10: Glucose-67* UreaN-13 Creat-0.7 Na-137 K-4.2 Cl-101 HCO3-29 Calcium-8.9 Phos-4.0 Mg-1.8 Micro: [**11-11**]: blood cx 1/4 bottles +E coli [**11-12**]: blood cx negative [**11-14**]: urine cx negative Imaging: CXR [**11-11**]: No definite evidence for an acute cardiopulmonary process, however, if symptoms persist, a dedicated PA and lateral chest radiograph should be obtained. CT abd/pelv [**11-12**]: 1. Bilateral pleural effusions. 2. Right basal lung consolidation. 3. Moderate ascites. CXR [**11-12**]: Bilateral lower lobe opacities, possibly representing aspiration or atelectasis. Bilateral effusions are likely. CXR [**11-13**]: Basal densities developing over the last two days and are suggestive of bilateral pleural effusions. Complete PA and lateral chest view is recommended for further confirmation of the somewhat subtle findings. A previous abdominal chest CT of [**2149-11-12**], included images of the basal portions of the lungs disclosed bilateral pleural effusions as well as some atelectasis in the dependent portion of the posterior segments. This finding is consistent with findings observed on the single portable chest view, which however, cannot present same detail as the CT examination. CXR [**11-14**]: Small bilateral pleural effusions have decreased since [**11-13**]. Minimal interstitial edema persists along with left lobe atelectasis. No findings to suggest pneumonia. A paucity vessels in the upper lobes suggest emphysema. Heart size is normal and midline. No pneumothorax. RLE LENI [**11-15**] 6am: This examination had suboptimal images of the superficial femoral vein and was repeated. RLE LENI [**11-15**] 12pm: No evidence of DVT in the right lower extremity. Brief Hospital Course: Assessment: 56yo man with h/o poorly controlled DM admitted with DKA secondary to medication non-adherence in the setting of depression. Hospital course is reviewed below by problem: 1. DKA - The patient was started on an insulin drip per standard protocol for ~30 hours. His anion gap closed, and he was started on NPH at 15u [**Hospital1 **] given his poor PO intake (on 25u [**Hospital1 **] at home). After adjustment during his hospital stay, he was discharged on 25 units NPH qam and 18 units NPH qhs. 2. Leukocytosis - The patient presented with a WBC of 24. This was initially thought to be a stress reaction similar to that evidenced in a prior admission, but after one blood culture grew E coli he was started on levofloxacin and flagyl. The remainder of the blood cultures were positive, including the other 3 from that day, and he had no source of infection, nor was he febrile. As such, the levofloxacin was continued only for a 7 day course for possible pneumonia (CXR with unclear basal opacities on initial read). Flagyl was discontinued given the culture results of E coli. His WBC trended down and was normal at discharge. 3. ARF - He was admitted with a Cr of 3.2, a similar elevation to his last admission for DKA. This was most likely secondary to dehydration from the hyperglycemia. He was aggressively hydrated with IVF and his Cr was 0.7 on discharge. 4. Hyperkalemia - On admission, he had peaked T waves on ECG and a K of 8.3. His hyperglycemia was treated with IVF and insulin, and he received calcium for the hyperkalemia. This resolved and was within normal limits once his anion gap closed. 5. CV - He had a h/o cardiomyopathy, but not CAD. He had no evidence of active ischemia during this admission. He was discharged on home regimen of ASA and lisinopril. Outpatient echo was recommended to re-assess his LVEF. 6. H/o EtOH - The patient denied recent EtOH use. He had no evidence of withdrawal. 7. Socioeconomic issues - The social worker was extensively involved in this hospitalization. At discharge, Pharmacare had been contact[**Name (NI) **] to waive the copay for his prescriptions and he was notified of this. He was given information about the resources available to him for aid and instructed on how to contact the agencies involved. 8. Code status - full. 9. depression- a major contributor to his original presentation. Pt requested an inpatient psychiatric consultation, which was obtained. Medications on Admission: NPH 25u [**Hospital1 **], regular SS ASA 81mg Lisinopril 5mg Citalopram 20mg Not taking any medications except insulin (and not recently taking this due to monetary issues) Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Lisinopril 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: asdir Subcutaneous asdir: Inject 25 units in the morning before breakfast and 18 units at bedtime. Disp:*1 mo supply* Refills:*2* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 6. One Touch Basic System Kit Sig: One (1) kit Miscell. asdir. Disp:*1 kit* Refills:*0* 7. One Touch Test Strip Sig: One (1) strip Miscell. four times a day. Disp:*1 mo supply* Refills:*2* 8. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscell. asdir. Disp:*1 mo supply* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis cardiomyopathy Acute renal failure - secondary to volume depletion. Depression History of substance abuse. E. coli bacteremia of unclear etiology Discharge Condition: Stable; he is no longer in DKA, blood sugars are normal, electrolytes are normal. He still has minimal abdominal pain, no other complaints. Discharge Instructions: Please take all medications as prescribed. Make sure you continue to take your insulin. Follow up with your doctor's appointments as listed below. If you have any return of your symptoms, please call your doctor or come to the hospital right away. Call your doctor or go to the emergency room if you have abdominal pain, nausea, vomiting, chest pain, dizziness, high blood sugars, diarrhea/loose stools, or any other concerning symptoms. Followup Instructions: Please follow up with: Provider: [**Name10 (NameIs) 1238**] [**Name8 (MD) **], [**MD Number(3) 1240**] [**Telephone/Fax (1) 250**] Date/Time:[**2149-11-26**] 10:40am, [**Location (un) **] [**Hospital Ward Name 23**] building Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2149-12-3**] 3:00pm, [**Location (un) **] [**Hospital Ward Name 23**] building Please follow up with [**Last Name (un) **] Diabetes Center on [**2149-11-24**] at 9 a.m. with Dr. [**Last Name (STitle) 9978**]. You will have an appointment with a teaching nurse at 8 a.m. The phone number is [**Telephone/Fax (1) 2378**]. Please follow up with psychiatry at [**Last Name (un) **]. They can arrange psychiatry appointments for you when you go to see them for your diabetes management. Have your doctor make you an appointment for an outpatient ECHO. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Admission Date: [**2107-10-16**] Discharge Date: [**2107-10-26**] Service: NEUROSURGERY Allergies: Penicillins / Naprosyn / Tetanus Antitoxin Attending:[**First Name3 (LF) 2724**] Chief Complaint: FALL Major Surgical or Invasive Procedure: right subdural hematoma evacuation via burr holes History of Present Illness: HPI: 88yo F lives by herself at home, was found on the floor at home today. Per her family, she was awake and moving all extremities when found, but not as alert as usual. No external bleeding or apparent injury. c/o of pain during hospital transfer. the last time she was spoken to on the phone was Friday (two days ago). She also fell on her front porch 10days ago and was taken to home by a neighbor, no medical evaluation since pt seemed fine after the fall. Past Medical History: PMHx: CAD, kyphosis. denied MI/stroke. Social History: Social Hx: lives alone at home; her nephew checks on her once or twice a week. Nonsmoker/nondrinker Family History: Family Hx: NC Physical Exam: PHYSICAL EXAM: O: T: 98.6 BP: 150/64 HR: 88 R 18 O2Sats 95% Gen: eyes closed. open to voice. HEENT: Pupils: PERRLA Neck: on hard collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: sleepy but arousable, follow some commands during exam. Orientation: Oriented to self, place, and year/month. Language: simple answer to questions; some difficulty with comprehension. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2mm to 1.5 mm bilaterally. Tongue in midline. The rest of CNs difficult to exam due unable to follow instruction. Motor: increasing tone of LE bilaterally. No abnormal movements, tremors. Moving both UE spontaneous/purposeful and antigravity. Wiggle bilat toes to commands; withdrawal of both LE to pain, but not antigravity. unable to fully assess strength. Sensation: withdrawal to pain of all the four extremities symmetrically. Reflexes: [**12-2**] thoughout. Toes upgoing on right and downgoing on left. Coordination: unable to assess on discharge she is aaox3, clear speech, appropriate conversation, no facial asymmetry, motor full, no drift, gait not tested. Pertinent Results: CT/MRI: CT heaD: Large, mixed attenuation extraaxial collection overlying the right cerebral hemisphere causing leftward shift of the midline consistent with acute on chronic subdural hemorrhage. Dilatation of the temporal [**Doctor Last Name 534**] of the left lateral ventricle concerning for obstructive hydrocephalus. CT c-spine: Extensive, multilevel degenerative changes throughout the cervical spine. Grade I anterolisthesis of C3 on C4 and C4 on C5, likely degenerative. However, ligamentous injury cannot be excluded on CT. If there is clinical concern, an MRI of the cervical spine is recommended. LABS: CK 4079; CK-MB 136; TROPONIN 0.03 EKG: ST-T changes on lateral leads Brief Hospital Course: PT WAS ADMITTED TO THE ICU/ NEUROSURGERY SERVICE for close monitoring. She was brought to the OR where under general anesthesia she underwent right burr hole drainage of SDH. She tolerated this procedure well and was transferred back to ICU. She was hemodynamically stable, her neurologic exam slowly improved and she was ultimately weaned from ventilator. She was transferred out of ICU to floor. Her incisions were clean and dry and sutres were removed. She was able to tolerate PO. Foley was removed and she urinated without difficulty. She was seen by PT and OT and appropriate for rehab. Medications on Admission: Medications prior to admission: Unclear. Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: dc after 11/2 doses. 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Levothyroxine 75 mcg 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). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: subdural hematoma 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 ?????? You may shower before this time with assistance and use of a shower cap ?????? 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 ?????? 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: ?????? 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.[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Completed by:[**2107-10-26**]

Admission Date: [**2174-10-15**] Discharge Date: [**2174-10-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Chills and cough Major Surgical or Invasive Procedure: none History of Present Illness: 80y/o M with CAD, EF 55%, COPD, HTN, DM who presented with 1-2 days of increasing cough that became productive, sudden acute weakness and chills. He was sent to the ED because wife was afraid of patient falling. In the ED patient initially normotensive, then suddenly had blood pressure drop to 70/40. Patient given 3L of NS bolus with improvement in blood pressure to 140's. However, increase in blood pressure not sustained and patients blood pressure decreased to 90/50 and started on MUST protocol [**1-3**] increased lactate. Patient was then transferred to the MICU. In MICU given CTX/Azithro, was pan cultured, obtained [**Last Name (un) 104**] stim test. Observed o/n and stabilized. Also noted to have elevated trops which have begun to decrease and no ecg changes. Transferred to floor. Past Medical History: 1. CAD with evidence of 3vessel disease on cardiac cath [**9-4**]. 2. CHF with EF of 55% 3. CRI (b/l 1.7) 4. OSA 5. HTN 6. Diabetes Social History: Retired meat packer, lives with wife, has a nurse that helps him at home up until 4pm. She helps with most of the activities and treatments that the patient needs. She also does some rehab. no tob, no etoh, no ivdu Family History: NC Physical Exam: On admission to floor. T: 97.3, P: 64, BP: 140/79, R: 23 96% on 3L NC GEN: Alert and oriented x 3, NAD, wife at bedside [**Name (NI) 4459**]: NC/AT, wears glasses, EOMI, PERRL, o/p clear, mmm NECK: no LAD, unable to appreciate JVD [**1-3**] neck girth CV: distant, RRR, no m/r/g Pulm: right lung base with crackles, expiratory wheezes. Left lung field without crackles/rhonchi/wheezes. Abd: soft, NABS, protuberant, NT, mild distension. Ext: no c/c/e, DP/PT 1+ b/l Neuro: NC II-XII grossly intact, sensation intact to light touch, strenght: lower ext hip flexors [**2-4**] b/l rest wnl. Pertinent Results: [**2174-10-15**] 06:28PM LACTATE-2.6* [**2174-10-15**] 04:38PM URINE HOURS-RANDOM [**2174-10-15**] 04:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2174-10-15**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2174-10-15**] 03:04PM LACTATE-3.1* [**2174-10-15**] 02:45PM GLUCOSE-211* UREA N-37* CREAT-2.0* SODIUM-139 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-19 [**2174-10-15**] 02:45PM CK-MB-8 cTropnT-0.58* [**2174-10-15**] 02:45PM ALBUMIN-4.2 CALCIUM-9.7 MAGNESIUM-1.7 [**2174-10-15**] 02:45PM CORTISOL-39.0* [**2174-10-15**] 02:45PM WBC-14.0* RBC-4.95 HGB-14.4 HCT-40.9 MCV-83 MCH-29.2 MCHC-35.3*# RDW-15.5 [**2174-10-15**] 02:45PM NEUTS-69 BANDS-23* LYMPHS-2* MONOS-4 EOS-0 BASOS-1 ATYPS-1* METAS-0 MYELOS-0 [**2174-10-15**] 02:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2174-10-15**] 02:45PM PLT COUNT-186 CHEST (PORTABLE AP) [**2174-10-15**] 8:04 PM No subclavian line is present. There is no evidence of a pneumothorax. The heart remains enlarged, right effusion is present. Compared to the prior film of 5 hours earlier the vasculature appears slightly more prominent and the degree of failure may be now occurring. IMPRESSION: No pneumothorax, cardiomegaly with some evidence of failure. CHEST (PORTABLE AP) [**2174-10-15**] 3:05 PM AP CHEST: This study is limited by low lung volumes and respiratory motion. The heart, mediastinal and hilar contours are unchanged in the interval allow- ing for differences in technique. The aorta is tortuous. There is some elevation of the right hemidiaphragm with possible atelectasis at the right base. IMPRESSION: Limited study due to Low lung volumes and motion. ECG: Sinus rhythm. Conduction defect of right bundle-branch block type. Low QRS voltages in precordial leads. Since the previous tracing of [**2173-9-30**] ventricular ectopy is resolved Brief Hospital Course: 1. PNA: Patient was admitted to the MICU and was aggressively hydrated with fluids and treated with abx: azithromycin and Ceftriaxone. He was pancultured with blood culture and urine culture both negative. His sputum grew many diferent types of oral flora. [**Last Name (un) **] stim test was done but was no longer needed as patient quickly stabilized, no steroides were instituted. He was stabilized and transferred to floor. Abx were continued, Physical therapy and pulmonary toilet were both requested and performed while on the floor. He was continued on his alb/atrovent nebs for the wheezes. He was discharged stable on room air without supplemental oxygen and on azithromycin and cefpodoxime. 2. CAD: asa, lipitor were both continued while in the hospital. He was noted to have elevated troponins but in review of his records he has elevated troponins at baseline due to his CRI. Thus, the small rise in his troponins on this admission was [**1-3**] demand ischemia in setting of stress/hypotension. No further workup was done. CHF: stable, no evidence of heart failure. His Accupril was restarted on day of discharge as his blood pressure had been stable while on the floor for more than 24hours. 3. COPD: stable continued on fluticasone/salmeterol, alb/atrovent, tiotropium 4. OSA: stable, continued on his outpatient doses of ritalin sr and ritalin 5. HTN: restarted on Accupril 5mg once a day. 6. DM: stable, continued on his outpatient NPH doses, and RISS 7. Glaucoma: stable continued on his outpatient latanoprost and timolol 8. Psych: stable continued on his outpatient meds 9. FEN: cardiac healthy diet, [**Doctor First Name **], 2gm sodium 10. Full code. Medications on Admission: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pyridoxine HCl 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. Methylphenidate HCl 20 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 15. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-3**] Puffs Inhalation Q6H (every 6 hours). 17. medication NPH 20U before breakfast and 20U before dinner 18. Accupril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pyridoxine HCl 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. Methylphenidate HCl 20 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 15. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-3**] Puffs Inhalation Q6H (every 6 hours). 17. medication NPH 20U before breakfast and 20U before dinner 18. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Disp:*1 Tablet(s)* Refills:*0* 19. Cefpodoxime Proxetil 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 8 days. Disp:*32 Tablet(s)* Refills:*0* 20. Accupril 5 mg Tablet Sig: One (1) Tablet PO once a day. 21. equipment Home Nebulizer Dispense: one Refills: zero Discharge Disposition: Home Discharge Diagnosis: 1. Pneumonia 2. Hypotension Secondary 3. CAD 4. CHF 5. COPD 6. OSA 7. HTN 8. Diabetes 9. Cervical Spondylosis 10. Myopathy Discharge Condition: Stable, ambulatory sats stable. Discharge Instructions: Please take all your medications as prescribed and follow up with all your recommended appointments. Please call your primary care physician if you develop: fevers, chills, chest pain, shortness of breath or other concerning symptoms. You can restart your accupril. Followup Instructions: 1. Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week. Please call to schedule an appointment at [**Telephone/Fax (1) 904**].

Admission Date: [**2151-5-21**] Discharge Date: [**2151-6-5**] Date of Birth: [**2079-7-18**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**Name (NI) 9308**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 71 year old man with recent hospitalization [**Date range (1) 28125**] for heart failure, during which he was diuresed and discharged home. He is a poor historian. He reports that he has been taking his Lasix, but for the past day or so has been having shortness of breath and discomfort in his xiphoid/epigastric region. It is "mild" in intensity and does not radiate. He denies nausea, vomiting, and abdominal pain. His shortness of breath limits his ability to walk. He saw his primary care RN three days ago and was instructed to increase his Lasix dose by 80mg daily x 3 days. . In the ED, triage vitals were T97.4F, BP 101/56, HR 95, Sat 94%RA. He was given 325mg aspirin. CXR showed no acute process and improvement from prior with better aeration, although he still has decreased lung volumes. He was noted to have bibasilar rales and expiratory wheezes, and given increased creatinine (1.7) . Review of the Atrius records indicates that his [**Location (un) 2274**] caregivers were quite concerned about him at home given his medication noncompliance and recommended that he stay in the hospital until completely diuresed or go to short term rehab. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. All other review of systems are negative. Past Medical History: - Coronary artery disease s/p stent (LCx, [**2145**]) - CHF (EF 30-35%) - Aortic stenosis (1.2cm2) - CVA on warfarin - BPH - Prostate CA - Hyperlipidemia - Hypertension - Thalassemia trait, G6PD Social History: Lives alone in [**Location (un) 686**]. He is able to cook for himself. Able to walk [**12-12**] blocks without dypnea. Poor compliance with diet. Uses bubble packs for his medications. Doesn't know the names of any of his medications. Has assistance of his son and daughter. [**Name (NI) **] [**Name (NI) 5586**] is his HCP [**Telephone/Fax (1) 38272**]. EtOH: none Tobacco: former 20 pack year smoker, quit 20 years ago. Illicits - none Family History: Mother deceased from MI at age 37. Father deceased with CVA and lung cancer. Maternal aunts with DM. Brother deceased from esophageal cancer. Physical Exam: ADMISSION PHYSICAL EXAM VS - BP 102/65, HR 87, RR 18, Sat 100%2L Gen: No acute distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Neck: Supple. JVP unappreciable. CV: RR, normal S1, S2. + 1-2/6 systolic ejection murmur. No S3 or S4. Chest: Rales [**12-13**] bilaterally. Occasional wheezes at apices. Abd: Soft, NTND. No HSM. Tender in epigastric region worse with deep palpation. Ext: No clubbing or cyanosis. 1+ pitting edema to the knee bilaterally. Pertinent Results: Admission labs: [**2151-5-21**] 02:15PM BLOOD WBC-8.6 RBC-3.91* Hgb-9.1* Hct-29.5* MCV-75* MCH-23.2* MCHC-30.7* RDW-20.3* Plt Ct-203 [**2151-5-21**] 02:15PM BLOOD Neuts-77.6* Lymphs-12.1* Monos-7.2 Eos-2.7 Baso-0.3 [**2151-5-21**] 02:15PM BLOOD PT-17.5* PTT-29.5 INR(PT)-1.6* [**2151-5-21**] 02:15PM BLOOD Glucose-99 UreaN-51* Creat-1.7* Na-134 K-4.3 Cl-94* HCO3-31 AnGap-13 [**2151-5-22**] 07:40AM BLOOD CK(CPK)-943* [**2151-5-22**] 01:45AM BLOOD CK(CPK)-1097* [**2151-5-22**] 07:40AM BLOOD CK-MB-5 cTropnT-0.04* [**2151-5-22**] 01:45AM BLOOD CK-MB-6 cTropnT-0.04* [**2151-5-21**] 02:15PM BLOOD cTropnT-0.05* [**2151-5-22**] 07:40AM BLOOD Calcium-8.1* Phos-5.6*# Mg-1.9 . CHEST X-RAY PA and lateral [**2151-5-21**]: Similar to the prior exam, lung volumes are diminished with marked elevation of the right hemidiaphragm again noted and stable. There is improved aeration with no focal consolidation or superimposed edema noted. Mild aortic tortuosity is again noted with calcified plaque at the arch. The cardiac silhouette size is stable and likely top normal accounting for patient and technical factors. No effusion or pneumothorax is noted. The osseous structures are unremarkable. IMPRESSION: Stable chest x-ray examination with no definite acute pulmonary process. . CT Scan of CHEST on [**2151-5-29**]: 1. Mild atelectasis at the right base. 2. Opacification noted in prior study is due to vessels tortuosity. No concerning lung lesion or lymphadenopathy is noted. 3. Small amount of ascites. . RENAL Ultrasound on [**2151-5-26**]: The study is slightly limited by difficulties with positioning. The right kidney measures 10.4 cm. The left kidney measures 9.8 cm. No stones or hydronephrosis are identified. The bladder is decompressed with a Foley catheter noted. IMPRESSION: No evidence of hydronephrosis. Brief Hospital Course: ASSESSMENT/PLAN: 71 yo M with history of CHF (EF 30-35%) and recent admission for CHF now admitted with dizziness, chest pain, and shortness of breath. . #) Shortness of Breath: Likely multifactorial. His initial presentation was consistent with acute on chronic systolic heart failure. The patient was diruesed with IV Lasix, but subsequently became dehydrated and developed hypotension and acute on chronic renal failure. He was transfered to the CCU for further management. In the CCU: his diuretics were held to allow renal recovery. Despite diuresis and appearing near-euvolemic on exam, he remained dyspneic. Pulmonology was consulted for further investigation. ABGs demonstrated hypercarbic respiratory acidosis, likely due to his obstructive airway disease. Patient improved by using BIPAP from 10pm-7am, and treating for COPD exacerbation with azithromycin and prednisone taper. He has an appoitment to follow up with his outpatient cardiologist. . #) Acute on chronic renal failure: The patient developed acute on chronic renal failure in the setting of overdiuresis. He was treated with initially IV fluids and then with holding of Lasix. Upon recovery of renal function, Lasix was resumed at 80mg po daily. . #) Hypotension: On [**2151-5-25**], the patient's blood pressure was noted to be 82/doppler. This responded quickly, with a fluid bolus, with systolic blood pressure subsequently 110. The patient was transferred to the CCU for further management. On admission to the CCU, his blood pressure was normotensive and remained such throughout the rest of his admission. . #) Chest pain: The patient had chest pain prior to admission, which recurred on [**2151-5-25**], in the setting of hypotension to 82. He ruled out for MI. . #) History of CVA: The patient was subtherapeutic on admission. Warfarin was started at 10 mg daily. Subsequently, the patient became supratherapeutic and warfarin was held. Warfarin continued to be held in the setting of hematuria and rectal bleeding. . #) Rectal bleeding: Patient had intermittent boughts of BRBPR. According to Atrius records, he has known hemorroids. H/H have been stable. Patient will follow up with his PMD for this issue. . #) Hematuria: Patient's foley was frequently irrigated and eventually switched to a 3 way foley. He has known prostate CA. H/H stable throughout admission and there were no signs of urinary tract obstruction. Patient will follow up with his PMD and his PMD will refer to urology as needed. . Confirmed full code . Dispo: to rehab Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 6. Colchicine 0.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for back pain. 8. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO once a day: to complete 21 day course as directed. 9. Zoladex 10.8 mg Implant Sig: One (1) implant Subcutaneous as directed: per your oncologist. 10. Viagra 50 mg Tablet Sig: One (1) Tablet PO as needed as needed for erectile dysfunction. 11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 18. Bipap at night 19. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO at bedtime. Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center for Rehab & Sub-Acute Care - [**Location (un) 2312**] Discharge Diagnosis: Primary: 1. Acute on chronic systolic heart failure . Secondary: 1. Aortic stenosis 2. Back pain 3. Benign prostatic hypertrophy 4. History of stroke Discharge Condition: Mental Status: Alert and oriented to person and place. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital with shortness of breath. This was thought to be due to congestive heart failure and chronic obstructive pulmonary disease. You were treated with Lasix with improvement in your symptoms. You were also treated with antibiotics, steroids, and used CPAP at night to help with your breathing. . Continue to take all of the medications that you were on prior to admission, with the following changes: 1. Change Lasix (furosamide) from 80mg twice a day to 80mg once a day 2. Please stop taking Calcium Acetate 3. Please stop taking Ipratropium bromide. 4. Please stop taking coumadin (warfarin). . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Use CPAP every night to help with your breathing. Followup Instructions: 10:30AM on Friday, [**6-18**] Name: [**Last Name (LF) 38274**],[**First Name3 (LF) **] X. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 19604**] Phone: [**Telephone/Fax (1) 3530**] Fax: [**Telephone/Fax (1) 6808**] . 11:50AM on FRIDAY, [**6-11**] Name: [**Name (NI) **], [**Name (NI) **] Location: [**Hospital1 641**] Address: [**Street Address(2) **], [**Location **] MA Phone: [**Telephone/Fax (1) 38275**] Fax: [**Telephone/Fax (1) 38276**]

Admission Date: [**2123-5-31**] Discharge Date: [**2123-6-6**] Date of Birth: [**2091-8-18**] Sex: F Service: SURGERY Allergies: Codeine / Remicade / Vancomycin Attending:[**First Name3 (LF) 3376**] Chief Complaint: nausea/vomitting Major Surgical or Invasive Procedure: percutaneous drain placement PICC line placement History of Present Illness: 31 yo w/ crohn's history refractory to medical managment present with nausea and vomiting x 3 days. She was discharged on [**2123-5-25**] after a month long hospitalization for treatment of intra-abdominal abcesses. Since her dischange she has been tolerating clears but regular food has made her increasingly nauseated. Yesterday she has had several bouts of intractable vomitting and she has been unable to tolerate even clears. She denies f/c. She has only mild abdominal pain controlled with 2mg PO dilaudid x 1. She has had flatus and several watery bowel movements per day. Past Medical History: Crohn's Disease Depression h/o arthritis related to medications Anorexia Nervosa/OCD Past Surgical History s/p Wisdom teeth removal in [**2103**] LEEP procedure in [**2121**] Primary Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5781**] GI: Dr. [**Last Name (STitle) 2161**] Social History: Works at [**Hospital3 328**] in PR department [**11-21**] EtOH drinks, ~3 times per week smoked [**11-20**] ppd X 3-4yrs quit 9 years ago Family History: Cousin with [**Name (NI) 4522**] Disease Father CAD Physical Exam: GEN: a and o x 3, nad V.S.S CV: rrr, no m/r/g RESP: lscta, bilat ABD: soft, nt, nd, + BS Drain site d/c/i no s/s of infection Ext: no c/c/e Pertinent Results: CT abd- (6cm trans, 4/4cm, 6x2cm, sm midline inc 2x 0.5cm) fluid collections. 3.5 cm LUQ dilated sm (same as [**Month (only) **]) likely ileus CXR: A new left PICC tip projects over the mid SVC in good position . IR drainage: Status post successful percutaneous drain placement, with the catheter traversing the anterior lower pelvic collection and coursing posteriorly to terminate within the posterior pelvic collection. A sample of the fluid was sent for laboratory evaluation. The catheter should be flushed and aspirated 2-3 times daily until the aspirate is clear. . [**2123-5-31**] 06:00PM BLOOD WBC-20.3*# RBC-4.38# Hgb-10.5*# Hct-32.4*# MCV-74* MCH-24.0* MCHC-32.5 RDW-18.1* Plt Ct-900* [**2123-6-1**] 07:00AM BLOOD WBC-32.8*# RBC-4.04* Hgb-9.7* Hct-29.7* MCV-74* MCH-24.1* MCHC-32.8 RDW-18.3* Plt Ct-758* [**2123-6-1**] 12:54PM BLOOD WBC-36.8* RBC-3.98* Hgb-9.6* Hct-28.7* MCV-72* MCH-24.2* MCHC-33.6 RDW-18.2* Plt Ct-779* [**2123-6-2**] 04:50AM BLOOD WBC-15.5*# RBC-3.33* Hgb-8.1* Hct-24.0* MCV-72* MCH-24.3* MCHC-33.7 RDW-18.2* Plt Ct-549* [**2123-6-3**] 06:40AM BLOOD WBC-10.8 RBC-3.63* Hgb-8.6* Hct-26.2* MCV-72* MCH-23.8* MCHC-33.0 RDW-18.1* Plt Ct-639* [**2123-6-4**] 06:01AM BLOOD WBC-9.7 RBC-3.58* Hgb-8.5* Hct-26.2* MCV-73* MCH-23.8* MCHC-32.5 RDW-18.3* Plt Ct-634* [**2123-5-31**] 06:00PM BLOOD Neuts-91.1* Lymphs-4.7* Monos-3.4 Eos-0.6 Baso-0.2 [**2123-6-4**] 06:01AM BLOOD Plt Ct-634* [**2123-6-2**] 04:50AM BLOOD PT-15.0* PTT-33.0 INR(PT)-1.3* [**2123-6-4**] 06:01AM BLOOD Glucose-103 UreaN-12 Creat-0.7 Na-140 K-3.6 Cl-106 HCO3-23 AnGap-15 [**2123-6-4**] 06:01AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.9 [**2123-6-3**] 06:40AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-1.9 Iron-42 [**2123-6-3**] 06:40AM BLOOD calTIBC-192* Ferritn-335* TRF-148* [**2123-6-4**] 06:01AM BLOOD Triglyc-121 . C-DIFFICILE TOXIN [**2123-6-4**]: Feces negative Brief Hospital Course: The patient was admitted to the surgical service from the ER. She was maintained NPO with IVF/MEDS/ABX. CT abd/pelvis demonstrated reaccumulation of intraabdominal fluid collections previously drained by pigtails, and a new fluid collection below her incision. Initially treated with Zosyn 4.5gm IV q8h, and received one dose vancomycin 1gm IV. At 7am, she spiked a temp to 101.2. Around noon, the patient triggered on the floor for tachypnea with RR 30-40s, HR 120s, and altered mental status. Labs were notable for WBC 20-->30-->36 over the course of the day. As patient worsened, on [**6-1**], Zosyn switched to meropenem 500mg IV q8h, and was given one dose Fluconazole 400mg IV. She went to IR where she underwent CT-guided drain placement to drain her pelvic fluid collections, ~75cc purulent drainage was noted at the time of the procedure. Additionally 1L of bilious fluid was drained from an NG tube placed at the time of the procedure. She was intubated for the procedure. She became hypotensive during the procedure in the setting of general anesthesia, requiring neo at one point, however has otherwise been hemodynamically stable throughout this admission. She returned to the floor and was continued to receive TPN/IV abx and maintained as NPO. Her foley was removed and she was started on oral/home medications. Drain teaching/PICC/TPN was provied to the patient and mother. The patient will follow up with Dr. [**Last Name (STitle) 1120**] in [**11-20**] weeks. Medications on Admission: Acetaminophen, Citalopram 20', Iron 325 mg, Ciprofloxacin 500'' Pantoprazole 40 mg EC', Budesonide 9 mg SR, Ambien 10 mg qHS. Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Ertapenem 1 gram Recon Soln Sig: One (1) bag Intravenous once a day for 14 days. Disp:*14 bag* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*28 Tablet(s)* Refills:*0* 8. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection every eight (8) hours: flush with 10 cc and withdraw around the same amount. ****If you are unable to withdraw at least 5 cc, please stop flushes****. Disp:*60 flushes* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: anterior lower pelvic collection coursing posteriorly to terminate within the posterior pelvic collection. Discharge Condition: Stable. Pain well controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . TPN: you will continue with home TPN and [**Location (un) 511**] Home Therapies will assist you with this. Abx: [**Location (un) 511**] Home Therapies will set up ertapenem at home for you. . PICC: A PICC line was placed for TPN while you were in the hospital. The VNA will assist with dressing changes and care. You may shower but you must cover the PICC and not get it wet. . Pigtail Drain: A drain was placed while you were in the hospital. You should continue to empty and record daily and PRN. Please flush and aspirate drain with 10cc of NS every 8 hrs. If you are unable to aspirate more than 5 cc each time, please stop flushes. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2123-6-15**] 3:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2123-6-21**] 10:00 NEITHER DICTATED NOR READ BY ME Completed by:[**2123-6-7**]

Admission Date: [**2146-4-20**] Discharge Date: [**2146-4-27**] Date of Birth: [**2111-2-28**] Sex: M Service: CARDIOTHORACIC Allergies: Vancomycin Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: [**2146-4-20**] redo sternotomy/AVR ( [**Street Address(2) 6158**]. [**Male First Name (un) 923**] mechanical)/repl. asc. aorta ( 24 mm Gelweave)/ aortic root enlargement (pericardial patch)/right fem. art. repair [**2146-4-21**] RLE fasciotomy History of Present Illness: 35 yo male with prior homograft Bentall procedure done [**5-11**] for bicuspid AV and ascending aortic aneurysm. This was complicated by a sternal wound infection. Presented in [**2-18**] with CHF/ DOE. First evaluated in [**3-21**], and a prior echo revealed prosthetic AS/ AI. Referred for surgery. Past Medical History: prosthetic aortic stenosis/insufficiency s/p redo operation ( see below) s/p Homograft Bentall procedure [**5-11**] sternal wound infection [**5-11**] gastroesophageal reflux disease hypertension hemorrhoids Social History: He is a civil engineer, having a desk job. He is a never-smoker. He drank alcohol socially. He denies street drug use. Family History: There is no family history of premature coronary artery disease or sudden death. His aunt had [**Name2 (NI) 499**] cancer and grandmother had uterine cancer. Physical Exam: 5' 10" 160# HR 105 RR 14 right 106/58 left 102/60 NAD skin warm, dry NCAT, PERRL, sclera anicteric, OP benign, teeth in good repair neck supple, full ROM, no JVD CTAB, healed sternotomy scar, stable sternum RRR , [**Last Name (un) 13778**], [**5-16**] blowing holosystolic murmur, [**3-18**] diastolic murmur, +PVCs warm, well-perfused, trace edema alert and oriented x3, nonfocal exam 2+ bil. fem/DP/PT/radials murmur transmits to bil. carotids Pertinent Results: Conclusions PREBYPASS 1. The left atrium is moderately dilated. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is borderline normal (LVEF 45-50%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta tube graft appears abnormal with a supravalvular obstruction which may represent a kinking of the aortic root (homograft root) and ascending aortic tube graft connection. A bioprosthetic aortic valve prosthesis is present. Motion of the aortic valve prosthesis leaflets/discs is abnormal with one leaflet prolapsing into the LVOT and the other two leaflets are calcified and fairly immobile. The prosthetic aortic valve leaflets are thickened. There is moderate aortic valve stenosis ?supravalvular(area 1.0-1.2cm2). Moderate to severe (3+) aortic regurgitation is seen. 5. Mild (1+) mitral regurgitation is seen. 6. There is no pericardial effusion. 7. Dr. [**Last Name (STitle) **] was notified in person of the results during the surgery on [**2146-4-20**] at 1156 POST-BYPASS: The patient is in sinus rhythm and on infusions of phenylephrine, epinephrine 0.03 mcg/kg/min, and vasopressin 3units/hour 1. Biventricular is mildly depressed in the immediate post bypass period. The function normalized by the end of the surgery (on vasoactive infusions). Overall LVEF 50 to 55% 2. A new mechanical aortic valve is present is good position with good leaflet motion and appropriate washing jets. The peak velocity through the valve is approximately 3 m/s with a peak gradient of 37 mmHg (C.O 6 l/min] 3. A new aortic tube graft has replaced the previous one and relieved the supravalvular obstrucion. 4. Mild MR and trivial TR. 5. Intact thoracic aorta. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**2146-4-25**] 07:05AM BLOOD WBC-5.7 RBC-3.39* Hgb-10.2* Hct-29.1* MCV-86 MCH-30.1 MCHC-35.0 RDW-15.6* Plt Ct-159# [**2146-4-26**] 06:55AM BLOOD PT-27.2* INR(PT)-2.7* [**2146-4-25**] 07:05AM BLOOD PT-25.7* INR(PT)-2.5* [**2146-4-24**] 12:34AM BLOOD PT-19.0* PTT-34.6 INR(PT)-1.8* [**2146-4-25**] 07:05AM BLOOD Glucose-90 UreaN-11 Creat-0.7 Na-139 K-4.3 Cl-108 HCO3-27 AnGap-8 Brief Hospital Course: Admitted [**4-20**] and underwent surgery with Dr. [**Last Name (STitle) **]. Please refer to separate operative note. Extubated the following morning and suffered a single seizure. Neurology was consulted. CT of the head revealed no bleed, and multiple old granulomas. EEG did not reveal evidence for seizure. The patient developed compartment syndrome of right lower extremity. He was reintubated for surgical fasciotomy by Dr. [**Last Name (STitle) **] after right calf swelling noted on POD #1. Extubated again on POD #2. He awoke neurologically intact without further seizure or neurological complication. Wound vac was placed to fasciotomy sites. Chest tubes and pacing wires were discontinued in the usual fashion without complication. Coumadin was started. He was gently diuresed toward his preoperative weight. The physical therapy service was consulted for assistance with post-operative strength and mobility. The patient noted difficulty with [**Location (un) 1131**] comprehension, so neurology was re-consulted. MRI/MRA of the head and neck were performed and results are pending at the time of discharge. Postop course was otherwise uneventful and the patient was discharged home with appropriate follow up instructions as well as VNA services on POD 5. Medications on Admission: ASA 81 mg daily lisinopril 5 mg daily lasix 40 mg 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:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: dose will change daily- to be managed by Dr. [**Last Name (STitle) 13779**] goal INR [**3-15**]. Disp:*30 Tablet(s)* Refills:*2* 9. Outpatient Lab Work Serial PT/INR Dx: mechanical aortic valve Goal INR [**3-15**] Results to Dr. [**Last Name (STitle) 2204**], fax: [**Telephone/Fax (1) 13780**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: prosthetic aortic stenosis/insufficiency s/p redo operation ( see below) right lower extremity compartment syndrome s/p right lower extremity fasciotomies this admission s/p Homograft Bentall procedure [**5-11**] sternal wound infection [**5-11**] gastroesophageal reflux disease hypertension hemorrhoids Discharge Condition: good Discharge Instructions: shower daily and pat incisions dry no lotions, creams or powders on any incision call for fever greater than 100, redness, drainage, weight gain of 2 pounds in 2 days or 5 pounds in a week no driving for one month no lifting greater than 10 pounds in 10 weeks Followup Instructions: see Dr. [**Last Name (STitle) 2204**] in [**2-11**] weeks Dr. [**Last Name (STitle) 2204**] will follow coumadin/INR, fax: [**Telephone/Fax (1) 13780**] (confirmed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) see Dr. [**Last Name (STitle) 120**] in [**3-15**] weeks see Dr. [**Last Name (STitle) **] in 4 weeks see Dr. [**Last Name (STitle) **] in 2 weeks please call for all appts. Completed by:[**2146-4-26**]

Admission Date: [**2195-7-5**] Discharge Date: [**2195-7-8**] Service: CCU HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old male with three vessel coronary artery disease with a history of atrial fibrillation, congestive heart failure and ejection fraction of 55%, chronic renal insufficiency, and hypertension, who was sent to the Emergency Department from home after being noted to have shortness of breath at home. Very scant records, but per the home health aid, the patient was found to be mottled with rales half way up. The patient received sublingual Nitroglycerin times two and 80 mg of Lasix intravenous with urine output. In the Emergency Department, the patient was noted to be in pulmonary edema and also developed sustained ventricular tachycardia for two minutes with hypotension. He was started on Amiodarone drip. The patient was also put on BiPAP for signs of hypoxia. At that point, there was discussion with the family and with the patient and he was confirmed to be DNR/DNI, no shocks, no pressors, no catheterizations. The patient was then transferred to the CCU where his blood pressure was 96/54, heart rate 70, respiratory rate 16, 100% nonrebreather mask. The patient denied chest pressure or chest pain and states that his shortness of breath had improved. PHYSICAL EXAMINATION: On admission, in general, the patient was responsive to voice, breathing more comfortably, temperature 97.4, blood pressure 97/47, heart rate 79, respiratory rate 20, oxygen saturation 100% on nonrebreather mask. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Sclera nonicteric. Neck was supple with jugular venous distention at eight centimeters. The lungs had decreased breath sounds at the bases, rales two thirds of the way up. Cardiovascular was regular rate and rhythm, with II to III/VI systolic ejection murmur at the left lower sternal border. The abdomen was soft, nontender, nondistended. Hemoccult positive per the Emergency Department. Extremities showed no edema. LABORATORY DATA: White blood cell count was 18.1, hemoglobin 13.6, hematocrit 43.0, platelet count 276,000. Sodium 139, potassium 4.5, chloride 102, bicarbonate 16, blood urea nitrogen 36, creatinine 1.5, glucose 313. CK 194, troponin 1.1, and Digoxin level was less than 0.3. The urinalysis was within normal limits. The first electrocardiogram at 3:15 a.m. showed atrial fibrillation at 105 beats per minute with a left axis deviation, wide QRS complexes with frequent ectopy, ST depressions in V4 through V6. The electrocardiogram at 6:55 a.m. showed a sinus rhythm at 70 beats per minute with left axis deviation, prolonged PR interval. This was post Amiodarone. ST depression 2.0 millimeters in V4 through V6 and in aVL. Chest x-ray showed pronounced congestive heart failure with volume overload and bilateral small pleural effusions. On [**2195-7-6**], the patient ruled in with a peak CK of 432 and MB fraction of 79. The Amiodarone was discontinued and Heparin was started. Lopressor dose was increased and the patient also was noted to have some intermittent nonsustained ventricular tachycardia, three beats on the monitor. On the evening of [**2195-7-6**], the Metoprolol was held for bradycardia and in addition, there was an echocardiogram that was performed which showed severe impairment in the left ventricular function compared with the echocardiogram of [**4-14**]. Of note, the echocardiogram showed an ejection fraction of 20 to 30% with anteroapical hypokinesis, mild aortic insufficiency, mild to moderate mitral regurgitation, diastolic dysfunction, severe dilation of the left ventricle with a normal thickness. As a result of the low ejection fraction, the patient was then started on Lisinopril 5 mg p.o. He tolerated this quite well. On [**2195-7-7**], the patient continued to remain hemodynamically stable and remained in normal sinus rhythm. His discharge plans were discussed and there was an extensive discussion regarding anticoagulation, however, it was felt that at this time given the patient's age and risk of falling that anticoagulation would not be opted for despite the fact that the patient has atrial fibrillation as well as wall motion abnormalities. The final decision regarding anticoagulation will be up to the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**]. The patient was advised to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] in two to three days for renal function tests as the patient was started on once daily Lisinopril 5 mg tablet one tablet p.o. once daily. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Last Name (NamePattern1) 1811**] MEDQUIST36 D: [**2195-7-9**] 03:56 T: [**2195-7-15**] 20:40 JOB#: [**Job Number 19239**]

Admission Date: [**2164-1-3**] Discharge Date: [**2164-1-31**] Date of Birth: [**2097-4-28**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 52495**] is a 66 year old man with known coronary arteries, status post multiple interventions with the last catheterization on [**2163-1-21**] with stents to his proximal and mid right coronary artery as well as his proximal left anterior descending coronary artery. Prior to admission the patient complained of shortness of breath with exertion, chest pain with rest and with exertion and palpitations, all worsening over the past year. Chest pain is relieved with rest and/or nitroglycerine. A stress test done [**2163-12-16**] showed reversible ischemia in the inferior left ventricular wall with an ejection fraction of 56 percent. He was then referred for cardiac catheterization which was done on the day of admission showing three vessel disease and then was referred for coronary artery bypass grafting. As stated, the patient's catheterization showed left main 60 percent, left anterior descending coronary artery with patent stents in the mid vessel, 60 percent stenosis, circumflex with minimal disease and right coronary artery with 80 percent ostial disease. PAST MEDICAL HISTORY: Is significant for hypertension, hypercholesterolemia, CLAD, thrombocytopenia, hypothyroidism and gastroesophageal reflux disease. PAST SURGICAL HISTORY: Is significant for a transurethral resection of the prostate and a penile implant. ALLERGIES: He has no known drug allergies. He is lactose intolerant. MEDICATIONS: Include Zoloft 75 daily, Prilosec 40 daily, Carafate 1 gram q.i.d., atenolol 50 daily, aspirin 325 daily, Pravachol 40 daily, Synthroid 125 B.I.D. and Zantac 150 B.I.D. SOCIAL HISTORY: Lives with his wife and son, works part-time in a wood flooring company. Tobacco - quit in [**2140**]. Alcohol rare use. FAMILY HISTORY: Brother had a coronary artery bypass graft at age 60 and father died of a myocardial infarction at 51 years old. REVIEW OF SYSTEMS: Is noncontributory. PHYSICAL EXAMINATION: Height 5 feet, 8 inches, weight 200 pounds. Vital signs: Heart rate 65, sinus rhythm, blood pressure 122/56, respiratory rate 18, O2 saturation 98 percent on room air. General: Lying flat in bed in no acute distress. Neurologic: Alert and oriented times three, moves all extremities, follows commands. Nonfocal examination. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1, S2 with no murmurs, rubs or gallops. Gastrointestinal: Is firm, taut, nontender, nondistended with normal active bowel sounds. Extremities are warm and well perfused with no clubbing, cyanosis or edema. Pulses 2 plus throughout. LABORATORY DATA: White count 4.9, hematocrit 36.7, platelets 56. Sodium 144, potassium 3.2, chloride 111, CO2 19, BUN 11, creatinine 0.8, glucose 200. PT 15.5, PTT 106.9, INR 1.5, ALT 37, AST 36, alkaline phosphatase 57, total bilirubin 1.0, albumin 3.2. Patient had bilateral duplex examination, carotid duplex that showed no significant carotid disease. Additionally patient was seen by the neurology as well as the hematology service and cleared to proceed surgery and cleared for surgery. The patient was followed by the medical service during these evaluations and was ultimately brought to the operating room on [**1-8**]. Please see the operating room report for full details. In summary, the patient had an off pump coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to the right coronary artery, and saphenous vein graft to the obtuse marginal. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient was in sinus rhythm at 74 beats per minutes with a mean arterial pressure of 66 and a CVP of 11. He was on propofol at 20 mcg per kilogram per minute. The patient did well in the immediate postoperative period. He failed his initial attempt at extubation and was begun on Apresodex due to agitation. Following a second attempt to extubate which failed the patient was sedated throughout the night of operative day one. On postoperative day one the patient was hemodynamically stable. He was successfully weaned from the ventilator and extubated. On postoperative day two the patient continued to be hemodynamically stable. All intravenous medications were converted to oral medications. His chest tubes were removed and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. On the first two days on the floor the patient remained hemodynamically stable. He was, however, noted to be extremely lethargic but has nonfocal neurological examination at that time. On postoperative day six the patient continued to be lethargic and somnolent with orientation, good attention and intact short term memory but with the need to repeat questions before the patient seemed to be able to verbalize a response. Sepsis work up was initiated at that time on postoperative day seven. Patient showed increasing agitation and was uncooperative with the medical as well as the surgical as well as the nursing staff and at that time the patient was sent for a head CT scan which revealed hydrocephalus, following which a neurosurgery consult was obtained and a ventriculostomy drain was placed. At that time the patient was transferred to the neurosurgical Intensive Care Unit. Additionally the CT scan showed an embolic right sided stroke. Patient was followed by the neurosurgery service as well as the cardiac surgery service for the remainder of his hospitalization. He remained in the neurosurgical Intensive Care Unit until [**1-26**] at which time the drain was clamped. The patient had a head CT following which he was transferred to the Neurosurgical Step Down unit. The intracranial drain was removed and the patient was transferred to [**5-21**] for continuing postoperative care. Over the next several days the patient remained hemodynamically stable. He was evaluated by physical therapy, was found to become hypotensive with ambulation. This was felt to be secondary to prolonged inactivity. At that time a decision was made that the patient should be screened for rehabilitation and transferred when a bed became available in order to give the patient adequate time to increase the strength and endurance. On postoperative day 27 it was decided that the patient was stable and ready to be discharged to rehabilitation. At this time the patient's physical examination is as follows. Temperature 98.1, heart rate 76, blood pressure 110, 60, respiratory rate 18, rate 85.2 kilos, preoperatively 101 kilos. PHYSICAL EXAMINATION: Neurologic: Alert and oriented times three, moves all extremities. Follows commands. Nonfocal examination. Pulmonary clear to auscultation bilaterally. Cardiac: Regular rate and rhythm. S1, s2. Sternum is stable. Incision healing well without drainage or erythema. Abdomen is soft, nontender, nondistended with normal active bowel sounds. Extremities were warm and well perfused with no edema. Left open saphenous vein graft harvest site healing well, no erythema or edema. ICP drain excision site with sutures clean and dry, covered with a dry sterile dressing. He also has a Foley to gravity due to postoperative failure to void. Patient has a history of transurethral resection of the prostate in the past with difficulty voiding after Foley removal times two in the past. Patient's medications at time of discharge include aspirin 325 daily, Synthroid 125 B.I.D., Lopressor 25 mg B.I.D., Prilosec 40 daily, folate 1 daily, Pravastatin 40 daily, Zoloft 75 daily, thiamine 100 daily and Flomax 0.4 daily. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post off pump coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to the right coronary artery, saphenous vein graft to the right coronary artery, saphenous vein graft to the obtuse marginal. 2. Status post right posterior cerebellar embolic stroke. 3. Hypertension. 4. Hypercholesterolemia. 5. Thrombocytopenia. 6. Hypothyroidism. 7. Gastroesophageal reflux disease. 8. Status post transurethral resection of the prostate. 9. Status post penile implant. Patient is to be discharged to rehabilitation. He is to have follow up with Dr. [**Last Name (STitle) 1327**] of the neurosurgery service in two weeks. Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the urology service after discharge from rehabilitation and follow up with Dr. [**Last Name (STitle) **] in four weeks. Additionally the patient to have the sutures removed from his ICP drainage site on [**2-3**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2164-1-31**] 16:09:56 T: [**2164-1-31**] 17:43:18 Job#: [**Job Number 52496**]

Admission Date: [**2116-12-22**] Discharge Date: [**2116-12-22**] Date of Birth: Sex: HISTORY OF PRESENT ILLNESS: The patient is the 4.05 kg product of a 35 3/7 weeks gestation born to a 34-year-old gravida 2, para 1 to 2 woman whose pregnancy was complicated by the ultrasound notation of an omphalocele. The rest of also reported as normal. Normal 46 XY karyotype done by amniocentesis. The patient was followed by Dr. [**Last Name (STitle) **] of maternal fetal medicine here at [**Hospital1 188**]. Pregnancy was otherwise uncomplicated in this healthy mother until the day prior to delivery when noted on routine screening to have a non reactive, non stress test and a biophysical profile of [**5-22**]. Today, non stress test was AFI of 8. Decision was made to deliver via cesarean section. Prenatal screens were notable for an AB positive blood type with a negative antibody screen. Maternal HBSAG negative. RPR non reactive. Group B strep status unknown. There were no sepsis risk factors noted at the time of delivery. Rupture of membranes with clear fluid occurred at the time of delivery. The patient did well in the delivery room. He was vigorous at delivery. There was a baseball sized omphalocele with intact membranes noted. There was no liver noted within the mass. There was edematous umbilical cord noted. Apgars were [**7-23**]. The patient was intubated in the delivery room because of mild to moderate respiratory distress and desire to avoid gastric insufflation with C-pap. He was intubated with 3-0 endotracheal tube and a 0 blade. The tongue was perhaps somewhat large and there was marked frenular shortening noted. The abdomen was draped in sterile gauze soaked in normal saline and placed in a sterile bag for preservation of moisture. The patient was brought to the NICU after visiting with parents. PHYSICAL EXAMINATION: The patient was pink, active, generally non dysmorphic, large for gestational age infant. Weight was 4.05 kg (with the dressing on greater than 90th percentile). Head circumference was 34 cm (90th percentile). HEENT: Notable for slightly large tongue as noted above. The tongue was somewhat bifid with a tight frenulum. The ears were slightly posteriorly rotated with large lobes. There were no vertical creases noted in the earlobes. Cardiac exam showed normal S1 and S2 without murmurs or gallops. Pulses were 2+ and equal bilaterally. The abdomen was as described above. Genitalia, normal male with possible glandular hypospadias. The exam of the genitalia was somewhat brief due to the omphalocele defect. Testes were in the scrotum bilaterally. Neuro exam showed non focal age appropriate exam. Hips were not examined due to dressing a bag over the baby's lower extremities. Spine was intact. HOSPITAL COURSE: 1. Respiratory: The patient, as noted above, was intubated in the delivery room for mild to moderate respiratory distress. Chest x-ray showed mildly granular lung fields bilaterally consistent with mild hyaline membrane disease. Endotracheal tube was pulled back 1 cm with normal breath sounds noted afterwards. A single dose of Survanta 4 cc/kilo was administered. The patient had initial venous blood gas that showed a PH of 7.18 with CO2 of 80. At this time patient was well saturated and 30% oxygen. Settings were increased slightly and repeat blood gas is pending at the time of this dictation. 2. Cardiovascular: No murmurs were noted. The patient had a mean blood pressure in the 40's and was well perfused. 3. Fluids, Electrolytes & Nutrition: The patient was maintained npo with gastric decompression. Total fluids were begun at 100 cc/kilo/day of D10W based on a birth weight of 3.9 kg. 4. Hematologic: CBC on admission showed a hematocrit of 55.9 with white count of 11.0. Platelet count was 393,000. Differential was pending at the time of this dictation. 5. Infectious Disease: Given the patient's respiratory distress, was started on antibiotics, Ampicillin, Gentamycin for 48 hour rule out. 6. Gastrointestinal: Defects as noted above. Patient on NG decompression. 7. Routine health care maintenance: The patient has received Vitamin K and Ilotycin at [**Hospital1 190**]. Specimen has been sent to [**Location (un) 511**] regional newborn screening program for newborn screening. A repeat screening will be required at [**Hospital3 1810**]. The patient has not received hepatitis immunization. The patient will require hearing screening prior to discharge. Also car seat testing prior to discharge is recommended given the patient's gestational age of 35 weeks. Patient's primary pediatrician will be Dr. [**First Name (STitle) **] [**Name (STitle) 37101**] in [**Location (un) **]. The patient is being transferred to [**Hospital3 1810**], 7 North, under the care of Dr. [**Last Name (STitle) 37080**] and the NICU team. DISCHARGE DIAGNOSIS: 1. 35 week premature infant. 2. Respiratory distress syndrome. 3. Omphalocele. 4. Rule out sepsis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**] Dictated By:[**Last Name (NamePattern1) 37102**] MEDQUIST36 D: [**2116-12-22**] 18:43 T: [**2116-12-22**] 18:48 JOB#: [**Job Number 37103**]

Admission Date: [**2198-10-7**] Discharge Date: [**2198-12-6**] Date of Birth: [**2140-3-12**] Sex: M Service: OMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7591**] Chief Complaint: Fever and Malaise. Major Surgical or Invasive Procedure: Hickman Line Placement and Removal. History of Present Illness: Mr [**Known lastname 5655**] is a 58 year old male without significant past medical history who presented to an outside hospital with one month of fevers (up to 103), sweats, and malaise. He also noted increasing generalized weakness and fatigue. He had a decrease in his appetite and 13 pounds weight loss over the previous month. He also noted easy bruising. ROS: The patient did not have an head aches, shortness of breath, dizziness, chest pain, nausea, vomiting, abdominal pain, epistaxis or other bleeding. At the outside hospital he had a WBC of 45.3 (90% Blasts) and a HCT of 25 with 19% nucleated RBC's. He was transfered to [**Hospital1 18**] for management of a presumptive hematologic malignancy. Past Medical History: DJD S/P Discectomy ([**2174**]). Had not seen a doctor in 10 years. Social History: The patient was divorced, but lived with his girlfriend, [**Name (NI) **]. [**Name2 (NI) **] had never used cigarettes or illegal drugs. He quit drinking ETOH in [**2174**]. He is a private business owner and works as a [**Last Name (un) 33982**]. Family History: No known cancers, leukemia, or lymphoma. Physical Exam: T98.6 BP123/60 HR88 OS99%RA GEN - NAD. COMFORTABLE. SKIN - LE BRUISING. NO RASHES. HEENT - ANICTERIC. PALE CONJ. MMM. NO LAD. NECK - SUPPLE. NO LAD. RESP - DISTANT BS. GOOD FLOW. CTAB. CV - RRR. S1/S2 NML. NO MGR. NO JVD. ABD - S/NT/ND. POS BS. NO HSM. EXT - POS B/L CLUBBING. NO CYANOSIS OR EDEMA. NEURO - A&OX3. CNII-XII INTACT GROSSLY. STRENGTH AND [**Last Name (un) **] TO LT NORMAL THROUGHOUT. Pertinent Results: BONE MARROW BIOPSY AND FLOW CYTOMETRY ([**2198-10-7**]): AML: Immunophenotypic findings consistent with acute myelogenous leukemia, with an immature phenotype. RVG ([**2198-10-8**]): Following the intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, first pass and equilibrium images were obtained. The first pass study shows prompt tracer flow through the central circulation. IMPRESSION: 1) Normal LV wall motion. 2) Normal right and left ventricular sizes. 3) LVEF of 55%. CXR ([**2198-10-8**]): FINDINGS: There is a left subclavian central venous catheter with the tip in satisfactory location in the distal SVC. There is no pneumothorax. The cardiac and mediastinal contours are unremarkable. The pulmonary vascularity is normal, and the lungs are clear. No pleural effusions are seen on this film, although the left costophrenic sulcus is not visualized. The osseous structures and soft tissues are unremarkable to the extent visualized. CT TORSO ([**2198-10-17**]): IMPRESSION: 1. No infectious source detected. 2. Single 6-mm left upper lobe nodule. 3. Fat-containing right inguinal hernia. RUQ U/S ([**2198-10-22**]): IMPRESSION: Normal right upper quadrant ultrasound examination. BONE MARROW BIOPSY AND FLOW CYTOMETRY ([**2198-10-23**]): DIAGNOSIS: Persistent involvement by acute myelogenous leukemia. CT ABD ([**2198-10-26**]): IMPRESSION - 1. Limited study of the abdomen secondary to significant patient debility as described above. There is no intrahepatic ductal dilatation. 2. Extensive patchy airspace opacities throughout both lungs, which given the patient's neutropenic state could represent a diffuse widespread pneumonia, as well as alveolar hemorrhage. ECHO ([**2198-10-26**]): 1.The LA is mildly dilated. 2.There is mild symmetric LV hypertrophy. The LV cavity size is normal. There is severe global LV hypokinesis. Overall LV systolic function is severely depressed with more marked anterior and inferior HK. 3.The aortic root is mildly dilated. The ascending aorta is mildly dilated. 4.The AV leaflets (3) appear structurally normal with good leaflet excursion. Trace AI is seen. 5.The MV leaflets are mildly thickened. Mild (1+) MR is seen. 6.There is mild pHTN. 7. There is no pericardial effusion. 8. Normal RV size and function. RUQ U/S ([**2198-10-28**]): IMPRESSION: No evidence of cholecystitis or dilation of intrahepatic bile ducts. CT CHEST ([**2198-10-31**]): IMPRESSION: 1. Interval development of diffuse pulmonary opacities throughout both lungs in a central distribution. This may represent pulmonary edema or a diffuse infection. Infectious etiologies include PCP or CMV. Some areas are nodular, which may represent a superimposed fungal infection such as aspergillus. 2. Small bilateral pleural effusions. ECHO ([**2198-11-6**]): The LA is mildly dilated. LV wall thicknesses are normal. The LV cavity is moderately dilated with severe global HK. No masses or thrombi are seen in the LV. The RV cavity is mildly dilated with moderate free wall HK. The aortic root is mildly dilated. The AV leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) AI is seen. The MV appears structurally normal with trivial MR. There is no MV prolapse. Mild (1+) MR is seen. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. Compared with the report of the prior study (tape reviewed) of [**2198-10-26**], the LV cavity is now dilated (previous [**Last Name (un) **] 6.0cm). The RV cavity and systolic function are similar. CXR ([**2198-11-24**]): PORTABLE AP CHEST, ONE VIEW: Comparison [**2198-10-31**]. Since the prior study, the left subclavian line has been removed. There are diffuse multifocal alveolar opacities. Differential includes multifocal pneumonia as well as asymmetric edema. There are no large pleural effusions (left lateral CP angle not included). The heart is upper normal in size. Overall appearances are slightly improved from [**2198-10-31**]. ECHO ([**2198-11-26**]): The LA is mildly dilated. The RA is moderately dilated. LV wall thicknesses are normal. The LV cavity is moderately dilated. Overall LV systolic function is severely depressed. The RV cavity is mildly dilated. There is severe global RV free wall hypokinesis. The aortic root is mildly dilated. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. The AV leaflets are mildly thickened. Mild (1+) AR is seen. The MV leaflets are mildly thickened. Mild (1+) MR is seen. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2198-11-6**], biventricular systolic function now appears slightly worse. BONE MARROW BIOPSY ([**2198-11-27**]): DIAGNOSIS - Markedly hypocellular bone marrow for age, with left-shifted granulocytic maturation and markedly decreased erythropoiesis. Acute leukemia is not seen. RUQ U/S ([**2198-11-28**]): FINDINGS: Sludge is no longer seen in the gallbladder. The gallbladder appears normal without evidence of stones. There is no intrahepatic or extrahepatic biliary ductal dilatation. The liver parenchyma appears unremarkable. Brief Hospital Course: Mr. [**Known lastname 5655**] was admitted to the [**Hospital1 18**] BMT service with acute myelogenous leukemia (AML). He subsequently developed severe congestive heart failure after anthracycline chemotherapy. 1) AML: The patient had a white blood cell count of 40,000 to 60,000 on admission. He was started on hydroxyurea for temporary stabilizing measures. A bone marrow biopsy with flow cytometry revealed acute myelogenous leukemia, with an immature phenotype. The patient was started on [7+3] chemotherapy with cytarabine and idarubacin. As anticipated, his cell lines dropped and the patient soon became neutropenic. He thus had neutropenic fevers early in his course (without any obvious source of infection). Empiric antimicrobials and then antifungals were commenced (see below). Approximately two weeks after his [7+3] regimen, a bone marrow biopsy revealed persistent involvement by AML. Re-induction chemotherapy was planned, but the patient developed an acute decline in his repiratory status: pulmonary nodules and then congestive heart failure and atrial fibrillation were noted. The patient's respiratory status declined to a level that he required ICU support (see below). Upon recovery from acute congestive heart failure, the patient returned to the BMT service for re-induction chemotherapy with HIDAC (high-dose cytarabine). He again became profoundly pancytopenic and neutropenic, developing fevers and a presumptive line infection with staph epidermidis. After two to three weeks of pancytopenia, a repeat bone marrow biopsy was obtained because of a concern for persistence of AML. However, the bone marrow was relatively acellular without evidence of leukemia. The patient was started on G-CSF and his neutrophils and other cell lines (to a lesser degree) promptly recovered and his fevers abatted. He required several platelet and packed red blood cell transufusions over his course, but did not require tranfusions over the last several days prior to discharge. On discharge, his platelets were 74, hematocrit was 32.5, white blood cell count of 3.4, and an absolute neutrophil count greater than 3000. He was discharged with oncologic follow-up with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] at [**Hospital1 18**]. 2) Neutropenic Fevers: As mentioned, the patient developed febrile neutropenia after his initial induction chemotherapy. Initial broad-specturm choices were Cefipime, Vancomycin, Caspofungin, and then Ambisome. After persistence of his fevers a chest CT revealed pulmonary edema as well as bilateral nodular opacities, concerning for aspergillosis or pneumocystis gondii infections. Bronchoscopy was not pursued. He was continued on anti-fungals. He was later changed from Cefipime to Meropenem. Late in his course, he grew staph epidermidis from four of four blood culture bottles (anaerobic and aerobic) and his Hickman line was removed. Concominantly with Vancomycin therapy and a rising neutrophil count, his fevers abatted and all follow-up blood cultures were negative. The patient was discharged on two additional weeks of Voriconazole to complete and empiric course of antifungal therapy for his presumptive recovering lung infection. A repeat chest CT was attempted, but the patient could not tolerate the study because of orthopnea. Of note, Caspofungin was changed to Voriconazole because of rising alkaline phosphatase and bilirubin and a concern for causation; these values decreased after the change was made. 3) CHF: As mentioned the patient had a declining respiratory status two weeks after anthracycline therapy. Because of concern for a pulmonary infection, a chest CT was sought, but the patient developed acute worsening of his dyspnea, oxygen desaturation and hemoptysis while on the CT scanner. He was noted to have severe congestive heart failure by imaging. His pre-chemotherapy ventriculogram revealed an LVEF of greater than 55%. Upon developing respiratory failure, his LVEF was 20% with global wall motion depression. He was transferred to the ICU with severe pulmonary edema. He was aggressively diuresed but did not require intubation. The patient stabilized, and was then transferred back to the BMT service. He was followed by Cardiology and the CHF service. He was initially maintained on daily IV Lasix, Beta-Blocker and Digoxin. On account of teniously low blood pressures (systolic blood pressures to the 70s) with Lasix boluses, he was changed to a Lasix drip ([**2-16**] mg/hr). Thereafter, he made great progress with diuresis and held his systolic blood pressures at a level greater than 90. He was discharged on Lasix 30 mg PO BID along with follow-up with the CHF service. The plan was to add-on an ace-inhibitor and aldactone when the patient's blood pressures could tolerate these agents. 4) AF/RVR: As noted, along with his new onset CHF, the patient developed atrial fibrillation with a rapid ventricular response. His atrial fibrillation persisted throughout his course and he reached heart rates to the 170s early on. He was mainted on beta-blocker and Digoxin as above and his heart rates ranged from the 60's to the 100's late in his course, when his CHF was better controlled. Anticoagulation was not initiated because of thrombocytopenia, associated with his chemotherapy and AML. 5) NSVT: The patient had several episodes of asymptomatic NSVT over his course. Additionally, he had one episdoe of symptomatic NSVT of 12 beats with 3/10 chest discomfort and the sensation of a 'racing heart.' An ECG showed no signs of ischemia. He was continued on beta-blockade. Despite his severe heart failure, he was not deemed a candidate for a BiV/ICD given his low platlets. 6) Hyperbilirubinemia/Elevated Alk Phos: The patient had a large rise in these values early in his course, in conjunction with his severe heart failure. Hepatic and biliary imaging were not remarkable. He then again had an elevation in these values late in his course. The etiology early in the course may have been hepatic congestion via CHF (as there was an associated transaminitis). Later in his course, there was no transaminits. A repeat right upper quadrant ultra-sound was unremarkable. He was changed from Caspofungin to Voriconazole and these values trended downwards. On discharge, his alkaline phosphatase was 500 with a bilirubin of 1.4. The former value peaked in the thousands while the later peaked at 6. Medications on Admission: Alieve PRN Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO once a day. Disp:*qs 1 mo packets* Refills:*0* 8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. Outpatient Lab Work 1) On Monday, [**2198-12-9**], please go to the lab at [**Hospital3 **] to have your blood checked. A CBC, SMA10 (sodium, potassium, chloride, bicarbonate, BUN, urea, and glucose) and digoxin level should be checked. These results should be faxed to your new primary doctor, Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 57652**] at [**Telephone/Fax (1) 57653**], your new heart failure nurse [**First Name (Titles) 3639**] [**First Name8 (NamePattern2) 6794**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 13133**], and to the [**Hospital1 18**] BMT Floor (7 [**Hospital Ward Name 1826**]) at [**Telephone/Fax (1) 45103**]. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis: Acute Myeloid Leukemia. Secondary Diagnosis: Chemotherapy-Induced Congestive Heart Failure, Staph Epidermidis Bacteremia. Discharge Condition: Fair/Stable Discharge Instructions: 1) Please call Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] ([**Telephone/Fax (1) 3760**]), your primary doctor ([**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 57652**] at [**Telephone/Fax (1) 4018**]), the oncall [**Hospital1 18**] oncologist ([**Telephone/Fax (1) 2756**]) or go to an emergency department if you have any fevers, chills, back pain, nausea, vomiting, chest pain, palpitations, shortness of breath, cough, or any other concerning symptoms. 2) Please take your medications as instructed. 3) If you have any dizziness, or light-headedness while standing, please do not take your Lasix, Carvedilol (Coreg), or Digoxin and call your doctor immediately. 4) Please follow the dietary instructions of the nutrionist in regards to your heart failure: some of these recommendations include limiting your fluid intake to 1.5 liters per day and limiting your salt intake to 2 grams per day. 5) Weigh yourself daily (with the same scale) and record this so it may be reported to your heart failure and primary doctors. If you gain more than 2 pounds in one day, please call your heart failure doctor. Followup Instructions: 1) On Monday, [**2198-12-9**], please go to the lab at [**Hospital3 **] to have your blood checked. A CBC, SMA10, and digoxin level should be checked to evaluate your blood count, electrolytes, and digoxin level. These results should be faxed to your new primary doctor, Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 57652**] at [**Telephone/Fax (1) 57653**], your new heart failure nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57654**] at [**Telephone/Fax (1) 13133**], and to the [**Hospital1 18**] BMT Floor (7 [**Hospital Ward Name 1826**]) at [**Telephone/Fax (1) 45103**]. 2) Please see Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] ([**Hospital1 18**] Oncology and Bone Marrow Transplant) on [**2198-12-13**] for the following appointment: Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Where: [**Hospital6 29**] HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3760**] Date/Time:[**2198-12-13**] 10:00 3) Please see your new heart failure doctor, Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**] at the Heart Failure Clinic on [**2198-12-20**]. You may call [**Telephone/Fax (1) 3512**] to confirm or change this appointment: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2198-12-20**] 4:00 4) Please also see your new primary doctor, Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 57652**] for the following appointment: [**2199-1-4**] at 2:45 PM. You may contact her at [**Telephone/Fax (1) 4018**] to confirm or change this appointment.

Admission Date: [**2140-9-4**] Discharge Date: [**2140-9-7**] Date of Birth: [**2071-3-26**] Sex: F Service: CARDIAC INTENSIVE CARE UNIT CHIEF COMPLAINT: Syncopal episode. HISTORY OF PRESENT ILLNESS: This is a 69-year-old female with a past medical history of type 2 diabetes mellitus, hypertension, and hypercholesterolemia, who presented to the Emergency Department with three syncopal episodes. The patient reported that she woke up "feeling funny" the morning of admission and then passed out. This pattern was repeated a total of three times while the patient remained at home. The patient reported that before each episode, she felt as though she was falling asleep. She thought the room may have spinning during one episode. The patient denied chest pain, dyspnea, vomiting, diarrhea, and visual symptoms in relationship to the episodes. She did note heart palpitations after regaining consciousness, and she noted that she became diaphoretic and lightheaded. Noticeably, on the morning of admission, the patient reports that her blood sugar was 400 and she had a systolic blood pressure of 200, which was extremely unusual for her. She took her home medications including atenolol and presented to the Emergency Department. In the ED, the patient had four more syncopal episodes. Telemetry during these episodes revealed complete heart block with an atrial rate in the 60s and 70s. There was no ventricular response for up to nine seconds during these episodes. At other times, the patient had a [**2-6**] block, but at other times was in [**1-6**] block with a heart rate of 90. A right internal jugular catheter was placed with a temporary pacing wire in the Emergency Department. The patient was then transferred to the CCU for further care with a plan for a permanent pacemaker placement on [**2140-8-6**]. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. Hypertension. 3. Hypercholesterolemia. 4. Hypothyroidism. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Hydrochlorothiazide 25 mg p.o. q.d. 3. Atenolol 50 mg p.o. q.d. 4. Lipitor 5 mg p.o. q.d. 5. Lisinopril 40 mg p.o. q.d. 6. Ambien 10 mg p.o. q.h.s. prn. 7. Glyburide 10 mg p.o. q.d. 8. Metformin 1,000 mg p.o. b.i.d. 9. Synthroid 112 mcg p.o. q.d. SOCIAL HISTORY: The patient lives alone as her husband recently passed away from malignant melanoma. She denies any alcohol or tobacco use. PHYSICAL EXAM ON ADMISSION: Blood pressure 154/96, heart rate 82, respiratory rate 14, oxygen saturations 100% on room air. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Dry mucous membranes. Cardiac: Point of maximal impulse nondisplaced. Regular, rate, and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. Jugular venous pressure inappreciable. No carotid bruits. Pulmonary: Clear to auscultation bilaterally. Abdomen: Soft. Nontender. Nondistended. Positive bowel sounds. No hepatosplenomegaly. Extremities: No clubbing, cyanosis, or edema. Dorsalis pedis 2+ pulses bilaterally. LABORATORIES ON ADMISSION: White blood cell count 6.8, hemoglobin 12.4, hematocrit 38.0, MCV 90, MCH 29.2, MCHC 32.6, platelets 242. Sodium 138, potassium 4.1, chloride 103, bicarb 24, BUN 24, creatinine 0.9. Glucose 220. CK 78, amylase 45, lipase 19. Troponin less than 0.01. Calcium 9.9, phosphorus 2.8, magnesium 1.6. TSH 3.2, free T4 1.3. Chest x-ray on admission: Heart was mildly enlarged. Calcifications in the aortic arch. No congestive heart failure, focal infiltrate, or effusion. No pleural effusions. Osseous structures are unremarkable. ECG on admission: Sinus rhythm with a rate of 76. A-V conduction delay. SUMMARY OF HOSPITAL COURSE: 1. Cardiac: Coronaries - No known history of coronary artery disease, however, patient has multiple risk factors including age and diabetes mellitus. Was ruled out for a myocardial infarction by cardiac enzymes. Patient was continued on aspirin, ACE inhibitor, and statin. Beta blocker was held on admission. Rhythm - Patient had episodes of complete heart block in the Emergency Department. A temporary pacing wire was placed at that time, and she was in normal sinus rhythm throughout admission. On [**2140-9-6**], an ICD was placed by the Electrophysiology service. Pump - An echocardiogram was obtained on [**2140-9-6**]. The echocardiogram revealed the left atrium and right atrium were normal in size. The left ventricular wall thickness, cavity size, and systolic function were normal with a left ventricular ejection fraction greater than 55%. Regional left ventricular wall motion was normal. Right ventricular chamber size and free wall motion were normal. The aortic root was mildly dilated as was the ascending aorta. The aortic valve leaflets were structurally normal with good leaflet excursion. There was trace aortic regurgitation. The mitral valve appeared structurally normal with trivial mitral regurgitation. There was mild mitral annular calcification. The tricuspid valve appeared structurally normal with trivial tricuspid regurgitation. There was borderline pulmonary artery systolic hypertension. There was no pericardial effusion. 2. Type 2 diabetes mellitus: Patient was placed on sliding scale insulin during her stay in the Coronary Care Unit. Her oral diabetic medications were held on admission as she was to be NPO for the procedure, and will not be eating her normal home diet. 3. Hypercholesterolemia: Patient was continued on her statin. 4. Hypothyroidism: Patient had normal TSH and free T4 on admission. She was continued on her home dose of levothyroxine. 5. FEN: Cardiac American Diabetic Association Diet. Patient has aggressive electrolyte repletion throughout the admission. DISCHARGE CONDITION: Good. DISCHARGE STATUS: Patient will be discharged to home. DISCHARGE DIAGNOSES: 1. Complete atrioventricular block status post ICD placement. 2. Syncope. 3. Diabetes mellitus type 2. 4. Hypertension. 5. Hypercholesterolemia. 6. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Hydrochlorothiazide 25 mg p.o. q.d. 3. Atorvastatin 10 mg p.o. q.d. 4. Levothyroxine 112 mcg p.o. q.d. 5. Percocet 1-2 tablets po q4-6h prn, 10 tablets dispensed. 6. Keflex 500 mg p.o. q.i.d. for three days. 7. Atenolol 50 mg p.o. q.d. 8. Lisinopril 40 mg p.o. q.d. 9. Glyburide 5 mg p.o. q.d. 10. Metformin 1,000 mg p.o. b.i.d. 11. Ambien 10 mg p.o. q.h.s. prn. FOLLOW-UP APPOINTMENTS: 1. M. Doust at the [**Hospital Ward Name 23**] Center Cardiac Services on [**2140-9-13**] at 11:30. 2. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital Ward Name 23**] Center Dermatology [**2140-10-4**] at 10 o'clock. 3. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] in one month. 4. Dr. [**Last Name (STitle) **], the patient's PCP [**Last Name (NamePattern4) **] [**2140-10-18**] at 10:10. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 315**] MEDQUIST36 D: [**2140-9-7**] 15:34 T: [**2140-9-8**] 06:48 JOB#: [**Job Number 94834**]

Admission Date: [**2130-9-20**] Discharge Date: [**2130-9-22**] Date of Birth: [**2085-9-4**] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 78**] Chief Complaint: returns for completion of coiling Major Surgical or Invasive Procedure: cerebral angiogram with coiling of aneurysm History of Present Illness: 44-year-old female who was found to have a sylvian, sulcal and prominent cisterna subarachnoid hemorrhage. She presents for admission after review of MRI scan shows possible recanalization of the aneurysm. Past Medical History: h/o EtOH abuse "in [**2125**]" h/o PSA h/o depression/psych/?schizoaffective (pt takes Seroquel per report) Social History: unknown; apparently a son and a daughter were here to give consent for [**Name (NI) 10788**]/coiling, but I have not been able to speak with them at this point. Family History: unknown Physical Exam: Non focal neuro exam / pupils [**1-31**] b/l, right groin angio site intact. Pertinent Results: Brief Hospital Course: Pt was was admitted for the proposed procedure. She underwent a coiling of Left MCA aneurysm. Pt underwent the procedure without issue and had an uneventful post operative course. She was maintained on a heparin gtt overnight following her procedure. Post op CT scan was stable. heparin gtt was d/c' the next am and all lines/foley as well. Pt was allowed to advance in her diet and activity. She was discharged to home on postoperative day #2. She agrees with this plan. On [**9-22**] she was discharged home. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. 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* 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 7. trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 9. amphetamine-dextroamphetamine 5 mg Tablet Sig: Four (4) Tablet PO bid (). 10. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). Discharge Disposition: Home Discharge Diagnosis: completion of coiling of left MCA aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Take Plavix (Clopidogrel) 75mg once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. ?????? You may remove your dressing on day 2 from your angiogram What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin 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 or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please call the office of Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) **] for an appointment to be seen in 4 weeks. Completed by:[**2130-9-22**]

Admission Date: [**2113-10-8**] Discharge Date: [**2113-10-12**] Date of Birth: [**2046-9-19**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1042**] Chief Complaint: hematochezia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 67 y/o woman with PMH of diverticulitis, colitis, and recent IMI s/p BMS to the RCA who presents with 5-6 episodes of bright red blood per rectum. The patient initially presented to [**Hospital3 **] on [**10-3**] with diffuse chest pressure; at that time, she was found to have an inferior MI with 100% RCA occlusion. She received a bare metal stent to the RCA. Following her original cath, she had ongoing dyspepsia and was sent to [**Hospital1 2025**] for repeat catheterization on [**10-6**] which did not show any new blockage or instent thrombosis. She was discharged on [**10-7**] on aspirin, plavix, lopressor, and captopril. . This morning at about 4:30 am, the patient woke up with abdominal cramping which is usual for her. She had one large bowel movement with some "dark" blood per her report. Her abdominal cramping resolved but she had [**4-27**] more dark bloody stools. At that time, she returned to [**Hospital3 **] where she received 1 U PRBCs and was subsequently transferred to [**Hospital1 18**]; she requested this as she has had a 1-year history of diarrhea and was recently referred to Dr. [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) 6880**]. . In our ED, initial vitals were T 98.3, HR 66, BP 125/90, with O2 sat 100% on RA. She refused NG lavage in the emergency room and was seen by GI who are planning a colonoscopy tomorrow. She was given 40 mg PO protonix and 75 mg plavix as well as 1 mg ativan. She received 1 L NS and her 2nd unit of PRBCs prior to transfer to the [**Hospital Unit Name 153**]. . On arrival to the [**Hospital Unit Name 153**], the patient states that her abdominal pain is much improved. She feels thirsty and hungry. She denies lightheadedness and dizziness. She also denies chest pain/pressure, nausea, vomiting, dyspnea, orthopnea, dysuria, hematuria, and lower extremity swelling. She has had blood in her stools a long time ago secondary to hemorrhoids; she states that the blood in her stools at that time was much brighter. Past Medical History: * CAD - cath [**2113-10-3**] revealing 100% rca occlusion subsequently stented with BMS, 60% LAD occlusion; peak enzymes CK 1111, CKMB 155, MB fraction 128% trop T 3.09 on [**10-4**] * Chronic diarrhea - X 1 year, h/o diverticulitis, intussusception in [**2113-7-23**] * Endometriosis * h/o oophorectomy * h/o arrhythmia (? no further info in chart, on atenolol previously) Social History: She lives alone. Her daughter is with her in the hospital today. Ms. [**Known lastname **] works as the assistant registrar at [**University/College **] school. She smokes [**1-24**] ppd X 35 years. She drinks 2-3 glasses of wine nightly. Family History: + for ovarian ca in mother, + breast CA in daughter, two aunts; father passed away from leukemia . Physical Exam: PE: T: 98.4 BP: 127/55 HR: 70 RR: 14 O2 99% RA Gen: Pleasant, well appearing female in NAD HEENT: No conjunctival pallor. No scleral icterus. MM slightly dry. OP clear. NECK: Supple, No LAD, JVD < 10 cm. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: clear to auscultation bilaterally, no wheezing or crackles ABD: normoactive bowel sounds, no tenderness to palpation throughout, no rebound, no guarding EXT: warm, well perfused througout, DP pulses 2+ bilaterally SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. speaking clearly and in full sentences, moving all extremities without difficulty PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2113-10-8**] 11:15AM BLOOD WBC-6.8 RBC-2.97* Hgb-9.7* Hct-28.1* MCV-95 MCH-32.6* MCHC-34.5 RDW-15.8* Plt Ct-252 [**2113-10-8**] 11:15AM BLOOD PT-12.3 PTT-26.0 INR(PT)-1.1 [**2113-10-8**] 11:15AM BLOOD Glucose-85 UreaN-23* Creat-1.0 Na-144 K-4.7 Cl-108 HCO3-27 AnGap-14 [**2113-10-8**] 11:15AM BLOOD ALT-23 AST-33 LD(LDH)-237 CK(CPK)-173* AlkPhos-50 Amylase-61 TotBili-0.4 ECG ([**2113-10-8**]): Sinus rhythm. Minor T wave abnormalities. Brief Hospital Course: 1. Diverculosis with hemorrhage: the patient received PRBC transfusion with stabilization of her hemoglobin. On discharge, her hemoglobin had been stable for 36 hours. Gastroenterology was consulted, and outpatient follow up was arranged. No further studies were done given the multiple colonoscopies done recently. 2. Recent inferior myocardial infarction, status post RCA bare metal stent: the patient was maintained on her aspirin, clopidogrel, and metoprolol. As she was in the low end of the normotensive range, her captopril was put on hold. She had no cardiac symptoms or issues this hospitalization, and serial cardiac enzymes were negative. Medications on Admission: ASA 325 daily plavix 75 mg daily lopressor 25 [**Hospital1 **] prilosec 40 mg daily captopril 6.25 TId carafate 1 gm TID zocor 40 mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for Chest pain/ pressure: [**Month (only) 116**] repeat two times. If chest pain/pressure persists, go to the emergency room. 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: 1. Diverticular hemorrhage 2. Recent inferior myocardial infarction, status post RCA stent 3. Endometriosis 4. Chronic diarrhea Discharge Condition: Stable, without melena or hematochezia Discharge Instructions: Please go to the emergency room if you develop chest pain, chest pressure, palpitations, or persistent shortness of breath. If you begin to pass blood in your stool, you should also seek urgent medical evaluation. Followup Instructions: 1. Make a follow up appointment with your cardiologist within the next 2 weeks. 2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Date/Time:[**2113-11-1**] 10:00 3. Make a follow up appointment with your primary care physician [**Name Initial (PRE) 176**] 2 weeks.

Admission Date: [**2145-12-1**] Discharge Date: [**2145-12-18**] Date of Birth: [**2090-11-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Bronchoscopy lumbar Puncture History of Present Illness: Mr. [**Known lastname 3060**] is a 55 year old male with hypertension, type II diabetes, alcohol abuse, ESLD s/p orthotopic liver transplant in [**6-/2137**], and severe motor vehicle accident with cervical spinal fracture and subsequent tracheostomy and PEG tube placement in [**8-/2145**] who was admitted to [**Hospital3 417**] Hospital from [**Hospital1 15454**] Rehabilitation Facility on [**2145-11-21**] for evaluation of fevers. History is taking exclusively per notes. Per notes, he spiked a fever to 104.5 degrees on the day of presentation and was initially tachycardic and hypotensive and was initially started on doripenem. Upon arrival to the emergency room at OSH, he was no longer hypotensive but was persistently tachycardic. In the emergency room his initial vitals were T: 103.8, HR 127 RR: 20 BP: 113/69 O2: 100% on ventilator. Initial WBC count was 7.3, Hct 25, creatinine 1.85, AST of 61. UA with 10-20 RBCs, [**3-10**] WBCs. He received IVF and was admitted to the medical ICU. While in the ICU it appears that he had a broad infectious workup. Initial blood and urine cultures were negative. He was c. diff negative. Sinus cultures from [**2145-11-21**] and endotracheal washings from [**11-24**] grew acinetobacter sensitive to tobramycin, amkacin and bactrim and he was started on amikacin from [**2145-11-21**] and received this until [**2145-11-30**]. G-tube cultures [**2145-11-25**] with enterobacter, enterococcus and mixed gram negative rods. He had a non-contrast head CT which showed sinus disease but was otherwise negative. CT of the abdomen without contrast did not show evidence of abscess. CT chest showed a possible hazy right sided infiltrate. Gallium scan showed uptake in areas of known fractures and in the tracheostomy and PEG tube sites. He continued to spike fevers as high as 106 degrees despite broad spectrum antibiotics. He was also persistently tachycardic as high as the 170s which they were treating with metoprolol. He received amikacin as above, with a short period of levofloxacin and micafungin early in his hospitalization. All antibiotics it appears were discontinued on [**11-30**] after no fever source was identified but he continued to spike fevers and was started on vancomycin and cefepime on [**12-1**]. Final blood cultures from [**11-30**] are now 4/4 bottles with gram negative rods, not yet speciated. Was transfered to [**Hospital1 18**] for further w/u and management . Unable to obtain review of systems secondary to mental status Past Medical History: Alcoholic Cirrhosis s/p orthotopic liver transplant [**2137-6-11**] (last seen in transplant center in 5/[**2143**]). Per notes he had a liver biopsy in [**9-14**] which showed early chronic rejection Alcohol Abuse with relapse in [**2141**]. History of DTs in the past Type II Diabetes Pancytopenia following liver transplant thought to be secondary to immunosuppressive medications Hyperlipidemia Hypertension Motor Vehicle Accident with multiple injuries [**8-13**] (C6-C7 facet fractures s/p corpectomy, C7-T1 anterior cervical fusion and C5-T2 posterior cervical depression fusion, left mandibular fracture, left wrist fracture s/p ORIF, multiple rib fractures, right clavicular fracture, mediastinal hematoma, small pericardial effusion, asysolic arrest for 5 minutes) Social History: Currently living at [**Hospital1 **] LTAC. Remote smoking history. Past alcohol abuse, currently not drinking. No IVDU. Wife died after fall in the setting of longstanding alcohol abuse, daughter died in the car accident this summer, son has substance abuse issues but is health care proxy. Family History: Noncontributory. Physical Exam: Vitals: Tm 100.4 97 120/90-->90/60s 120 100% on 35%FM Pain: unknown-nonverbal, no grimacing Access: RUE PICC [**12-3**] Gen: chronically ill, diaphoretic HEENT: trach site clean CV: tachy, regular, no m Resp: scattered rhonchi, mostly clear, poor effort Abd; soft, no grimacing, PEG tube, +BS, foley yellow urine Ext; no edema Neuro: baseline nonverbal, blinks to command, contractures UE/LE Skin: b/l lateral feet with deep erythematous area with darkened center(blood blister vs deep tissue injury), no skin breakdown Pertinent Results: Other labs/interpretation: no leukocytosis Hgb stable [**8-14**] Chem panel remarkable for rising BUN 38 today, creat 1.0 Tobra 14.6 [**12-15**] . UA [**12-11**] negative Sputum cx [**12-6**] mod acenitobacter, sparse pseudomonas, proteus, klebsiella BAL [**12-11**]: mod acenitobacter, sparse pseudomonas. LP negative cx . Imaging/results: EEG [**12-16**] prelim: diffuse encephelopathy, no seizures . . cxr [**12-14**] In comparison with the study of [**12-12**], there has been decrease in lung volumes. Some prominence of ill-defined pulmonary vessels persists,suggesting continued pulmonary vascular congestion. Poor definition of the left hemidiaphragm could reflect atelectasis and small pleural effusion. No evidence of acute focal pneumonia. . [**12-7**] CT chest IMPRESSION: 1. Right upper lobe collapse due to obstruction of the right upper lobe bronchus with secretions; nonobstructive left lower lobe collapse. 2. Bilateral nonhemorrhagic pleural effusions, more marked on the right with dependent right lung base atelectasis. 3. Small pericardial effusion. 4. Aortic annulus, aortic valve, and coronary artery calcifications. 5. Multiple old fractures and fixation hardware in the ervicothoracic spine from previous trauma. . . CHEST (PORTABLE AP) Study Date of [**2145-12-1**] 7:19 PM IMPRESSION: Perihilar opacities, raising question of early CHF. Multiple rib fractures and right clavicle fracture. No pneumothorax detected. Patchy opacity at the left base, question atelectasis versus early infiltrate. . FOOT 2 VIEWS RIGHT PORT Study Date of [**2145-12-1**] 11:28 PM IMPRESSION: Somewhat limited exam, but no findings to confirm the presence of osteomyelitis . CT ABDOMEN W/O CONTRAST Study Date of [**2145-12-2**] 2:44 AM IMPRESSION: 1. No acute pathology is identified in the abdomen and pelvis to explain the patient's symptoms. No abscess cavity is identified. 2. Mild bibasilar atelectasis. 3. Unchanged calcified hepatic lesion in the interlobar fissure. . TTE (Complete) Done [**2145-12-3**] at 11:27:07 AM FINAL Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets 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. The mitral valve leaflets are structurally normal. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial 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. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No vegetations found. Normal overall left ventricular systolic function. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the report of the prior study (images unavailable for review) of [**2137-5-21**], there is no significant change Brief Hospital Course: 55 year old male with DM, ETOH abuse/cirrhosis s/p OLT [**6-/2137**] c/b chronic rejection, ETOH related MVA [**8-13**], complicated course, now anoxic brain injury s/p trach/PEG admitted from extended care facility->OSH [**11-21**]-->[**Hospital1 18**] [**Hospital Unit Name 153**] [**11-30**] for persistant fevers, presumed pulm source, stable on Abx, now on Gen Med [**12-14**] awaiting placement. Complicated patient, please see progress note below that details his plan per problem: . . Sepsis/fevers: Blood cx/Urine Cx here all negative. Imaging so far has been unrevealing and has included abdominal CT without contrast, head CT (sinus disease) and chest CT. TTE negative for gross endocarditis. LP was performed after several Abx, but Cx negative after. Gallium scan also not revealing. ID following, Presumed source likely pulmonary, OSH enterobacter bacteremia (?source), here sputum/BAL with acenitobacter/pseudomonas/ klebsiella/ proteus -->trancheobronchitis vs HCAP. No open skin lesions. no diarrhea. UA negative. Afebrile for >48hours, only low grade temps likely [**2-6**] atelectasis from thick mucous. -cont IV Tobramycin 100mg IV q12 (adjust dose c level) and Meropenem until [**12-22**] (10day course), finally defervesced with addition of Tobra. note, will send to LTAC on ertapenum (cost issue), got one dose here and tolerated. - blood cx here negative to date -aggressive Chest PT, frequent suctioning, mucomyst nebs for thick secretions -ID signed off, reconsult if fevers. . . Altered Mental Status/Encephelopathy: we do not have a clear baseline for this patient with anoxic brain injury. Exams here have been inconsistent by neuro and ID. Per neuro, severe baseline anoxic injury with toxic/metabolic encephalopathy. ID reports a few instances where pt was more interactive. multiple RF for seizures (tacrolimus, carbepenem abx, baseline anoxic injury) but none clinically obvious and EEG on [**12-16**] c/w encephlopathy (prelim), no seizures. -encephalopathy is likely from diffuse axonal damage (anoxic injury) but worse with acute infection, multiple meds, etc. -would be great to have pt seen by his prior caregivers (neurologists, nurses, doctors) to know what his baseline was previously -plan will be for neuro f/u in 2-3weeks after discharge (at LTAC), can reeval at that time. . . Tachycardia: sinus tachy. some degree volume depletion (insensible losses with sweats) since BP also low when tachy worse. Also worse when low grade fevers. Was on albuterol, stopped today. note, echo [**11-13**] normal EF/function -small IVFs prn tachy >115 and SBP<100. Cant give continuous IVF [**2-6**] pulm edema on CXR. -no albuterol. tylenol for fevers. . . Wound: b/l feet with deep erythema, pressure ulcer/Deep tissue injury. per staff, has been STABLE since admission to [**Hospital Unit Name 153**]. -appreciate wound care reccommendations, boots . . Acute on Chronic Respiratory Failure: Patient required vent support for few days in setting of likely pneumonia/tracheobronchitis and possible volume overload. Now improved, on trach mask 35%. - wean O2 as tolerated, agressive pulm toilet, frequent suctioning, cont mucomyst nebs - treat infection as above -CXR suggesing pulm edema but intravascularly depleted (hypotension/tachy/elevated BUN) so cannot do now . . Acute Renal Failure - Resolved, likely secondary to sepsis on initial presentation - monitor, BUN has been going up, gets IVFs boluses prn, 1L today. Monitor closely for volume depletion. . . ESLD s/p orthotopic transplant: Patient seen by Hepatology this admission. Recommendation was goal levels in high 3s. Recommendation to check once weekly - tacro level 1.7 [**12-15**] (low). increased tacro to home dose of 2mg [**Hospital1 **]. - LFTs normal . . Diabetes II, controlled without complication: - continue lantus 28 U with sliding scale . . Anoxic brain injury: as above, unsure about baseline MS (see above), noncommunicative currently. decorticate posturing. s/p trach/PEG. Contractures. Pressure ulcers. EEG c/w enceph -cont baclofen 10mg tid (increased dose [**2-6**] frequent spasm) fentanyl patch 50mcg q72, roxicodone 5mg q4prn (likely confounding proper neuro MS [**Last Name (Titles) **]) -tube feeds as tolerated, bowel regimen -turn q2, wound care, physical therapy for ROM . . Hypertension: Blood pressures currently in high 90s not on any anti-hypertensive - hold outpatient Lopressor - receiving feeds/fluids, bolus PRN . . FEN/proph: 1L IVF today, small boluses prn, monitor lytes, Tube feeds with free water flushes, TEDs/SCDs, heparin tid, PPI, bowel regimen, wound care . . Dispo: transfering to LTAC Code: Full per current proxy/guardian . Communication: Son/guardian, [**Name (NI) **] [**Telephone/Fax (1) 30916**], has not been reachable Sister: [**Name (NI) **] [**Name (NI) 7716**] [**Telephone/Fax (3) 30917**], working on guardianship [**Name (NI) 30918**]: [**Name (NI) **] [**Name (NI) 30919**] ([**Telephone/Fax (1) 30920**] cell ([**Telephone/Fax (1) 30921**] Medications on Admission: Lactulose 20 grams daily per G tube Heparin SC Nexium 40 mg daily Haldol 10 mg Q4H:PRN Lopressor 25 mg PO Q8H Baclofen 5 mg PO TID Tylenol 650 mg PO Q4H:PRN Roxicodone 5 mg PO Q4H:PRN Miconazole powder Morphine 2 mg IV Q1H:PRN Regular insulin sliding scale Atrovent inhaler 6 puffs Q6H Prograf 2 mg PO BID Levemir 28 units QHS Free water flushes 250 mL Q6H Vancomycin 1 gram IV Q18 hours Ceftazidime 2 grams IV Q12H Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection twice a day. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours). 10. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 13. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Levemir 100 unit/mL Solution Sig: 28 Units Subcutaneous at bedtime. 15. Insulin Regular Human 100 unit/mL Cartridge Sig: per sliding scale Injection three times a day. 16. Tobramycin Sulfate 60 mg/6 mL Solution Sig: 100mg Intravenous every twelve (12) hours for 5 days: until [**12-22**]. 17. Ertapenem 1 gram Recon Soln Sig: 1gram Intravenous every twenty-four(24) hours for 5 days: until [**12-22**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Fevers tracheobronchitis vs HCAP/VAP Acute renal failure Discharge Condition: STABLE Discharge Instructions: Admitted with fevers, likely tracheobronchitis vs PNA, on antibiotics (tobramycin/ertapenum) until [**12-22**] Followup Instructions: please f/u PCP Dr, [**Name9 (PRE) **] in 2weeks. Please f/u neurology in 2weeks

Admission Date: [**2120-1-16**] Discharge Date: [**2120-2-7**] Date of Birth: [**2070-4-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: back pain intermittently for one month Major Surgical or Invasive Procedure: [**2120-1-20**] thoracoabdominal aneurysm repair History of Present Illness: 49 M transferred from an OSH w/ a 7 cm thoracoabdominal aneurysm. He speaks French Creole. He complains of back pain intermittently for one month. He developed worseing [**5-28**] left sided chest pain radiating to the back. He then presented to an OSH because it was not getting better. He was hypertensive to the 190s systolic but on transfer that had resolved with labetolol. Denies SOB, abd pain, nausea, vomiting. Past Medical History: None Social History: Moved from [**Country 2045**] 1 [**12-20**] month ago, no smoking, drugs, EtOH Family History: N/C Physical Exam: PE: P 90, BP 111/74, RR 15, O2 sat 98% RA gen- NAD, AxOx3 neck- supple, no bruits heart- RRR, no murmur lungs- CTA b/l abdomen- well healed abdominal incision, flat, BS+, nondistended Ext- no c/c/e, palpable pulses throughout Pertinent Results: [**2120-2-6**] 06:10AM BLOOD WBC-7.7 RBC-3.52* Hgb-9.0* Hct-28.9* MCV-82 MCH-25.6* MCHC-31.2 RDW-15.1 Plt Ct-600* [**2120-2-7**] 06:10AM BLOOD PT-19.2* PTT-47.6* INR(PT)-1.9* [**2120-1-16**] 09:38PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2120-2-2**] 3:21 IMPRESSION: 1. Extensive pulmonary embolus, which is greater on the right. 2. Expected postoperative changes of aortic aneurysm repair with no evidence of leak. Mediastinal hematoma, most likely post-surgical. 3. New elevation of the left hemidiaphragm. No evidence of herniation of the stomach into the thorax. However, the entire left hemidiaphragm is not included on this study and the upper abdomen should be included on the followup examination. CHEST (PA & LAT) [**2120-1-29**] IMPRESSION: PA and lateral chest compared to [**1-23**]: Opacification at the base of the left hemithorax and leftward mediastinal shift are stable since [**1-23**]. Most of this is due to persistent moderate left pleural effusion, and although I don't think there is collapse of the left lower lobe, there must be appreciable atelectasis in order to produce left rather than right mediastinal shift. Right lung is clear. Post-operative cardiomediastinal silhouette is unremarkable and unchanged. Nasogastric tube ends in the stomach. DUPLEX DOPP ABD/PEL [**2120-1-17**] IMPRESSION: Normal [**Doctor Last Name 352**] scale and doppler evaluation of the kidneys. CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2120-1-16**] IMPRESSION: Large thoracoabdominal aneurysm measuring 6.9 x 6.6 cm at the widest point at the level of the left ventricle. Aneurysmal dilatation is markedly ectatic particularly within the lower thorax. There is no CT evidence of acute rupture. [**2120-1-29**] 6:50 PM ABDOMEN (SUPINE & ERECT) THREE VIEWS OF THE ABDOMEN: Just right of the midline, in the mid abdomen, a dilated loop of small bowel is again identified. However, the number and degree of dilated small bowel loops is decreased since the radiograph obtained two days prior. Air is identified distally in the rectum. No abnormal air- fluid levels are identified. The lung bases demonstrate a left pleural effusion with associated atelectasis. The left heart border is obscured, likely by a left lower lobe consolidation. Surgical clips in the thorax and upper abdomen are indicative of prior surgery. Osseous structures are unremarkable. IMPRESSION: 1. Interval improvement in ileus. 2. Left pleural effusion and consolidation, likely atelectasis alone, but superimposed infection is possible. Brief Hospital Course: CTA showing a large thoracoabdominal aneurysm measuring 6.9 x 6.6 cm at the widest point at the level of the left ventricle. Aneurysmal dilatation is markedly ectatic particularly within the lower thorax. There is no CT evidence of acute rupture. Admitted to Vascular Surgery / Dr. [**Last Name (STitle) **] for further management. [**2120-1-17**] patient was taken to the OR by Dr. [**Last Name (STitle) **] for resection and repair of thoracoabdominal aneurysm with 32-mm Dacron graft with visceral reimplantation. [**Date range (1) 76861**]/08 Post-operatively patient was in the ICU. Patient recieved routine ICU care, blood gases, electrolytes and other lab works were monitored. Electrolytes repleted as needed. Patient was transfused with red blood cells for low HCT. Patient remained intubated and sedated, successfully extubated on [**2120-1-21**]. Patient had a chest tube from the OR that was dicontinued without incident on POD 7, CXR taken post chest tube pull was neg. Patient's BP and HR were monitored per ICU routine. Patient had problems of hypertension and tachycardia. He was treated with Hydralazine, Metoprolol and Labetalol IV, eventually switched to oral form. Pain managed with PCA Morphine. Patient had no neurological [**2120-1-24**] patient was transfered to [**Hospital Ward Name 121**] 5 VICU status/telemetry with and NGT, PCA Morphine, started on sips. [**2120-1-25**] PCA Morphine d/c'd, switched over to Hydromorphone IV prn, then switched over to Oxycodone. NGT d/c'd. [**2120-1-26**] patient started physcial after evaluation, continued physical therapy, currently cleared for home d/c. Central line d/c'd, PIV placed. [**2120-1-27**] patient had problems with abdominal distention, NGT replaced. KUB showing-Mild dilatation of small bowel loops, consistent with ileus, better on [**1-29**] KUB. Patient kept NPO except meds. [**2120-1-31**] Foley was d/c'd. No urinary problems after. [**2120-2-2**] started sips, tolerated well, NGT d/c'd the following day. [**2120-2-2**] Patient had some episodes of desturation and tachycardia during ambulation, no SOB at rest. CTA showed-Extensive pulmonary embolus, which is greater on the right, treated with Heparin drip, placed on Lovenox bridge / Coumadin, will be dicharged on Coumadin and will follow outpatient with PCP. [**Name10 (NameIs) **] further episodes, currently stable on no oxygen support. Resumed telemetry. [**2120-2-4**] Patient had tachycardia with activity again- EKG no acute changes, self limiting, pt r/o for MI [**2-5**] - [**2-7**] Awaiting DC planning / pt with no PCP, [**Name10 (NameIs) **] to set patient up with PCP to [**Name9 (PRE) **] INR. Medications on Admission: None Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 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:*1* 5. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 4 days: DC when INR is [**1-21**]. Disp:*6 80 mg/0.8 mL Syringe* Refills:*0* 6. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime: INR goal is [**1-21**] / Stop your lovenox when INR is [**1-21**]. Disp:*60 Tablet(s)* Refills:*6* 7. Coumadin 1 mg Tablet Sig: zero Tablet PO zero: take as directed from PCP / this is for minor adjustments in your coumadin dosage. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Thoracoabdominal aneurysm Pulmonary Embolism Anemia secondary to blood loss / tranfused Post operative ileus / resolved with NPO and NG tube ARF - resolved with PRBC / Hydration Discharge Condition: Stable Labs on DC [**2120-2-7**]: Hct: 28.7 INR: 1.9 (goal INR [**1-21**]) CREAT: 1.8 / DC: 1.1 Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-26**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**1-21**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Coumadin/Lovenox teaching. You are being put on coumadin for clots found in your lung. How will I be treated for this condition ? You will receive two daily subcutaneous (underneath the skin) injections of enoxaparin (Lovenox) for 5-7 days along with a longer course of an oral medication called warfarin (Coumadin). Both medications belong to a class of drugs known as anticoagulants. Anticoagulants prevent clots. How is enoxaparin (Lovenox) given Enoxaparin is given subcutaneously twice daily. Many patients can give the injections to themselves at home, and you can be given instructions to learn how to give yourself these injections if this is an appropriate plan for you. It is important to give the medication exactly as directed. When to stop enoxaparin (Lovenox)? Your PCP will tell you when to stop enoxaparin. This is stopped when your INR is above 2 (this is a reflection of coumadin). When your INR is at 2, this means that you blood is thin enough to be on coumadin alone. The level of INR when you are on coumadin is 2-2.5. How is warfarin (Coumadin) given? Warfarin is given orally once daily. You will be getting regular blood tests to measure how well this medication is working. The dose of warfarin may be adjusted according to the results of the blood tests. What should I do if I miss a dose of enoxaparin or warfarin? You should contact your PCP as soon as you notice that you have missed a dose. What are some of the side effects of enoxaparin? Approximately 2% of patients may experience bleeding. Please notify Pcp: [**Name10 (NameIs) 2227**] if you experience any of the following symptoms: unusual bleeding or bruising (e.g., bleeding gums, red spots on the skin, nose bleeds), heavy menstrual bleeding blood in urine or stool; black tarry stools back pain or stomach pain cold, blue, or painful feet other minor side effects include skin irritation, pain, and bruises at the injection site. What are some of the side effects of warfarin? Like enoxaparin the major complication of warfarin is bleeding. Therefore, you should notify Pcp: [**Name10 (NameIs) **] you experience any of the symptoms listed in the previous answer. Please check with your doctor for more information on warfarin. Should I be aware of other signs and symptoms? You should notify PCP immediately if you experience chest pain, shortness of breath, a feeling of passing out, or palpitation (heart racing). What medications do I need to avoid while on these medications? You should avoid taking medications that contain aspirin, medications such as ibuprofen (Advil, Motrin, Nuprin), naproxen (Aleve), ketoprofen (Orudis KT, Actron Caplets), or any other non-steroidal anti-inflammatory drugs (NSAIDs). You should always check with your doctor before starting any new prescription or over-the-counter medication. Moreover, alcohol and various food may also interact with warfarin. Please check with your doctor, nurse [**First Name (Titles) **] [**Last Name (Titles) 57**] for more information. What other precautions do I need to take while on these medications? Monitor signs and symptoms of bleeding. Be careful while brushing or flossing your teeth. Avoid injuries. Keep enoxaparin syringes at room temperature. Do not refrigerate or freeze enoxaparin. Store away from heat and direct light. Keep all medications out of the reach of children Followup Instructions: Call Dr.[**Name (NI) 5695**] office to schedule an appointment in 2 weeks [**Telephone/Fax (1) 76862**]. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2120-2-8**] 9:45 Have your INR drawn when you go to see Dr. [**Last Name (STitle) 11616**] on [**2120-2-8**], he will call you to adjust you Coumadin dose when the result comes back. You are on lovenox. This will stop when your coumadin (INR) is at 2. Completed by:[**2120-2-7**]

Unit No: [**Numeric Identifier 63557**] Admission Date: [**2104-6-26**] Discharge Date: [**2104-7-27**] Date of Birth: [**2104-6-26**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [**Known lastname 951**] [**Known lastname 63558**]-[**Known lastname 48716**] is the former 2.395 kg product of a 33-3/7 week gestation pregnancy born to a 39-year-old G5 P0 woman. The pregnancy was conceived by in [**Last Name (un) 5153**] fertilization and complicated by maternal paroxysmal nocturnal hematuria. The mother did not experience any thrombotic events prior to this pregnancy. She was treated prophylactically on Lovenox and IV heparin while pregnant. She had signs of ongoing hemolysis with a hematocrit in the high 20s. She was admitted 1 week prior to delivery for labile blood pressures and hemolysis. She had a full course of betamethasone at 30 weeks gestation. Delivery was via cesarean section for a known breech presentation. Rupture of membranes occurred at delivery. He emerged vigorous and crying and received blow-by oxygen for central cyanosis. Mild grunting was noted at 5 minutes of life. He was admitted to the neonatal intensive care unit for treatment of prematurity. PHYSICAL EXAMINATION: Upon admission to the neonatal intensive care unit, weight was 2.395 kg, 75th percentile, length of 45.5 cm, 50th-75th percentile, head circumference of 33.5 cm, 90th percentile. General - ruddy, active, appropriate for gestational age infant. Head, eyes, ears, nose and throat - anterior fontanelle open and flat, normocephalic, non-dysmorphic facial features, palate intact, trachea midline, positive red reflex on right, unable to visualize on the left. Chest - moderate aeration bilaterally, mild grunting and flaring. Cardiovascular - regular rate and rhythm, normal S1, S2, grade 2/6 systolic ejection murmur in the left upper sternal border. Abdomen - soft, nontender, nondistended, no hepatosplenomegaly with a 3 vessel cord. GU - normal male, testes descended bilaterally, anus patent, no sacral dimple. Extremities - mild right hip click, moving all extremities, no skin fold with asymmetry. Neurological - symmetric tone and reflexes consistent with gestational age. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: Respiratory: [**Known lastname 951**] required nasal cannula O2 upon admission to the neonatal intensive care unit for cyanosis. He weaned to room air by day of life #6 and continued in room air until discharge from the neonatal intensive care unit. At the time of discharge, he is breathing comfortably 40-50 breaths per minute. Cardiovascular: [**Known lastname 951**] remained normotensive with normal heart rates. The murmur heard on admission resolved, but then became intermittent through the 2nd week of life. At the time of discharge, the murmur is heard intermittently, soft, systolic in the left upper sternal border. Blood pressures in 4 limbs have been normal. Recent baseline blood pressure is 70/34 with a mean of 48. Fluids, Electrolytes and Nutrition: [**Known lastname 951**] was initially NPO and treated with intravenous fluids. Enteral feeds were started on day of life #2 and gradually advanced to full volume. On day of life #13, he presented with bloody stools and was made NPO. He was given 2 weeks of bowel rest and treated with total parenteral nutrition through a percutaneously inserted central catheter. Feeds were reinitiated on [**2104-7-23**] and have been well tolerated. At the time of discharge, he is taking breast milk or Enfamil 20 p.o. ad lib. Discharge weight is 2.97 kg with a length of 51 cm and a head circumference of 35 cm. Serum electrolytes were checked in the 1st week of life and during the 2 weeks of bowel rest and were within normal limits. Infectious Disease: [**Known lastname 951**] was initially evaluated for sepsis upon admission to the neonatal intensive care unit secondary to his respiratory distress. A complete blood count was within normal limits. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. The blood culture was no growth at 48 hours and the antibiotics were discontinued. With the onset of the bloody stools and x-rays suggestive for pneumatosis and necrotizing enterocolitis, he was again cultured and treated for 14 days with Zosyn. The blood culture was no growth. Hematological: [**Known lastname 951**] is blood type A negative, Coombs negative. His hematocrit at birth was 51%. His most recent hematocrit was on [**2104-7-16**] at 36.9%. He did not receive any transfusions of blood products. Gastrointestinal: As previously mentioned, [**Known lastname 951**] was diagnosed with necrotizing enterocolitis. X-rays obtained around the time of the onset of bloody stools was suggestive for pneumatosis. He was treated with 14 days of bowel rest and intravenous antibiotics. The abdominal x-rays normalized by the 3rd day into treatment and were normal prior to the re- initiation of feeds. [**Known lastname 951**] also required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin was 11.4 total/0.4 direct mg/dl. He received approximately 4 days of phototherapy. The rebound bilirubin was 5.5 total/0.4 mg/dl direct on day of life #8. Neurology: [**Known lastname 951**] has maintained a normal neurological exam during admission and there are no neurological concerns at the time of discharge. Sensory, Audiology: Hearing screening was performed with automated auditory brainstem responses and [**Known lastname 951**] passed in both ears. Psychosocial: [**Hospital1 69**] social work was involved with this family. The contact social worker is [**Name (NI) 553**] [**Name (NI) **] and she can be reached at [**Telephone/Fax (1) 8717**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 41215**] [**Last Name (NamePattern1) 41216**], [**Last Name (un) 62188**], [**Location (un) **], [**Numeric Identifier 56937**], telephone [**Telephone/Fax (1) 41217**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding - ad lib p.o. Enfamil 20 or breast milk. 2. No medications. 3. Car seat position screening was performed. [**Known lastname 951**] was observed in his car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia. 4. State newborn screens were sent on [**7-4**], [**7-10**] and [**2104-7-27**]. The results from [**7-4**] and [**7-10**] were within normal limits. 5. Immunizations administered - Hepatitis B vaccine was administered on [**2104-7-27**]. 6. Immunizations recommended - Synergist RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria - i) born at less than 32 weeks; ii) born between 32 and 35 weeks with 2 of the following - day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or iii) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contacts and out-of- home caregivers. 7. Follow-up appointments - appointment with Dr. [**Last Name (STitle) 41216**] on Monday, [**2104-7-28**]. DISCHARGE DIAGNOSES: 1. Prematurity at 33-3/7 weeks gestation. 2. Transitional respiratory distress. 3. Suspicion for sepsis ruled out. 4. Necrotizing enterocolitis. 5. Unconjugated hyperbilirubinemia. 6. Status post circumcision. 7. Status post breech presentation at birth. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2104-7-27**] 01:23:51 T: [**2104-7-27**] 06:01:00 Job#: [**Job Number 63559**]