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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Rectal Pain Major Surgical or Invasive Procedure: Incision and Drainage with ___ Placement for treatment of Perirectal Abscess History of Present Illness: HPI: ___ with IBS and prior I&D of ___ and ischiorectal abscesses in ___ and ___ now p/w worsening rectal pain over the past several days. She was recently seen in ED on ___ with 2 days of worsening rectal pain after anal sex, examination at that time exam was unremarkable and pt was instructed to avoid anal intercourse and discharged home. Patient states that since that time she has had increased rectal pain and swelling, fevers/chills, and night sweats. Feels that this is consistent with her prior presentations of perianal abscesses. She has refrained from all sexual contact since her last ED visit. She also reports some nausea and bloating, but denies vomiting, hematochezia or black stools. She has no pain with defecation and her last BM was yesterday. Past Medical History: PMH: Depression, anxiety, perineal/perianal condylomata PSH: # Microscopically-assisted biopsy and transanal laser destruction of anal, perineal, vulvar, and vaginal condylomata ___ # perirectal abscess drainage in ___ # perirectal abscess drainage ___ Social History: ___ Family History: Maternal grandmother with skin cancer. Paternal aunt with breast cancer. Physical Exam: General: Doing well, pain controlled, tolerating medications by mouth, minimal pain A&OX3 No chest pain or shortness of breath Abd: soft, nondistended Pertinent Results: ___ 05:40AM BLOOD WBC-19.3* RBC-3.63* Hgb-11.8* Hct-34.9* MCV-96 MCH-32.6* MCHC-33.8 RDW-11.8 Plt ___ ___ 02:17PM BLOOD WBC-20.3* RBC-4.22 Hgb-13.5 Hct-41.3 MCV-98 MCH-32.0 MCHC-32.7 RDW-11.5 Plt ___ ___ 02:17PM BLOOD Neuts-89.3* Lymphs-6.9* Monos-3.5 Eos-0.1 Baso-0.2 ___ 05:40AM BLOOD Glucose-103* UreaN-6 Creat-0.5 Na-139 K-3.5 Cl-105 HCO3-24 AnGap-14 ___ 02:17PM BLOOD Glucose-84 UreaN-7 Creat-0.7 Na-138 K-3.8 Cl-103 HCO3-26 AnGap-13 ___ 05:40AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.5* CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:36 ___ IMPRESSION: IMPRESSION: A large perianal fluid collection consistent with abscess does not definitely involve the anal sphincter, but is not well evaluated on CT. If definite determinent of sphincter involvement is required, MR can help with further evaluation. Brief Hospital Course: Ms. ___ was admitted overnight after I&D of a perirectal abscess. She was doing well on post-operative day one. Her wbs was 19 however, the abscess was drained. She was seen by the surgical attending and discharged home. She was given a week of Augmentin by mouth and pain mediacation. She tolerated a regular diet without issue. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H do not take more than 3000mg of tylenol in 24 hours or drink alcohol while taking 2. Docusate Sodium 100 mg PO BID 3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain do not drink alcohol or drive a car while taking this medications RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills:*0 4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days Please take entire prescription, start first dose evening of ___ RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 Tablet by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Perirectal 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 inpatient Colorectal Surgery Service after I&D of horseshoe perirectal abscess with ___ placement. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You can shower, let the warm soapy water run over the area and keep as clean and dry as possible. You may preform ___ baths ___ times daily as needed. Please preform these as instructed by the nursing staff. Please eat foods that promote bowel motility such as: prunes, oat meal, apple juice, etc. Please avoid constipation. You have ___ which has been incerted into the abscess and this will help keep the abscess draining and allow it to heal. This can be left open to air and a gauze dressing o pad may be worn in your underwear collect drianage. The ___ will stay in place until your first clinic visit and Dr. ___ will decide if the abscess has resolved enough for it to be removed. Please monitor or rectal area for signs and symptoms of worsening infection including: increasing redness, increased pain, increased draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. Avoid intercourse until your follow-up with Dr. ___. You may gradually increase your activity as tolerated but clear heavy exercise with your surgeon. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 3000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___

{'Rectal Pain': ['Abscess of anal and rectal regions'], 'Worsening rectal pain': ['Abscess of anal and rectal regions'], 'Fevers/chills': ['Abscess of anal and rectal regions'], 'Night sweats': ['Abscess of anal and rectal regions'], 'Nausea': ['Abscess of anal and rectal regions'], 'Bloating': ['Abscess of anal and rectal regions'], 'Perirectal abscess': ['Abscess of anal and rectal regions']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: HISTORY OF PRESENTING ILLNESS: . ___ yo female presented to ___ today with chest pain. She awoke this AM with burning substernal chest pain. The pain radiated to her neck, shoulders, left arm and back. She denies associated shortness of breath, nausea, or diaphoresis. She reports she had a very similar episode 8 months ago which resolved with rest. She reports similar but less severe chest pain during exercise. Her vital signs on arrival to ___ were 97.8, 98, 154/75, and 99% on RA. She was found to have ST elevations inferiorly, II, III, aVR and laterally, V5, V6, with reciprocal changes in V1, V2, V3, I, aVL. The patient was given nitro, plavix 600mg, aspirin 325mg, 4600units of heparin bolus, 8mg of morphine, and zofran. She was air lifted to ___ for further management. . In the cath lab, she was found to have non-obstructive coronary artery disease. She was found to have a LAD ostial lesion that was not thought to be causing her EKG changes. She did have basal inferior wall motion abnormalities. Upon further questioning she reported she has been going through a stressful time in her life with the death of an uncle and the attempted suicide of her daughter. ___ diltiazem 1mg was attempted to improve vasospasm as Takotsubos was suspected. She received metoprolol 10mg IV during the case for sinus tachycardia. . On arrival to the CCU, the patient is asymptomatic and vital signs stable. . 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, ankle edema, palpitations, syncope or presyncope. . Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: none -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Depression . . Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: HR 67 BP 132/83 RR 14 O2 95% GENERAL: WDWN 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: Supple with JVP not elevated. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Right groin angioseal in place, dressing clean dry intact, no femoral bruit or hematoma. No edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ . Pertinent Results: CK(CPK) AlkPhos Amylase TotBili DirBili IndBili ___ 242* ___ 441* ___ 832* ___ 1127* ___ 1127* CK-MB MB Indx cTropnT ___ 10 4.1 1.57*1 ___ 24* 5.4 1.29*1 ___ 73* 8.8* 1.47*1 ___ 118* 10.5* ___ 138*2 12.2* 1.42*___ORONARIES: Her initial EKG changes were thought to be consistent with inferior wall STEMI, however no obstructing lesions were seen on cardiac cath. Her V-gram on cath revealed what looked like apical and inferior wall hypokinsesis. Given the history of excess stress, and this v-gram our working diagnosis was Takotsubos cardiomyopathy. However, when her EKG did not return to baseline, and she developed inferior q waves it was determined that she had an inferior MI with autolysis and early presentioin. She was started on aspirin, high dose atorvastatin, beta-blocker, and ACE-inhibitor for her STEMI. She did not have an intervention and was not started on plavix. . # PUMP: Her wall motion abnormalities were thought to be ___ ischemia with some contribution of stunning and myocyte death. Her EF was oreserved on ECHO. . # RHYTHM: The patient had an episode of sinus tachycardia in the cath lab and received metoprolol 10mg IV. Her heart rate remained well controlled on metoprolol throughout her stay. . #GERD: Ms ___ had chest pain intermittently throughout the stay. Her EKGs were not consistent with cardiac source. It was relieved by maalox, and she was started on omeprazole for suppression. . # Hypercholesterolemia: Given her STEMI her new LDL goal will be 70. Towards that end and also in accordence the PROVE-IT trial she was started on 80mg of Atorvastatin. . # Depression: We continued her zoloft and he was seen by an in house social worker to help her cope with both her life stressors and her new disease. . FEN: She was kept on a Heart Healthy diet. . PROPHYLAXIS: DVT ppx was acheived with heparin SC TID Pain management was acheived with tylenol and oxycodone PRN Bowel regimen was acheived with colace and senna PRN Medications on Admission: lipitor 10 mg amlodipine 10 mg atenolol 25 mg Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) 2. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 6. Vicodin ___ mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST Elevation Myocardial Infarction Depression Hyperlipidemia Discharge Condition: Mental Status:Clear and coherent Activity Status:Ambulatory - Independent Discharge Instructions: You had a heart attack that damaged a small portion of your heart. Your heart function was slightly compromised. A cardiac catheterization did not show any signs of blockages or narrowings of the coronary arteries. A cardiac MRI was done and results are pending at this time. You will be started on new medicines to prevent another heart attack and help your heart recover from this one. Please get a blood pressure cuff and check your blood pressure at home, keep a log to show to your doctors. ___ changes: 1. Start Aspirin 325 mg every day to prevent blood clots 2. Start Metoprolol 12.5 mg mg twice daily to lower your heart rate and prevent another heart attack 3. Start Lisinopril, this is to lower your blood pressure and help your heart recover. 4. Start Atorvastatin to lower your cholesterol 5. Start Vicodin to treat the chest pain, take only as needed 6. Start omeprazole to prevent heartburn. You can try to stop this when the chest pain is gone. 7. Start ciprofloxacin to treat your urinary infection. You will need a total of 7 days, take until all pills are gone. 8. STOP taking Pravastatin . Followup Instructions: ___

{'Chest pain': ['Acute myocardial infarction of inferolateral wall'], 'Radiated pain': ['Acute myocardial infarction of inferolateral wall'], 'ST elevations': ['Acute myocardial infarction of inferolateral wall'], 'Non-obstructive coronary artery disease': ['Acute myocardial infarction of inferolateral wall'], 'Basal inferior wall motion abnormalities': ['Acute myocardial infarction of inferolateral wall'], 'Takotsubos cardiomyopathy': ['Acute myocardial infarction of inferolateral wall'], 'Inferior MI with autolysis and early presentioin': ['Acute myocardial infarction of inferolateral wall'], 'Depression': ['Depressive disorder'], 'Hypercholesterolemia': ['Other and unspecified hyperlipidemia'], 'GERD': ['Esophageal reflux']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___ Chief Complaint: Fall off ladder, presents with R foot pain and low back pain Major Surgical or Invasive Procedure: ___: I&D right open calcaneus fracture with VAC placement ___: I&D right open calcaneus fracture with VAC change ___: I&D right open calcaneus fracture with ORIF and Split Thickness Skin Graft to wound. History of Present Illness: Mr. ___ is a ___ year old man who had a fall off a ladder (approx 12 feet)on ___. He was taken to ___ ___ and was found to have a Grade IIIb open right calcaneal fracture. He was then transferred to the ___ for further evaluation and care. Past Medical History: Depression Anxiety Right foot fx (___) treated non-operatively Low back injury (___) treated non-operatively Social History: ___ Family History: n/a Physical Exam: Upon admission Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear bilaterally Abdomen: Soft non-tender non-distended Extremities: RLE, SILT R foot/toes/plantar surface open fracture with large laceration medial to right ankle/heel Pertinent Results: ___ 07:20PM GENTA-1.2* ___ 07:20AM GLUCOSE-143* UREA N-10 CREAT-0.9 SODIUM-141 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13 ___ 07:20AM WBC-6.3 RBC-3.56* HGB-10.9* HCT-32.2* MCV-91 MCH-30.5 MCHC-33.7 RDW-13.6 ___ 07:20AM PLT COUNT-162 ___ 06:15PM ___ PTT-25.5 ___ ___:45PM GLUCOSE-100 UREA N-11 CREAT-0.8 SODIUM-139 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13 ___ 05:45PM WBC-6.3 RBC-4.15* HGB-12.4* HCT-36.8* MCV-89 MCH-29.9 MCHC-33.8 RDW-13.8 ___ 05:45PM NEUTS-78.8* LYMPHS-16.4* MONOS-4.1 EOS-0.3 BASOS-0.4 ___ 05:45PM PLT COUNT-164 ___ 05:45PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: Mr. ___ presented to the ___ on ___ via transfer from ___ with a right open calcaneal fracture. He was admitted, consented, and taken to the operating room. He underwent an I&D with VAC placement of his right calcaneal fracture wound. He tolerated the procedure well, was extubated, transferred to the recovery room and then to the floor. On ___ he returned to the operating room and underwent a repeat I&D of his right calcaneal fracture with VAC change. He tolerated the procedure well, was extubated, transferred to the recovery room and then to the floor. On ___ he returned to the operating room and underwent an I&D of the right calcaneal wound with ORIF by orthopaedics and a split thickness skin graft to his wound by plastic surgery. He tolerated the procedure well, was extubated, transferred to the recovery room and then to the floor. He remained on bedrest per plastic surgery for graft protection. His splint was changed on ___ to provide improved padding. On ___ his VAC was removed by plastic surgery and his antibiotics were stopped. On ___ he was taken off bedrest and worked with physical therapy, though was only allowed to dangle his leg (have it dependent for 15 minutes 3 times a day). On ___ he was able to start physical therapy and was cleared for home with ___. Foley ___ was removed and he voided 500cc prior to discharge. The rest of his hospital stay was uneventful with his lab data and vital signs within normal limits and his pain controlled. He is being discharged today in stable condition. Medications on Admission: Antidepressant - unknown med and dose Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours) for 18 days. Disp:*36 syringes* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Fall from ladder Right open calcaneus fracture Discharge Condition: Stable/Good Discharge Instructions: Continue to be non-weight bearing on your right leg Continue to take your lovenox injections as instructed Please take all medication as prescribed If you have any increased pain, swelling, and or numbness, not relieved with rest, elevation and or pain medication, or if you have any other concerning symptoms, please call the office or come to the emergency department 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 ___ through ___, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on ___, ___, or holidays. Please plan accordingly. Followup Instructions: ___

{'R foot pain': ['Fracture of calcaneus'], 'low back pain': ['Backache'], 'fall off ladder': ['Other accidental fall from one level to another']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: epigastric abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ male with history AML s/p 7+3 induction now s/p 3C of HiDAC. Developed FN after C2 of HiDAC with no obvious infectious source found now presenting with abdominal pain. SUBJECTIVE: Patient c/o slight epigastric pain hx of this with previous chemotherapy cycles feels similar to prior. No fevers since last admission, denies chills/rigors/uri sx. pain ___ on pain scale feels "gas pains". no recent n/v/d. He denies shortness of breath, cough, chest pain, rashes, and dysuria. Past Medical History: Past Medical History: Patient presented to ___ with a 3 week history of weakness on ___. CBC revealed leukocytosis with blasts for which he was transferred to ___. Bone marrow biopsy confirmed acute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. Patient was started on 7+3 on ___. Day 14 bone marrow with aplasia but persistent t(8;21) in 40% of cells per karyotype and RUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made not to re-induce. Day 21 bone marrow on ___ was with no morphologic or cytogenetic evidence of residual disease. Treatment History: - ___: 7+3 - ___: BMB with ___ - ___: C1D1 HiDAC - ___: C2D1 HiDAC - ___: C3D1 HiDAC Social History: ___ Family History: Both mother and father died of old age. He denies any family history of malignancy or blood disorders. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: Temp 98.2 BP 123/74 HR 96 RR 16 O2 sat 100% RA. ___: NAD. HEENT: MMM, no OP lesions, no cervical, supraclavicular, axillary adenopathy, no thyromegaly. CV: RR, NL S1S2 no S3S4 MRG. PULM: CTAB. GI: BS+, soft, slight pain on palpation of epigastric region. no masses or hepatosplenomegaly. LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy. SKIN: No rashes or skin breakdown port site intact w/o erythema. Pt does have darker brown skin lesions over anterior foreleg on left but states chronic. NEURO: A&Ox3. Cranial nerves II-XII are within normal limits. Gross strength and sensation intact. no nystagmus, rapid hand movements and tandem gait intact. DISCHARGE PHYSICAL EXAM: VITAL SIGNS: TC 98.3 ___ 20 99-100%RA GEN: NAD, awake and alert, non-toxic in appearance. HEENT: MMM, no OP lesions, no cervical, supraclavicular, axillary adenopathy, no thyromegaly. CV: RR, NL S1S2 no S3S4 MRG. PULM: Non-labored. CTAB. GI: BS+, soft. Pain on palpation of epigastric region resolved. No rebound tenderness. No palpable masses or hepatosplenomegaly. LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy. SKIN: No rashes or skin breakdown; port site intact w/o erythema, discharge or swelling. Does have darker brown skin lesions over anterior foreleg on left but states chronic. NEURO: A&Ox3. Cranial nerves II-XII are within normal limits. Gross strength and sensation intact. No nystagmus, rapid hand movements and tandem gait intact. Pertinent Results: LABS: ___ 09:45AM PLT SMR-RARE PLT COUNT-9*# ___ 09:45AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-1+ BITE-OCCASIONAL ___ 09:45AM NEUTS-4* BANDS-0 LYMPHS-96* MONOS-0 EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-0.01* AbsLymp-0.19* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 09:45AM WBC-0.2* RBC-2.37* HGB-7.7* HCT-21.5* MCV-91 MCH-32.5* MCHC-35.8 RDW-14.5 RDWSD-48.2* ___ 09:45AM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-2.0 ___ 09:45AM LIPASE-21 ___ 09:45AM ALT(SGPT)-62* AST(SGOT)-30 ALK PHOS-82 TOT BILI-0.5 ___ 09:45AM GLUCOSE-128* UREA N-13 CREAT-0.8 SODIUM-140 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-21* ANION GAP-19 ___ 12:15PM PLT COUNT-46*# ___ 11:45PM BLOOD WBC-0.4*# RBC-2.49* Hgb-8.2* Hct-22.4* MCV-90 MCH-32.9* MCHC-36.6 RDW-14.6 RDWSD-47.3* Plt Ct-21* ___ 11:45PM BLOOD Neuts-14* Bands-0 Lymphs-66* Monos-16* Eos-0 Baso-0 Atyps-4* ___ Myelos-0 AbsNeut-0.06* AbsLymp-0.28* AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00* ___ 11:45PM BLOOD Plt Ct-21* ___ 11:45PM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-134 K-4.0 Cl-100 HCO3-24 AnGap-14 ___ 11:45PM BLOOD ALT-48* AST-23 LD(LDH)-106 AlkPhos-75 TotBili-0.7 ___ 11:45PM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.8 Mg-2.2 ECG ___ Clinical indication for EKG: R___.31 - Abnormal electrocardiogram [ECG] [EKG] Sinus rhythm. Possible inferior wall myocardial infarction. Somewhat early R wave progression. Compared to the previous tracing of ___ the rate is now somewhat slower. Otherwise, unchanged. Brief Hospital Course: ASSESSMENT AND PLAN: Mr. ___ is a ___ male with history AML s/p 7+3 and C3 HiDAC consolidation presenting with epigastric pain. C3D17 ___ #Epigastric pain: (resolved), described as mild in nature and was minimal on exam, etiology likely GERD vs. gastritis related. Added protonix and simethicone on admission with improvement. Received IVF ___ overnight. No fevers throughout hospital course so no further workup necessitated as etiology of pain unlikely infectious in origin although we had a low threshold for initiating empiric antimicrobial given neutropenia. No nausea, vomiting or diarrhea. Patient eating and drinking well. Lipase WNL. CMV/EBV PCR pending at discharge. #AML: Favorable genetics given t(8.21) s/p 7+3 and now s/p C3 HiDAC consolidation. Bone marrow biopsy, FISH, and cytogenetics on day 21 of 7+3 indicate complete response. Will continue acyclovir, fluconazole and ciprofloxacin. Received neulasta given ___ and expect counts recovery soon. Follow up arranged for lab check on ___ at ___ and ___ with primary team #Panyctopenia (anemia, thrombocytopenia, neutropenia): counts at nadir secondary to recent cycle of HiDAC but showing signs of recovery. No e/o clinical blood loss currently. Likely all consequence of chemotherapy and underlying malignancy and inflammatory block. However, given downtrend of H/H on ___, received 1U of PRBCs on ___. Transfuse for hgb <7 and/or plt <10K. Will RTC to ___ on ___ for lab check as above. Prophylaxes: # Access: POC # Contact: ___ # Disposition: Discharged ___ RTC on ___ at ___ for labs and ___ for provider visit and labs # Code Status: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Fluconazole 400 mg PO Q24H 4. Montelukast 10 mg PO DAILY 5. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Medications: 1. Pantoprazole 40 mg PO Q24H 2. Acyclovir 400 mg PO Q12H 3. Ciprofloxacin HCl 500 mg PO Q12H 4. Fluconazole 400 mg PO Q24H 5. Montelukast 10 mg PO DAILY 6. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Disposition: Home Discharge Diagnosis: AML Abdominal pain likely GERD/Gastritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted due to dehydration and abdominal upset which improved with IV fluids time and adding a medication for heartburn. You will be discharged home and follow up as stated below. Please do not hesitate to call in the meantime with any questions or concerns. It was a pleasure taking care of you. Followup Instructions: ___

{'epigastric pain': ['Other gastritis without bleeding', 'Gastro-esophageal reflux disease without esophagitis'], 'neutropenia': ['Antineoplastic chemotherapy induced pancytopenia', 'Other myeloid leukemia not having achieved remission'], 'anemia': ['Antineoplastic chemotherapy induced pancytopenia', 'Other myeloid leukemia not having achieved remission'], 'thrombocytopenia': ['Antineoplastic chemotherapy induced pancytopenia', 'Other myeloid leukemia not having achieved remission'], 'dehydration': ['Dehydration'], 'adverse effect of antineoplastic and immunosuppressive drugs': ['Adverse effect of antineoplastic and immunosuppressive drugs'], 'initial encounter': ['initial encounter'], 'other specified places as the place of occurrence of the external cause': ['Other specified places as the place of occurrence of the external cause'], 'other long term (current) drug therapy': ['Other long term (current) drug therapy']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: HiDAC Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ male with history AML s/p 7+3 induction now s/p 3C of HiDAC. Developed FN after C2 of HiDAC with no obvious infectious source found now presenting for C4 of HiDAC. Past Medical History: Past Medical History: Patient presented to ___ with a 3 week history of weakness on ___. ___ revealed leukocytosis with blasts for which he was transferred to ___. Bone marrow biopsy confirmed acute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. Patient was started on 7+3 on ___. Day 14 bone marrow with aplasia but persistent t(8;21) in 40% of cells per karyotype and RUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made not to re-induce. Day 21 bone marrow on ___ was with no morphologic or cytogenetic evidence of residual disease. Treatment History: - ___: 7+3 - ___: BMB with ___ - ___: C1D1 HiDAC - ___: C2D1 HiDAC - ___: C3D1 HiDAC Social History: ___ Family History: Both mother and father died of old age. He denies any family history of malignancy or blood disorders. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: Temp 97.9 BP 130/70 HR 72 RR 16 O2 sat 98% RA. ___: NAD. HEENT: MMM, no OP lesions, no cervical, supraclavicular, axillary adenopathy, no thyromegaly. CV: RR, NL S1S2 no S3S4 MRG. PULM: CTAB. GI: BS+, soft, slight pain on palpation of epigastric region. no masses or hepatosplenomegaly. LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy. SKIN: No rashes or skin breakdown port site intact w/o erythema. Pt does have darker brown skin lesions over anterior foreleg on left but states chronic. NEURO: A&Ox3. Cranial nerves II-XII are within normal limits. Gross strength and sensation intact. no nystagmus, rapid hand movements and tandem gait intact. DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 97.8 PO ___ 20 98 RA ___: NAD. HEENT: MMM. CV: RR, NL S1S2 no S3S4 MRG. PULM: CTAB. ABD: soft/nt/nd, no HSM LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy. SKIN: No new rashes NEURO: A&Ox3. Cranial nerves II-XII are within normal limits. Gross strength and sensation intact. no nystagmus, rapid hand movements and tandem gait intact. FNF intacdt and negative romberg Pertinent Results: ADMISSION LABS: ___ 09:05AM BLOOD WBC-4.4 RBC-3.23* Hgb-10.8* Hct-32.4* MCV-100* MCH-33.4* MCHC-33.3 RDW-20.2* RDWSD-72.9* Plt ___ ___ 09:05AM BLOOD Neuts-50.8 ___ Monos-17.3* Eos-0.5* Baso-0.7 Im ___ AbsNeut-2.23 AbsLymp-1.34 AbsMono-0.76 AbsEos-0.02* AbsBaso-0.03 ___ 09:05AM BLOOD Glucose-112* ___ 09:05AM BLOOD UreaN-12 Creat-0.7 Na-139 K-4.2 Cl-102 HCO3-25 AnGap-16 ___ 09:05AM BLOOD ALT-117* AST-64* AlkPhos-83 TotBili-0.4 ___ 09:05AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1 DISCHARGE LABS: ___ 12:00AM BLOOD WBC-3.8* RBC-3.11* Hgb-10.4* Hct-31.0* MCV-100* MCH-33.4* MCHC-33.5 RDW-18.5* RDWSD-67.1* Plt ___ ___ 12:00AM BLOOD Neuts-97.0* Lymphs-1.9* Monos-0.5* Eos-0.0* Baso-0.3 Im ___ AbsNeut-3.67 AbsLymp-0.07* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.01 ___ 12:00AM BLOOD Glucose-133* UreaN-15 Creat-0.6 Na-136 K-4.2 Cl-102 HCO3-23 AnGap-15 ___ 12:00AM BLOOD ALT-104* AST-56* LD(LDH)-172 AlkPhos-65 TotBili-0.8 Brief Hospital Course: Mr. ___ is a ___ male with history AML s/p 7+3 and C3 HiDAC consolidation presenting for C4 C4D6 ___ # AML: Favorable genetics given t(8.21) s/p 7+3 and now s/p C3 HiDAC consolidation. Bone marrow biopsy, FISH, and cytogenetics on day 21 of 7+3 indicate complete response. He received Cytarabine 5940 mg IV Q12H on Days 1, 3 and 5. ___, ___ and ___ mg/m2). Neuro checks prior to each chemotherapy were performed and did nto show signs of cerebellar toxicity. He also received the following: - antiemetics/IVF per protocol - Continue acyclovir, fluc and cipro while neutropenic - neulasta to be given ___ - f/u set for clinic ___ #epigastric pain: mild in nature and minimal on exam, likely GERD/gastritis related. had w/u inhouse last admission, lipase WNL, afebrile. Improved with protonix, simethicone. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Montelukast 10 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Simethicone 40-80 mg PO QID:PRN gas pains 5. Ciprofloxacin HCl 500 mg PO Q12H 6. Fluconazole 400 mg PO Q24H Discharge Medications: 1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID 2. Acyclovir 400 mg PO Q12H RX *acyclovir 400 mg 1 tablet(s) by mouth q 12 hours Disp #*28 Tablet Refills:*0 3. Montelukast 10 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Simethicone 40-80 mg PO QID:PRN gas pains 6. HELD- Ciprofloxacin HCl 500 mg PO Q12H This medication was held. Do not restart Ciprofloxacin HCl until outpatient team tells you to restart 7. HELD- Fluconazole 400 mg PO Q24H This medication was held. Do not restart Fluconazole until outpatient team tells you to restart Discharge Disposition: Home Discharge Diagnosis: AML Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: Mr. ___, You were admitted to receive HiDAC chemotherapy. You tolerated this well and will be discharged home. You will follow up in clinic as stated below. Please do not hesitate to call in the meantime with any questions or concerns. It was a pleasure taking care of you. Followup Instructions: ___

{'weakness': ['Other myeloid leukemia not having achieved remission'], 'leukocytosis with blasts': ['Other myeloid leukemia not having achieved remission'], 'acute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement': ['Other myeloid leukemia not having achieved remission'], 'fever': ['Encounter for antineoplastic chemotherapy'], 'neutropenia': ['Encounter for antineoplastic chemotherapy'], 'epigastric pain': ['Gastro-esophageal reflux disease without esophagitis', 'Gastritis'], 'darker brown skin lesions': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cycle 3 of hidac Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with history AML s/p 7+3 induction now presenting for C3 of HiDAC. Developed FN after C2 of chemotherapy with no infectious source found and no further complications. SUBJECTIVE: Patient is feeling well. No fevers since last admission, denies chills/rigors/uri sx. no recent n/v/d. did c/o gas pains a few days prior to admission that improved with simethicone prn. He denies shortness of breath, cough, chest pain, abdominal pain, rashes, and dysuria Past Medical History: Past Medical History: Patient presented to ___ with a 3 week history of weakness on ___. CBC revealed leukocytosis with blasts for which he was transferred to ___. Bone marrow biopsy confirmed acute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. Patient was started on 7+3 on ___. Day 14 bone marrow with aplasia but persistent t(8;21) in 40% of cells per karyotype and RUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made not to re-induce. Day 21 bone marrow on ___ was with no morphologic or cytogenetic evidence of residual disease. Treatment History: - ___: 7+3 - ___: BMB with ___ - ___: C1D1 HiDAC - ___: C2D1 HiDAC - ___: C3D1 HiDAC Social History: ___ Family History: Both mother and father died of old age. He denies any family history of malignancy or blood disorders. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: Temp 97.8 BP 121/70 HR 77 RR 18, O2 sat 100%RA. GEN: NAD. HEENT: MMM, no OP lesions, no cervical, supraclavicular, axillary adenopathy, no thyromegaly. CV: RR, NL S1/S2 no S3S4 MRG. PULM: CTAB. GI: BS+, soft, NTND, no masses or hepatosplenomegaly. LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy. SKIN: No rashes or skin breakdown port site intact w/o erythema. Pt does have darker brown skin lesions over anterior foreleg on left but states chronic. NEURO: A&Ox3. Cranial nerves II-XII are within normal limits. Gross strength and sensation intact. no nystagmus, rapid hand movements and tandem gait intact. DISCHARGE PHYSICAL EXAM: VITAL SIGNS: TC 97.7 PO 110/62 97 18 96%RA GEN: NAD, awake and alert x 3 HEENT: MMM, no OP lesions, no cervical, supraclavicular, axillary adenopathy; no thyromegaly. CV: RR, NL S1/S2 no S3/S4 MRG. PULM: No increased WOB. CTAB. GI: BS+, soft, NT/ND, no masses or hepatosplenomegaly. LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy. SKIN: No rashes or skin breakdown. Has darker brown skin lesions over anterior foreleg on left which are chronic NEURO: A&Ox3. Cranial nerves II-XII are within normal limits. Gross strength and sensation intact. no nystagmus, rapid hand movements and tandem gait intact. Cerebellar testing WNL ACCESS: POC deaccessed at discharge Pertinent Results: ___ 06:03AM BLOOD WBC-2.7*# RBC-2.96* Hgb-9.7* Hct-28.7* MCV-97 MCH-32.8* MCHC-33.8 RDW-16.5* RDWSD-58.8* Plt ___ ___ 09:45AM BLOOD WBC-4.3 RBC-3.09* Hgb-10.1* Hct-30.3* MCV-98 MCH-32.7* MCHC-33.3 RDW-18.3* RDWSD-63.3* Plt ___ ___ 06:03AM BLOOD Neuts-97.0* Lymphs-2.6* Monos-0.0* Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.63# AbsLymp-0.07* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 09:45AM BLOOD Neuts-54.9 Lymphs-18.8* Monos-23.5* Eos-0.2* Baso-1.2* NRBC-1.2* Im ___ AbsNeut-2.34# AbsLymp-0.80* AbsMono-1.00* AbsEos-0.01* AbsBaso-0.05 ___ 06:03AM BLOOD Plt ___ ___ 09:45AM BLOOD Plt Smr-NORMAL Plt ___ ___ 06:03AM BLOOD Glucose-144* UreaN-15 Creat-0.6 Na-138 K-4.1 Cl-100 HCO3-24 AnGap-18 ___ 09:45AM BLOOD UreaN-10 Creat-0.8 Na-140 K-4.0 Cl-103 HCO3-25 AnGap-16 ___ 06:03AM BLOOD ALT-122* AST-71* LD(LDH)-186 AlkPhos-57 TotBili-0.6 ___ 09:45AM BLOOD ALT-83* AST-54* AlkPhos-72 TotBili-0.2 ___ 06:03AM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.1 Mg-2.3 UricAcd-5.0 ___ 09:45AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.___SSESSMENT AND PLAN: Mr. ___ is a ___ male with history AML s/p 7+3 presenting for C3 HiDAC consolidation. C3D6 ___ #AML: Favorable genetics given t(8.21) s/p 7+3 and now presenting for C3 HiDAC consolidation. Bone marrow biopsy, FISH, and cytogenetics on day 21 of 7+3 indicate complete response. Tolerated this cycle w/o acute complications. Cerebellar exam was stable throughout all doses. Initiated on fluconazole and ciprofloxacin at discharge per primary team. Remains on acyclovir. Will continue on prednisolone eye drops until ___. Has appointment on ___ with Dr. ___. #Pancytopenia (anemia, thrombocytopenia, neutropenia): stable now but expect to downtrend. Likely all consequence of chemotherapy and underlying malignancy and inflammatory block. Trend CBC with diff outpatient. #Transaminitis: Elevation in AST and ALT. No hyperbilirubinemia. Likely chemotherapy effect, continue to monitor and trend outpatient, consider RUQ U/S if worsens. #Constipation: on bowel regimen, stooling daily prior to discharge Prophylaxes: # Access: POC # Contact: ___ # Disposition: Discharged on ___. RTC on ___ with Dr. ___ # Code Status: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Fluconazole 400 mg PO Q24H 4. Montelukast 10 mg PO DAILY 5. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Medications: 1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID Continue this eye drop until ___ 2. Acyclovir 400 mg PO Q12H 3. Ciprofloxacin HCl 500 mg PO Q12H 4. Fluconazole 400 mg PO Q24H 5. Montelukast 10 mg PO DAILY 6. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Disposition: Home Discharge Diagnosis: AML Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to receive your third cycle of chemotherapy (high dose cytarabine) for your leukemia. You tolerated this well and will be discharged today. Please restart your oral antibiotics (ciprofloxacin and fluconazole) to help prevent infection. Please refer below for your outpatient appointment. It was a pleasure taking care of you. Sincerely, Your ___ TEAM Followup Instructions: ___

{'fevers': ['Encounter for antineoplastic chemotherapy', 'Antineoplastic chemotherapy induced pancytopenia'], 'chills/rigors/uri sx': ['Encounter for antineoplastic chemotherapy', 'Antineoplastic chemotherapy induced pancytopenia'], 'gas pains': ['Drug induced constipation'], 'shortness of breath': [], 'cough': [], 'chest pain': [], 'abdominal pain': [], 'rashes': [], 'dysuria': [], 'weakness': ['Other myeloid leukemia not having achieved remission'], 'leukocytosis with blasts': ['Other myeloid leukemia not having achieved remission'], 'aplasia': ['Other myeloid leukemia not having achieved remission'], 'persistent t(8;21)': ['Other myeloid leukemia not having achieved remission'], 'RUNX1/RUNX1T1 rearrangement': ['Other myeloid leukemia not having achieved remission'], 'elevation in AST and ALT': ['Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]'], 'anemia': ['Antineoplastic chemotherapy induced pancytopenia'], 'thrombocytopenia': ['Antineoplastic chemotherapy induced pancytopenia'], 'neutropenia': ['Antineoplastic chemotherapy induced pancytopenia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Melena, hematemesis Major Surgical or Invasive Procedure: ___: EGD History of Present Illness: Mr. ___ is a ___ year old gentleman with a h/o hip bursitis and hemorrhoids who presents with two days of black stool and hematemesis. On ___, he began having loose, watery diarrhea that was "jet black" and several episodes of "black" emesis. Yesterday, he had two formed black BMs and no emesis. Last BM was this morning and it remained black. He denies hematochezia. He reports headache, mild lightheadedness, and nausea but denies further emesis. He denies fever/chills, anorexia, abdominal pain, chest pain, and shortness of breath. Of note, ___ has been taking 400-1200mg ibuprofen for the past week for his hip bursitis. ___ went to his PCP ___ ___ and labs were notable for Hct 37.1 (down from 45 in ___. Repeat Hct on ___ was 32, so he was told to go to the ED for evaluation. In the ED, initial VS were T 99.8, HR 99, BP 136/79, RR 18, O2 100% RA. Labs were remarkable for Hct 34.5. He was given pantoprazole 40mg IV and transferred to the medicine floor. Past Medical History: Hip bursitis - bilateral, on ibuprofen Hemorrhoids - diagnosed by ___ in ___ Social History: ___ Family History: Sister with ___ disease. Physical Exam: ADMISSION EXAM: Vitals: T 98.2, BP 109/63, HR 67, RR 18, O2 100% RA General: AAOx3, pleasant, sitting comfortably in bed, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Breathing comfortably without accessory muscle use, clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes or lesions noted Neuro: CN II-XII intact, moving all extremities DISCHARGE EXAM: Vitals: T 98, BP 110/70, HR 72, RR 18, O2 99% RA General: AAOx3, pleasant, sitting comfortably in bed, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Breathing comfortably without accessory muscle use, clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes or lesions noted Neuro: CN II-XII intact, moving all extremities Pertinent Results: ADMISSION LABS: ___ 12:08PM BLOOD WBC-6.6 RBC-3.54* Hgb-11.5* Hct-34.5* MCV-98 MCH-32.5* MCHC-33.3 RDW-11.9 Plt ___ ___ 12:08PM BLOOD Neuts-65.2 ___ Monos-5.0 Eos-6.7* Baso-0.9 ___ 12:08PM BLOOD ___ PTT-29.4 ___ ___ 12:08PM BLOOD Glucose-100 UreaN-21* Creat-0.8 Na-139 K-4.1 Cl-106 HCO3-26 AnGap-11 DISCHARGE LABS: ___ 01:15PM BLOOD Hct-33.5* ___ 05:40AM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-141 K-4.2 Cl-108 HCO3-24 AnGap-13 ___ 05:40AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 EGD ___: Normal mucosa in the esophagus Mild erythema and erosions in the stomach consistent with gastritis (biopsy) Clean-based gastric ulcer seen in the pyloric channel. Re-bleeding rate within 30 days is less than 5%. Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Brief Hospital Course: ___ y/o M with hip bursitis and hemorrhoids who presents with two days of melena and hematemesis in the setting of excessive NSAID use. # Upper GI bleed: EGD was notable for a clean-based ulcer in the pyloric channel, most likely secondary to NSAID use. ___ remained hemodynamically stable throughout hospitalization. His hematocrit dropped slightly on day 2 (34.5 to 31.7), but was stable thereafter. ___ was started on pantoprazole 40mg IV bid, which was transitioned to omeprazole 40mg po on discharge, and all NSAIDs were held. He should continue high dose PPI for 8 weeks, at which point cessation can be considered. H. pylori IgG was negative; gastric biopsies for H. pylori are pending. Follow-up endoscopy is not required in the setting of a shallow pyloric ulcer with a clear cause. ___ has follow-up appointment scheduled with GI on ___. # Hip bursitis: NSAIDs were held in the setting of GI bleed. His bursitis pain was controlled with tylenol and tramadol prn. ___ was instructed to avoid NSAIDs/aspirin as these likely caused his ulcer. Consider steroid injection in the future if needed for pain. TRANSITIONAL ISSUES: [ ] ___ should continue high dose PPI for 8 weeks, at which point cessation can be considered. [ ] Follow-up endoscopy is not required in the setting of a shallow pyloric ulcer with a clear cause. [ ] Please recheck hematocrit at GI appointment on ___. [ ] Pending results: gastric biopsies for H. pylori. [ ] For PCP: ___ must avoid NSAIDs/aspirin. He was started on tramadol for his bursitis pain. Consider steroid injection if needed for bursitis pain. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 400 mg PO Q8H:PRN pain 2. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65 mg oral prn headache 3. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Multivitamins 1 TAB PO DAILY 3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Peptic ulcer disease Secondary diagnosis: Hip bursitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you during your stay at ___. You were admitted for black stools. An endoscopy showed an ulcer in the stomach, which was likely the source of bleeding. There was no evidence of active bleeding and your blood counts remained stable. Please continue to take your medications as prescribed and keep your follow-up appointments. It is very important that you STOP taking ibuprofen, aspirin, and NSAIDs, as this likely caused the ulcer. -Your ___ Team Followup Instructions: ___

{'melena': ['Peptic ulcer disease'], 'hematemesis': ['Peptic ulcer disease'], 'headache': [], 'lightheadedness': [], 'nausea': [], 'black stool': ['Peptic ulcer disease'], 'jet black emesis': ['Peptic ulcer disease'], 'formed black BMs': ['Peptic ulcer disease'], 'loose, watery diarrhea': [], 'denies hematochezia': [], 'denies fever/chills': [], 'anorexia': [], 'abdominal pain': [], 'chest pain': [], 'shortness of breath': [], 'hip bursitis': ['Enthesopathy of hip region'], 'hemorrhoids': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: "s/p cesarean section complicated by PPH requiring transfusion" Major Surgical or Invasive Procedure: cesarean section History of Present Illness: The patient is a ___ gravida 2, para 0, who presented in early labor on ___ after spontaneous rupture of membranes. She progressed to 8 cm at around 10 a.m. on ___ with expectant management, but cervical dilitation did not progress. The patient agreed to augment her labor with Pitocin. However, she did continue to labor without neuraxial anesthesia. The Pitocin was titrated per protocol, but she did not make any cervical change for several hours. At this point an intrauterine pressure catheter was recommended; the patient declined. She did elect for a combined spinal epidural and afterwards the Pitocin was continued to be titrated per protocol. However, after 12 hours, she was still found to be 8 cm, 100%, and -1 station. Therefore, the recommendation was made to proceed with a primary cesarean section due to arrest. The risks and benefits were discussed with the patient and her partner, all questions were answered, all consents were signed. She had a reassuring fetal status prior to surgery. Total EBL was 800cc. She was transferred to the postpartum floor and then experienced several gushed of bright red blood mixed with clots from her vagina. She was brought back to the Labor floor. Social History: ___ Family History: Non-contributory Physical Exam: On examination during PPH, pt had bled out 400cc of blood clots in the bed. U/S showed some lower uterine segment clots. Endometrial stripe appeared adequate. Evacuated 400cc more of blood from lower uterine segment. She received 1000mcg of cytotec and 40 units of pitocin. Pt was transferred back to labor and delivery for continued bleeding. Pertinent Results: ___ 12:15AM BLOOD WBC-15.5* RBC-4.59 Hgb-14.1 Hct-39.4 MCV-86 MCH-30.7 MCHC-35.7* RDW-13.4 Plt ___ ___ 12:41AM BLOOD WBC-20.4* RBC-3.91* Hgb-12.3 Hct-33.8* MCV-87 MCH-31.4 MCHC-36.4* RDW-13.6 Plt ___ ___ 03:27AM BLOOD WBC-22.4* RBC-3.50* Hgb-10.9* Hct-30.3* MCV-87 MCH-31.2 MCHC-36.0* RDW-13.7 Plt ___ ___ 07:31AM BLOOD WBC-15.9* RBC-2.71* Hgb-8.2* Hct-23.2* MCV-86 MCH-30.1 MCHC-35.2* RDW-13.8 Plt ___ ___ 05:06PM BLOOD WBC-15.1* RBC-3.05* Hgb-9.7* Hct-26.9* MCV-88 MCH-31.7 MCHC-36.0* RDW-14.1 Plt ___ ___ 08:35AM BLOOD WBC-16.6* RBC-2.90* Hgb-9.0* Hct-25.6* MCV-88 MCH-30.9 MCHC-35.0 RDW-14.2 Plt ___ Brief Hospital Course: Ms. ___ was transferred back to labor and delivery when her bleeding failed to stop with 40 units of pitocin, 1000mcg of cytotec and manual evacuation. Her bleeding however did resolve after she received 0.2mg of IM Methergine. Her HCT was trended and found to nadir at 23.2. She had tachycardia and a low urine output. The decision was the made to transfuse her for symptomatic anemia. She received 2 units of red cells and her hematocrit responded appropriately to 25.6, her urine output and heart rate improved significantly. The rest of her postpartum course was uncomplicated. Medications on Admission: - Prenatal vitamins Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp:*60 Capsule(s)* Refills:*1* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for Pain. Disp:*45 Tablet(s)* Refills:*0* 3. ibuprofen 600 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for Pain. Disp:*60 Tablet(s)* Refills:*1* 4. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO twice a day. Disp:*60 Capsule, Extended Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: s/p cesarean section s/p blood transfusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: routine postpartum Followup Instructions: ___

{'bleeding': ['Acute posthemorrhagic anemia', 'Other immediate postpartum hemorrhage'], 'cesarean section': ['Post term pregnancy', 'Secondary uterine inertia'], 'labor': ['Post term pregnancy', 'Secondary uterine inertia'], 'rupture of membranes': ['Post term pregnancy', 'Secondary uterine inertia'], 'PPH': ['Acute posthemorrhagic anemia', 'Other immediate postpartum hemorrhage']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year-old Gravida 2 Para 1 at 28 weeks 6 days gestational age who presented with acute onset left lower quadrant pain while laying still in bed. She got up and urinated and it gradually worsened to ___. She had never experienced this kind of pain before. It was twisting and very sharp in nature and constant. Worse with legs extended vs flexed. A couple of hours after the pain started, she started to feel uterine tightening. Denied fever, chills, nausea, vomiting, diarrhea, dysuria, vaginal bleeding, leaking of fluid, hematuria, abnormal vaginal discharge. + Fetal movement. Last intercourse the morning prior. Past Medical History: PRENATAL COURSE - Estimated Due Date: ___ - labs: A+/Ab- - screening: GLT wnl, FFS wnl . OBSTETRIC HISTORY Gravida 2 Para 1 (___) @ ___: Vacuum-assisted vaginal delivery @ 34 ___ wks, spontaneous preterm labor, had been hospitalized during pregnancy @ 30 weeks with vaginal bleeding and received betamethasone. 5#4, male GYNECOLOGIC HISTORY: remote history of chlamydia . PAST MED/SURG HISTORY: benign Social History: ___ Family History: non-contributory Physical Exam: (on admission) VS: T 98.3, RR 18, BP 97/66, HR 130->115 GENERAL: crying, lying on her side in fetal position, very uncomfortable, able to speak in full sentences CARDIO: reg rhythm, tachy PULM: CTAB BACK: no CVA tenderness ABDOMEN: soft, gravid, most TTP LLQ just superior to inguinal area (no palpable underlying masses) though tender more superiorly as well, no R/G, no uterine TTP EXTREMITIES: NT b/l SSE: def SVE/BME: L/C/P TOCO: no clear ctx FHT: 150, mod var, AGA, no decels BPP: ___, cephalic, DVP 5.3, EFW 1328g 2#15oz Pertinent Results: ___ WBC-9.0 RBC-3.95 Hgb-12.8 Hct-36.4 MCV-92 Plt-404 ___ Neuts-72.8 ___ Monos-6.3 Eos-1.4 Baso-0.4 ___ WBC-9.5 RBC-4.04 Hgb-12.3 Hct-36.4 MCV-90 Plt-417 ___ Neuts-70.0 ___ Monos-5.6 Eos-1.1 Baso-0.4 . ___ ___ PTT-31.1 ___ ___ . ___ Glucose-73 BUN-4 Creat-0.5 Na-134 K-4.2 Cl-102 HCO3-22 ___ Calcium-8.7 Phos-3.7 Mg-2.0 . ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM . Pelvic Ultrasound: Limited views demonstrate a live single intrauterine gestation with normal cardiac activity. The cervix remains long and closed. Please note that this limited exam does not substitute a full fetal survey. . Attention was then directed to bilateral superiorly displaced ovaries, necessitating use of linear probe. The left ovary measures 2.7 x 2 x 1.5 cm, with normal arterial and venous flow. The right ovary measures 2.2 x 1.4 x 1 cm, with normal venous flow. Arterial flow on the right is not demonstrated. The ovaries appear normal in size and morphology. There is no focal tenderness over the superiorly displaced ovaries. . Targeted ultrasound was performed to the site of symptomology in the lower abdomen, away from the ovaries, demonstrating no focal pathology. . IMPRESSION: 1. Normal size and morphology of bilateral ovaries. Normal vascularity of the left ovary. Limited arterial assessment of the right ovary. 2. Limited exam of single intrauterine gestation with normal cardiac activity and closed cervix. For full assessment of the fetus, continued routine fetal followup is recommended. 3. Tenderness in the lower abdomen is away from superiorly displaced ovaries. No discrete pathology is demonstrated at the site of symptom. Brief Hospital Course: Ms. ___ received 0.5mg of IV Dilaudid in triage and her pain greatly improved. As above, her pelvic ultrasound was negative for any pathology and her laboratory studies were unrevealing. She did not require any additional analgesics and was admitted to the antepartum floor for close observation and abdominal exams. While there, she had an episode of emesis after eating and began having chills and feeling generally unwell with no abdominal pain, but abdominal discomfort. She remained afebrile with no elevation of white count and had no other focal signs or symptoms. It was thought that she had a mild viral gastritis. Her left lower quadrant pain never returned. She was given zantac, oral zofran and IV hydration and by the afternoon on hospital day #2 was feeling better. . Fetal testing was reassuring by ultrasound and non-stress testing. She had no signs of labor and her cervix remained closed. . She was discharged home on hospital day #2 symptomatically improved. Medications on Admission: prenatal vitamin folic acid Discharge Medications: prenatal vitamin folic acid Discharge Disposition: Home Discharge Diagnosis: pregnancy at 29+0 weeks gestation suspected viral gastroenteritis Discharge Condition: stable Discharge Instructions: stay well hydrated Followup Instructions: ___

{'abdominal pain': ['Abdominal pain', 'left lower quadrant'], 'twisting and very sharp in nature and constant': ['Abdominal pain', 'left lower quadrant'], 'worsen with legs extended vs flexed': ['Abdominal pain', 'left lower quadrant'], 'uterine tightening': ['Abdominal pain', 'left lower quadrant'], 'fever, chills, nausea, vomiting, diarrhea, dysuria, vaginal bleeding, leaking of fluid, hematuria, abnormal vaginal discharge': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Topamax / Reglan Attending: ___. Chief Complaint: ============================ HMED Admission H&P ============================ CC: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of debilitating pudendal neuralgia who was admitted in ___ and ___ with worsening back pain, who presented to the ED today with subacutely worsening back pain. She had an intrathecal ziconotide pump for placed in ___ in ___ and had presented to ___ in ___ with worsened back pain at the site of the pump as well as urinary retention. Cord compression was ruled out at that time and her ziconotide was stopped (this was suspected as the cause of her urinary retention), and she was also started on prednisone for her pain which was attributed to inflammation around the site of her pump catheter where it passes by the L2 spinous process. She has also been managed on multiple chronic narcotics and other agents for her pain. During the prior admission she was seen by neurology, neurosurgery, and pain service. She reports that initially the steroids were extremely helpful at controlling her pain but that she has been completing a slow taper. The plan had been tapering to 15 mg in ___ and 10 mg in ___, but in recent weeks she has had worsening control of her pain, similar to its prior location and quality. The pain is most severe over the lumbar incision site and is severe to the point of limiting basic daily function - has been using commode d/t difficulty ambulating ___ pain. She is followed closely by her PCP, who increased the steroids back to 40 mg daily and attempted a rapid taper with 4 days of 40mg, 4 days of 30, and 4 days of 20. She noted some slight improvement with the increase to 40 mg but subsequently returned to severe pain when this was reduced to 30 and then 20. She also notes that she no longer sees the doctor in ___ who placed her pump. She reports that her PCP obtained an MRI in recent days, although she is unsure what the results showed. Her PCP recommended presenting to the ED given her worsening pain control. She denies any urinary retention, changes in bowel patterns, weakness, or numbness. Review of systems: Const: no fevers, chills HEENT: + HA x 2 weeks, bilateral, constant non-pulsating "not migraine" CV: + intermittent palpitations, no CP Pulm: + occasional dyspnea associated with palpitations, otherwise no dyspnea or cough GI: +RUQ pain for past week intermittently, no n/v, no changes in PO intake, no changes in BMs GU: no retention or urinary changes MSK: no new myalgias/arthralgias except as per HPI Neuro: no new focal weakness or numbness Derm: no new rashes Hem: no new bleeding/bruising Endo: no hot/cold intolerance Psych: no recent mood changes Past Medical History: HYPOTHYROIDISM ARRHYTHMIA PUDENDAL IMPINGEMENT SYNDROME s/p INTRATHECAL PUMP PLACEMENT SOMATIZATION DISORDER Social History: ___ Family History: No cardiac or cancer history in either parent. Mother and sister with depression. Physical Exam: Admission Physical Exam: Vital signs: 98 120/72 68 18 99% RA gen: pt in NAD, lying in bed HEENT: nc/at, sclera anicteric, conjunctiva noninjected, PER, EOMI, MMMs CV: RRR no m/r/g Pulm: CTAB No c/r/w Abd/GI: S NT ND BS+, no masses/HSM palpated (except pump) Back: tenderness over lumbar incision site Extr: wwp, distal pulses intact, no edema GU: no Foley Neuro: alert and interactive, strength, sensation, CNs grossly intact, reflexes brisk throughout all 4 extremities Skin: no rashes on limited skin exam Psych/MS: normal range of affect Discharge PE: VS: 98.0 132 / 84 86 18 100 RA Gen: NAD, occasionally tearful, resting on her side HEENT: EOMI, PERRLA, MMM CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, NT, ND +BS Ext: no c/c/e Back: pump site c/d/I, no erythema or swelling, diffuse lower back tenderness to even light palpation of skin Neuro: CN II-XII intact, ___ strength throughout Skin: warm, dry no rashes Pertinent Results: CBC: 6.0>12.6<227 BMP: ___ UA wnl MRI lumbar spine w/o contrast ___: Impression There has been interval placement of hardware since the prior exam as further discussed above. This results in extensive artifact including regions of signal loss and distortion of the anatomy. Allowing for this limitation, there is persistent changes of mild lumbar spondylosis but no definitive limiting central canal or foraminal stenosis at any level in the lumbar spine. Extrahepatic biliary ductal dilation. MRI thoracic spine w/o contrast ___: Impression Mild chronic T6 and T9 compression fracture deformities. No limiting central canal or foraminal stenosis at any level in the thoracic spine. Extrahepatic biliary duct dilation to 7.5 mm. RUQ ___: IMPRESSION: Unremarkable abdominal ultrasound. No evidence of biliary tree dilation. Normal CBD. Brief Hospital Course: ___ year old woman with pudendal neuralgia status post intrathecal pump catheter placement in ___ treated with ziconotide infusion complicated by urinary retention (pump currently not in use) presenting with worsening of chronic back pain. #Pudendal neuralgia with severe subacute on chronic pain: No significant change in character of pain, no fevers, chills, weakness, numbness, incontinence, retention or other concerning findings. MRI T/L spine on ___ showing no concerning findings, no evidence of infection or significant spinal stenosis. Chronic pain service was consulted. She reports she had significant benefit from her intrathecal pump prior to developing side effect of urinary retention and having it stopped, she is interested in trialing another medication through the pump. On discharge in ___ she was counselled to find a physician to manage the pump but has not done so, recommended that she work on seeing an outpatient doctor who can manage her Prometra intrathecal pump, given name and office information of a local physician who is certified to manage the Prometra pump. Concern that there is significant anxiety and/or possible somatization disorder contributing to symptoms. - Started Lidoderm patch, recommend following up with Dr. ___ to manage her intrathecal pump. - Home ___ - continuing home medication regimen, which is as follows: - methadone 5 tid prn - percocet 10 tid prn - pregabalin 150 AM 300 HS - Exalgo 16 mg daily (in hospital placed on hydromorphone 4 mg PO q6H as Exalgo non-formulary) - tizanidine 2 tid prn - ativan 1 q4h prn - duloxetine 120 - elmiron (will use home med) and miralax for constipation - topical lidocaine PRN - increasing prednisone to 40 mg daily with taper of 10 mg daily. - Recommend that she establish care with a psychiatrist and therapist to help manage her anxiety and psychiatric disorders which are likely contributing significantly to her symptoms. #Abdominal pain #Biliary ductal dilation on MRI She denies any current abdominal pain, n/v, pruritus, jaundice. LFTs normal and RUQ unremarkable without ductal dilation. #History of supraventricular arrhythmia -cont verapimil 120 #HA: History of migraine headaches. - Continue home PRN Imitrex #Other home meds: - cont albuterol PRN for wheezing - cont abilify 5 for mood - cont buspar 15 TID for anxiety - cont synthroid ___ for hypothyroidis - cont PRN zofran for nausea - cont PRN trazodone for insomnia - cont home ranitidine and substitute omeprazole for protonix for GERD # FEN: regular diet # Prophylaxis: Subcutaneous heparin # Access: peripherals # Communication: Patient # Code: Full (discussed with patient) # ___: home with home ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH BID 2. ARIPiprazole 5 mg PO DAILY 3. BusPIRone 15 mg PO TID 4. DULoxetine 120 mg PO DAILY 5. Levothyroxine Sodium 125 mcg PO DAILY 6. LORazepam 1 mg PO Q4H:PRN anxiety 7. Methadone 5 mg PO TID 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Polyethylene Glycol 17 g PO DAILY 10. Pregabalin ___ mg PO DAILY 11. Ranitidine 300 mg PO QHS 12. Tizanidine 2 mg PO TID 13. TraZODone 100 mg PO QHS:PRN insomnia 14. Verapamil SR 120 mg PO Q24H 15. Elmiron (pentosan polysulfate sodium) 100 mg oral TID 16. Exalgo ER (HYDROmorphone) 16 mg oral DAILY 17. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR 18. NexIUM (esomeprazole magnesium) 40 mg oral DAILY 19. Sumatriptan Succinate 6 mg SC ONCE:PRN HA 20. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain 21. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO TID 22. Linzess (linaclotide) 290 mcg oral DAILY 23. PredniSONE 20 mg PO DAILY Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % Apply one patch to lower back Daily Disp #*30 Patch Refills:*0 2. PredniSONE 40 mg PO DAILY 40 mg daily x 1 week, 30 mg daily x 1 week, 20 mg PO daily x 1 week then 10 mg PO daily x 1 week. Tapered dose - DOWN RX *prednisone 10 mg As directed tablet(s) by mouth Daily Disp #*70 Tablet Refills:*0 3. Albuterol 0.083% Neb Soln 1 NEB IH BID 4. ARIPiprazole 5 mg PO DAILY 5. BusPIRone 15 mg PO TID 6. DULoxetine 120 mg PO DAILY 7. Elmiron (pentosan polysulfate sodium) 100 mg oral TID 8. Exalgo ER (HYDROmorphone) 16 mg oral DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR 11. Linzess (linaclotide) 290 mcg oral DAILY 12. LORazepam 1 mg PO Q4H:PRN anxiety 13. Methadone 5 mg PO TID 14. NexIUM (esomeprazole magnesium) 40 mg oral DAILY 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO TID 17. Polyethylene Glycol 17 g PO DAILY 18. Pregabalin ___ mg PO DAILY 19. Ranitidine 300 mg PO QHS 20. Sumatriptan Succinate 6 mg SC ONCE:PRN HA 21. Tizanidine 2 mg PO TID 22. TraZODone 100 mg PO QHS:PRN insomnia 23. Verapamil SR 120 mg PO Q24H 24. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute on chronic back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with worsening of your chronic back pain. You had a recent MRI of your spine which did not show any significant abnormalities. You were seen by the chronic pain service, you were started on a lidocaine patch. We recommend that you follow-up with a pain physician who specializes in your Prometra pump. Followup Instructions: ___

{'Back pain': ['Acute on chronic back pain'], 'Urinary retention': [], 'Const': [], 'HA': ['Migraine headaches'], 'Intermittent palpitations': ['Supraventricular arrhythmia'], 'RUQ pain': ['Other specified diseases of gallbladder'], 'Biliary ductal dilation': ['Other specified diseases of gallbladder'], 'Anxiety': ['Anxiety disorder'], 'Somatization disorder': ['Somatization disorder'], 'Pudendal neuralgia': ['Other specified mononeuropathies'], 'Hypothyroidism': ['Hypothyroidism'], 'Gastro-esophageal reflux disease': ['Gastro-esophageal reflux disease without esophagitis'], 'Presence of other specified functional implants': ['Presence of other specified functional implants']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: Iodine; Iodine Containing / Latex Attending: ___. Chief Complaint: Acquired absence of the right breast, status post nipple sparing mastectomy for breast cancer Major Surgical or Invasive Procedure: Immediate reconstruction of nipple-sparing mastectomy with deep inferior epigastric perforator flap from the contralateral side, harvest of pedicle of the flap, and anastomosis of the thoracodorsal artery and vein (___) History of Present Illness: Patient is a ___ female with a history of having a mammogram finding of newly diagnosed ductal carcinoma on the right breast with a focus of suspicious microinvasion. She has a history of microinvasive carcinoma of the right breast diagnosed first in ___ of which she was found to have been diagnosed with invasive ductal carcinoma with ER negativity and HER-2/neu positivity. She has also been treated with breast conservation surgery as well as postoperative radiotherapy. She is now here for planned mastectomy for breast cancer to be followed by desired immediate breast reconstruction. Past Medical History: PMH: Polio, breast disease, radiation therapy, left knee Bakers cyst PSH: Lumpectomy ___, cholecystectomy ___, tubal ligation ___ Social History: Smokes 1.5 ppd for 30+ years, trying to quit; denies alcohol yes; last used IV drugs ___ years ago Physical Exam: VS: Afebrile, VSS Gen: NAD CV: RRR, no murmurs Resp: CTAB, no crackles or wheezes Breasts: R breast flap viable and intact, incision c/d/i without hematoma, Dopplerable pulse. JP with serosanguinous fluid. Abd: Soft, mildly TTP, +BS. Incision c/d/i without hematoma. Ext: Warm, distal pulses palpable Pertinent Results: ___ 04:14AM BLOOD WBC-12.0*# RBC-3.55* Hgb-11.1* Hct-32.6* MCV-92 MCH-31.2 MCHC-34.0 RDW-13.4 Plt ___ Brief Hospital Course: The patient was admitted to the plastic surgery service on ___ and had an immediate reconstruction of nipple-sparing mastectomy with deep inferior epigastric perforator flap from the contralateral side, harvest of pedicle of the flap, and anastomosis of the thoracodorsal artery and vein. She tolerated the procedure well. Neuro: The patient received morphine PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#2. Intake and output were closely monitored. ID: Post-operatively, the patient was started on IV cefazolin. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: Depakote, fluoxetine, quetiapine, trazodone Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acquired absence of the right breast, status post nipple sparing mastectomy for breast cancer. Discharge Condition: Good Discharge Instructions: Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * ___ nursing services will help you with JP drain care. Empty JP drains daily and record daily output. Followup Instructions: ___

{'Acquired absence of the right breast': ['Malignant neoplasm of upper-outer quadrant of female breast'], 'Difficulty in walking': ['Difficulty in walking'], 'Other acute postoperative pain': ['Other acute postoperative pain'], 'Other specified disorders of skin': ['Other specified disorders of skin'], 'Constipation': ['Constipation'], 'Late effects of acute poliomyelitis': ['Late effects of acute poliomyelitis'], 'Personal history of irradiation': ['Personal history of irradiation'], 'presenting hazards to health': ['presenting hazards to health'], 'Personal history of malignant neoplasm of breast': ['Personal history of malignant neoplasm of breast'], 'Tobacco use disorder': ['Tobacco use disorder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Spine wound Major Surgical or Invasive Procedure: 1. Debridement of skin down to bone of thoracolumbar wound (25 x 10cm). 2. Paraspinous flap x2 coverage of the previous spinal fusion hardware. 3. Complex closure of back incision (25 cm). 4. Removal of spinous processes of T9, T10, and L2, L3. History of Present Illness: ___ s/p T11-L2 fusion and laminectomy and T12 corpectomy for T12 lumbar stenosis ___ multiple myeloma mets, performed by Dr. ___ on ___. The patient will undergo radiation treatment in the future, but no prior XRT. Patient was discharged to rehab following discharge on ___. She returned on ___ to the ED with lumbar wound dehiscence in addition to increasing confusion beyond baseline. She was discharged with wet to dry dressing changes to area and comes in today for closure of her lumber wound. Past Medical History: SAH, s/p b/l Aneurysm clipping. With frontal craniotomy. Residual aphasia. HTN Hyperlipidemia Right knee replacement VP shunt Multiple myeloma T12 extracavitary corpectomy for removal of tumor ___ Social History: ___ Family History: Multiple family members, particularly cousins with brain aneurysms requiring clipping, some of who had strokes. No history of cancer in the family. Physical Exam: AM vital signs: T97.9, P71, BP116/60, RR18, 100RA Gen: Sitting in bed, eating, NAD. Alert, expressive aphasia per baseline Lungs: Breathing nonlabored CV: RRR ABD: Soft, NT/ND Extrem: WWP x4 Back: Dressing changed on midline of back this AM. Incision intact with mild weeping, no gross bleeding or exudate. JP drains in place (1 midline, 1 Right Lateral, both with serrosang outtput). Brief Hospital Course: BRIEF HOSPITAL COURSE - ___ was admitted on ___ for spine wound washout and closure. The patient tolerated the procedure well without complications. Neuro: Post-operatively, the patient received PO Oxycodone with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was quickly advanced when appropriate, which was tolerated well. She continued her normal bowel regimen of Polyethylene Glycol 17g per day. Foley remained in place per usual. ID: As the wound did not appear infected, she recieved no post op antibiotics. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay as per her usual. At the time of discharge on POD#2, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, had her usual menal status, and pain was well controlled. Medications on Admission: 1. Allopurinol ___ mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Atorvastatin 20 mg PO DAILY 4. Calcium Carbonate 1250 mg PO DAILY 5. Dexamethasone 4 mg PO DAILY 6. Cardizem CD *NF* 240 mg Oral Daily 7. Dipyridamole-Aspirin 1 CAP PO BID 8. Famotidine 20 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Heparin 5000 UNIT SC TID 11. Losartan Potassium 50 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 1 TAB PO BID 14. TraZODone 25 mg PO HS 15. Acetaminophen 650 mg PO Q6H:PRN fever/pain 16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain Discharge Medications: No change to discharge medications 1. Acetaminophen 650 mg PO Q6H:PRN fever/pain 2. Allopurinol ___ mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Calcium Carbonate 1250 mg PO DAILY 6. Cardizem CD *NF* 240 mg ORAL DAILY 7. Dexamethasone 4 mg PO DAILY 8. Dipyridamole-Aspirin 1 CAP PO BID 9. Famotidine 20 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Heparin 5000 UNIT SC TID 12. Losartan Potassium 50 mg PO DAILY 13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain 14. Polyethylene Glycol 17 g PO DAILY 15. Senna 1 TAB PO BID 16. TraZODone 25 mg PO HS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Spine wound, takent to the OR for washout and closure Discharge Condition: Overall Condition - Good Mental status - Per usual, alert with expressive aphasia Ambulation - Non ambulatory per usual Discharge Instructions: POST OPERATIVE GENERAL DISCHARGE INSTRUCTIONS: Personal Care: 1. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 2. Strip drain tubing, empty bulb(s), and record output(s) ___ times per day. 3. A written record of the daily output from each drain should be brought to every follow-up appointment. Your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. Activity: 1. You may resume your regular diet. 2. Activity as tolerated. OK to roll patient, but be careful not to tug on her incision (ie, roll from shoulder and hip, DO NOT pull from her back or side). Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by tylenol. 4. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different stool softener if you wish. Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness,swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: ___

{'Spine wound': ['Disruption of external operation (surgical) wound'], 'Expressive aphasia': ['Aphasia'], 'Multiple myeloma': ['Multiple myeloma', 'without mention of having achieved remission'], 'Hypertension': ['Unspecified essential hypertension'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Postprocedural status': ['Other postprocedural status'], 'Arthrodesis status': ['Arthrodesis status'], 'Abnormal patient reaction': ['Surgical operation with implant of artificial internal device causing abnormal patient reaction', 'or later complication', 'without mention of misadventure at time of operation'], 'Knee joint replacement': ['Knee joint replacement']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: SI Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ y/o F with PMHx of complex PTSD, borderline PD, endorses anxiety and depression, with multiple psych admissions and prior SA, who initially presented to the ED on ___ after making statements to friends concerning for suicidal ideation, now found to have flu. According to ED notes on initial presentation: "She was looking for razors, stating she wanted to cut herself, and she did want to cut herself but did not want to kill herself. She denies SI/HI/AVH. She reports that in therapy this week she started remembering previous trauma that she had not previously remembered. Today this all came "flooding" back, and it set off this episode today. She states she had one drink today, denies any more alcohol use and denies drug use." During her initial ED stay, she was diagnosed with flu and was started on Tamiflu. She was also placed on Macrobid for possible UTI. She was ultimately placed in an inpatient psych unit. However, when she arrived there, she was sent back to the ED given + flu. ED Course: Initial VS: 97.9 79 96/69 12 99% RA No new labs during most recent ED stay. Labs during initial ED stay notable for negative serum and urine tox screens. UA with 11 WBCs and few bacteria. Flu B positive. Meds given: ___ 02:08 PO Acetaminophen 1000 mg ___ 02:08 PO Ibuprofen 600 mg ___ 08:12 PO/NG OSELTAMivir 75 mg ___ 08:12 PO Nitrofurantoin Monohyd (MacroBID) 100 mg ___ 16:14 PO Acetaminophen 1000 mg ___ 16:14 PO Ibuprofen 600 mg ___ 19:52 PO/NG OSELTAMivir 75 mg ___ 19:52 PO Nitrofurantoin Monohyd (MacroBID) 100 mg ___ 07:41 PO/NG OSELTAMivir 75 mg ___ 07:41 PO Nitrofurantoin Monohyd (MacroBID) 100 mg ___ 10:45 PO Acetaminophen 1000 mg ___ 20:06 PO/NG OSELTAMivir 75 mg ___ 20:06 PO Nitrofurantoin Monohyd (MacroBID) 100 mg VS prior to transfer: 97.7 78 99/60 16 98% RA On arrival to the floor, the patient endorses the above story. Regarding her psychiatric symptoms, she denies having any true SI. She states that the told her friends that she wanted to cut herself but not kill herself. She feels that some statements she had made in the past were mistaken as statements made on the day of presentation. She reports that her mood is "good." She denies any current SI, anxiety. Otherwise, she endorses fevers, myalgias, cough (productive of clear sputum), headache that began the day prior to her ED presentation. Her roommate was recently sick with the flu. The patient reports that her symptoms have largely resolved at this time, with only mild lingering aches and headache. Her last fever appears to have been on the evening of ___ in the ED (101.6). Regarding potential UTI, the patient reports that the only urinary symptom she has had is dark urine. She denies any dysuria or urinary frequency. Past Medical History: Pt denies PHMx to me. Per psych note: -complex PTSD, borderline PD; patient also endorses anxiety and depression -Hospitalizations: Multiple, at least 4- ___ in ___ in ___ after attempting to hang herself. ___ @ ___ after ___ by suffocation. ___ ___. ___ ___. -Psychiatrist: denies having one, reports she is waiting for one at ___, previously seeing Dr. ___ @ ___ -Therapist: ___ ___ and ECT trials: sertraline, fluoxetine, clonidine, prazosin -Self-injury/Suicide attempts: history of cutting and burning since age ___. Multiple SAs by hanging, overdosing, drowning -Harm to others: denies -Trauma: history of emotional and physical abuse from father while growing up. Social History: ___ Family History: Significant for cancer and psychiatric illness. Pt unaware of further details. Physical Exam: ADMISSION EXAM: VS - ___ 0230 Temp: 99.5 PO BP: 109/67 HR: 83 RR: 16 O2 sat: 97% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ GEN - Alert, NAD HEENT - NC/AT, MMM NECK - Supple CV - RRR, no m/r/g RESP - Breathing appears comfortable, no w/r/r appreciated ABD - S/NT/ND, BS present EXT - No ___ edema or calf tenderness SKIN - No apparent rashes NEURO - MAE PSYCH - Flat affect DISCHARGE EXAM: Afebrile in the AM, with SBP 94. Lungs clear with normal symmetric chest rise. Pertinent Results: LABORATORY RESULTS: ___ 02:30AM BLOOD WBC-6.0 RBC-4.15 Hgb-12.1 Hct-36.5 MCV-88 MCH-29.2 MCHC-33.2 RDW-13.4 RDWSD-43.2 Plt ___ ___ 02:30AM BLOOD Neuts-64.8 Lymphs-12.3* Monos-20.2* Eos-1.5 Baso-0.5 Im ___ AbsNeut-3.86 AbsLymp-0.73* AbsMono-1.20* AbsEos-0.09 AbsBaso-0.03 ___ 02:30AM BLOOD Plt ___ ___ 02:30AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-138 K-3.8 Cl-103 HCO3-24 AnGap-11 ___ 02:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG Brief Hospital Course: On admission, the patient's influenza symptoms had resolved. She will need to finish one additional day of oseltamavir, and otherwise has no contraindication to returning to her dorm. She was followed up by our psychiatry team. I am quoting their recommendations here: - PTSD - Borderline personality d/o - Chronic: eczema Complex case of young ___ freshman with trauma hx, recently admitted to ___, brought to ED after making further statements about killing herself to her roommate, c/w dissociative state based on information in OMR and from therapist. Patient has benefited from the contained environment in the ED and has not been suicidal or had any dissociative episodes since ___. Risk assessment complex; certainly remains at chronic elevated risk given both family hx of suicide attempts and personal hx of suicide attempts, but insight/judgment have been improving steadily, and she is engaged in treatment planning. At this point appears at low acute risk of harm to self; hopeful, forward looking, caring for self here throughout stay, motivated for school and keeping up grades, has not been cutting, agreeable to more intensive supports. Cannot r/o some sort of ongoing trauma in community, although patient adamantly denies, given continued dissociative events with no obvious trigger (usually triggers have been impending contact with family); outpatient therapist continuing to work with patient on this. Unfortunately, inpatient psychiatric admission continues to present elevated risk of regression in that more intensive setting. In terms of treatment, given patient not willing to consider additional medications at this time, I don't think an inpatient unit would be useful; she would benefit more from additional outpatient supports eg The Trauma Center in ___ (therapist will refer for DBT). She is also wlling to consider an IOP. Both would be most likely way to decrease her long term risk. RECOMMEND: - No psychiatric contraindication to d/c - ED social worker working on referral to IOP (she will call patient with appointment if obtained after pt is discharged) - Re:entry meeting today at 11 am ___, ___ - Pt should f/u with her therapist ___ - Patient should return to the ED if any thoughts of self-harm or any further dissociative episodes - Therapist making referral for psychiatry through her clinic and will also likely refer to additional trauma based resources - ___ requesting call from medicine if patient is going to be discharged to discuss flu precautions needed for dorm if any ___ After discussion with ___ health, she was discharged back to ___ health. > 30 minutes spent on complex discharge. Discharge Medications: 1. OSELTAMivir 75 mg PO BID Duration: 5 Days RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*2 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Influenza Suicidal ideation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the medical ward with influenza. You received four days of Tamiflu; you will need to finish one final day. You were closely followed by our psychiatry team, and you will transfer back to BU to continue your care there. Followup Instructions: ___

{'fevers': ['Influenza due to unidentified influenza virus with other respiratory manifestations'], 'myalgias': ['Influenza due to unidentified influenza virus with other respiratory manifestations'], 'cough': ['Influenza due to unidentified influenza virus with other respiratory manifestations'], 'headache': ['Influenza due to unidentified influenza virus with other respiratory manifestations'], 'anxiety': ['Suicidal ideations', 'Post-traumatic stress disorder', 'Borderline personality disorder'], 'depression': ['Suicidal ideations', 'Post-traumatic stress disorder', 'Borderline personality disorder'], 'self-injury': ['Suicidal ideations', 'Post-traumatic stress disorder', 'Borderline personality disorder'], 'suicidal ideation': ['Suicidal ideations', 'Post-traumatic stress disorder', 'Borderline personality disorder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: gluten Attending: ___. Chief Complaint: unstable thoracic spine fractures with left lower extremity motor deficits Major Surgical or Invasive Procedure: 1. T3 to T11. 2. Multiple thoracic laminotomies. 3. Laminectomy T6 and 7. 4. Instrumentation T3 to 11. 5. Autograft. History of Present Illness: ___ s/p recent MVC w/ multiple T-spine fxs & LLE motor deficits. CT in ___ revealed fxs of T3 SP, T4 R TP, T5 SP, T6 SP, and T7 vertebral body. She recently had repeat imaging showing interval displacement of her T-spine fxs. She was seen by. Dr ___ who is planning for posterior T3-12 fusion for stability. She endorses persistent LLE motor deficits. Denies neck pain or UE sxs. Denies bowel or bladder sxs. Past Medical History: -hx of thyroid nodules -hx of mild persistsant asthma, previously on proair and fluticasone, but no script since ___ -hx of migraines Social History: ___ Family History: NC Physical Exam: On examination the patient is well developed, well nourished, A&O x3 in NAD. AVSS. Range of motion of the thoracolumbar spine is somewhat limited on flexion, extension and lateral bending due to pain. Ambulating with the assistance of a walker and ___, with TLSO brace and soft cervical collar for support. Gross motor examination reveals ___ strength throughout the bilateral upper extremities and right lower extremity. Persistent weakness in left lower extremity unchanged as compared to pre operative examination. Sensation is grossly intact throughout all affected dermatomes. The thoracic incision is clean, dry and intact without erythema, edema or drainage. Foley catheter in place to gravity. Pertinent Results: ___ 09:15AM BLOOD WBC-8.9 RBC-3.40* Hgb-9.2* Hct-29.7* MCV-87 MCH-27.1 MCHC-31.0* RDW-13.3 RDWSD-42.5 Plt ___ ___ 09:15AM BLOOD Glucose-125* UreaN-6 Creat-0.5 Na-140 K-3.7 Cl-103 HCO3-29 AnGap-12 ___ 09:15AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.___riefly, ___ was admitted to the ___ Spine Surgery Service and taken to the Operating Room on ___ for the above procedure. Refer to the dictated operative note for further details. The surgery was performed without complication, the patient tolerated the procedure well, and was transferred to the PACU in a stable condition. TEDs/pneumoboots/SC heparin were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initially, postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley catheter remained in place to gravity. Post-operative labs were grossly stable. A hemovac drain that was placed at the time of surgery was removed on POD#2. Physical therapy was consulted for mobilization OOB. A TLSO brace was fitted for the patient. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Diazepam 5 mg PO Q6H:PRN pain/anxiety RX *diazepam [Valium] 5 mg 1 tab by mouth every six (6) hours Disp #*90 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Gabapentin 300 mg PO TID RX *gabapentin [Neurontin] 300 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 5. Heparin 5000 UNIT SC BID 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*90 Tablet Refills:*0 7. Morphine SR (MS ___ 30 mg PO Q8H RX *morphine [MS ___ 30 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 8. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: T6 and 7 fractures, kyphosis. 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: ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks. ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. You will be more comfortable if you do not sit or stand more than ~45 minutes without changing positions. BRACE: You have been given a TLSO brace and soft cervical collar. Both braces should be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. WOUND: Remove the external dressing in 2 days. If your incision is draining, cover it with a new dry sterile dressing. If it is dry then you may leave the incision open to air. Once the incision is completely dry, (usually ___ days after the operation) you may shower. Do not soak the incision in a bath or pool until fully healed. If the incision starts draining at any time after surgery, cover it with a sterile dressing. Please call the office. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. MEDICATIONS: You should resume taking your normal home medications. Refrain from NSAIDs immediately post operatively. You have also been given Additional Medications to control your post-operative pain. Please allow our office 72 hours for refill of narcotic prescriptions. Please plan ahead. You can either have them mailed to your home or pick them up at ___ Spine Specialists, ___. We are not able to call or fax narcotic prescriptions to your pharmacy. In addition, per practice policy, we only prescribe pain medications for 90 days from the date of surgery. Followup Instructions: ___

{'unstable thoracic spine fractures': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra'], 'left lower extremity motor deficits': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra'], 'persistent LLE motor deficits': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra'], 'hx of thyroid nodules': ['Major depressive disorder'], 'hx of mild persistsant asthma': ['Unspecified asthma'], 'hx of migraines': ['Migraine'], 'Range of motion of the thoracolumbar spine is somewhat limited on flexion, extension and lateral bending due to pain': ['Unspecified kyphosis'], 'Ambulating with the assistance of a walker': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra'], 'Gross motor examination reveals ___ strength throughout the bilateral upper extremities and right lower extremity': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra'], 'Persistent weakness in left lower extremity unchanged as compared to pre operative examination': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra'], 'Sensation is grossly intact throughout all affected dermatomes': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra'], 'The thoracic incision is clean, dry and intact without erythema, edema or drainage': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra'], 'Foley catheter in place to gravity': ['Unspecified fracture of T5-T6 vertebra', 'Unspecified fracture of T7-T8 vertebra']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: rash, leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with no significant PMH who presents with rash and leg swelling. He is visiting from ___ and is Portugeuse speaking only. He got Tdap and MMR vaccines on ___ prior to coming to the ___ for a visit. Just prior to leaving ___, he noticed a rash on his neck that was pruritic and erythematous. He thought it was irritation from the hot weather and came to the ___ during the week of ___. The rash was progressing, so he went to ___ urgent care on ___. At that time, there was concern for viral xanthem and he was referred to dermatology. He saw Dr. ___ on ___ and due to concern for syphilis vs. measles-like syndrome, RPR was sent as was measles, mumps and rubella serology. Fluocinonide cream was prescribed for the leg swelling. Pt presented to the ED due to concern for worsening leg swelling. Echo ws negative for an acute cardiomyopathy. UA showed trace protein. Patient was admitted for further workup and for transaminitis. In the ED, initial vitals: 100.8 97 158/89 18 99% - Exam notable for: erythematous rash on neck, chest and groin - Labs notable for: ALT 126, AST 182, RPR + 1:64. Lactate 2.2 On arrival to the floor, pt reports no discomfort. Rash is nonpainful. Denies rhinorrhea, corrhyza or mucosal lesions. ROS: 11 point ROS is positive per HPI otherwise negative. Past Medical History: GERD Social History: ___ Family History: NC Physical Exam: ADMMISSION: =========== Vitals- 98.6 87 137/86 16 97% RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal SKIN: erythematous papules on neck, behind ears, over scalp, chest and groin. Few scattered papules on back. One crusted lesion on R neck. DISCHARGE: ========== Vitals- 99.5, 98.7, 118/59, 93, 16, 99%RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal SKIN: erythematous papules on neck, behind ears, over scalp, chest and groin. Few scattered papules on back. One crusted lesion on R neck. Pertinent Results: ADMISSION: ========== ___ 02:45PM ALT(SGPT)-116* AST(SGOT)-96* LD(LDH)-206 ALK PHOS-96 TOT BILI-0.4 ___ 03:40AM URINE HOURS-RANDOM ___ 03:40AM URINE HOURS-RANDOM ___ 03:40AM URINE UHOLD-HOLD ___ 03:40AM URINE GR HOLD-HOLD ___ 03:40AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 03:40AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 03:40AM URINE MUCOUS-RARE ___ 02:44AM LACTATE-2.2* K+-4.1 ___ 02:00AM GLUCOSE-116* UREA N-11 CREAT-0.8 SODIUM-131* POTASSIUM-7.3* CHLORIDE-98 TOTAL CO2-23 ANION GAP-17 ___ 02:00AM estGFR-Using this ___ 02:00AM ALT(SGPT)-126* AST(SGOT)-182* ALK PHOS-93 TOT BILI-0.3 ___ 02:00AM LIPASE-37 ___ 02:00AM proBNP-99* ___ 02:00AM TOT PROT-7.7 ALBUMIN-3.9 GLOBULIN-3.8 CALCIUM-9.5 PHOSPHATE-4.6* MAGNESIUM-2.0 ___ 02:00AM CRP-41.1* ___ 02:00AM WBC-10.0 RBC-4.37* HGB-13.4* HCT-41.1 MCV-94 MCH-30.7 MCHC-32.7 RDW-14.4 ___ 02:00AM NEUTS-73.4* LYMPHS-14.8* MONOS-5.6 EOS-5.4* BASOS-0.8 ___ 02:00AM PLT COUNT-315 DISCHARGE: ========== ___ 06:15AM BLOOD WBC-14.2* RBC-4.47* Hgb-13.7* Hct-41.7 MCV-93 MCH-30.6 MCHC-32.8 RDW-14.3 Plt ___ ___ 06:15AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-137 K-4.3 Cl-101 HCO3-29 AnGap-11 ___ 06:15AM BLOOD ALT-108* AST-72* LD(LDH)-192 AlkPhos-105 TotBili-0.6 ___ 06:15AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9 ___ 02:00AM BLOOD HCV Ab-NEGATIVE ___ 04:45PM BLOOD HIV Ab-NEGATIVE ___ 02:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE ___ 10:03 am SEROLOGY/BLOOD RPR w/check for Prozone (Final ___: REACTIVE. Reference Range: Non-Reactive. QUANTITATIVE RPR (Final ___: REACTIVE AT A TITER OF 1:64. Reference Range: Non-Reactive. TREPONEMAL ANTIBODY TEST (Preliminary): SENT TO STATE. IMAGING: ======== ___ CXR FINDINGS: The lungs are well inflated and clear. The cardiomediastinal silhouette, hila contours, and pleural surfaces are normal. There is no pleural effusion or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary process. Brief Hospital Course: Mr. ___ is a ___ with no significant PMH who presents with rash and leg swelling. # Syphilis, leg swelling: In the setting of transaminitis, positive RPR, concerning for secondary syphilis. Leg swelling has unclear relation but began in this setting. He was treated with a test dose of penicillin 500mg on ___ and tolerated this without difficulty. He received 2.4 million units of penicillin IM on the morning of ___, was observed for several hours and then discharged home. FTA-abs are still pending at the ___ lab at the time of discharge. # Tachycardia: Had episode of tachycardia to 150s while ambulating, asymptomatic. Received 1 L NS with resolution. # GERD: continued omeprazole TRANSITIONAL ISSUES: -will be returning to ___, but will need follow up to ensure resolution of symptoms Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Fluocinonide 0.05% Cream 1 Appl TP BID Discharge Medications: 1. Fluocinonide 0.05% Cream 1 Appl TP BID 2. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: secondary syphilis Secondary: GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted with a rash and leg swelling. Your rash was found to be caused by syphilis infection. You were given a test dose of penicillin and treated with a full dose once you tolerated the test. Your leg swelling is of uncertain cause, but may be related to the syphilis. You should follow up with your doctor in ___. Make sure to use condoms when having sex as this will protect you against syphilis and other infections. Wishing you the best, Your ___ Care Team Followup Instructions: ___

{'rash': ['secondary syphilis'], 'leg swelling': ['secondary syphilis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Facial trauma Major Surgical or Invasive Procedure: ___: Open reduction internal fixation left mandibular fracture left angle placement of IMF screws and wiring of jawextraction of left upper third tooth (Number 16). History of Present Illness: Mr. ___ is a ___ male prisoner patient with no significant past medical history who presents to the ED after being assaulted. He reports that he was assaulted there was no loss of consciousness. Given his trauma he underwent laboratory testing which was significant for white cell count of 17.8 but a normal CBC, coags, and electrolytes. He underwent CT scan of the head, and torso which showed a left 10 - 11 posterior rib fracture and a left comminuted mandible fracture. We are consulted for management. Patient reports that he has left chest pain and mandible tenderness. He denies chills, fevers, palpitations, and SOB. A 10+ review of systems is otherwise negative. Past Medical History: PMH none PSH none Social History: ___ Family History: Non-contributory. Physical Exam: Admission Physical Exam: VS: Temp 98.8, HR 97, BP 150/76, RR 16, O2 sat 97% on RA General: NAD, AAOx3 HEENT: PERRL, EOMI, anicteric sclera, left mandible edematous and deformed Chest: tender to palpation in the right chest Cardiovascular: Regular rate and rhythm Pulmonary: Clear to auscultation bilaterally, no respiratory distress Abdominal: Soft, nondistended, non-tender Extremities: Warm, well-perfused, without edema Discharge Physical Exam: VS: T: 98.5 PO BP: 131/66 HR: 73 RR: 18 O2: 98% Ra GEN: A+Ox3, NAD HEENT: left facial edema. Left eye injected. CV: RRR, no m/r/g PULM: CTA b/l CHEST: left mid-axillary chest wall tenderness c/w known rib fractures. No crepitus, symmetric chest wall expanxion. ABD: wwp, no edema b/l EXT: Pertinent Results: IMAGING: CT head ___ Left comminuted mandible fxr CT Torso ___ posterior rib fractures LABS: ___ 01:40AM GLUCOSE-139* UREA N-16 CREAT-1.2 SODIUM-140 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14 ___ 01:40AM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-1.6 ___ 01:40AM WBC-17.8* RBC-4.22* HGB-13.5* HCT-40.3 MCV-96 MCH-32.0 MCHC-33.5 RDW-12.9 RDWSD-45.2 ___ 01:40AM NEUTS-85.7* LYMPHS-6.8* MONOS-6.9 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-15.27* AbsLymp-1.21 AbsMono-1.22* AbsEos-0.00* AbsBaso-0.03 ___ 01:40AM PLT COUNT-221 ___ 01:40AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:40AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-300* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 01:40AM URINE RBC-5* WBC-8* BACTERIA-FEW* YEAST-NONE EPI-<1 ___ 01:40AM URINE MUCOUS-RARE* Brief Hospital Course: Mr. ___ is a ___ year old male who presents as a transfer from an outside hospital s/p an assault to the left side of the face as well as trauma to the torso. Found to have a left mandibular comminuted fracture, left 10& 11th rib fractures. He was admitted to the Trauma/Acute Care Surgery service and the Oral Maxillofacial (OMFS) service was consulted to address the mandible fracture. On HD1, the patient underwent ORIF of the left mandible fracture. This procedure went well (reader, please refer to operative note for further details). After remaining hemodynamically stable in the PACU, the patient was transferred to the surgical floor. He initially received IV hydromorphone for pain control and he was then written for liquid acetaminophen and ibuprofen as well as lidocaine patches for pain control. He received cefazolin post-operatively and was later transitioned to a course of oral Keflex. Diet was advanced to full liquids which the patient tolerated well. The patient remained stable from a cardiopulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet and early ambulation were encouraged throughout hospitalization. The patient received subcutaneous heparin and ___ dyne boots were used during this stay and he was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 650 mg/20.3 mL 20.3 ml by mouth every six (6) hours Disp #*473 Milliliter Refills:*1 2. Cephalexin 500 mg PO Q6H Duration: 5 Days RX *cephalexin 250 mg/5 mL 10 mL(s) by mouth every six (6) hours Refills:*0 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID swish and spit RX *chlorhexidine gluconate 0.12 % 15 mL(s) every eight (8) hours Refills:*0 4. Ibuprofen Suspension 400 mg PO Q6H:PRN Pain - Mild Do not take on an empty stomach. RX *ibuprofen 100 mg/5 mL 20 ml by mouth every six (6) hours Refills:*0 5. Lidocaine 5% Patch 1 PTCH TD QAM left rib pain Apply patch and leave on for 12 hours, then remove and leave off for 12 hours. RX *lidocaine 5 % Apply to area of left-sided rib pain Every morning Disp #*15 Patch Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth once a day Disp #*5 Packet Refills:*0 7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Wean as tolerated. RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: -Left mandibular fracture -Left ___ posterior rib fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with a left jaw fracture as well as left-sided rib fractures. Your rib fractures will heal on their own with time and it is important that you continue to take deep breaths to keep your lungs expanded. The Oral Maxillofacial Surgery service took you to the operating room for surgical repair of your left jaw fracture. Please remain on a full liquid diet until your follow-up appointment in the Oral Surgery clinic. You are now ready to be discharged from the hospital. Please follow the discharge instructions below: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Discharge Instructions Regarding your Rib Fractures: * Your injury caused left-sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Followup Instructions: ___

{'Facial trauma': ['Fracture of angle of left mandible', 'Assault by unspecified means'], 'Left chest pain': ['Multiple fractures of ribs', 'left side'], 'Mandible tenderness': ['Fracture of angle of left mandible'], 'White cell count': ['initial encounter for closed fracture'], 'Normal CBC, coags, and electrolytes': ['initial encounter for closed fracture'], 'Left comminuted mandible fracture': ['Fracture of angle of left mandible'], 'Left 10 - 11 posterior rib fractures': ['Multiple fractures of ribs', 'left side']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R IF pain Major Surgical or Invasive Procedure: PROCEDURE: Irrigation, washout and debridement right index finger distal interphalangeal joint. History of Present Illness: ___ year-old right-hand dominant nurse at ___ with severe RA on methotrexate who underwent excision of distal right IF mass just proximal to eponychial fold concerning for mucus cyst on ___ at ___. She noted some drainage from the incision starting in the past ___, she had worsening pain therefore went to ___ earlier today where they cultured purulent discharge and GPCs in clusters and pairs were observed on gram stain, gave vancomycin and zosyn, and was superficially washed out and digital block performed for pain control. She was transferred to ___ for further management. She denies fevers or chills, only increasing pain, drainage, and swelling of the digit. Past Medical History: RA Social History: ___ Family History: non contributory Physical Exam: *** Pertinent Results: ___ 02:26PM WBC-8.9 RBC-3.94 HGB-12.5 HCT-37.7 MCV-96 MCH-31.7 MCHC-33.2 RDW-13.1 RDWSD-45.1 Brief Hospital Course: This is a delightful ___ female nurse ___ ___ who is on immunosuppressants for rheumatoid arthritis. She underwent excision of a draining mucous cyst by Dr. ___ ___ unfortunately she developed an infection at the surgical site. She was admitted to the hospital yesterday and underwent bedside I&D x2. The patient was formally admitted to hand service for ongoing observation as well as IV antibiotic treatment. She was placed on vancomycin and Unasyn. Her cultures from the OSH grew pan sensitive enterococcus and MSSA (resistant to b lactams) she was discharged on levofloxacin. She will follow up with Dr. ___ in clinic as scheduled. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Levofloxacin Discharge Disposition: Home Discharge Diagnosis: R IF wound infection Discharge Condition: AVSS, AOx3 Discharge Instructions: You were admitted to the ED with a wound infection. Please follow this instructions for postoperative care: 1. Soak your wound four times daily in warm soapy water. After this, replace the dressing. 2. Take your antibiotics as prescribed 3. Only take narcotic pain medications for sever pain and do not drive while taking these medications Followup Instructions: ___

{'R IF pain': ['Infection following a procedure', 'Other specified local infections of the skin and subcutaneous tissue'], 'drainage': ['Infection following a procedure', 'Other specified local infections of the skin and subcutaneous tissue'], 'worsening pain': ['Infection following a procedure', 'Other specified local infections of the skin and subcutaneous tissue'], 'swelling of the digit': ['Infection following a procedure', 'Other specified local infections of the skin and subcutaneous tissue']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope, Visual Changes, Tinnitus Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M ___ M with history of ?TIA, HTN, HLD, who presents with episodes of altered consciousness. Occurred ___ in the morning while sitting, he describes feeling out-of-body in that his perception was "off," and then his vision in both eyes narrowed circumferentially and then expanded. He sat down in a chair, and continued to have series of about 6 brief episodes of this. He then loses memory of what happened. Per sister, her other brother witnessed this and stated he was not speaking but remained sitting up without fall or convulsions, loss of bowel or bladder function. Directly prior to these episodes he could hear a "whooshing sound" in his ear. He recovered quickly from the events without any weakness numbness or balance issues. He does say his chest felt "tight" prior to the episodes. He did have palpitations, lightheadedness, chest pain, shortness of breath. He reports they also occurred about 4 months ago, and again 6 months prior to that. They did occur in the setting of poor PO intake and possibly taking an extra dose of his Amlodipine. There was no clear positional component to his symptoms. He denies melena, hematochezia. He does have a history of "ulcers" diagnosed 6 weeks ago in ___. He had an EGD there. He does not recall being told if he had H. pylori. He was put on several medications, he believes antibiotics for a total of 3 weeks to which he was compliant. also reports he intermittently notices blood on his toilet paper and that a lump extrudes at times when he strains when having bowel movements. He recently moved to ___ from ___ within the last two weeks. He is living with his sister. He used to drink heavily but has not had alcohol in "many years." He denies other drug use. He denies fevers, chills, nausea, diaphoresis, any recent cough, abdominal pain, shortness of breath. He denies dyspnea on exertion. In the ED, initial VS were: 98.1 67 115/70 19 100% RA Imaging showed: NCTH with no acute intracranial abnormality CXR wnl Neuro were consulted and recommended to admit to medicine for syncopal/cardiac work-up On arrival to the floor, patient reports he is feeling well. He is concerned that he had a small amount of blood on the toilet paper when having a bowel movement upon arrvial. He is very worried about this. He does strain when having bowel movements. Past Medical History: ? PUD Psoriasis HTN HLD ? TIA ? CAD ? "arrhythmia" Social History: ___ Family History: mother- uterine cancer father- kidney cancer maternal grandmother kidney cancer no family history of strokes or seizure Physical Exam: EXAM ON ADMISSION ====================== tele sinus, rates ___ VS: 96.4 AdultAxillary 91 / 58 60 18 94 Ra GENERAL: NAD, laying comfortably in bed. barrel-chested HEENT: AT/NC, EOMI, PERRL,pink conjunctiva, MMM NECK: no JVD HEART: Distant heart sounds, RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly Rectal: deferred per patient EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, CNII-XII, strength, sensation grossly intact SKIN: warm and well perfused, no excoriations. hyperpigmented patches to back. EXAM ON DISCHARGE =========================== Vitals: 98.0, 130/76, hr 64, RR 17, 97 Ra Telemetry: sinus with rates 50-60's General: Alert, oriented, no acute distress, well appearing HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: normal WOB on room air CV: RRR, no murmur, no gallop Abdomen: soft, NT/ND Ext: warm, no edema Neuro: Moving all extremities. Able to walk the halls with a normal gait. Skin: No rash or lesion Pertinent Results: ADMISSION LABS ========================= ___ 03:14PM BLOOD WBC-6.3 RBC-4.38* Hgb-13.2* Hct-39.8* MCV-91 MCH-30.1 MCHC-33.2 RDW-12.3 RDWSD-40.7 Plt ___ ___ 03:14PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-142 K-4.2 Cl-106 HCO3-20* AnGap-16 ___ 04:28PM BLOOD ___ PTT-31.1 ___ ___ 03:14PM BLOOD cTropnT-<0.01 ___ 05:28AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 03:14PM BLOOD CK(CPK)-102 ___ 05:28AM BLOOD ALT-27 AST-21 AlkPhos-96 TotBili-0.6 ___ 05:28AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.3 ___ 03:14PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:34PM BLOOD Lactate-0.8 ___ 04:45PM URINE Blood-TR* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 04:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG DISCHARGE LABS =========================== ___ 05:12AM BLOOD WBC-5.5 RBC-4.40* Hgb-13.2* Hct-40.8 MCV-93 MCH-30.0 MCHC-32.4 RDW-12.3 RDWSD-42.5 Plt ___ ___ 05:12AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-140 K-4.6 Cl-103 HCO3-27 AnGap-10 ___ 05:12AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3 Iron-115 MICROBIOLOGY =========================== ___ 4:45 pm URINE URINE CULTURE (Preliminary): GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL REPORTS =========================== CTA Head and Neck ___ Right MCA aneurysm measuring 5 x 4 x 3 mm. The aneurysm has a slightly lobulated/irregular appearance. No significant ICA stenosis by NASCET criteria. There is poor opacification of the left vertebral artery at its origin, this may be secondary to its tortuous origin or be related stenosis. Rest of the vertebral arteries and basilar artery are widely patent with no significant stenosis. Lobular/tubular structure just posterior to the suprasternal notch which seems to connect to the left brachiocephalic vein which most likely represents an anomalous venous structure. However correlation with neck ultrasound is advised. NCCT Head ___ No acute intracranial abnormality. CXR ___ No acute cardiopulmonary abnormality. EEG ___ This is a normal awake and asleep EEG with no epileptiform discharges or features. EKG ___ Sinus Bradycardia Brief Hospital Course: ___ from ___, reported hx of possible CAD, possible hx of TIA, possible hx of "arrhythmia," HTN, HLD, who presented to the ED with transient episode of alteration in consciousness, visual changes, and tinnitus. He reports episodes of symptoms similar to this occurring about 6 months ago, and again a few months before that, while in ___. No etiology had previously been identified. On arrival to the floor, orhostatics were positive. He received IV fluid and Amlodipine was stopped. Even after stopping Amlodipine, blood pressures remained low-normal, so it was discontinued. He had a workup for this while in house, including telemetry monitoring (no tachy- or bradyarrthymia was seen), CT of the Head, EEG, and EKG, all of which were normal or unremarkable. Neurology was consulted in the Emergency Room, and recommended a CTA of the Head and Neck. This was negative for acute pathology in the posterior circulation to explain his presenting symptoms, but did show an incidental Right MCA aneurysm measuring 5 x 4 x 3 mm. He had no further symptoms or episodes while in house, and was feeling well on the day of discharge. Ultimately, given the lack of other etiology identified, his symptoms were felt to most likely be due to orthostatic hypotension in the setting of Amlodipine, but he will need further monitoring as an outpatient for recurrence of symptoms and consideration of further workup. CHRONIC ISSUES ======================== # HLD - Atorva 20mg daily # HTN - holding amlodipine given hypotension and positive orthostatics, as above # CAD (per report) - Aspirin 81mg # GERD - omeprazole 40mg daily TRANSITIONAL ISSUES ======================== [ ] NO HEALTH INSURANCE at the time of discharge. Patient is having ongoing discussions with the Financial Department at ___ for arranging insurance. Once insurance arranged, he will be contacted by ___ Health Care Associates and see Dr. ___ ___ in clinic [ ] have STOPPED Amlodipine given orthostatic hypotension on admission and normal BP's without it [ ] incidental Right MCA aneurysm measuring 5x4x3mm found on CTA of Head and Neck [ ] mild normocytic anemia with normal iron studies, B12, Folate. Follow up as outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Aspirin 81 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Omeprazole 40 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Omeprazole 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Syncope - likely from antihypertensive medication Incidental finding of R MCA Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure meeting you at ___. You were admitted to our hospital after developing dizziness, passing out, visual symptoms, and ear ringing. We did multiple tests. We found that your blood pressure was low, and for this we gave you IV fluids and stopped your Amlodipine. The EEG of the brain did not show any seizures. Your Head CT did not show anything to explain your symptoms. It did show a finding of an aneurysm in one of the arteries of your brain. This was NOT what was causing your symptoms, but you will need to follow up on this as an outpatient to for further monitoring. Please stop your Amlodipine, and continue your other medications. It was a pleasure, we wish you the best, ___ Medicine Team Followup Instructions: ___

{'Syncope': ['Syncope and collapse'], 'Visual Changes': ['Unspecified visual disturbance'], 'Tinnitus': ['Tinnitus', 'unspecified ear'], 'Altered Consciousness': ['Syncope and collapse'], 'Chest Pain': [], 'Palpitations': [], 'Lightheadedness': [], 'Shortness of Breath': [], 'Tightness in Chest': [], 'Whooshing Sound': ['Tinnitus'], 'Memory Loss': [], 'Narrowing of Vision': ['Unspecified visual disturbance'], 'Expansion of Vision': ['Unspecified visual disturbance'], 'Out-of-body Perception': [], 'Loss of Bowel or Bladder Function': [], 'Convulsions': [], 'Fall': [], 'Ulcers': ['Gastro-esophageal reflux disease without esophagitis'], 'Blood on Toilet Paper': ['Hemorrhage of anus and rectum'], 'Lump Extrudes': [], 'Straining with Bowel Movements': [], 'History of TIA': ['Essential (primary) hypertension'], 'HTN': ['Essential (primary) hypertension'], 'HLD': ['Essential (primary) hypertension'], 'CAD': ['Essential (primary) hypertension'], 'Arrhythmia': [], 'Right MCA Aneurysm': ['Aneurysm of carotid artery'], 'Psoriasis': ['Psoriasis', 'unspecified'], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'Orthostatic Hypotension': ['Orthostatic hypotension']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: erythromycin base Attending: ___. Chief Complaint: dental pain, facial swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___, previously healthy, who presented with left lower dental abscess. He noticed tooth pain 2 weeks ago, but put off seeing his dentist. Experienced progressive swelling and worsening pain since, and saw dentist 3 days ago. An xray was performed and showed abscess. He was prescribed a course of amoxicillin, which he has been taking for 3 days, but his symptoms have continued to progress. He has been taking ibuprofen for the pain, but says it is not helpful. Last ibuprofen dose was ___ AM. He went to ___ ___ AM where a CT was performed. He was given 900mg IV clindamycin and transferred to ___ for ENT evaluation. In the ED he reported minimal pain, localized to left mandible without radiation. No dyspnea, stridor. No numbness. Reported some pain with chewing and odynophagia, no dysphagia. No fever, chills, sweats. Past Medical History: none Social History: ___ Family History: Reviewed and determined to be non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ___ Temp: 98.1 PO BP: 133/68 Lying HR: 67 RR: 18 O2 sat: 99% O2 delivery: Ra Weight: 174.21 (Standing Scale) (Entered in Nursing IPA). BMI: 27.3. GENERAL: WD/WN male, NAD HEENT: tender fluctuant and mobile mass below the left jaw that extends posteriorly, able to open mouth fully, swallowing secretions, no oral lesions or trauma. RESP: Normal lung sounds bilaterally, no wheezes or rales, no dullness to percussion CV: RRR, + S1/S2, no M/R/G ABD: + BS, soft, non tender, non distended, no rebound or guarding NEURO and EXTR: CN II-XII grossly intact, ___ strength and normal tone in extremities bilaterally DISCHARGE PHYSICAL EXAM: ___ ___ Temp: 98.2 PO BP: 129/81 L Lying HR: 63 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: NAD, lying in bed, cooperative HEENT: Head: atraumatatic and normocephalic Eyes: EOMI, PERRL Ears: right ear normal, left ear normal, no external deformities Nose: straight septum, non-tender, no epistaxis Teeth/Mouth: left lower submandibular area swelling, poor dentition NECK: No LA CARDIAC: Regular rate and rhythm, Normal S1 and S2, no murmurs RESPIRATORY: CTAB with no crackles ABDOMEN: Soft, nondistended, nontender EXTREMITIES: Warm and well perfused, no edema SKIN: No rashes NEURO: CN ___ intact, moving bilateral extremities spontaneously Pertinent Results: ADMISSION LABS: ___ 02:50PM BLOOD WBC-7.4 RBC-4.05* Hgb-13.2* Hct-37.1* MCV-92 MCH-32.6* MCHC-35.6 RDW-11.7 RDWSD-39.0 Plt ___ ___ 02:50PM BLOOD Neuts-69.2 Lymphs-17.2* Monos-12.2 Eos-0.7* Baso-0.4 Im ___ AbsNeut-5.10 AbsLymp-1.27 AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03 ___ 02:50PM BLOOD Glucose-67* UreaN-10 Creat-0.6 Na-141 K-4.5 Cl-103 HCO3-24 AnGap-14 ___ 03:21PM BLOOD Lactate-1.1 DISCHARGE LABS: ___ 07:25AM BLOOD WBC-6.3 RBC-4.14* Hgb-13.8 Hct-38.2* MCV-92 MCH-33.3* MCHC-36.1 RDW-11.6 RDWSD-39.3 Plt ___ ___ 07:25AM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-142 K-4.5 Cl-104 HCO3-23 AnGap-15 ___ 07:25AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.___ previously healthy male with a left lower dental abscess, admitted for Unasyn administration and to be assessed by ___ for possible surgery. ACTIVE ISSUES: #Dental Abscess. Unclear etiology. ___ be due to poor dental hygiene given poor dentition on exam. He also has had history of tobacco use which may predispose him to infection from long-term damage to mucosa. Oral maxillofacial surgery evaluated the patient and advised to give IV Unasyn 3g q6hrs. They evaluated him on the morning of ___ and felt that he could get his tooth extraction and incision and drainage completed as an outpatient. They recommended a 10 day course of PO Augmentin 875mg BID. At time of discharge, blood cultures ___ were pending from ___. Patient was instructed to return to the ED immediately if he had any worsening pain, swelling, new stridor or voice changes, or any other concerning symptoms. Core Measures # CODE: full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amoxicillin 500 mg PO Q8H 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*21 Tablet Refills:*0 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Dental abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, What brought you to the hospital? You came in with a tooth infection and were admitted for IV antibiotics and evaluation by the oral surgery team. What did we do for you in the hospital? You received IV antibiotics. The oral surgery team felt that you could get the dental extraction procedure done as an outpatient. What should you do after leaving the hospital? -Call ___ at 7AM to set up an appointment for the tooth extraction. -Continue your antibiotics as prescribed below. We wish you the very best. Sincerely, Your ___ Team Followup Instructions: ___

{'tooth pain': ['Periapical abscess without sinus'], 'facial swelling': ['Periapical abscess without sinus'], 'dental abscess': ['Periapical abscess without sinus'], 'poor dentition': ['Nicotine dependence'], 'history of tobacco use': ['Nicotine dependence', 'cigarettes']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: leg pain, rash Major Surgical or Invasive Procedure: None History of Present Illness: PCP: Name: ___ Location: ___ GROUP Address: ___, ___ Phone: ___ Fax: ___ ___ yo M with eczema well controlled, hypothyroidism, who presents with acute LLE rash, pain, and fever. The patient first noticed the onset of redness in inner thigh with the feeling of a muscle pull. Over the next day he noticed a rash in his LLE at the shin, punctate, which then became more confluent. This was assoc with a sharper pain. He describes HA and feeling hazy as well. He also reports fever to 102. He denies recent trauma to leg or bug bite. He denies recent travel. He otherwise has felt well and denies vision change, CP, SOB, cough, n/v/d, bloody stool, dysuria, or leg swelling,=. He saw his PCP and was referred to dermatology. The lower rash was biopsied but derm was concerned about cellulitis. He was therefore referred into the hospital for more aggressive treatment. He currently feels better and notes that his rash has stopped spreading. 10 point review of systems reviewed otherwise negative except as listed above Past Medical History: ECZEMA ___'S THYROIDITIS ORTHOSTATIC HYPOTENSION ADRENAL FATIGUE BENIGN PROSTATIC HYPERTROPHY Social History: ___ Family History: Father with prostate cancer. mother with COPD and renal failure Physical Exam: VS: T96.8, BP 151/101, HR 98, RR 14, 100%RA GEN: well appearing in NAD HEENT: MMM OP clear anicteric sclera NECK: supple no LAD HEART: RRR no mrf LUNG: CTAB ABD: soft NT/ND +BS no rebound or guarding EXT: Mild blanching erythema in inner thigh of RLE, mildly tender. No tender LAD or fluctuance or drainage. Distal ___ at shin with non-blanching confluent erythema, tender to touch, no discharge. Connecting the two is a mild erythematous cord. Mild eczematous change in RLE SKIN: as above NEURO: no focal deficits Pertinent Results: ___ 04:30AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 02:44AM ___ PTT-31.6 ___ ___ 12:42AM LACTATE-2.4* ___ 12:30AM GLUCOSE-96 UREA N-21* CREAT-0.9 SODIUM-137 POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-28 ANION GAP-18 ___ 12:30AM WBC-5.9 RBC-4.71 HGB-14.8 HCT-43.2 MCV-92 MCH-31.4 MCHC-34.3 RDW-12.6 RDWSD-42.3 ___ 12:30AM NEUTS-54.1 ___ MONOS-16.0* EOS-0.0* BASOS-0.5 IM ___ AbsNeut-3.20 AbsLymp-1.72 AbsMono-0.95* AbsEos-0.00* AbsBaso-0.03 ___ 12:30AM PLT COUNT-___ with hypothyroidism presents with acute RLE erythema c/w acute cellulitis with lymphangitis. Acute RLE cellulitis: Exam most consistent with acute cellulitis of distal RLE with lymphatic spread to upper RLE. There is no tender LAD or fluctuance to suggest abscess. There is no discharge. portal of entry likely eczema on leg. Vasculitis is also to be considered though less likely. There is no characteristic feature of Lyme disease. Strep is the most likely cause. He was started on IV with stabilization and improvement in his overall condition. The derm biopsy results were reviewed. Dermatology here was consulted for a second opinion and agreed that this was likely related to cellulitis, strep. After 48 hrs of IV Vanco, he was transitioned to Dicloxacillin to complete a 10 day course. His Doxycycline was stopped on discharge. Lyme negative. Blood cultures pending on discharge. Hypothyroidism: Continued home pork thyroid Medications on Admission: Pork Thyroid ___ daily Medications - OTC ASCORBATE CALCIUM-BIOFLAVONOID [___] - Dosage uncertain - (Prescribed by Other Provider; ___) BETA CISTEROL - Dosage uncertain - (Prescribed by Other Provider; ___) CALCIUM CITRATE - Dosage uncertain - (Prescribed by Other Provider; ___) COENZYME Q10 - Dosage uncertain - (Prescribed by Other Provider; ___) GARLIC - Dosage uncertain - (Prescribed by Other Provider; ___) GRAPE SEED EXTRACT - Dosage uncertain - (Prescribed by Other Provider; ___) GUGGALIPID - Dosage uncertain - (OTC) MAGNESIUM CITRATE - Dosage uncertain - (Prescribed by Other Provider; ___) MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth once a day - (OTC) OMEGA-3 FATTY ACIDS [FISH OIL CONCENTRATE] - Dosage uncertain - (Prescribed by Other Provider) PANTETHINE - Dosage uncertain - (OTC) PSYLLIUM HUSK [FIBER (PSYLLIUM HUSK)] - Dosage uncertain - (Prescribed by Other Provider; ___) PYCNOGENAL - Dosage uncertain - (___) SAW ___ - Dosage uncertain - (OTC) VITAMIN A-VITAMIN C-VIT E-MIN [ANTIOXIDANT FORMULA] - Dosage uncertain - (Prescribed by Other Provider) VITAMIN B COMPLEX [B-50 COMPLEX] - Dosage uncertain - (Prescribed by Other Provider; ___) VITAMIN E - Dosage uncertain - (Prescribed by Other Provider; ___) Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain fever 2. thyroid (pork) 162.5 mg oral DAILY 3. DiCLOXacillin 500 mg PO Q6H RX *dicloxacillin 500 mg 1 capsule(s) by mouth four times a day Disp #*32 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute RLE cellulitis Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of right leg rash, likely caused by infection in your skin (cellulitis). Please complete your doxycycline given to you previously (subtract the last 2 days worth), and complete the course of Dicloxicillin given to you. please follow up with your PCP in the next ___ days. You can use Vaseline to your wound with dry gauze dressing change daily Followup Instructions: ___

{'leg pain': ['Cellulitis of right lower limb', 'Hypothyroidism'], 'rash': ['Cellulitis of right lower limb', 'Dermatitis'], 'fever': ['Cellulitis of right lower limb'], 'HA': ['Cellulitis of right lower limb'], 'hazy': ['Cellulitis of right lower limb'], 'redness': ['Cellulitis of right lower limb'], 'muscle pull': ['Cellulitis of right lower limb'], 'punctate rash': ['Cellulitis of right lower limb'], 'confluent rash': ['Cellulitis of right lower limb'], 'sharper pain': ['Cellulitis of right lower limb'], 'eczema': ['Dermatitis'], 'hypothyroidism': ['Hypothyroidism']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old male who complains of RIGHT SIDED ABDOMINAL PAIN. Patient presents with 2 days of right lower quadrant pain. Patient states noticed it while walking. Patient's noticed intermittent pain worsens. Patient had no relief with Pepto-Bismol. Patient denies fevers or chills. Patient reports some anorexia. Past Medical History: none Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Temp: 97.8 HR: 90 BP: 124/86 Resp: 14 O(2)Sat: 100 Constitutional: Comfortable HEENT: Normocephalic, atraumatic Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Right lower quadrant pain without Rovsing sign GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent Pertinent Results: ___ 06:10AM BLOOD WBC-8.9 RBC-5.59 Hgb-12.5* Hct-42.0 MCV-75* MCH-22.4* MCHC-29.8* RDW-14.2 Plt ___ ___ 10:43PM BLOOD WBC-6.6 RBC-5.71 Hgb-12.9* Hct-42.3 MCV-74* MCH-22.7* MCHC-30.6* RDW-14.3 Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 10:43PM BLOOD Glucose-99 UreaN-13 Creat-1.0 Na-137 K-4.0 Cl-103 HCO3-22 AnGap-16 ___: US of appendix: ReportFINDINGS: Non-visualization of a normal or abnormal appendix. Several loops Preliminary Reportof peristalsing bowel are noted. ___: cat scan of abdomen and pelvis: Appendix demonstrates dilation of the midportion to 8 mm with tapering distally. No adjacent fat stranding, but air is not seen distal to the focal dilation. Acute appendicitis is improbable with these findings. Brief Hospital Course: The patient was admitted to the hospital with abdominal pain. Upon admission, he was made NPO, given intravenous fluids and underwent imaging. Cat scan imaging showed a large appendix with a maximum diameter of 8 mm and a small amount of fat stranding. The patient underwent serial abdominal examinations and his white blood cell count was closely monitored. As the patient's abdominal pain resolved, he was introduced to clear liquids and advanced to a regular diet. There was no recurrence of pain, nausea or vomiting. The patient's vital signs remained stable and he was afebrile. The patient was discharged home on HD #1 in stable condition. An appointment for follow-up was made with his primary care provider. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: abdominal pain 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 right sided abdominal pain. You were placed on bowel rest. Your abdominal pain has slowly resolved. You are now preparing for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have 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. * 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. Followup Instructions: ___

{'abdominal pain': ['Abdominal pain', 'right lower quadrant'], 'intermittent pain': ['Abdominal pain', 'right lower quadrant'], 'anorexia': ['Abdominal pain', 'right lower quadrant']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: lightheadedness Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o with hx diffuse burns, depression/anxiety who awoke from sleep this am and felt lightheaded. She called EMS and was brought to ED where sbp was in ___, this responded well to 3 litres IVF - sbp now over 100. Guaiac negative, tox negative, no fevers, hcg neg. Hct 30 (unknown baseline), ct head and cxr negative. Etiology unknown. Admitted for further e and m. ROS - has mild headache, no visual changes, no st, cough, fevers, no chest pain, no sob, no abd pain, no n/v/d, no blood pr. no arthralgias or rash. Pt. recently had menorrhagia, now completed cycle - no bleeding at current. Past Medical History: Depression, anxiety, burns. Social History: ___ Family History: states parents/family have no medical problems. Physical Exam: AF and VSS - sbp is now 97/64 HR 72 Diffuse scaring from burns RRR no MRG MMM CTA t/o S/NT/ND/BS present No edema or rash Alert, oriented. Strange affect, laughs inappropriately, will not share details of history, medical or psychiatric. Endorses depression, passive suicidality, anxiety. States she 'does not care to live anymore'. Pertinent Results: ___ 05:23AM ___ PTT-25.4 ___ ___ 05:23AM PLT COUNT-274 ___ 05:23AM NEUTS-33.9* LYMPHS-54.4* MONOS-5.5 EOS-5.4* BASOS-0.8 ___ 05:23AM WBC-4.2 RBC-3.61* HGB-10.1* HCT-30.9* MCV-86 MCH-27.9 MCHC-32.5 RDW-15.7* ___ 05:23AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 05:23AM ALBUMIN-4.6 CALCIUM-9.4 PHOSPHATE-3.8 MAGNESIUM-1.8 ___ 05:23AM LIPASE-28 ___ 05:23AM ALT(SGPT)-9 AST(SGOT)-13 ALK PHOS-32* TOT BILI-0.2 ___ 05:23AM estGFR-Using this ___ 05:23AM GLUCOSE-92 UREA N-17 CREAT-0.6 SODIUM-140 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12 ___ 05:36AM LACTATE-0.4* ___ 07:05AM URINE UCG-NEGATIVE ___ 07:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 07:05AM URINE HOURS-RANDOM ___ 08:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 08:10AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:10AM URINE GR HOLD-HOLD ___ 08:10AM URINE HOURS-RANDOM CXR and CT head negative, reviewed reports. Brief Hospital Course: Impression - Lightheadedness with hypotension, likely due to dehydration, relative anemia given recent menorrhagia. No evidence of sepsis - no fevers, leukocytosis, rash. - ECG reportedly normal from ED (report to RN) - but I cannot find this. Will attempt to get copy from ED or will repeat - repeated, normal. - RN to examine pt. now for presence of tampon - need to make sure this is out in case this could have been evolving toxic shock although threre is no other evidence to suggest/support this etiology at current - no tampon present - orthostatics now and daily - if positive, will bolus IVF - guaiac all stools - PO ad lib Anemia - baseline unclear. Follow. UCG negative. Depression/anxiety - pt. actively depressed, anxious, passively suicidal. Psychiatry consultation now for assistance in evalution of the above and for recommendations in medication mgmt, ? need for psychiatric hospitalization if medically stable. Continue prozac for now to avoid the SSRI withdrawal syndrome. Psychiatry saw pt. and felt that pt. had no indications for inpatient hospitalization, and that she should continue on with her current outpatient psychiatrist. No medication changes were recommended and none were made. Chronic pain, with description consistent with trigeminal neuropathy? Continue gabapentin for now - withdrawal from this agent can cause seizures. Tylenol prn. I suspect that this pt. has not been eating and drinking well given depression and developed a relative anemia from menorrhagia which was likely symptomatic overnight (orthostasis) and will do well with hydration. Hospital course - Pts bp stabilized with hydration alone. Hct stable. No bleeding seen. Orthostatics negative. Discharged home with new pcp ___. arranged as below. Medications on Admission: Gabapentin 100 bid and 300 hs. Prozac 10 daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: for headache; do not combine this medication with tylenol. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: dehydration, anemia Discharge Condition: Stable. BP 100-110. No menstrual bleeding ongoing. Orthostatics negative. Pt. without complaints at time of discharge. Ambulatory independently, tolerating po intake and voiding independently. Discharge Instructions: Return to the emergency room for: lightheadedness, significant vaginal bleeding Followup Instructions: ___

{'lightheadedness': ['Dehydration', 'Hypotension'], 'hypotension': ['Dehydration', 'Hypotension'], 'anxiety': ['Anxiety state', 'Depressive disorder'], 'depression': ['Anxiety state', 'Depressive disorder'], 'headache': ['Other chronic pain', 'Tension type headache']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: Penicillins / Sulfa (Sulfonamides) Attending: ___ Chief Complaint: "I need to stop drinking." Major Surgical or Invasive Procedure: Radiation therapy to left breast on ___ and ___ ___. History of Present Illness: ___ year old ___ woman brought herself to the ED for alcohol detoxification at the insistence of her outpatient psychiatrist, Dr. ___. She reports that since she was diagnosed with breast cancer in ___ she has been feeling more depressed and drinking more. She reports no social support in the area and this it difficult for her, though she denies any SI or neurovegetative symptoms. The patient is currently receiving radiation therapy s/p breast surgery. She saw Dr. ___ ___, at which time she agreed to come in to the hospital for alcohol detox. This was discussed with Dr. ___ on Deac 4 and a bed was placed on hold. She has been drinking >1 liter of red wine daily for the past several months and her last drink was right before coming to the ED. She denies any history of delirium tremens or seizures. She does report a history of blackouts in the past. She identifies her relapse into drinking after her mother, a ___, passed away last year. She has had periods of sobriety in the past and has had multiple previous hospitalizations for alcohol detox, most recent . She currently complains of sweats and shakiness, denies nausea and vomiting. Initial CIWA score = 23. She denies any SI/SA, HI/HA, hallucinations/delusions. Past Medical History: PPH: Outpatient psychiatrist, Dr. ___, being treated for alcohol dependence and mood disorder with Effexor XR, Abilify, and Trazodone. PMH: -hepatitis C -cirrhosis due to alcohol abuse and hepatitis C -recently diagnosed breast cancer s/p lumpectomy ___, currently undergooing XRT -asthma Social History: ___ Family History: -Mother reported +CAD with first event at age ___, second event in ___. Also with h/o DM. -Father with CAD - at age ___ Family psychiatric history: no history of suicide, substance abuse, or major mental illness. Physical Exam: Medically stable and safe for admission. Normal physical exam. VS: BP:156/99 HR:110 temp: resp:16 O2 sat:98 MSE: Appearance:dressed in hospital gown, hair pulled neatly back, no make up, good eye contact Mood and Affect:"alright", somewhat flattened but appropriate to content, smiles occasionally Behavior: slight tremulousness in both upper extremities Cognition: Attention:serial sevens, stopped at 93, "I'm not good at mathematics" MOYF correct and rapid, MOYR slow/stopped at ___ Memory:long term memory intact, ___ registration, ___ recall Fund of knowledge:average Calculations: "3x7=21", "9x4=16" Abstraction:Apple, Orange ="similar in weight", Grass is always greener="grass is different on other side" Speech: normal volume and tone, "I have to stop drinking, it's too much" Language: accented ___, no neologisms Thought process/associations: Somewhat tangential, no LOA, no FOI Thought Content: Hallucinations: no hallucinations in any modality Delusions: none Homicidal ideation: none Suicidal ideation: none Judgment: impaired Insight: fair Pertinent Results: ___: WBC-4.5 RBC-4.03* HGB-13.9 HCT-40.4 MCV-100* MCH-34.6* MCHC-34.4 RDW-15.2 NEUTS-64.2 ___ MONOS-4.7 EOS-0.9 BASOS-0.7 PLT 142 GLUCOSE-94 UREA N-10 CREAT-0.7 SODIUM-138 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14 ALT(SGPT)-55* AST(SGOT)-152* ALK PHOS-99 TOT BILI-0.7 LIPASE-69* CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.1 TSH-2.1 HCG-<5 SERUM TOX: ASA-NEG ETHANOL-76* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG U/A: COLOR-Yellow APPEAR-Clear SP ___ BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG URINE TOX: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: 1. LEGAL: ___ 2. PSYCHIATRIC: On admission the patient's home psychiatric meds were continued which included: Effexor XR, Abilify, Remeron and Trazodone PRN for insomnia. The patient was under good behavioral control on the unit, with no safety concerns. Her mood improved throughout hospitalization as her detox progressed and discharge plans were set in place. 3. MEDICAL -Etoh detox: the patient presented in moderate alcohol withdrawal and was placed on a standing Ativan 1mg PO Q6H dose with PRN doses given for CIWA >7 every two hours. This was tapered over the course of her hospitalization so she could be discharged without Ativan. -Breat CA: the patient was transported for two radiation treatments on ___ during her hospitalization. She will continue the treatments as an outpatient on discharge. 4. PSYCHOSOCIAL -The patient currently has outpatient behavioral health treaters, psychiatrist Dr. ___ therapist ___ whom she will follow-up with after discharge. She also will continue to participate in Ms ___ substance tx group. The patient will also be referred to dual diagnosis evening treatment program at ___ in ___ upon discharge. 5. DISPO -The patient is being discharged back to home. Her daughter will provide transportation to and from appointments. She will be going to ___ IOP in ___ starting on the day of discharge. Medications on Admission: ALBUTEROL - 90 mcg Aerosol - 2 puffs INH Q4-6H as needed for shortness of breath, wheeze ARIPIPRAZOLE [ABILIFY] - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs INH twice a day MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth before sleep OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day TRAZODONE - 50 mg Tablet - ___ to 1 Tablet(s) by mouth at bedtime as needed for insomnia VENLAFAXINE [EFFEXOR XR] - 75 mg Capsule, Sust. Release 24 hr - 3 Capsule(s) by mouth every morning Discharge Medications: 1. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*0* 2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 3. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:*90 Capsule, Sust. Release 24 hr(s)* Refills:*0* 4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). Disp:*1 inhaler* Refills:*0* 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for left breast pain. Disp:*14 Tablet(s)* Refills:*0* 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: ___ puffs Inhalation Q6H (every 6 hours) as needed for wheeze, sob. 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Axis I: Major depressive disorder, partially treated; r/o substance induced mood disorder; etoh dependence; PTSD Axis II: deferred Axis III: breast cancer, chronic hepatitis C, liver cirrhosis, asthma Axis IV: unemployed, health issues, life altering event, limited social supports Axis V: 55 Discharge Condition: Medically stable and safe for discharge. MSE: Well-groomed ___ F dressed in street clothes. No abnormal behaviors. Speech normal in rate, volume, prosody. Affect is brighter, full range. Thought process linear. Thought content future oriented, no delusions/paranoia/AVH/SI. Insight/judgment is fair. Discharge Instructions: -Please take medications as prescribed. -Please follow up with outpatient appointments as scheduled. -Please call ___ or return to your nearest ER if having thoughts of hurting yourself or others. Followup Instructions: ___

{'sweats': ['Other and unspecified alcohol dependence', 'continuous'], 'shakiness': ['Other and unspecified alcohol dependence', 'continuous'], 'blackouts': ['Other and unspecified alcohol dependence', 'continuous'], 'depressed': ['Major depressive affective disorder', 'recurrent episode', 'unspecified'], 'drinking more': ['Other and unspecified alcohol dependence', 'continuous'], 'no social support': ['Posttraumatic stress disorder'], 'radiation therapy': ['Malignant neoplasm of other specified sites of female breast'], 'hepatitis C': ['Chronic hepatitis C without mention of hepatic coma'], 'cirrhosis': ['Alcoholic cirrhosis of liver'], 'asthma': ['Asthma', 'unspecified type', 'unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy and stone extraction - ___. History of Present Illness: ___ year-old male presents as transfer from ___ for abdominal pain. Pain started at 10 AM yesterday after breakfast. Pain was located in epigastric region. After lunch time, the patient felt an increased degree of back pain. Patient then had dinner, and his pain became much worse - associated with nausea, but no vomiting. He had subjective fevers but no chills. He went to OSH last night and TB and lipase were elevated. CT showed large gallbladder. He was transferred to ___ for further workup. At the current time, his pain is much improved with pain medication. Last BM was yesterday morning - no blood, and normal in color/caliber. He is still passing gas. ROS is otherwise only positive for occasional reflux. Past Medical History: PMHx: Duodenal ulcer s/p bleed . PSHx: Ex lap/repair of duodenal ulcer > ___ yrs ago (unclear as to what type of surgery patient had - whether pyloroplasty vs. reconstruction), repair of L hand tendon, pilonadial cyst and sinus tract excision. Social History: ___ Family History: Paternal GF died of prostate CA, Father died of colon cancer. Physical Exam: On Admission: VS: T 98.6, HR 68, BP 139/71, RR 16, 96%RA GEN: NAD, A&O x 3 HEENT: slight scleral icterus LUNGS: Clear B/L CV: RRR, nl S1 and S2 ABD: Soft, NT, ND, midline incision with palpable reducible hernias, + periumbilical hernia, no groin hernias, no guarding, no rebound RECTAL: Guaiac neg, no masses EXT: no c/c/e Pertinent Results: On Admission: ___ 05:07AM LACTATE-1.5 ___ 04:55AM GLUCOSE-104 UREA N-13 CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-24 ANION GAP-13 ___ 04:55AM ALT(SGPT)-162* AST(SGOT)-197* ALK PHOS-125* TOT BILI-3.7* ___ 04:55AM LIPASE-44 ___ 04:55AM WBC-8.7 RBC-4.31* HGB-13.7* HCT-39.1* MCV-91 MCH-31.8 MCHC-35.1* RDW-13.5 ___ 04:55AM NEUTS-75.7* ___ MONOS-5.0 EOS-0.5 BASOS-0.5 ___ 04:55AM PLT COUNT-377 ___ 04:55AM ___ PTT-22.4 ___ . Prior to Discharge: ___ 06:40AM BLOOD WBC-6.5 ___ 06:40AM BLOOD ALT-213* AST-85* LD(LDH)-178 AlkPhos-207* TotBili-1.3 . ___ Liver/Gallbladder U/S: 1. Multiple small gallstones in the dependent portion of a mildly distended gallbladder. Normal gallbladder wall. No pericholecystic fluid. No intrahepatic biliary ductal dilatation. 2. Nonspecific findings, cannot exclude acute cholecystitis. Recommend clinical correlations. If clinically indicated, a HIDA scan may be performed. . ___ MRCP (MR ABD ___: Radiologist reading pending. . ERCP (___): Cannulation of the biliary duct was difficult due to Billroth II anatomy. Multiple attempts with standard catheters were unable to achieve deep cannulation. A small pre-cut needle sphincterotomy was performed. Cannulation was successful and deep with a ___ tapered catheter using a free-hand technique. Contrast medium was injected resulting in complete opacification. A single 5 mm round stone that was causing partial obstruction was seen at the upper third of the common bile duct. After the small pre-cut needle knife sphincterotomy and cannulation a 10mm wire guided CRE balloon was introduced for dilation biliary sphincteroplasty and the diameter was progressively increased to 12 mm successfully. 2 stones were extracted successfully using a balloon catheter. Partial pancreatogram was normal. . MICROBIOLOGY: ___ ER Blood culture: No growth to date. Brief Hospital Course: The patient was admitted to the ___ Surgical Service on ___ for evaluation of the aforementioned problem. He was made NPO, started on IV fluids, and given Dilaudid IV PRN for pain with good effect. An MRCP performed on ___ revealed a dilated gallbladder, but no stones were visulaized in the biliary tree. On ___, the patient underwent an ERCP with sphincterotomy and extraction of 2 small stones from the common bile duct, which went well without complication. . The next morning, follow-up liver function tests were improved, and the patient was started on a diet of clears, which was later advanced to a regular diet with good tolerability. He was not experiencing any significant pain. He voided regularly with good output. He ambulated early and frequently, was adherent with respiratory toilet, and had a bowel movement. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. He was discharged home without services. Dr. ___ (___) has recommended probable open cholecystectomy, at which time his large ventral hernia would be repaired. The patient's other option is referral within the ___ ___ system for surgical consultation and treatment of this issue. The patient will follow-up with ___, NP (PCP at ___), with whom he will discuss surgical recommendations and decide on a course of treatment. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for fever or pain. 3. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO Q3-4HOURS: PRN as needed for pain. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Choledocholithiasis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: ___

{'Abdominal pain': ['Calculus of bile duct without mention of cholecystitis', 'with obstruction'], 'Back pain': ['Calculus of bile duct without mention of cholecystitis', 'with obstruction'], 'Nausea': ['Calculus of bile duct without mention of cholecystitis', 'with obstruction'], 'Fever': ['Calculus of bile duct without mention of cholecystitis', 'with obstruction'], 'Reflux': ['Ventral hernia without mention of obstruction or gangrene'], 'History of smoking': ['Personal history of tobacco use']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Cholelithiasis and incisional hernia. Major Surgical or Invasive Procedure: ___: 1. Open cholecystectomy. 2. Repair of incisional hernia with AlloDerm . ___: Evacuation of hematoma from the subcutaneous space with washout and reclosure of the abdominal wound. Past Medical History: PMHx: Duodenal ulcer s/p bleed . PSHx: Ex lap/repair of duodenal ulcer > ___ yrs ago (unclear as to what type of surgery patient had - whether pyloroplasty vs. reconstruction), repair of L hand tendon, pilonadial cyst and sinus tract excision. Physical Exam: On dischage: afvss Gen:nad aox3 ___: reg Pulm:no resp disteress Abd: soft, approp tender, mild distension, JP in place: serosanguinous drainage midline incsion healing, sutures in place ___: no LLE Pertinent Results: ___ 01:07PM BLOOD Hct-39.6* ___ 07:35AM BLOOD WBC-10.4 RBC-4.01* Hgb-12.8* Hct-38.1* MCV-95 MCH-32.0 MCHC-33.6 RDW-12.5 Plt ___ ___ 04:30PM BLOOD Hct-32.5* ___ 09:41PM BLOOD WBC-9.7 RBC-3.47* Hgb-11.1* Hct-31.2* MCV-90 MCH-31.9 MCHC-35.4* RDW-13.9 Plt ___ ___ 03:06AM BLOOD Hct-29.3* ___ 06:42AM BLOOD Hct-27.2* ___ 10:13AM BLOOD Hct-29.0* ___ 06:07PM BLOOD WBC-8.8 RBC-3.26* Hgb-10.2* Hct-29.2* MCV-89 MCH-31.2 MCHC-34.8 RDW-13.7 Plt ___ ___ 02:17AM BLOOD WBC-8.2 RBC-3.03* Hgb-9.5* Hct-27.1* MCV-89 MCH-31.1 MCHC-34.9 RDW-13.5 Plt ___ ___ 01:20PM BLOOD WBC-9.1 RBC-3.13* Hgb-9.7* Hct-28.1* MCV-90 MCH-31.1 MCHC-34.6 RDW-13.7 Plt ___ ___ 04:24AM BLOOD WBC-7.1 RBC-3.09* Hgb-9.6* Hct-27.5* MCV-89 MCH-31.0 MCHC-34.8 RDW-13.6 Plt ___ ___ 04:24AM BLOOD ___ PTT-19.8* ___ ___ 04:24AM BLOOD Glucose-106* UreaN-6 Creat-0.8 Na-141 K-3.4 Cl-106 HCO3-27 AnGap-11 ___ 04:24AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9 ___ 06:15PM BLOOD Type-ART pO2-333* pCO2-29* pH-7.43 calTCO2-20* Base XS--3 ___ 06:15PM BLOOD Lactate-1.___ s/p CCY, ventral hernia repair w/ Alloderm ___. Patient postoperatively was triggered on the floor x2 for hypotension and AMS. Patient transferred to trauma sicu. Receiving two units of PRBCs on arrival to the ___ SBP fluid responsive and stable in TSICU, pt with O2sat 100% on RA. There was a complication of abdominal wall hematoma with decreasing Hct and patient was returned to OR on ___ for evacuation of hematoma from the subcutaneous space with washout and reclosure of the abdominal wound. Post operatively the patient did well, his hct remained stable and after bowel function returned his diet was advance. He had 2 drains left to bulb suction. One drain was removed on POD 7. By discharge he was tolerating regular diet and his pain was controlled on PO pain meds. He is being discharged with ___ with one JP in place. Medications on Admission: Meds: vitD, tylenol, loratadine, guaifenesin Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for fever or pain. 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 7. Vitamin D Oral 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation: Over-the-counter. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Cholelithiasis and incisional hernia. 2. Postoperative bleeding, status post open cholecystectomy and incisional hernia repair with AlloDerm. Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___

{'Cholelithiasis': ['Calculus of gallbladder without mention of cholecystitis'], 'Incisional hernia': ['Incisional hernia without mention of obstruction or gangrene'], 'Postoperative bleeding': ['Hemorrhage complicating a procedure'], 'Precipitous drop in hematocrit': ['Precipitous drop in hematocrit'], 'Pulmonary insufficiency': ['Other pulmonary insufficiency'], 'Surgical operation complication': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'Iatrogenic hypotension': ['Other iatrogenic hypotension'], 'Altered mental status': ['Altered mental status'], 'Esophageal reflux': ['Esophageal reflux'], 'Gout': ['Gout']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Simvastatin Attending: ___ Chief Complaint: L hip OA Major Surgical or Invasive Procedure: L THR History of Present Illness: ___ with L hip OA Past Medical History: HTN Social History: ___ Family History: NC Physical Exam: At the time of discharge: AVSS NAD wound c/d/i without erythema ___ intact SILT distally Pertinent Results: ___ 07:10AM BLOOD WBC-9.0 RBC-4.09* Hgb-11.9* Hct-34.7* MCV-85 MCH-29.0 MCHC-34.2 RDW-13.0 Plt ___ ___ 07:25AM BLOOD WBC-11.3*# RBC-4.34* Hgb-13.0*# Hct-36.3*# MCV-84 MCH-29.9 MCHC-35.7* RDW-12.9 Plt ___ ___ 07:25AM BLOOD Glucose-119* UreaN-12 Creat-0.9 Na-138 K-3.5 Cl-103 HCO3-30 AnGap-9 ___ 07:25AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8 Brief Hospital Course: The patient was admitted on ___ and, later that day, was taken to the operating room by Dr. ___ L THR without complication. Please see operative report for details. Postoperatively the patient did well. The patient was initially treated with a PCA followed by PO pain medications on POD#1. The patient received IV antibiotics for 24 hours postoperatively, as well as lovenox for DVT prophylaxis starting on the morning of POD#1. The drain was removed without incident. The Foley catheter was removed without incident. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services in a stable condition. The patient's weight-bearing status was WBAT. Medications on Admission: atenolol, hctz Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 3 weeks: To be followed by aspirin 325mg bid for 3 weeks. Disp:*21 syringe* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 5. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed: Do not drink, drive or operate heavy machinery while taking this medication. Disp:*80 Tablet(s)* Refills:*0* 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Discharge Disposition: Home With Service Facility: ___ ___: L hip OA Discharge Condition: Stable Discharge Instructions: 1. Please return to the emergency department or notify MD if you experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg twice daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by ___ in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. ___ (once at home): Home ___, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative leg. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT Treatments Frequency: Physical therapy -- WBAT. Lovenox injections. Wound checks. ___ to remove staples at 2 weeks. Followup Instructions: ___

{'L hip OA': ['Osteoarthrosis', 'pelvic region and thigh'], 'HTN': ['Unspecified essential hypertension'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tree nut / Bactrim Attending: ___ Chief Complaint: admit for HD Cytoxan prior to stem cell mobilization Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with MM s/p 4 cycles RVD now admitted for Cytoxan stem cell mobilization. Bone marrow biopsy ___ showed 4% of aspirate plasma cells, significant reduction compared to prior (was 48% of aspirate). States ___ previously had leg swelling on dex but none currently, otherwise no headaches, cough, sore throat, fevers, rash, abd pain, diarrhea, chest pain/SOB, constipation, BRBPR, melena. All other 10 point ROS neg. REVIEW OF SYSTEMS: GENERAL: No fever, chills, night sweats, recent weight changes. HEENT: No sores in the mouth, painful swallowing, intolerance to liquids or solids, sinus tenderness, rhinorrhea, or congestion. CARDS: No chest pain, chest pressure, exertional symptoms, or palpitations. PULM: No cough, shortness of breath, hemoptysis, or wheezing. GI: No nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel habits, hematochezia, or melena. GU: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, myalgias, or bone pain. DERM: Denies rashes, itching, or skin breakdown. NEURO: No headache, visual changes, numbness/tingling, paresthesias, or focal neurologic symptoms. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: ONC HISTORY: Regarding his myeloma: His presentation is notable for a history of worsening back pain for ~1 month, which when worked up by MRI demonstrated multiple compression fractures and a BM signal intensity c/f myeloma. W/u revealed leukopenia (WBC 2.4), Anemia (Hgb 8.7), Cr 1.01, Ca 8.8, Alb 2.8, IgG of 9190, M spike with 7.2g/dL, IgA and IgM <10 with Kappa: Lambda ratio of >90.5, B2 Microglobulin of 6.38 BMBx on ___ demonstrated infiltrate with 80% plasma cells, c/w with a Dx of Stage III (IgG > 7g/dl and Advanced lytic lesions) ISS Stage III (Beta 2 >5.5mg/dL). ___ was started on RVD by Dr. ___ on ___. ___ has tolerated it fairly well and has completed 4 cycles. PAST MEDICAL HISTORY: lower back pain PAST SURGICAL HISTORY: - Tonsillectomy; eye surgery for lazy eye - right hand surgery Social History: ___ Family History: Siblings: Brother with soft tissue sarcoma on knee Mother: No known history of cancer or blood disorders Father: No known history of cancer or blood disorders; still alive, ___ year old Aunts: No known history of cancer or blood disorders Uncles: No known history of cancer or blood disorders Maternal Grandmother: No known history of cancer or blood disorders; died of unknown type Maternal Grandfather: No known history of cancer or blood disorders; lived to ___ Paternal Grandmother: No known history of cancer or blood disorders Paternal Grandfather: No known history of cancer or blood disorders Children: No known history of cancer or blood disorders Physical Exam: VITAL SIGNS: 98.4 102/60 80 18 95% RA General: NAD HEENT: MMM, no OP lesions CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors SKIN: No rashes or skin breakdown NEURO: Oriented x3. Non-focal Pertinent Results: ___ 08:33AM BLOOD WBC-5.2 RBC-3.96* Hgb-12.5* Hct-37.1* MCV-94 MCH-31.6 MCHC-33.7 RDW-14.0 RDWSD-48.8* Plt ___ ___ 04:40PM BLOOD Na-141 ___ 09:00PM BLOOD Na-129* ___ 05:30PM BLOOD Na-126* ___ 11:01AM BLOOD Na-127* ___ 07:38AM BLOOD Glucose-120* UreaN-17 Creat-0.6 Na-129* K-3.7 ___ 01:00PM BLOOD Glucose-101* UreaN-22* Creat-0.8 Na-138 K-3.8 ___ 06:24AM BLOOD Glucose-76 UreaN-16 Creat-0.7 Na-138 K-4.1 Cl-103 HCO3-29 AnGap-___ w/ MM s/p 4 cycles RVD admitted for Cytoxan stem cell mobilization c/b mod-severe hyponatremia. # Hyponatremia Na dropped from 138 to 127 within 24 hrs with associated HA but no MS changes. ___ was seen by nephrology. Considering the elevated UNa and Osms, along with clinical history of Cytoxan induced nausea and ongoing aggressive IVF administration, it was thought that this was ADH induced hyponatremia from Cytoxan related nausea. ___ was placed on 1L PO fluid restriction and salt tabs and Na improved to back to 141 within 24 hrs. His symptoms improved and ___ was monitored overnight without PO restrictions and NaCL tabs and his Na remained normal on 138. ___ will need to have his sodium monitored carefully if ___ will receive Cytoxan again. # MM Completed RVD, Bm BX ___ with 4% plasma cells in aspirate and ___ in marrow, significant reduction from 48%. ___ was admitted for Cytoxan mobilization and completed it with the complication of hyponatremia and nausea. - ___ started cipro and zarxio, has scripts and zarxio at home - SC collection in 10 days - c/w zometa as outpatient - plan for upcoming auto transplant per ___ - monitor for nausea with chemo, anti-emetics prn - ppx: cont acyclovir, pt taking BID ___ reports # Lower back pain # H/o compression fractures at T5/T7 - chronic - cont prn oxy/tramadol ____________________ ___, D.O. Heme/___ Hospitalist ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. LORazepam 0.5 mg PO Q8H:PRN nausea/insomnia/anxiety 3. Ondansetron 8 mg PO Q8H:PRN nausea 4. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain 5. Vitamin D 1000 UNIT PO DAILY 6. Senna 8.6 mg PO DAILY 7. Docusate Sodium 100 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Docusate Sodium 100 mg PO DAILY 3. Ciprofloxacin HCl 500 mg PO Q12H start ___, for 10 days 4. LORazepam 0.5 mg PO Q8H:PRN nausea/insomnia/anxiety 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 8.6 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Filgrastim 300 mcg SC Q24H Discharge Disposition: Home Discharge Diagnosis: Multiple Myeloma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for high dose Cytoxan for stem cell mobilization. Please follow the instructions given to you by your nurse ___. In brief this includes taking ciprofloxacin (antibiotic) and neupogen injections until you are told to stop. You also had low sodium levels. This was most likely due to a side effect from the chemotherapy and nausea. You improved with time, salt tablets, and fluid restriction. You do not have to be on any further restrictions. Followup Instructions: ___

{'lower back pain': ['Multiple myeloma not having achieved remission', 'Pathological fracture in neoplastic disease'], 'leg swelling': [], 'headaches': [], 'cough': [], 'sore throat': [], 'fevers': [], 'rash': [], 'abd pain': [], 'diarrhea': [], 'chest pain/SOB': [], 'constipation': [], 'BRBPR': [], 'melena': [], 'no fever, chills, night sweats, recent weight changes': [], 'no sores in the mouth, painful swallowing, intolerance to liquids or solids, sinus tenderness, rhinorrhea, or congestion': [], 'no chest pain, chest pressure, exertional symptoms, or palpitations': [], 'no cough, shortness of breath, hemoptysis, or wheezing': [], 'no nausea, vomiting, diarrhea, constipation or abdominal pain': [], 'no dysuria or change in bladder habits': [], 'no arthritis, arthralgias, myalgias, or bone pain': [], 'no rashes, itching, or skin breakdown': [], 'no headache, visual changes, numbness/tingling, paresthesias, or focal neurologic symptoms': [], 'no feelings of depression or anxiety': [], 'hyponatremia': ['Encounter for antineoplastic chemotherapy', 'Hypo-osmolality and hyponatremia'], 'worsening back pain': ['Multiple myeloma not having achieved remission', 'Pathological fracture in neoplastic disease'], 'elevated UNa and Osms': [], 'clinical history of Cytoxan induced nausea': [], 'ongoing aggressive IVF administration': [], 'ADH induced hyponatremia from Cytoxan related nausea': ['Encounter for antineoplastic chemotherapy', 'Hypo-osmolality and hyponatremia'], 'nausea with vomiting': ['Nausea with vomiting'], 'adverse effect of antineoplastic and immunosuppressive drugs': ['Adverse effect of antineoplastic and immunosuppressive drugs']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Status post left thyroid lobectomy with follicular thyroid carcinoma. Major Surgical or Invasive Procedure: Completion right thyroidectomy. History of Present Illness: This elderly patient has undergone resection of a very large left substernal goiter last year and the pathology showed widely invasive follicular carcinoma, and completion was recommended. Past Medical History: PMH:- Toxic multinodular goiter causing tracheal stenosis and deviation,Mild mitral regurg, moderate pulm HTN,HLD,DM2 ,Paroxysmal afib on lovenox, DVT L arm ___ now on lovenox, pulm embolism in ___ s/p lower extremity bypass graft, COPD,Gout,Prior stroke, possibly with neurogenic bladder now s/p suprapubic catheter,ongoing tobacco use as of ___ Social History: ___ Family History: Mother, aunt, and uncle all had CHF, unknown cause; no known hx of CAD in her family. Daughter with heart arrhythmia Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist Neck incision w/ staples c/d/I, no erythema/ecchymosis or drainage CV: RRR, No M/G/R PULM: clear to auscultation b/l, No W/R/R ABD: soft, nondistended, nontender, no rebound or guarding GU: suprapubic catheter w/clear yellow urine Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 06:50AM BLOOD WBC-10.1* RBC-4.46 Hgb-11.2 Hct-36.8 MCV-83 MCH-25.1* MCHC-30.4* RDW-15.0 RDWSD-45.5 Plt ___ ___ 06:50AM BLOOD Glucose-93 UreaN-20 Creat-0.8 Na-140 K-4.2 Cl-101 HCO3-27 AnGap-16 ___ 06:50AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.8 Brief Hospital Course: Ms. ___ is a ___ F with hx of multinodular goiter and follicular thyroid carcinoma s/p prior left thyroid lobectomy and resection of medial aspect of right lobe now s/p complete right thyroidectomy. Surgery was uncomplicated; reader is referred to operative report for details of surgery. She was admitted overnight for observation. Following admission her calcium level was monitored and was found to be appropriate. Postoperatively she had adequate urine output via her suprapubic catheter. Her diet was advanced and well tolerated. She ambulated and was able to achieve adequate pain control on oral medications. Her surgical site remained c/d/I and without evidence of hematoma or drainage. Once she met the appropriate criteria she was discharged home on POD1 with scheduled follow up with Dr. ___ postoperative care. Additionally, thyroid hormone replacement, calcium and vitamin D supplementation were added to her medication regimen, as well as pain medication. In regards to her anticoagulation for h/o Afib/DVT, which was held ___ patient has been instructed to restart Lovenox on ___. She was discharged home on POD 1, with detailed follow-up instructions and verbalized good understanding. Medications on Admission: Medications: - Amlodipine 5 mg PO DAILY - Atorvastatin 40 mg PO QPM - Lisinopril 15 mg PO DAILY - Aspirin 81 mg PO DAILY - Enoxaparin Sodium 80 mg SC QD - HCTZ 12.5mg daily - Methimazole 1.25mg daily - Metoprolol XR 25 qdaily - Ferrous sulfate 325 daily - MVI daily - Calcium 500 + D 500 mg (1,250 mg)-200 unit tablet Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Calcitriol 0.25 mcg PO DAILY RX *calcitriol 0.25 mcg 1 capsule(s) by mouth once a day Disp #*10 Capsule Refills:*0 3. Levothyroxine Sodium 112 mcg PO DAILY RX *levothyroxine 112 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 4. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral QID 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Enoxaparin Sodium 80 mg SC DAILY Start: Tomorrow - ___, First Dose: First Routine Administration Time 10. Ferrous Sulfate 325 mg PO DAILY 11. Hydrochlorothiazide 12.5 mg PO DAILY 12. Lisinopril 15 mg PO DAILY 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Senna 17.2 mg PO HS 16. Vitamin D 200 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Status post left thyroid lobectomy with follicular thyroid carcinoma. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure being involved in your care at ___. You were admitted to the inpatient general surgery unit after your completion thyroidectomy. You have adequate pain control and have tolerated a regular diet and may return home to continue your recovery. You will be discharged home on thyroid hormone replacement, calcium and vitamin D supplement, please take as prescribed. For your calcium supplement please purchase Oscal(chewable tablets are acceptable) over the counter at the pharmacy and take 1 tablet FOUR times a day. Please go to any ___ lab on ___ Before 12:00 pm, and have your calcium level drawn. If there is a need to change your calcium dosage your endocrinologist will give you further instructions. Please monitor for signs and symptoms of low Calcium such as numbness or tingling around mouth/fingertips or muscle cramps in your legs. If you experience any of these signs or symptoms please call Dr. ___ for advice or if you have severe symptoms go to the emergency room. Please restart your LOVENOX on THURS ___ as prescribed. You may restart all regular home medications, and take any new medications as prescribed. You will be given a prescription for narcotic pain medication, take as prescribed. You may take acetaminophen (Tylenol) as directed, but do not exceed 3000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. You may shower and wash incisions with a mild soap and warm water. Avoid swimming and baths until cleared by your surgeon. Gently pat the area dry. Your neck incision has been closed with staples, please call the office and schedule an appointment for staples to be removed by ___. Thank you for allowing us to participate in your care. Your ___ care Team Followup Instructions: ___

{'Toxic multinodular goiter causing tracheal stenosis and deviation': ['Malignant neoplasm of thyroid gland'], 'Mild mitral regurg': ['Nonrheumatic mitral (valve) insufficiency'], 'Moderate pulm HTN': ['Other secondary pulmonary hypertension'], 'HLD': ['Hyperlipidemia'], 'DM2': ['Type 2 diabetes mellitus without complications'], 'Paroxysmal afib on lovenox': ['Paroxysmal atrial fibrillation'], 'DVT L arm ___ now on lovenox': ['Personal history of other venous thrombosis and embolism'], 'Pulm embolism in ___ s/p lower extremity bypass graft': ['Personal history of pulmonary embolism'], 'COPD': ['Chronic obstructive pulmonary disease'], 'Gout': [], 'Prior stroke, possibly with neurogenic bladder now s/p suprapubic catheter': ['Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits'], 'Ongoing tobacco use as of ___': ['Nicotine dependence', 'cigarettes'], 'Status post left thyroid lobectomy with follicular thyroid carcinoma': ['Malignant neoplasm of thyroid gland'], 'Completion right thyroidectomy': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Toxic large substernal multinodular goiter. Major Surgical or Invasive Procedure: Resection of left substernal goiter and resection of medial aspect right lobe. History of Present Illness: This is a ___ year old woman who lady presented with a chronically toxic multinodular goiter that was however,enlarging causing tracheal deviation and stenosis. FNA of a nodule on the left side, also was suspicious for papillary cancer. Consequently, we arranged to do a total thyroidectomy but the possibility of a staged operation had been raised preoperatively. Past Medical History: Toxic multinodular goiter causing tracheal stenosis and deviation,Mild mitral regurg, moderate pulm HTN,HLD, DM2, Paroxysmal afib on lovenox, DVT L arm ___ now on lovenox, pulm embolism in ___, HTN, PAD s/p lower extremity bypass graft, COPD, Gout,Prior stroke, possibly with neurogenic bladder now s/p suprapubic catheter,ongoing tobacco use as of ___ PSH: Cataracts,Fem-pop BPG,Hysterectomy,Suprapubic urinary catheter ___ Social History: ___ Family History: Mother, aunt, and uncle all had CHF, unknown cause; no known hx of CAD in her family. Daughter with heart arrhythmia on amiodarone Physical Exam: General: AA&O, pleasant,no distress Cardiac: irreg irreg rate and rhythm, normal S1 S2 Pulm:clear, no stridor Abd:soft, NT/ND INC:neck soft, incision c/d/I, no erythema/drainage EXT:warm well perfused, no ___ edema Brief Hospital Course: ___ with massive multinodular goiter with FNA suspicious for papillary thyroid cancer. She presented to ___ on ___ and underwent left thyroid lobectomy. Initially postoperatively, she was hypertensive and received IV Labetalol and responded appropriately. She was transferred to the surgical ward overnight for observation. Postoperatively she was able to tolerate regular diet, ambulate, and achieve adequate pain control on oral medications. Her surgical site remained c/d/I and without evidence of hematoma or drainage. Once she met the appropriate criteria she was discharged home on POD1 with scheduled follow up with Dr. ___ postoperative care. She was given instructions on wound care as well as symptoms of complications to look out for, of which she expressed understanding. Medications on Admission: - Amlodipine 5' QAM - Atorvastatin 40' QHS - Lovenox 80mg SQ QAM - Lisinopril 30' QHS - Methimazole 2.5' QAM - ASA 81' - Calcium + vitD QD - Iron 325' - MVI Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Amlodipine 5 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Lisinopril 30 mg PO DAILY 5. Aspirin 81 mg PO DAILY please restart your aspirin 48 hours after surgery on ___. 6. Enoxaparin Sodium 80 mg SC QD Start: Tomorrow - ___, First Dose: First Routine Administration Time Please restart your Lovenox 48 hours after your surgery. Discharge Disposition: Home Discharge Diagnosis: Toxic multinodular goiter 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. ___, You were admitted to the inpatient general surgery unit after your left thyroid lobectomy. You have adequate pain control and have tolerated a regular diet and may return home to continue your recovery. Monitor for signs and symptoms of low Calcium such as numbness or tingling around mouth/fingertips or muscle cramps in your legs. If you experience any of these signs or symptoms please call Dr. ___ for advice or if you have severe symptoms go to the emergency room. Please note that your Methimazole has been discontinued. You may restart your Aspirin and Lovenox on ___ (48 hours after your surgery). You may take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. You may shower and wash incisions with a mild soap and warm water. Avoid swimming and baths until cleared by your surgeon. Gently pat the area dry. You have a neck incision with steri-strips in place, do not remove, they will fall off on their own. Thank you for allowing us to participate in your care. Your ___ Team Followup Instructions: ___

{'tracheal deviation and stenosis': ['Malignant neoplasm of thyroid gland', 'Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm'], 'irreg irreg rate and rhythm': ['Paroxysmal atrial fibrillation'], 'moderate pulm HTN': ['Other secondary pulmonary hypertension'], 'HLD': ['Hyperlipidemia'], 'DM2': ['Type 2 diabetes mellitus without complications'], 'COPD': ['Chronic obstructive pulmonary disease'], ' PAD s/p lower extremity bypass graft': ['Peripheral vascular disease'], 'ongoing tobacco use': ['Nicotine dependence'], 'prior stroke': ['Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits'], 'pulm embolism': ['Personal history of pulmonary embolism'], 'DVT L arm': ['Personal history of other venous thrombosis and embolism']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: non-healing left foot ulcer Major Surgical or Invasive Procedure: Left poplitetal artery-Post Tib artery bypass History of Present Illness: This is a ___ man who presented with progressive left leg ischemia to the point of ulceration of the toes. He underwent arteriogram which showed occlusion of the posterior tibial artery and the tibioperoneal trunk and the anterior tibial artery. Given these findings the patient was consented for a popliteal to posterior tibial artery bypass in an attempt at limb salvage. Past Medical History: Lung CA MI Bladder CA PAST SURGICAL HISTORY: R lung lobectomy ___ CABG*4 ___ TURT bladder; L CEA Social History: ___ Family History: N/A Physical Exam: On discharge: VS: T 98.2, HR 85, BP 135/55, RR 20, O2Sat 96%RA Gen: NAD CV: RRR, no m/r/g Resp: CTAB Abd: soft, nt/nd Ext: dp pt R dop dop L dop dop Pertinent Results: ___ 06:44PM BLOOD Hgb-11.3* Hct-33.3* Plt ___ ___ 07:20AM BLOOD Hct-32.7* Plt ___ ___ 06:44PM BLOOD ___ PTT-28.0 ___ ___ 06:44PM BLOOD Glucose-108* UreaN-21* Creat-0.8 Na-142 K-3.7 Cl-105 HCO3-32 AnGap-9 ___ 03:08AM BLOOD UreaN-12 Creat-0.7 Na-139 K-4.1 ___ 06:44PM BLOOD ALT-29 AST-51* AlkPhos-70 ___ 04:05AM BLOOD ALT-26 AST-46* AlkPhos-70 TotBili-0.4 ___ 06:44PM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8 ___ 04:05AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.___, the patient was admitted direct to the holding room where patient was pre-oped, lined and consented. Patient is a difficult foley catherter placement, therefore it was decided that the patient will go to surgery without a foley catheter. Patient was taken to the OR for L ___ bypass. Patient tolerated the procedure well, recovered in the PACU then transferred to the VICU. Lower extremity bypass pathway started. ___, the patient's vital signs was stable. Patient has not voided since surgery, was allowed to sit at the edge of the bed to void. Patient was able to void and had been voiding since. Continued on pathway. Good pain control. ___, patient was stable coninuing on the distal bypass pathway. He got OOB to chair on POD 2 and walked with physical therapy on POD 3. He was cleared to go home by ___. ___, no events overnight. at the time of discharge, patient was afebrile with stable vital signs, tolerating a regular diet, ambulating and voiding without assistance, with his pain well controled. Medications on Admission: amlodipine 5 mg qd metoprolol 50 mg qd pregabalin 75 mg qd duloxetine 60 mg qd simvastatin 20 mg qhs allopurinol ___ mg qd percocet prn ASA 325 mg qd lantus 50 units SC QHS Discharge Medications: 1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Allopurinol ___ mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 10. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. 11. Santyl 250 unit/g Ointment Sig: One (1) application Topical once a day: apply topically to left ___ toe daily. Disp:*1 tube* Refills:*0* Discharge Disposition: Home With Service Facility: ___ ___: Non-healing left foot ulcer History of: lung ca MI Bladder ca PSH: R lung lobectomy ___ CABG*4 ___ TURT bladder; L CEA; RLE angio ___ Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Discharge Instructions ACTIVITIES: - ambulate essential distances ___ with Dr. ___ - ___ wrap leg from foot-knee when ambulating, to prevent swelling - Your operated leg is expected to have some swelling and will resolve over time - Elevate leg when sitting - no driving till ___ - may shower, pat dry your incisions, no tub baths WOUND: - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than ___ - Your staples will be removed on your ___ with Dr. ___ ___: - Diet as tolerated eat a well balanced meal - Your appetite will take time to normalize - Prevent constipation by drinking adequate fluid and eat foods rich in fiber, take stool softener while on pain medications MEDICATIONS: - Continue all medications as directed - Take your pain medications conservatively - Your pain will get better over time ___ APPOINTMENTS: - Keep all ___ appointments - Call Dr. ___ for ___ appointment. Phone ___ Followup Instructions: ___

{'non-healing left foot ulcer': ['Atherosclerosis of native arteries of the extremities with ulceration', 'Ulcer of other part of foot'], 'progressive left leg ischemia': ['Atherosclerosis of native arteries of the extremities with ulceration'], 'lung CA': ['Personal history of malignant neoplasm of bronchus and lung'], 'MI': ['Old myocardial infarction'], 'Bladder CA': ['Personal history of malignant neoplasm of bladder']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Non healing left big toe ulcer Major Surgical or Invasive Procedure: Diagnostic angiogram left lower extremity History of Present Illness: ___ year old year old gentleman with h/o trauma to Left big toe when he stubbed it. Was being treated with antibiotics by his PCP. When it failed to heal he had noninvasive arterial studies done whowed decreased blood supply to his left leg. was seen by ___ was scheduled for an angiogram. Past Medical History: Lung CA MI Bladder CA PAST SURGICAL HISTORY: R lung lobectomy ___ CABG*4 ___ TURT bladder; L CEA Social History: ___ Family History: N/A Physical Exam: Admission: Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No right carotid bruit, No left carotid bruit, abnormal: L CEA scar. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses. Rectal: Not Examined. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities. Pertinent Results: ___ 06:20AM BLOOD Hct-37.9* ___ 06:20AM BLOOD UreaN-13 Creat-0.9 K-4.6 CHEST (PRE-OP PA & LAT) Study Date of ___ 7:51 ___ PA AND LATERAL VIEWS OF THE CHEST: The appearance of the right hemithorax is unchanged since ___, with an elevated right hemidiaphragm and overall volume loss consistent with prior resection. There is likely a small right pleural effusion, similar to prior exams. The left lung remains well expanded and clear without consolidation or left pleural effusion. The heart size is normal. There is no hilar or mediastinal enlargement. Pulmonary vascularity is normal. Median sternotomy wires and mediastinal clips are unchanged. Pleural calcifications consistent with asbestos exposure are again noted. IMPRESSION: No acute cardiopulmonary abnormalities. Stable volume loss of the right lung following resection. Brief Hospital Course: ___, patient was admitted for pre-op for left lower extremity angiogram. patient was started on IV broad spectrum antibiotics. Routine labs, ECG, CXR were done. Patient was pre-oped, consented, made NPO after MN, and IV hydrated. On ___, the patient was taken to the angio suite and underwent left lower extremity angiogram, patient was determined to need popliteal artery-posterior tibila artery bypass. This was booked for ___. Patient recovered, then transferred back to ___ 5. Patient was on bed rest for the prescribed amount of time. PO meds and diet resumed. On ___, the patient's labs were within normal limits. The patient ambulated, eating and voiding. Vein mapping was done and seen by PAT in preparation for OR on ___. Discharged to home in good condition. He will return on ___ for a shceduled bypass surgery. Instructions were given for patient to call Dr. ___ for instructions regarding his surgery. Medications on Admission: Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Pregabalin 75 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Duloxetine 60 mg Capsule, Delayed Release(E.C.) PO DAILY (Daily). Simvastatin 20 mg Tablet Sig: Two (1) Tablet PO DAILY (Daily). Allopurinol ___ mg Tablet Sig: Three (1) Tablet PO DAILY (Daily). Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.___.) PO DAILY (Daily). Glargine Sig: Fifty (50) units subcutaneous once a day. Import Discharge Medications CoQ10 1 daily multivitamin 1 daily Glargine 50 units SC daily Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Allopurinol ___ mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Glargine Sig: Fifty (50) units subcutaneous once a day. Discharge Disposition: Home Discharge Diagnosis: Left lower extremity ischemia with ulceration History of: lung ca MI Bladder ca PSH: R lung lobectomy ___ CABG*4 ___ TURT bladder; L CEA Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Post Angiogram Angioplasty Discharge Instructions - Monitor your groin, call if pain, swelling, and bruising is noted - No lifting or straining - Stool softener while on pain medications - If bleeding is noted in the groin, hold pressure and go to the ED - Resume normal activities gradually - Continue all medications as instructed Followup Instructions: ___

{'Non healing left big toe ulcer': ['Atherosclerosis of native arteries of the extremities with ulceration', 'Ulcer of other part of foot'], 'Decreased blood supply to left leg': ['Atherosclerosis of native arteries of the extremities with ulceration'], 'History of trauma to Left big toe': [], 'Elevated right hemidiaphragm': [], 'Volume loss consistent with prior resection': [], 'Small right pleural effusion': [], 'Stable volume loss of the right lung following resection': [], 'Asbestos exposure': [], 'No acute cardiopulmonary abnormalities': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hypertension Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of HTN (prescribed unknown medication in ___ and recently ran out) who was sent in to the ED for hypertension found to have sternal fracture. Patient established care at ___ today and was noted to be significantly hypertensive to 190s systolic. While the patient did not have any overt symptoms, she was sent to the ED for evaluation of hypertensive urgency/emergency and initiation of antihypertensives. She reports that he was taking a medication for his hypertension but ran out 4 days ago. On arrival to the ED, initial vitals notable for afebrile, HR 120, BP 175/106, RR 16, 98% RA. Labs notable for Chem 7 with mild hypernatremia to 148, normal CBC, bland UA without proteinuria, negative troponin. EKG sinus tach with LVF and no evidence of ischemia. CXR with concern for sternal fracture. CT chest then performed which confirmed minimally displaced lower sternal fracture and atelectasis. Trauma surgery consulted and patient reports fall/blunt trauma several days PTA (tripped walking over a curb and fell onto an elevated concrete structure with her chest. No head strike no LOC. First fall, denies prior history) however trauma service did not feel patient required admission for the fracture, but rec f/u in clinic in ___ weeks. Patient given 1gm tylenol 2.5mg oxycodone, amlodipine 5mg and IVF. Given the patient's labile BP and HR, she was admitted to medicine for pain control and further monitoring. Upon arrival to the floor, patient is resting in bed. She reports pain only with movement and deep inspiration. She also reports that her BP generally is in the 170s to 180s at baseline. No other acute complaints. Past Medical History: Hypertension Social History: ___ Family History: Sister has hypertension. No family history of heart attack, stroke, or cancer. Physical Exam: ADMISSION PHYSICAL EXAM VITALS: 98.5; 190/110; 110; 20; 96RA; Pain ___ GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple CARDIAC: tachycardic with occasional PVCs PULMONARY: decreased breath sounds at bilateral bases ___ poor effort. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. DISCHARGE PHYSICAL EXAM Vitals: 98.5 | 158/99 | 18 | 96% on RA General: lying in bed, pleasant, alert, oriented, no acute distress HEENT: sclera anicteric, moist mucous membranes, oropharynx clear Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, well perfused, no evidence of edema Neuro: CNs2-12 intact, motor function normal Pertinent Results: COMPLETE BLOOD COUNT ===================== ___ 05:24AM BLOOD WBC-6.4 RBC-4.05 Hgb-11.5 Hct-36.2 MCV-89 MCH-28.4 MCHC-31.8* RDW-13.7 RDWSD-45.1 Plt ___ ___ 04:20PM BLOOD WBC-7.3 RBC-4.66 Hgb-13.1 Hct-41.3 MCV-89 MCH-28.1 MCHC-31.7* RDW-13.8 RDWSD-44.4 Plt ___ ___ 04:20PM BLOOD Neuts-53.9 ___ Monos-6.1 Eos-1.4 Baso-0.4 Im ___ AbsNeut-3.96 AbsLymp-2.78 AbsMono-0.45 AbsEos-0.10 AbsBaso-0.03 CHEMISTRIES =========== ___ 05:24AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-142 K-4.0 Cl-104 HCO3-28 AnGap-14 ___ 04:20PM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-148* K-3.9 Cl-103 HCO3-30 AnGap-19 ___ 05:24AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.8 URINE STUDIES ============ ___ 04:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG TROPONIN ======== ___ 04:20PM BLOOD cTropnT-<0.01 IMAGING ======= ___ ImagingCHEST (PA & LAT) 1. Minimal cortical step-off involving the lower sternum is suspicious for a minimally displaced sternal fracture. 2. Bibasilar atelectasis. ___HEST W/O CONTRAST 1. Minimally displaced lower sternal fracture with adjacent small hematoma. No other fractures identified. 2. Bibasilar atelectasis. Brief Hospital Course: ___ ___ female with history of chronic hypertension who presents to the hospital after being found to be hypertensive to the 190s and found to have sternal fracture. #Hypertension At presentation patient had BP 175/106 and asymptomatic. She reports taking an unknown medication for hypertension (prescribed by provider in ___ and having been off the medication for the past 4 days because she ran out of it. Patient denied any vision changes, headaches, shortness of breath, or palpitations while interviewed in ___. Initial workup showed no evidence of proteinuria on UA or cardiac ischemia on ECG. Radiograph was notable for sternal fracture which was confirmed on CT (see below). Patient is thought to have elevation of baseline chronic hypertension which was triggered by pain from sternal fracture and being off medication. #Sternal Fracture Patient experienced mechanical fall without evidence of loss of consciousness or head strike on ___. Patient found to have some sternal tenderness on exam. Fracture is depressed but stable on palpation. CXR revealed minimal cortical step-off involving the lower sternum is suspicious for a minimally displaced sternal fracture and atelectasis. CT confirmed these results. Acute Care Surgery evaluated patient in the ED and recommended ambulatory follow up in ___ weeks. Patient was started on tramadol and acetaminophen for pain management. TRANSITIONAL ISSUES #Hypertension: Given 1-month supply of amlodipine, please titrate as appropriate #Concern for Osteopenia/Osteoporosis: Recommend getting outpatient DEXA scan as an outpatient. Patient started on Vitamin 1000U daily and Calcium Carbonate 1000mg daily given concern for osteoporosis/osteopenia. #ACS follow-up: Voice mail to arrange appointment with ACS for follow-up left at ___, please ensure that appointment is made. #Pain management: Discharged with prescription for 10-day course of tramadol 50mg q6h:prn Medications on Admission: Unknown antihypertensive prescribed in ___ Discharge Medications: 1. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Calcium Carbonate 1000 mg PO DAILY osteoporosis RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 3. traMADol-acetaminophen 37.5-325 mg oral Q6H:PRN Duration: 10 Days RX *tramadol-acetaminophen 37.5 mg-325 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 4. Vitamin D ___ UNIT PO DAILY osteoporosis RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS - Chronic Hypertension - Sternal Fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to the hospital after being seen at ___ ___ on ___ with an elevated blood pressure. In the Emergency Department you where evaluated and also were found to have experienced a fall on ___ causing you to experience increased pain. Imaging showed that you have a sternal fracture. It is likely that your blood pressure was elevated in the setting of not taking your medication and stress caused by pain. We started you on amlodipine for your blood pressure and tramadol and Tylenol for your pain. It is likely that you have some bone mineral deficiency so we are also recommending that you take Vitamin D and Calcium at home. Acute Care Surgery (ACS) evaluated you while you were in the Emergency Department and recommend that you follow up in ___ clinic in ___ weeks. Please also follow up with your primary care physician. It was a pleasure taking care of you. We wish you well. Sincerely, Your ___ Care Team Followup Instructions: ___

{'Hypertension': ['Essential (primary) hypertension'], 'Sternal Fracture': ['Unspecified fracture of sternum', 'initial encounter for closed fracture'], 'Fall': ['Fall on same level from slipping', 'tripping and stumbling with subsequent striking against other object', 'initial encounter', 'Sidewalk as the place of occurrence of the external cause'], 'Cardiomegaly': ['Cardiomegaly'], 'Supraventricular tachycardia': ['Supraventricular tachycardia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: liver biopsy Major Surgical or Invasive Procedure: Liver biopsy ___ History of Present Illness: ___ yo M w/ hemophilia, factor VIII deficiency, hep C/cirrhosis with coinfection with HIV secondary to contaminated factor VIII in ___, admitted for observation post liver biopsy for hepatic mass workup. Had rising AFP (61 on ___ --> 181 on ___ and found to have a right lobe lesion on MRI (but not on ultrasound or CT). Lesion is 2.8-cm x 2.0-cm within segment IVb/V of liver, with irregular almost septal-like enhancement. Of note, cirrhosis decompensated by variceal UGIB. His last CD4 count was 236, 31%, HIV VL undetectable. Recently seen Dr. ___ on ___ and his HAART was changed from ritonavir/atazanavir to raltegravir 400mg BID. He was also continued on truvada 1mg po daily. On arrival to the floor, patient feels well and has no complaints. States that the biopsy went well without any complications. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. Hemophilia A - mild, transfusion only during procedures 2. HIV- Dx ___ contracted from clotting factor 3. HCV- Dx ___ G-4 infection. h/o pegIFN/RBV treatment x 3 months and withdrawn due to non-response. 4. WPW tachycardia - diagnosed in the late ___ and does not cause him any discomfort 5. Cirrhosis. Path report, ___: Grade 2 necroinflammatory changes; Stage 4 fibrosis c/w cirrhosis. 6. PCP pna in the early ___ 7. s/p cholecystectomy Social History: ___ Family History: His brother died at ___ of complications of hemophilia in ___. No other family history of lymphoma or malignancies. Father had triple bypass. Physical Exam: ADMISSION PHYSICAL EXAM VS: 98.2, 115/74, 80, 20, 97% RA GENERAL: Well appearing M who appears stated age. Comfortable, appropriate and in good humor. HEENT: Sclera anicteric. PERRL, EOMI, OP clear NECK: Supple with low JVP CARDIAC: RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft, non-tender to palpation. well healed RUQ scar from a previous cholecystectomy, biopsy site covered with dressing and c/d/i, no sign of hematoma and no tenderness to palpation. +splenomegaly. No shifting dullness or fluid wave. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No edema. SKIN: discoloration most notable at lower b/l shins and forehead (pt states it is secondary to HAART) DISCHARGE PHYSICAL EXAM VS: 98.5, 120/78, 67, 18, 98% RA GENERAL: Well appearing M who appears stated age. Comfortable, appropriate and in good humor. HEENT: Sclera anicteric. PERRL, EOMI, OP clear NECK: Supple with low JVP CARDIAC: RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft, non-tender to palpation. well healed RUQ scar from a previous cholecystectomy, biopsy site covered with bandaid and c/d/i, no sign of hematoma and no tenderness to palpation. +splenomegaly. No shifting dullness or fluid wave. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No edema. SKIN: light discoloration most notable at lower shins, forehead (pt states it is secondary to HAART) Pertinent Results: ADMISSION LABS ___ 05:15PM BLOOD WBC-2.7* RBC-3.22* Hgb-13.4* Hct-38.6* MCV-120*# MCH-41.6* MCHC-34.7 RDW-14.8 Plt Ct-57* ___ 05:15PM BLOOD ___ PTT-60.7* ___ ___ 05:15PM BLOOD Glucose-116* UreaN-13 Creat-0.5 Na-136 K-3.3 Cl-105 HCO3-23 AnGap-11 ___ 05:15PM BLOOD ALT-72* AST-121* AlkPhos-74 TotBili-2.3* ___ 05:15PM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8 DISCHARGE LABS ___ 05:42AM BLOOD WBC-2.7* RBC-3.12* Hgb-13.0* Hct-37.2* MCV-119* MCH-41.7* MCHC-34.9 RDW-13.8 Plt Ct-53* ___ 05:42AM BLOOD ___ PTT-60.6* ___ ___ 05:42AM BLOOD Glucose-101* UreaN-12 Creat-0.5 Na-135 K-3.8 Cl-105 HCO3-25 AnGap-9 ___ 05:42AM BLOOD ALT-68* AST-114* LD(LDH)-229 AlkPhos-73 TotBili-1.9* RELEVANT LABS ___ 08:30AM BLOOD FacVIII-77 ___ 05:42AM BLOOD FacVIII-45* ___ CT FLUOROSCOPY-GUIDED CORE BIOPSY IMPRESSION: CT fluoroscopy-guided core biopsy of a contour deforming isoattenuating lesion within segment IV. Pathology pending. ___ LIVER BIOPSY (PATHOLOGY) Liver lesion, segment IVb/V, targeted needle core biopsy: 1. No malignancy identified. 2. Established cirrhosis (Stage 4 fibrosis, confirmed by trichrome and reticulin stains). 3. Scattered bile duct hamartomas; see note. 4. Mild to moderate portal/septal, mild periportal and lobular, predominantly mononuclear inflammation with scattered apoptotic hepatocytes (Grade 2). 5. No significant steatosis or iron deposition identified (iron stain evaluated). Note: The features are those of established cirrhosis, clinically secondary to chronic viral hepatitis C, with Grade 2 inflammation. No malignancy is identified; recommend radiographic correlation to ensure sampling of the reported mass lesion. Given the presence of scattered bile duct hamartomas, an underlying component of polyfibrocystic liver disease cannot be excluded. ___ CYTOLOGY NEGATIVE FOR MALIGNANT CELLS. Brief Hospital Course: ___ yo M with history of hemophilia/factor VIII deficiency, hep C/cirrhosis with coinfection with HIV secondary to contaminated clotting factor, decompensated by prior UGIB admitted for observation after liver biopsy for hepatic mass workup. # Hemophilia s/p liver biopsy: No complications from biopsy. Received factor VIII prior to procedure and post procedure. No signs of bleeding or discomfort at the biopsy site. Denied abdominal pain, fevers/chills, sob. Hct remained stable. Factor VIII was checked day after biopsy and it was 45. Per hematology recommendations, he will continue with Advate ___ generation recombinant factor VIII) 1500 q12h for five more days (day 1: ___. # HCV Cirrhosis: decompensated by varices and UGIB. Currently stable on nadolol. MELD score is 10. No evidence of HE or ascites. Inactive on the liver transplant list at the present time because his MELD score has been around 10 or less. New found liver lesion on MRI 2.8-cm x 2.0-cm within segment IVb/V of liver with recent rising AFP (61 on ___ --> 181 on ___. Per pathology report, no sign of malignancy, cirrhosis secondary to viral hepC with grade 2 inflammation. In addition, presence of scattered bile duct hamartomas, which may indicate underlying component of polyfibrocystic liver disease. # HIV: stable, followed by Dr. ___. Currently on HAART and doing well. History of opportunistic infection with PCP pneumonia in the ___. Last CD4 on ___ was 236, viral load < 20/ml. He was continued on his home dose of Truvada (emtricitabine-tenovir) 200/300 mg qd, Raltegravir 400 mg bid (integrase inhibitor), Zidovudine 300 mg bid (NRTI), and prophylaxis with bactrim SS 400/80 qd. # Esophagitis: continued on home omeprazole 20 mg qd # TRANSITIONAL ISSUES -liver biopsy pathology results without signs of malignancy; presence of scattered bile duct hamartomas -patient to complete 5 days of Advate q12h Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 2. Nadolol 40 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Raltegravir 400 mg PO BID 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. Sumatriptan Succinate 25 mg PO DAILY:PRN headache at the onset of headache. can be repeated after two hours if no relief 7. Zidovudine 300 mg PO BID 8. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Nadolol 40 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Raltegravir 400 mg PO BID 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. Zidovudine 300 mg PO BID 8. Sumatriptan Succinate 25 mg PO DAILY:PRN headache at the onset of headache. can be repeated after two hours if no relief 9. ADVATE *NF* (antihemoph.FVIII plas-alb free) 1,500 (+/-) unit Injection q12 Duration: 5 Days Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - hemophilia - cirrhosis Secondary diagnosis: - HIV - Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your stay at ___ ___. You were admitted to the hospital after a liver biopsy for monitoring given your history of hemophilia. You were treated with factor VIII repletion, and tolerated the procedure well. You will need to continue to administer the factor VIII as prescribed. After you go home, please schedule an appointment with Dr. ___ ___ followup regarding the biopsy results. Followup Instructions: ___

{'hemophilia': ['Congenital factor VIII disorder'], 'factor VIII deficiency': ['Congenital factor VIII disorder'], 'hep C/cirrhosis': ['Cirrhosis of liver without mention of alcohol', 'Chronic hepatitis C without mention of hepatic coma'], 'coinfection with HIV': ['Human immunodeficiency virus [HIV] disease'], 'variceal UGIB': ['Cirrhosis of liver without mention of alcohol'], 'rising AFP': ['Cirrhosis of liver without mention of alcohol'], 'right lobe lesion on MRI': ['Cirrhosis of liver without mention of alcohol'], 'irregular almost septal-like enhancement': ['Cirrhosis of liver without mention of alcohol'], 'splenomegaly': ['Cirrhosis of liver without mention of alcohol'], 'WPW tachycardia': ['Anomalous atrioventricular excitation'], 'PCp pna': ['Other esophagitis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Dark stools Major Surgical or Invasive Procedure: ___: endoscopic banding and injection of sodium laurate by GI History of Present Illness: Mr. ___ is a ___ year old male with history of hemophilia, HepC and HIV contracted from clotting factor transfusions in 1990s, HepC cirrhosis with known varices who presents with dark stools beginning this am. He is otherwise without complaint. He was recently admitted ___ with complaints of melena in the setting of recent variceal bleeding requiring banding while in ___ one month prior. On his last admission, he had not been taking his prescribed PPI. During his last admission he received an octreotide gtt x 24 hours and EGD found that one of the previously placed bands had fallen off but there was no active bleeding at the site. He was discharged on an H2B in place of a PPI due to interactions with HAART. He was scheduled to have a repeat EGD with banding on ___ but given new dark stools he decided to present to the ED. . In the ED, T was 98.5, HR 100, BP 109/60, RR 16, O2 sat 100% on RA. Labs remarkable for Hct of 19.1 (28.9 ___ and slightly elevated AST 54. PTT 57.2, INR 1.4. GI was consulted who recommended octreotide bolus and gtt and Heme consult. Heme also evaluated patient and recommended factor VIII bolus to be followed by BID dosing. He received Protonix 40 mg IV, octreotide 50 mcg bolus followed by 50 mcg/hr gtt, and was scheduled to get factor VIII 50U/kg bolus but did not receive this in the ED before arriving in the ICU. He also received 500 mg of IV levofloxacin and 2 mg of Zofran. Past Medical History: 1. Hemophilia. 2. HIV- Dx ___ contracted from clotting factor; ___ VL 51 and CD4 264 3. HCV- Dx ___ treated with pegylated interferon and ribavirin for three months, stopped early due to failure to achieve any viral response and anemia; now on maintenance pegasysis 4. WPW tachycardia. 5. Hypertriglyceridemia. Social History: ___ Family History: His brother died of complications of hemophilia in ___. He died from HCV. No other family history of lymphoma or malignancies. Physical Exam: : 99.1 BP: 129/81 HR: 88 RR: 24 O2 100% RA Gen: Pleasant, well appearing, although somnolent from sedation given during EGD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, No JVD. CV: RRR. nl S1, S2. No murmurs, rubs ___ LUNGS: CTAB, good BS ___, No W/R/C ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. 2+ DP pulses ___ SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. Neuro exam unable to be completed due to somnolence from sedation given during EGD. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: On Admission: ___ 02:35PM ___ PTT-57.2* ___ ___ 02:35PM PLT SMR-NORMAL PLT COUNT-201# ___ 02:35PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+ ___ 02:35PM NEUTS-65 BANDS-0 ___ MONOS-8 EOS-2 BASOS-2 ___ MYELOS-0 NUC RBCS-1* ___ 02:35PM WBC-7.0# RBC-1.82*# HGB-6.9*# HCT-19.1*# MCV-105* MCH-37.7* MCHC-35.9* RDW-15.6* ___ 02:35PM ALT(SGPT)-35 AST(SGOT)-54* ALK PHOS-57 TOT BILI-1.1 ___ 02:35PM estGFR-Using this ___ 02:35PM GLUCOSE-108* UREA N-29* CREAT-0.6 SODIUM-138 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-10 . On Discharge: ___ 05:35AM BLOOD WBC-2.4* RBC-2.54* Hgb-8.8* Hct-24.2* MCV-95 MCH-34.5* MCHC-36.3* RDW-20.0* Plt Ct-89* ___ 05:35AM BLOOD ___ ___ 05:35AM BLOOD Plt Ct-89* ___ 05:35AM BLOOD Glucose-92 UreaN-16 Creat-0.6 Na-139 K-3.7 Cl-110* HCO3-25 AnGap-8 ___ 05:35AM BLOOD ALT-31 AST-47* AlkPhos-52 TotBili-0.6 ___ 05:35AM BLOOD Calcium-7.6* Phos-3.5 Mg-1.9 Iron-20* ___ 05:35AM BLOOD calTIBC-439 Ferritn-33 TRF-338 . Please see OMR for EGD report. Brief Hospital Course: ___ year old male with hemophilia, HIV, and Hep C cirrhosis with known varices who presents with recurrent melena and HCT 19. . # Acute upper GI bleed: Due to recurrent variceal bleeding. Was last banded ~5 wks ago in ___, then repeat banding during last hospitalization at end of ___. Was scheduled for repeat banding procedure ___, however presented to ER due to dark stools. Complicated by h/o Hemophilia. Received octreotide bolus and factor VIII bolus in ER. Admitted to MICU for urgent EGD which demonstrated 2 cords of grade II varices in the lower third of the esophagus. 1 band was placed just distal to the area of clot/ulceration and area injected with sodium morrhuate. Pt had poor response to first two units PRBC, however HCT bumped appropriately with 2 additional units to 25.4. Did not need further Factor 8. Patient transferred to floor. Monitored on octreotide ggt. Advanced to regular diet and demonstrated stable crit. Patient discharged on ciprofloxacin and Sucralfate for a 7 day course. Patient instructed to take Pantoprazole 40 mg 12 hours apart from Atazinavir. Later was called by pharmacy - switched pantoprazole to omeprazole for insurance purposes. Continued Propranolol 60 mg for varices. - Patient will require repeat banding in 2 weeks . # Hemophilia: Received factor 8 in ER when acutely bleeding. To follow up with heme. . # HIV: Continued HAART meds, Bactrim prophylaxis. Patient instructed to take ppi 12 hours apart from Atainavir. . # HepC: Continued peg-interferon Medications on Admission: Ritonavir 100 mg PO DAILY Atazanavir 150 mg PO DAILY Emtricitabine-Tenofovir 200-300 mg One Tablet PO DAILY Zidovudine 300 mg PO BID Peginterferon Alfa-2a 90 mcg 1X/WEEK (FR) Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY Sucralfate 1 gram three times a day for 2 weeks: At 8am, Noon and 4pm daily x 2 weeks. Ranitidine HCl 150 mg PO once a day as needed for indigestion for 2 weeks: Take 12 hours apart from Atazanavir . Ciprofloxacin 250 mg PO BID Discharge Medications: 1. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atazanavir 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): Separate from Protonix by 12 hours. 4. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 5. Peginterferon Alfa-2a 180 mcg/mL Solution Sig: 90 mcg Subcutaneous 1X/WEEK (FR): 180 mcg/0.5 mL Kit Inject 90mcg . 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Propranolol 60 mg Capsule,Sustained Action 24 hr Sig: One (1) Capsule,Sustained Action 24 hr PO once a day. Disp:*30 Capsule,Sustained Action 24 hr(s)* Refills:*2* 8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 4 days: Take for ___ay 7 ___. . Disp:*16 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): Separate 12 hours from atazinavir . Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days: Take for ___ay 7 ___ . Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute upper GI bleed Esophageal varices and ulcer Anemia from blood loss Hemophilia A HCV cirrhosis HIV Discharge Condition: Good, ambulating, HCT stable Discharge Instructions: You were admitted for anemia due to bleeding from your esophagus. You had an upper endoscopy which demonstrated an oozing esophageal ulcer and varices (1 varix was banded). You received factor 8 for your hemophilia and blood for the anemia. . Please take all your medications as directed. You will be given a prescription for ciprofloxacin, an antibiotic, which you should take for 4 more days to help prevent an infection following your esophageal bleed. You will also be given a prescription for a medication called sucralfate, which you should take for 4 more days. This medication will help your esophagus heal following the bleeding. It is important to take your Pantoprazole 12 hours apart from Atazanavir. . Attend all your follow-up appointments. Please have you blood count checked at your appointment next week with your hematologist. . Return to the ER if you experience dark black stool, lightheadness, dizziness, bleeding, shortness of breath, fever, chills, nausea, vomiting or any other concerning symptoms. Followup Instructions: ___

{'dark stools': ['Esophageal varices in diseases classified elsewhere', 'Cirrhosis of liver without mention of alcohol'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'hemophilia': ['Congenital factor VIII disorder'], 'HepC': ['Chronic hepatitis C without mention of hepatic coma']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: black stools Major Surgical or Invasive Procedure: EGD History of Present Illness: Mr. ___ is a ___ yo M with PMH of HIV, hemophilia, HepC cirrhosis with varices, s/p bleeding episode about one month prior which required banding who presents with complaint of black stools since the morning of admission. States black stools began this morning, but had not been present the day prior. He denies any N/V, lightheadedness or chest paoin. Gave himself 2 vials of Factor 7 and presented to the ED. Upon ED arrival, VS 97.8, 126/74, 87, 14 and 99 on RA. Benign exam except guaiac positive brown stools. He was given Protonix 40mg IV, octreotide bolus, Cipro 400mg IV and Zofran 4mg IV x 1. Liver was consulted and recommened ICU admission for EGD. Upon transfer, HR ___, 126/80, 23, 96/RA. . Upon admission, patient confirms story as above. States he has not been taking his home PPI since leaving ___ one week prior. No abdominal pain. In ___ had hematemesis then banded. Has been admitted one other time with black stools. He had an EGD but not colonoscopy at that time. No obvious source was ever found. Past Medical History: 1. Hemophilia. 2. HIV- Dx ___ contracted from clotting factor; ___ VL 51 and CD4 264 3. HCV- Dx ___ treated with pegylated interferon and ribavirin for three months, stopped early due to failure to achieve any viral response and anemia; now on maintenance pegasysis 4. WPW tachycardia. 5. Hypertriglyceridemia. Social History: ___ Family History: His brother died of complications of hemophilia in ___. He died from HCV. No other family history of lymphoma or malignancies. Physical Exam: BP: 106/68 HR: 87 RR: 18 O2 97% RA Gen: Pleasant, well appearing male. HEENT: Mild conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs ___ LUNGS: CTAB, good BS ___, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: WWP, NO CCE. 2+ DP pulses ___ SKIN: No rashes/lesions, ecchymoses. Pigmentation changes extensively on face. NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: ___ EGD 4 bands were seen in the lower esophagus. The lower band had fell off, the base of which was ulcerated with no active bleeding. Impression: Abnormal mucosa in the esophagus Otherwise normal EGD to third part of the duodenum ___ 04:33AM BLOOD WBC-4.4 RBC-2.64* Hgb-10.7* Hct-28.9* MCV-109* MCH-40.6* MCHC-37.2* RDW-13.1 Plt ___ ___ 11:01PM BLOOD Hct-30.3* ___ 04:56PM BLOOD Hct-31.6* ___ 11:20AM BLOOD WBC-3.9* RBC-3.29* Hgb-12.8* Hct-36.1* MCV-110* MCH-38.9* MCHC-35.5* RDW-13.3 Plt ___ ___ 11:20AM BLOOD Plt ___ ___ 04:33AM BLOOD Plt ___ ___ 11:20AM BLOOD ___ PTT-51.2* ___ ___ 04:33AM BLOOD ___ PTT-63.5* ___ ___ 11:20AM BLOOD Glucose-110* UreaN-24* Creat-0.6 Na-138 K-4.4 Cl-107 HCO3-24 AnGap-11 ___ 04:33AM BLOOD Glucose-102 UreaN-21* Creat-0.6 Na-135 K-4.0 Cl-107 HCO3-26 AnGap-6* ___ 11:20AM BLOOD ALT-47* AST-63* AlkPhos-63 TotBili-2.5* ___ 04:33AM BLOOD ALT-49* AST-91* AlkPhos-50 TotBili-3.0* ___ 11:20AM BLOOD Albumin-3.7 Calcium-8.3* Phos-2.4* Mg-1.8 ___ 04:33AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.8 ___ 11:20AM BLOOD VitB12-616 Folate-10.6 Brief Hospital Course: This is a ___ year old gentleman HIV, HepC, hemophilia who presented with black stools that began the morning of admission. . # GIB: Had a variceal bleed one month prior to admission while in ___ and had his varices banded. Had EGD on admission which showed that one of the bands had prematurely dropped off and this was believed to be the culprit though no active bleeding was seen at the site. Remained hemodynamically stable throughout admission. Started on octreotide drip for 24 hours and discharged on ciprofloxacin 250mg PO BID prophylactically per the liver service. Patient d/c on H2 blocker instead of PPI b/c of interaction w/HAART medications. . # HIV: HIV-1 Viral Load/Ultrasensitive (Final ___ than 48 copies/ml. Followed by Dr. ___. Continued HAART therapy, but consulted w/ ID regarding how to dose atazanavir while on acid suppression. Continued Bactrim prophylaxix. . # HCV: Followed by ___. Currently on Pegasus with ___ dosing. . # WPW: Not on any cardiac medications. No e/o arrythmia during this admission. . # Hemophilia: Patient not followed for some time. Factor VIII given, Factor VIII level and Antibody level drawn. Seen by Hematology, to f/u in clinic. . Was listed as full code. Medications on Admission: Prilosec 20mg po daily Atazanavir 300 mg PO DAILY Peginterferon Alfa-2a 90 mcg SC 1X/WEEK (FR) RiTONAvir 100 mg PO DAILY Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY Sulfameth/Trimethoprim SS 1 TAB PO DAILY Octreotide Acetate 50 mcg/hr IV DRIP INFUSION Zidovudine 300 mg PO BID Discharge Medications: 1. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 5. Peginterferon Alfa-2a 180 mcg/mL Solution Sig: Ninety (90) mcg Subcutaneous 1X/WEEK (FR). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO three times a day for 2 weeks: At 8am, Noon and 4pm daily x 2 weeks. Disp:*42 Tablet(s)* Refills:*0* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day as needed for indigestion for 2 weeks: Take 12 hours apart from Atazanavir . Disp:*14 Tablet(s)* Refills:*0* 9. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Variceal bleeding, upper GI bleeding Secondary: HIV, Hepatitis C Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted after developing black stools concerning for bleeding in your gastrointestinal track. You were treated with IV fluids and medications to stop the bleeding. You also had an EGD that revealed a possible source in your prior variceal banding. Now improved with stable blood tests, you are being discharge home for further recovery. Please keep all outpatient appointments. Please take all medications as prescribed. You have been prescribed two new medications: - Take Sucralfate 3 times daily, at 8am, noon, 4pm - Do not take Sucralfate within 4 hours of taking Atazanavir as this can decrease absorption - You can also take Ranitidine for stomach upset. If you take this medication, take it 12 hours apart from Atazanavir because this may change the absorption Return to the ED if you notice persistent black stools, lightheadedness, chest pain, difficulty breathing, fevers, chills, severe abdominal pain or any other symptoms which are concerning to you. Followup Instructions: ___

{'black stools': ['Esophageal varices in diseases classified elsewhere', 'Cirrhosis of liver without mention of alcohol'], 'bleeding': ['Esophageal varices in diseases classified elsewhere', 'Cirrhosis of liver without mention of alcohol'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'Hepatitis C': ['Chronic hepatitis C without mention of hepatic coma'], 'hemophilia': ['Congenital factor VIII disorder'], 'hypertriglyceridemia': ['Other and unspecified hyperlipidemia'], 'WPW tachycardia': ['Anomalous atrioventricular excitation']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Foot ulcer pain and fever. Major Surgical or Invasive Procedure: ___ line placement. History of Present Illness: Mr. ___ is a ___ male with DMII, Afib on coumadin (cardioverted in ___, HTN, and obesity here with fevers and diabetic foot ulcer. Patient noted this ulcer on the plantar aspect of his right foot two weeks ago after he pulled off some dead skin in that area. He has no feeling in either foot but has noted increase pain over his baseline. He went to his podiatrist (Dr. ___ at ___ 3 days prior to admission for some bothersome ulcers on L toe when podiatrist noted this wound and some associated red streaks extending up the foot. He debrided the wound and started patient on Augmentin. Wound culture reportedly sent at that time to patient's PCP at ___. The night prior to admission, patient woke up with fever to 101 and has been feeling generally unwell since debridement. The wound had been draining some yellow pus. In the ER, initial vitals 7 97.6 108 133/78 18 95% RA. Labs notable for WBC 12.7 (66%N), ESR 23, CRP 7.5, lactate and Chem 7 normal. Foot XR showed no clear evidence of osteo. Blood cultures were sent and he received vanc and unasyn. Currently, patient has mild bilateral foot pain related to his neuropathy. REVIEW OF SYSTEMS: (+) Per HPI dry cough, chronic abdominal pain and diarrhea (-) Denies weight change, Denies headache, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting. Denies dysuria, frequency, or urgency. Past Medical History: Neuropathy Insomnia Hypercholesteremia Hypertension DM (diabetes mellitus) type II Atrial fibrillation s/p cardioversion ___ Social History: ___ Family History: Mother had a large MI at age ___ and died from cancer/heart failure at age ___. Uncle had an MI in his late ___. Father's hx unknown. Physical Exam: EXAM ON ADMISSION: VS: 97.8 124/68 92 18 96%RA 147.7kg GENERAL: well appearing obese man in NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, no JVD LUNGS: +scattered wheezes bilat, no rales, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-distended, no rebound or guarding, no masses, mild ttp over upper abdomen b/l EXTREMITIES: no edema, 2+ pulses pt dp though cooler toes on R than L, numb feet b/l, 2cm in diameter shallow clean-based round ulcer on plantar surface of R foot w/some faint red streaking to dorsal surface of foot, two bandaged toes on L EXAM ON DISCHARGE: VS: 97.6 140/83 ___ 97%RA ___ 185 GENERAL: well appearing obese man in NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, no JVD LUNGS: clear to auscultation bilaterally, no rales, resp unlabored, no accessory muscle use HEART: regular, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, obese, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses pt dp though cooler toes on R than L, numb feet b/l, 2cm in diameter shallow clean-based round ulcer on plantar surface of R foot w/no erythematous streaking, previous marks of streaking to dorsal surface of foot now resolved, L toe lesions without erythema or purulence Pertinent Results: Labs on Admission: ___ 06:05PM BLOOD WBC-12.7* RBC-5.03 Hgb-15.2 Hct-44.8 MCV-89 MCH-30.3 MCHC-34.0 RDW-12.6 Plt ___ ___ 06:05PM BLOOD Neuts-66.6 ___ Monos-5.5 Eos-1.5 Baso-0.7 ___ 06:05PM BLOOD ESR-23* ___ 06:05PM BLOOD Glucose-86 UreaN-19 Creat-1.1 Na-141 K-3.8 Cl-104 HCO3-25 AnGap-16 ___ 06:22PM BLOOD Lactate-1.6 ___ 08:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.3* ___ 08:10AM BLOOD ALT-26 AST-27 AlkPhos-78 TotBili-0.5 ___ 08:10AM BLOOD ___ PTT-42.0* ___ Labs on Discharge: ___ 02:35AM BLOOD WBC-6.2 RBC-4.59* Hgb-13.9* Hct-41.1 MCV-90 MCH-30.3 MCHC-33.9 RDW-12.3 Plt ___ ___ 02:35AM BLOOD ___ PTT-38.9* ___ ___ 02:35AM BLOOD Glucose-187* UreaN-10 Creat-0.9 Na-137 K-4.6 Cl-100 HCO3-27 AnGap-15 ___ 02:35AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7 ___ 02:35AM BLOOD Vanco-10.5 ___ Blood cultures pending. XR FOOT AP,LAT & OBL RIGHT Study Date of ___: Soft tissue ulcer along the plantar and lateral aspect of the foot at the level of the midshaft of the metatarsals. No subcutaneous gas or definite radiographic evidence for osteomyelitis. Please note that MRI or bone scan is a more sensitive exam for the detection of osteomyelitis. CXR ___: Low lung volumes, no pleural effusions. No parenchymal abnormality, in particular no evidence of pneumonia. Borderline size of the cardiac silhouette without pulmonary edema. No hilar or mediastinal abnormalities. Brief Hospital Course: ___ with DMII c/b neuropathy here with a foot ulcer and fever. . # Neuropathic Foot ulcer: Despite debridement by podiatry and oral antibiotics as an outpatient, patient developed fever and cellulitis concerning for resistant organism. Wound culture from OSH shows only skin flora ___ strep, diptherioids) but the patient reports a history of MRSA ulcer infection. Wound had some lymphangitic spread on admission but resolved with vanc/unasyn, now on vanc/augmentin. Low levels of inflammatory markers (see results) and foot XR without e/o osteomyelitis make this unlikely. Patient has good pulses. Podiatry recommended wet to dry betadine dressings and f/u with outpatient podiatry provider. Has been afebrile throughout admission. Has PICC for continued vanc/augmentin to complete total ___s outpatient. Vanc trough 10.5 (therapeutic). . # Afib: Missed coumadin dose ___ night of admission; INR ___ -> ___ -> ___, below goal INR of ___. Was cardioverted in ___, regular rate and rhythm on exam. Continued coumadin and beta blocker. Patient will follow up in ___ clinic ___ to follow-up INR. . # Abdominal pain: Mild on admission and seemed resolved during admission. On last admission, pt was felt to have diverticulitis but current pain is located in the mid-epigastrium so differential more likely to include gastritis, GERD, gastroparesis, gallstones. Per patient he also has associated chronic diarrhea. LFTs/lipase unremarkable ___. . # DM2: continued home insulin regimen and restarted metformin on day prior to discharge. HgbA1c 8.5. # HL: continued statin. # HTN: continued BB, ACEi. . ## Transitional Issues ## 1. pending studies at discharge - blood cx's drawn ___, no growth to date, final pending 2. complete course of antibiotics for cellulitis with IV Vancomycin and PO Augmentin for total 7 day course (___) 3. f/u with outpt podiatrist for 5 metatarsal base resection 4. f/u with ___ for INR monitoring and Coumadin adjustment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO DAILY 2. Glargine 56 Units Breakfast Glargine 30 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner 3. Metoprolol Tartrate 100 mg PO BID HOLD for SBP < 100, HR < 60 4. Warfarin 8.75 mg PO 2X/WEEK (MO,FR) 5. Lisinopril 10 mg PO DAILY HOLD for SBP < 100 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H severe pain 8. Vitamin D 800 UNIT PO DAILY 9. Warfarin 10 mg PO 5X/WEEK (___) 10. Clonazepam 1 mg PO QHS:PRN insomnia Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Clonazepam 1 mg PO QHS:PRN insomnia 3. Glargine 56 Units Breakfast Glargine 30 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner 4. Lisinopril 10 mg PO DAILY 5. Metoprolol Tartrate 100 mg PO BID 6. Vitamin D 800 UNIT PO DAILY 7. Warfarin 8.75 mg PO 2X/WEEK (MO,FR) 8. Warfarin 10 mg PO 5X/WEEK (___) 9. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H severe pain 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Vancomycin 1500 mg IV Q 12H RX *vancomycin 750 mg 1500 mg(s) IV every twelve (12) hours Disp #*20 Vial Refills:*0 12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Neuropathic Diabetic Foot Ulcer c/b cellulitis Seconadry Diagnosis: Atrial Fibrillation s/p Cardioversion HTN 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 Mr. ___, It was a pleasure taking care of you at ___. You were admitted for treatment of cellulitis complicating an ulcer on your right foot. You were started on antibiotics to treat this infection. Your infection appears markedly improved and you are now safe to return home. You missed your ___ evening warfarin dose. Your INR was 1.6 (below your goal of ___ for two days (on ___ and ___. Please follow up in ___ clinic and have your INR checked again on ___, they are aware and will be expecting you. We made the following changes to your medication: Please START Vancomycin Please CONTINUE Augmentin Followup Instructions: ___

{'Foot ulcer': ['Diabetes with neurological manifestations', 'Ulcer of heel and midfoot'], 'Fever': ['Cellulitis and abscess of foot', 'Polyneuropathy in diabetes'], 'Neuropathy': ['Diabetes with neurological manifestations', 'Polyneuropathy in diabetes'], 'Atrial fibrillation': ['Atrial fibrillation'], 'MRSA history': ['Personal history of Methicillin resistant Staphylococcus aureus'], 'Anticoagulant use': ['Long-term (current) use of anticoagulants'], 'Abdominal pain': ['Abdominal pain', 'epigastric'], 'Hypertension': ['Unspecified essential hypertension'], 'Obesity': ['Obesity', 'unspecified'], 'Diarrhea': ['Diarrhea'], 'Hypercholesterolemia': ['Pure hypercholesterolemia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Niacin / Bextra / Tessalon / Fosamax / Hydromorphone Attending: ___ ___ Complaint: Progressive right knee pain with activity Major Surgical or Invasive Procedure: Right total knee replacement History of Present Illness: Ms. ___ is a ___ year old female with a history of osteoarthritis and progressive right knee pain with activity. She presents for definitive treatment. Past Medical History: mild asthma (only w/ infections), chronic pain, hyperlipidemia, osteoporosis, aortic stenosis. Social History: ___ Family History: ___ Physical Exam: On discharge: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Extremities: right lower Weight bearing: partial weight bearing Incision: intact, no swelling/erythema/drainage Dressing: clean/dry/intact Extensor/flexor hallicus longus intact Sensation intact to light touch Neurovascular intact distally Capillary refill brisk 2+ pulses Pertinent Results: ___ 10:37AM BLOOD WBC-8.1 RBC-3.71* Hgb-10.5* Hct-31.7* MCV-85 MCH-28.3 MCHC-33.2 RDW-13.8 Plt ___ ___ 07:25AM BLOOD Hct-28.6* ___ 06:50AM BLOOD Hct-25.6* ___ 06:30AM BLOOD Hct-26.9* Brief Hospital Course: Ms. ___ was admitted to ___ on ___ for an elective right total knee replacement. Pre-operatively, she was consented, prepped, and brought to the operating room. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any complication. Post-operatively, she was transferred to the PACU and floor for further recovery. On POD#2 she received one unit PRBC's for post operative anemia. She had a fever to 101.3 at the end of the transfusion and the transfusion reaction protocol was followed. On the floor, she remained hemodynamically stable with her pain was controlled. She progressed with physical therapy to improve her strength and mobility. She was discharged in stable condition. Medications on Admission: Lipitor 80 daily, Flonase 50mcg BID, Vit D, Calcium Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal BID (2 times a day) as needed for allergies. 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for Pain. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Osteoarthritis Discharge Condition: Stable 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 bear weight on your right leg. Please use your crutches/walker for ambulation. 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 ___ through ___, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on ___, ___, 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: Partial weight bearing Treatments Frequency: Keep your incision/dressing clean and dry. Apply a dry sterile dressing daily as needed for drainage or comfort. Keep your knee dry for 5 days after your surgery. Your skin staples may be removed 2 weeks after your surgery or at the time of your follow up visit. Followup Instructions: ___

{'right knee pain': ['Osteoarthrosis'], 'activity': ['Osteoarthrosis'], 'asthma': ['Asthma'], 'hyperlipidemia': [], 'aortic stenosis': ['Aortic valve disorders'], 'osteoporosis': ['Osteoporosis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Niacin / Bextra / Tessalon / Fosamax / Hydromorphone Attending: ___ ___ Complaint: Right knee stiffness s/p prior R TKA. Major Surgical or Invasive Procedure: ___ R TKR manipulation under anesthesia History of Present Illness: ___ had a total knee replacement in ___ after which she developed arthrofibrosis. She presents for definitive treatment. Past Medical History: mild asthma (only w/ infections), chronic pain, hyperlipidemia, osteoporosis, aortic stenosis. Social History: ___ Family History: NC Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healed * Thigh full but soft * No calf tenderness * ___ strength ___ * SILT DP/SP/T/S/S * Toes warm Pertinent Results: ___ 08:19AM CALCIUM-8.9 PHOSPHATE-4.9* MAGNESIUM-2.0 ___ 08:19AM estGFR-Using this ___ 08:19AM GLUCOSE-98 UREA N-25* CREAT-0.6 SODIUM-141 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16 Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The procedure was uncomplicated and the patient tolerated the procedure well. Postoperative course was remarkable for the following: Otherwise, pain was initially controlled with a PCA + epidural by the pain service followed by a transition to oral pain medications on ___. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The patient was seen daily by physical therapy. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. At time of discharge, patient was deemed stable for safe discharge to home. The patient's weight-bearing status is weight bearing as tolerated Medications on Admission: Atorvastatin 40' Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO twice a day for 21 days. Disp:*42 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home with Service Discharge Diagnosis: Right knee fibroarthrosis s/p prior R TKA Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Call if there is an issue with your knee. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please take Aspirin 325mg TWICE daily for three weeks. 10. WOUND CARE: None needed. 11. ___ (once at home): none needed. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. CPM at home. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT R knee. ROM as tolerated R knee. CPM to Right knee daily as per use in hospital. Treatments Frequency: None. Followup Instructions: ___

{'Right knee stiffness': ['Stiffness of joint', 'Knee joint replacement'], 'Afebrile with stable vital signs': [], 'Pain well-controlled': ['Chronic pain syndrome'], 'Mild asthma': ['Aortic valve disorders'], 'Chronic pain': ['Chronic pain syndrome'], 'Hyperlipidemia': [], 'Osteoporosis': ['Osteoporosis'], 'Aortic stenosis': ['Aortic valve disorders'], 'Arthrofibrosis': ['Stiffness of joint', 'Knee joint replacement'], 'Incision healed': [], 'Thigh full but soft': [], 'No calf tenderness': [], '___ strength ___': [], 'SILT DP/SP/T/S/S': [], 'Toes warm': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal aortic aneurysm Major Surgical or Invasive Procedure: ___: aortography and bilateral lower extremity angiography History of Present Illness: This patient is a ___ gentleman, who presents with complaints of left thigh claudication. It is noninvasive and demonstrates diffuse peripheral vascular disease suggestive of inflow disease on the left and more peripheral disease below the knee bilaterally. He is presenting for a diagnostic, possible therapeutic angiography. Past Medical History: CAD, Carotid stenosis, HTN, CKD Social History: ___ Family History: non-contributory Physical Exam: On Discharge: Vitals: T=98.5, HR=65, BP=150/85, RR=18, SaO2=100 on RA Gen: NAD, AAOx3 Abd: soft, nontender, nondistended Pulse Exam: monophasic pulses on the left with a biphasic DP on the righ Pertinent Results: ___ 07:05AM BLOOD Creat-1.3* Na-137 K-4.2 Cl-102 ___ 07:05AM BLOOD Hct-35.1* Brief Hospital Course: ___ admitted for aortography and bilateral lower extremity angiography. He tolerated the procedure well and was brought to the floor in stable condition. There, his diet was resumed. He was bedbound initially but out of bed the next morning. He tolerated his diet and his pulse exam was unchanged from admission. He was then seen by Anaesthesia for preoperative clearance for a planned EVAR given his findings on aortography/angiography. After he met with Anaesthesia, he was discharged home in stable condition. He will follow up with Dr. ___ as an outpatient to schedule his elective procedure. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. cilostazol *NF* 100 mg Oral BID 4. Furosemide 20 mg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Ascorbic Acid ___ mg PO DAILY 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. cilostazol *NF* 100 mg Oral BID 5. Furosemide 20 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: status post bilateral lower extremity angiography, aortography Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for your abdominal aortic aneurysm. We performed an operative study to better understand the anatomy and found the aneurysm. We also evaluated your legs bilaterally with angiography. You were seen by anaesthesia today for preoperative clearance for an endovascular repair of your aortic aneurysm. You tolerated the angiography well and are clear to return home today. Followup Instructions: ___

{'abdominal aortic aneurysm': ['Abdominal aneurysm without mention of rupture'], 'left thigh claudication': ['Atherosclerosis of native arteries of the extremities with intermittent claudication'], 'noninvasive': [], 'diffuse peripheral vascular disease': ['Atherosclerosis of native arteries of the extremities with intermittent claudication'], 'inflow disease': ['Atherosclerosis of native arteries of the extremities with intermittent claudication'], 'more peripheral disease below the knee bilaterally': ['Atherosclerosis of native arteries of the extremities with intermittent claudication']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left groin pain Major Surgical or Invasive Procedure: ___ ENDOVASCULAR AORTIC ANEURYSM REPAIR History of Present Illness: ___ presents for repair of abdominal aortic aneurysm. The aneurysm was discovered ___ on angiogram when the patient presented for left thigh claudication. At that time the aneurysm was approximately 6.5cm; the patient was scheduled for EVAR. Past Medical History: Past Medical History: 6cm AAA, bilateral CIA aneurysms, PVD with LLE claudication, bilateral CFA, SFA, and profunda disease, CAD, Carotid stenosis, HTN, CKD, SCC R ear Past Surgical History: ___: aortography and bilateral lower extremity angiography Social History: ___ Family History: non-contributory Physical Exam: Vitals: afebrile, vital signs stable Gen: well appering, no apparent distress Abd: soft, nontender, nondistended Cardio: regular rate and rhythm Pulm: clear to ascultation bilaterally, nonlabored breathing Ext: b/l groin puncture sites intact with dermabond, no bleeding or hematoma, mild tenderness to palpation; left leg pain with external rotation and abduction Pertinent Results: HIP UNILAT MIN 2 VIEWS LEFT ___ IMPRESSION: Severe degenerative changes involving the left hip. CHEST (PORTABLE AP) ___ FINDINGS: Lung volumes are relatively low. There is a status post CABG with sternal wires in situ. Normal size of the cardiac silhouette, tortuosity of the thoracic aorta. Areas of mild atelectasis are seen at both lung bases. No evidence of pneumonia and no pulmonary edema. No pneumothorax. Brief Hospital Course: The patient was admitted to the Vascular Surgery service. He had a known 7cm aneurysm (previously scheduled for elective EVAR) as well as a left inguinal hernia but presented with left hip/groin pain. Workup was negative for rupture or growth of the aneurysm and the inguinal hernia was nonincarcerated without any obstruction. However, the patient was taken for endovascular aortic aneurysm repair on ___ (see operative note for further details). The procedure went well without any complications. . Postoperatively, the patient had a fever to 101.7F but workup was negative and the patient was subsequently afebrile. The patient continued to have left hip pain and radiograph of the hip showed severe degenerative osteoarthritis. Orthopaedics was consulted; they recommended physical therapy and outpatient Orthopaedics follow up; if the patient continues to be unable to bear weight on the left leg an MRI may be indicated to rule out occult hip fracture. Secondary to the patient's poor mobility, he was discharged to Rehab for further physical therapy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Ascorbic Acid ___ mg PO DAILY 6. cilostazol *NF* 100 mg Oral BID 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. cilostazol *NF* 100 mg Oral BID 4. Furosemide 20 mg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Acetaminophen 650 mg PO Q6H:PRN fever/pain 7. Docusate Sodium 100 mg PO BID 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 1 TAB PO BID:PRN constipation 11. Ascorbic Acid ___ mg PO DAILY 12. Multivitamins 1 TAB PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: AAA L. Hip DJD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (___ or cane). Discharge Instructions: MEDICATIONS: •Take Aspirin 81mg (enteric coated) once daily •Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. •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 TO EXPECT AT HOME: It is normal to have slight swelling of the legs: •Elevate your leg above the level of your heart (use ___ pillows or a recliner) every ___ hours throughout the day and at night •Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time •Drink plenty of fluids and 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 ACTIVITIES: •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 CALL THE OFFICE FOR: ___ •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 FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) •Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call ___ for transfer to closest Emergency Room. Followup Instructions: ___

{'left groin pain': ['Abdominal aneurysm without mention of rupture', 'Peripheral vascular disease'], 'fever': ['Postprocedural fever'], 'severe degenerative changes involving the left hip': ['Osteoarthrosis'], 'left leg pain': ['Peripheral vascular disease'], 'mild tenderness to palpation': ['Abdominal aneurysm without mention of rupture', 'Inguinal hernia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left distal tibia and proximal fibular fracture Major Surgical or Invasive Procedure: Tibia ORIF with intramedullary nail History of Present Illness: This is a ___ year-old man in her USOH until yesterday afternoon when he sustained a syncope and sustained a torsional fall from standing. He was transferred from an ___ with a splint in place. He denies headstrike and LOC. He also denies, neck or chest pain. He presented to ___ ED with films demonstrating a distal tibia shaft fracture as well as a fibula fracture. Past Medical History: PMH: none PSH: L patellar tendon repair with anterior incision extending to tibial tubercle Social History: ___ Family History: NC Physical Exam: On Admission: A&O x 3 Calm and comfortable ___ Pelvis stable to AP and lateral compression. RLE skin clean and intact Tenderness over L tibia and obvious deformity however no erythema, edema, induration or ecchymosis. There is a small abrasion over anterior aspect of Thighs and leg compartments soft No pain with passive motion Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ ___ TA Peroneals Fire 1+ ___ and DP pulses On Discharge: A+Ox3, calm/comfortable RLE skin clean and intact Dressing c/d/i, incision healing well No pain with passive motion Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ ___ TA Peroneals Fire 2+ ___ and DP pulses Pertinent Results: XR Tibia/Fibula ___: FINDINGS: ___ spot fluoroscopic images of the left tibia were submitted for archival in order to document lateral fixation plate and screw placement across a comminuted distal tibial fracture. For further details, please refer to the operative note. Total operative fluoroscopic time was 141.2 seconds. Brief Hospital Course: On ___ the patient was admitted to the ortho trauma service and noted to have a closed, distal spiral tibial shaft fracture which was reduced and splinted without signs of compartment syndrome or neurovascular compromised. On ___ the patient underwent ORIF intramedullary rod fixation of left tibia fracture. On ___ the patient continued to recover well from surgery. His dressings were changed on post-op day 2 the incision was noted to be healing well. He was discharged home on lovenox for DVT prophylaxis with instructions to follow-up with Dr. ___ in clinic. Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp #*140 Tablet Refills:*0 RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp #*140 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: fracture left tibia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin 325mg daily for 2 weeks/until your follow-up appointment WOUND CARE: - You can get the wound wet/take a shower starting 3 days after your surgery. You may wash gently with soap and water, and pat the incision dry after showering. - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: touch-down weight bearing LLE Followup Instructions: ___

{'syncope': ['Fall from other slipping', ' tripping', ' or stumbling'], 'torsional fall': ['Fall from other slipping', ' tripping', ' or stumbling'], 'distal tibia shaft fracture': ['Closed fracture of shaft of tibia alone'], 'fibula fracture': ['Closed fracture of upper end of fibula alone']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: naproxen Attending: ___. Chief Complaint: left leg pain Major Surgical or Invasive Procedure: open reduction internal fixation of the right tibia/fibula fracture by Dr. ___ on ___ History of Present Illness: ___ yo F who was drinking ___ earlier tonight when she stumbled on the stairs. She twisted her left leg awkwardly and heard a crack. immediate pain and unable to bear weight. ambulance transported to ___ where xrays showed a distal tib/fib fracture. transferred for further care. no numbness or tingling in feet. no other injuries. did not fall. did not hit head. no other complaints. pain tolerable in splint Past Medical History: anxiety COPD Social History: ___ Family History: NC Physical Exam: NAD Breathing comfortably ___ fire +SILT SPN/DPN/TN distributions ___ pulses, foot warm and well-perfused In ACB Pertinent Results: ___ 05:05AM ___ PTT-28.0 ___ ___ 03:30AM GLUCOSE-102* UREA N-16 CREAT-0.6 SODIUM-138 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 ___ 03:30AM estGFR-Using this ___ 03:30AM WBC-10.4 RBC-4.35 HGB-13.8 HCT-40.7 MCV-94 MCH-31.6 MCHC-33.8 RDW-14.2 ___ 03:30AM NEUTS-77.3* LYMPHS-17.3* MONOS-4.7 EOS-0.5 BASOS-0.2 ___ 03:30AM PLT COUNT-188 ___ 02:50AM URINE HOURS-RANDOM ___ 02:50AM URINE HOURS-RANDOM ___ 02:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 02:50AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 02:50AM URINE GR HOLD-HOLD Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left tibia/fibula fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF left tibia/fibula which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home c home ___ was appropriate. She was placed in an aircast boot on POD1. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TDWB LLE in aircast boot, and will be discharged on lovenox x 2 weeks for DVT prophylaxis. The patient will follow up in two weeks with Dr. ___ per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: Prozac Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Doses Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 syringe SC once a day Disp #*14 Syringe Refills:*0 5. Lorazepam 0.5 mg PO Q8H:PRN Anxiety 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*80 Tablet Refills:*0 7. Senna 8.6 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left distal tibia/fibula fracture 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: Instructions After Orthopedic Surgery - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. Medicines - Resume taking your home medications unless specifically instructed to stop by your surgeon. Please talk to your primary care doctor within the next ___ weeks regarding this hospitalization and any changes to your home medications that may be necessary. - Do not drink alcohol, drive, or operate machinery while you are taking narcotic pain relievers (oxycodone/dilaudid). - As your pain lessens, decrease the amount of narcotic pain relievers you are taking. Instead, take acetaminophen (also called tylenol). Follow all instructions on the medication bottle and never take more than 4,000mg of tylenol in a single day. - If you need medication refills, call your surgeon's office 3-to-4 days before you need the refill. Your prescriptions will be mailed to your home. - Please take lovenox for 2 weeks to help prevent the formation of blood clots. Constipation - Both surgery and narcotic pain relievers can cause constipation. Please follow the advice below to help prevent constipation. - Drink 8 glasses of water and/or other fluids like juice, tea, and broth to stay well hydrated. - Eat foods that are high in fiber like fruits and vegetables. - Please take a stool softener like docusate (also called colace) to help prevent constipation while you are taking narcotic pain relievers. - You may also take a laxative such as senna (also called Senokot) to help promote regular bowel movements. - You can buy senna or colace over the counter. Stop taking them if your bowel movements become loose. If your bowel movements continue to stay loose after stopping these medications, please call your doctor. Incision - Please return to the emergency department or notify your surgeon if you experience severe pain, increased swelling, decreased sensation, difficulty with movement, redness or drainage at the incision site. - You can get the wound wet/take a shower starting 3 days after surgery. Let water run over the incision and do not vigorously scrub the surgical site. Pat the area dry after showering. - No baths or swimming for at least 4 weeks after surgery. - Your staples/sutures will be taken out at your 2-week follow up appointment. No dressing is needed if your wound is non-draining. - You may put an ice pack on your surgical site, but do not put the ice pack directly on your skin (place a towel between your skin and the ice pack), and do not leave it in place for more than 20 minutes at a time. Activity - Your weight-bearing restrictions are: touich down weight bearing in the left lower extremity. - You should wear your Aircast boot at all times. Physical Therapy: TDWB LLE in aircast boot with assistive devices ROMAT at all joints Treatments Frequency: Sutures/staples to be removed upon clinic follow up appointment in 2 weeks Daily dressing changes until no drainage, then leave open to air in aircast boot Followup Instructions: ___

{'left leg pain': ['Closed fracture of shaft of fibula with tibia'], 'anxiety': ['Anxiety state'], 'COPD': ['Chronic airway obstruction']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cramping Major Surgical or Invasive Procedure: vaginal delivery History of Present Illness: ___ y/o G5P0040 GDMA, ___ ___ presents to triage with the complaint of cramping and lower back pain. she states the cramping began yesterday and decided that if still cramping would call in the morning. she denies vaginal spotting or leaking. Active fetal movements. Past Medical History: PNC *) Dating ___ ___ by LMP consistant w/7+4 wk u/s *) Labs: AB pos/Ab neg/R-I/RPR-NR/HBsAg neg/HIV negHCV neg *) FFS unremarkable, placenta anterior no previa, cl 44mm *) glucola: ___ ___ ___ issues short CL,on vaginal progesterone, received BMZ and complete on ___. GDMA1 OBHx TAB x 2 SAB x 2 GYNHx LMP ___ LEEP denies STI's PMH benign Social History: ___ Family History: noncontributory Physical Exam: O: BP 126/73 HR 92 RR 14 temp 98 RRR CTA B ABD gravid, soft, NT FHT 145 ___, AGA Toco ctx q ___ mins fFN obtain but not sent given a change in cx SVE 1.5cm/100/BBOW cephalic by U/S Brief Hospital Course: Pt was initially found to be 1.5cm dilated. She was observed on the antepartum service and kept on bedrest. On the morning of ___, her cramping increased and became painful, she was found the be 7cm dilated and in active labor. She was transferred to L&D and had an uncomplicated vaginal delivery of a liveborn male, who was brought to NICU. She did well postpartum and was discharged home on PPD#2. Medications on Admission: prenatal vitamins insulin Discharge Medications: 1. Ibuprofen 600 mg PO Q6H:PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: preterm labor, insulin requiring gestational diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: pelvic rest Followup Instructions: ___

{'cramping': ['Early onset of delivery', 'Abnormal glucose tolerance of mother'], 'lower back pain': ['Early onset of delivery', 'Abnormal glucose tolerance of mother'], 'vaginal spotting': [], 'leaking': [], 'Active fetal movements': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Cough, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: The patient is ___ year old man with history of hypertension, DM2, blindness, and dementia presenting with ___ days of fatigue associated with dry cough, low grade fevers, and diffuse body aches. The patient defers much of the history to his wife who intermittently answers questions for him. He states that ~3 days he slipped outside of his home and hit his back. He has had no anginal chest pain nor shortness of breath. He has sinus congestion without runny nose or sore throat. He has no abd pain, no dysuria, no change in bowels. His AM blood sugars at home have been 95 and 135 the past 2 days. He has been eating and drinking poorly. He has diffuse sweats. The fatigue is notable enough to keep him from walking without assistance from his wife. Upon arrival to the ED, the initial vital signs were 100.3 156/79 110 14 99%RA. A chest xray was normal. He received 1L of saline and tylenol. A nasal aspirate was done for influenza. Upon review of systems, patient confirms pertinent positives as above. Denies) Denies recent weight loss or gain. Denies headache, sinus tenderness. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel habits. Past Medical History: Type 2 Diabetes mellitu Hypertension Hyperlipedmia Legal blindness (can see shapes but blurry) History of atypical chest pain Dementia PVD see ABI from ___ for details Social History: ___ Family History: Non-contributory Physical Exam: Vitals: 98.3 142/100 79 20 97%RA wt 198pounds Gen: thin, eldery ___ male in NAD, sweaty HEENT: EOMI, no pallor. mild sinus tenderness. dry MM. no oral lesions Neck: supple. flat JVP Chest: CTAB w/o wheeze CV: RRR no m/r/g Abd: soft minimal tender to RUQ Ext: no c/c/e Skin: right thigh with skin graft harvest Neuro: -MS: a,ox2 ("hospital, ___, President Obama"). coherent response to interview. unable to alternate A-1,B-2, etc. -CN: II-XII intact except for vision pupils reactive, face symmetric, palate and tongue midline. -Motor: nl tone and bulk. ___ hand grip/bicep/tricep hip-flex plantar/dorsiflex bilat. -DTR: 1+ throughout -___: light touch intact to face/hands/feet Pertinent Results: ___ 07:00PM BLOOD WBC-5.9 RBC-4.25* Hgb-13.1* Hct-37.8* MCV-89 MCH-30.9 MCHC-34.7 RDW-12.7 Plt ___ ___ 06:30AM BLOOD WBC-2.1* RBC-4.00* Hgb-12.5* Hct-35.3* MCV-88 MCH-31.2 MCHC-35.4* RDW-12.7 Plt ___ ___ 07:00PM BLOOD Neuts-84.0* Lymphs-9.7* Monos-5.3 Eos-0.5 Baso-0.5 ___ 06:30AM BLOOD Neuts-46.5* ___ Monos-10.9 Eos-2.9 Baso-1.1 ___ 07:00PM BLOOD ___ PTT-26.5 ___ ___ 07:00PM BLOOD Glucose-187* UreaN-18 Creat-1.5* Na-138 K-3.9 Cl-102 HCO3-24 AnGap-16 ___ 06:30AM BLOOD Glucose-127* UreaN-14 Creat-1.2 Na-141 K-4.3 Cl-106 HCO3-26 AnGap-13 ___ 07:45AM BLOOD ALT-49* AST-197* AlkPhos-47 Amylase-84 TotBili-0.4 ___ 06:30AM BLOOD ALT-55* AST-165* AlkPhos-43 TotBili-0.3 ___ 07:05PM BLOOD Lactate-1.3 ___ 9:55 pm Influenza A/B by ___ Source: Nasopharyngeal aspirate. **FINAL REPORT ___ DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Positive for Influenza A viral antigen. REPORTED BY PHONE TO ___. ___ (___) ON ___ AT 12;25PM. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. CHEST (PA & LAT) Study Date of ___ 8:34 ___ Study is somewhat compromised secondary to body habitus. The lungs are clear without consolidation or edema. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. The visualized osseous structures are unremarkable. IMPRESSION: No acute pulmonary process. Brief Hospital Course: The patient is a ___ year old man with diabetes, hypertension, hyperlipidemia, legal blindness presenting with URI symptoms, cough, and significant fatigue. # Influenza A, causing fever / Fatigue: Patient presented with fever, diffuse body aches, cough and sweats, all which would be quite consistent with influenza. Negative CXR is reassuring for no secondary bacterial pneumonia. No significant metabolic derangement other than mild pre-renal state. As patient presented nearly 5 days into symptoms would be outside of window for directed antivirals. Nasal aspirate was positive for influenza, type A. Given IV fluids. Once symptomatically improved, he was discharged home. # Anemia: Noted on admission. Additionally, patient was clinically dry. During his stay, he had some dropping in Hct, likely secondary to dilution combined with some bone marrow suppression given acute illness. Upon discharge, was recommended to follow-up with primary care physician ___ ___ days to have repeat lab draw. # Leukopenia: Worsening since admission. As above, may be secondary to marrow suppression, along with some dilution secondary to IV fluid. Although low, he was never neutrapenic. Upon discharge, was recommended to follow-up with primary care physician ___ ___ days to have repeat lab draw. # Transaminitis: Stable, some improvement in AST. ___ be secondary to viral illness. Also could be med effect given recently started Aricept. Wife denies alcohol consumption. Holding statin inpatient and post-discharge with plan to have lab rechecked as a outpatient. # Diabetes mellitus: Appears well controlled per OMR. Patient was continued on sulfonylurea and insulin sliding scale inpatient. Upon discharge, she was retarted on Metformin. # Hypertension: Normotensive, with improved volume status. Continued on Lisinopril. HCTZ was held initially but restarted prior to discharge. # Epigastric pain: Unclear etiology. ___ simply be heartburn in the setting of nausea and decreased po intake. Also with transaminitis as above, but pain not truly in in left upper quadrant. Improving by discharge and treated with Maalox inpatient. # Recent fall: Likely mechanical due to physical decline and poor vision. ___ evaluated and recommended home ___ services which were arranged on discharge. Medications on Admission: Aricept 10 mg daily Glipizide 10 mg bid Metformin 1000 mg bid Lisinopril/hydrochlorothiazide ___ mg daily Aspirin 81 mg daily Discharge Medications: 1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Lisinopril-Hydrochlorothiazide ___ mg Tablet One Tablet PO once a day. 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: ___ ___: Primary: Influenza, type A Secondary: Diabetes mellitus, hypertension, hyperlipedmia, legal blindness, dementia, peripheral vascular disease Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted with muscle aches and fever. You were found to have Influenza, type A. You were treated with IV fluids and nursing support. Once improved, you were dishcarged home for further recovery. Please take all medications as prescribed. While inpatient the following medication was held due to some elevated liver tests. - Simvastatin 40 mg daily Please do not restart this medication unless instructed to do so by your primary care physician. Keep all outpatient appointments. You need to get your influenza vaccine every year given your other illnesses put you at increased risk for severe complications. Seek medical advice if you notice fevers, chills, difficulty breathing, chest pain, recurrent falls or any other symptom which is concerning you. Followup Instructions: ___

{'cough': ['Influenza with other respiratory manifestations'], 'fatigue': ['Influenza with other respiratory manifestations'], 'fevers': ['Influenza with other respiratory manifestations'], 'body aches': ['Influenza with other respiratory manifestations'], 'sweats': ['Influenza with other respiratory manifestations'], 'low grade fevers': ['Influenza with other respiratory manifestations'], 'diffuse body aches': ['Influenza with other respiratory manifestations'], 'sinus congestion': ['Influenza with other respiratory manifestations'], 'diffuse sweats': ['Influenza with other respiratory manifestations'], 'anginal chest pain': [], 'shortness of breath': [], 'abd pain': [], 'dysuria': [], 'change in bowels': [], 'headache': [], 'sinus tenderness': [], 'weight loss or gain': [], 'chest pain or tightness': [], 'palpitations': [], 'nausea': [], 'vomiting': [], 'diarrhea': [], 'constipation': [], 'change in bowel habits': [], 'recent weight loss or gain': [], 'headache, sinus tenderness': [], 'shortness of breath, denied': [], 'chest pain or tightness, denied': [], 'palpitations, denied': [], 'nausea, vomiting, diarrhea, constipation, change in bowel habits, denied': []}

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Amoxicillin Attending: ___ Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o woman with h/o panic attacks, carotid artery stenosis, hypertension, hyperlipidemia, COPD (on 2.5L home 02 and daily prednisone), CAD, CHF with EF 10%(per OSH report) who presented with shortness of breath. She noted swelling in her legs (L >R) yesterday and felt herself gasping for breath, she took her home po dose of lasix and the swelling improved but the SOB persisted so she came to our ED. Of note, she has multiple recent admissions at ___ with the same complaint, and each time she was diuresed and sent home. Past Medical History: 1. Carotid artery stenosis status post bilateral endarterectomy in ___ now with recurrent stenosis. 2. Chronic Obstructive Pulmonary Disease on home oxygen at 2.5L at night. 3. Severe peripheral vascular disease. 4. Hypertension 5. Hyperlipidemia 6. Right renal artery stenosis 7. Abdominal aortic aneurysm, s/p surgery ___ 8. Status post left eye cataract surgery. 9. Right eye cataract (untreated) 10. History of panic attacks 11. Congestive Heart Failure, reported EF 10% Social History: ___ Family History: Her father died of a myocardial infarction at the age of ___. Physical Exam: VS - 98.0, 147/93, 110, 18, 99%RA Gen: female 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: Supple with JVP of 8-10 cm. CV: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. ___ systolic murmur. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. diminished BS bilaterally; no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: 1+ bilateral ankle edema Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ Brief Hospital Course: In the ED, she was tachycardic, received 250 cc bolus without much improvement of her HR. CTA was negative for PE. She appeared clinically euvolemic; CXR without significant pulm edema, no JVD, no ___ swelling. LLE US without DVT. She was also reported to have low grade temp in the ED, and received levofloxacin x 1. . On arrival to the floor, she denied chest pain, shortness of breath, she is not tachycardic and notes that her legs are not edematous. She had 02 sats of >95% on her home 02. . #. Dyspnea: Occured in the setting of volume overload ___ edema) and mildly elevated troponins (0.06). However, acute MI ruled out, and patient clinically euvolemic throughout hospitalization except for some ankle swelling. BNP of 27000. CTA ruled out PE. She was restarted on her home dose of lasix. She was also started on ipatropium nebs and albuterol nebs PRN and did not have any more shortness of breath or oxygen requirement. Repeat Echo showed EF ___. We ordered a CT trachea that showed severe tracheobronchomalacia, and our internventional pulmonologists performed bronchoscopy. The first bronchoscopy showed severe tracheomalacia and very large trachea. They were unable to place the non-metal stent because it was too small. So they repeated the bronchoscopy the following day under sedation and placed a metal stent in her left mainstem bronchus and another metal stent in the trachea. The patient tolerated the procedure well. She had mild cough with some sore throat after the procedure. . #. CAD: No chest pain here, no evidence of MI. We increased her beta blocker from 25 to 50 po daily, continued her ACE and Statin. We started Aspirin. . #. Pump: EF reportedly 10% from OSH records. Echo here showed EF ___. We continued her home lasix. After discussion with our cardiologists, we did not feel she would benefit from ICD. Patient required a lot of education regarding diet, exercize and course of illness regarding her CHF. We also consulted nutrition for education about low salt, fluid restricted diet as well as general nutrition to keep up body mass. . #. Hypertension: Well controlled on increased dose of metoprolol, and home dose of quinapril. The patient did not have any episodes of hypo- or hypertension here. . # COPD: Dyspnea was unlikely to be COPD flare as patient 02 sat >92% on home 02, no wheezing on exam. We continued her home 02 (2L) and her 02 sats remained >95%. We started her on ipatropium and albuterol nebs and continued her prednisone. . #. Hyperlipidemia: Continued simvastatin. . # Depression: Continued home citalopram and nortriptyline. Arranged home services including social work, physical therapy and skilled nursing to help patient cope at home. . Medications on Admission: Simvastatin 20mg Citalopram 20mg QD Toprol 25mg daily Nortriptyline 50mg QD Protonix 40mg QD Furosemide 40mg QD Quinapril 40mg QD Prednisone 15 mg daily Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*1 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) puff Inhalation twice a day. Disp:*1 inhaler* Refills:*5* 8. outpatient pulmonary rehab Please go for outpatient pulmonary rehab 9. Quinapril 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO at bedtime. 11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed for shortness of breath. 13. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO once a day as needed. 14. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day) as needed for cough. Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary Diagnosis: Acute systolic heart failure on chronic systolic heart failure COPD Hypertension Anxiety Secondary Diagnosis: Hyperlipidemia h/o panic attacks Discharge Condition: stable Discharge Instructions: You came to the hospital with shortness of breath and a high heart rate. We believe your shortness of breath was due to some fluid in your lungs and worse because you have underlying lung disease. We treated you by putting you back on your home dose of lasix and increasing you toprol XL to slow down your heart rate. We repeated an ultrasound of your heart and it showed that your heart function has not worsened. We got a CT of your chest and trachea that showed your trachea is dilated and floppy. We consulted our pulmonologists who performed a bronchoscopy and they placed two metal stents in your trachea. . We made the following changes to your medication: Changed Toprol XL 50 per day (up from 25 per day) Added Aspirin 81 mg po daily Added Ipatropium inhaler Please take your lasix as directed, 40mg po daily . Because you have heart failure, Please limit your fluid intake to 2L daily. Please limit your salt intake Please weigh yourself daily and if your weight increaes >3lbs call your doctor. . Please follow up with your doctor as below. . If you feel increasing short of breath, have swelling in your legs, have chest pain, dizziness, nausea, vomiting, fever, chills, or any other symptoms that are concerning to you please call your doctor or come to the emergency room. Followup Instructions: ___

{'shortness of breath': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'swelling in legs': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'gasping for breath': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'tachycardic': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'low grade temp': [], 'dyspnea': ['Other diseases of trachea and bronchus'], 'mildly elevated troponins': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'severe tracheobronchomalacia': ['Other diseases of trachea and bronchus'], 'cough': ['Chronic airway obstruction'], 'sore throat': [], 'hypo- or hypertension': ['Hypertensive chronic kidney disease'], 'anxiety': ['Depressive disorder', 'Panic disorder without agoraphobia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Cough. Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo man with known (new) metastatic pancreatic cancer with cough, hemoptysis, dyspnea. These symptoms have been present for the past ___ months but seem gradually worse, now productive of yellow phlegm and occasional blood tinge to sputum. No fevers or chills, recently started on atrovent with some releif. He notes also constipation x last few days. Of note he lives in ___ and ___ been down there until ___, came here to live with son. Noted anterior chest wall mass and associated pain in neck and shoulders, biopsy last week showed met panc ca. He notes wt loss of 10 lbs, ? poor po intake. Pain across low abdomen 'pressure like' ___. No dysuria but nocturia. No CP. He notes his mental status is 'a little off' and son feels this is deteroirating recently as well. He also notes some episodes of hypoglycemia due to poor po intake. In the ED: VS: 98.5 64 110/50 16 99% on RA. He was given levofloxacin. ROS: 10 point review of systems negative except as noted above. Past Medical History: CAD, s/p CABG pancreatic ca DM, type II with neuropathy hypertension bph Social History: ___ Family History: Father with ? sudden cardiac death. Physical Exam: VS: T 97.2 HR 63 BP 140/58 RR 20 Sat 100% RA Gen: Elderly man in NAD Eye: extra-occular movements intact, pupils equal round, reactive to light, sclera anicteric, not injected, no exudates, mild proptosis bilaterally ENT: mucus membranes dry, no ulcerations or exudates Neck: no thyromegally, JVD: flat, anterior neck mass palpable Cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: Soft, mildly tender to palpation over bilateral lower quadrants, slightly distended ? fluid wave, bowel sounds present Extremities: 3+ PE to knees bilaterally, no cyanosis, clubbing, joint swelling Neurological: Alert and oriented x3 but very tangential in speech, CN II-XII intact, normal attention Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, pleasant, slightly anxious Pertinent Results: Admit labs: cbc: WBC-22.3* RBC-4.20* HGB-11.8* HCT-36.7* MCV-88 MCH-28.2 MCHC-32.3 RDW-15.7* PLT COUNT-419 NEUTS-89.2* LYMPHS-5.5* MONOS-4.2 EOS-0.8 BASOS-0.2 BMP: GLUCOSE-42* UREA N-12 CREAT-0.5 SODIUM-133 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-28 AMMONIA-39 LACTATE-2.2* cTropnT-<0.01 ___ 07:10AM BLOOD CEA-288* ___ PTT-28.1 ___ UA: BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG ___ BACTERIA-OCC YEAST-NONE EPI-0 CTA ___ wet read: 1. no PE or acute aortic syndrome 2. pulmonary mets w/ new foci of opacity - may represent additional mets vs infection 3. worsening bony mets and mediastinal lymphadenopathy CT ABDOMEN Preliminary Report !! WET READ !! 1) Pancreatic tail mass measuring up to 6.1 x 5.1 cm, cannot be clearly separated from left adrenal gland. 2) Multiple liver hypodensities consistent with metastatic disease. 3) Lymphadenopathy, notably periportal and peripancreatic. 4) Pulmonary lesions and right pleural effusion better evaluated on chest CT ___, similar in appearance. 5) Non-visualized splenic vein with significant collateral formation, indicative of chronic occlusion. 6) Ascites. 7) Previously seen lytic lesion in L1 vertebral body, new from ___. 8) Splenic calcifications, likely sequelae of prior granulomatous disease. Brief Hospital Course: ___ yo man with met panc ca, dyspnea. 1. Dyspnea: suspect secondary to mets rather than infection given duration of symptoms, however, given ct findings, ___ empiric trial of abx may be reasonable. Initiated nebs and levofloxacin given. Patient symptomatically improved and remained afebrile. 2. Leukocytosis: no clear infection, possible pulmonary source, thought likely ___ malignancy 3. Pancreatic ca: metastatic, Oncology service was consulted for discussion of treatment options. They discussed with patient and his son the option of chemotherapy as well as the likely need for palliative radiation to the sterum given the high likelihood that this will cause worsening s 4. CAD, bypass graft: cont. aspirin, statin, bb, acei 5. DM, type II, uncontrolled: decrease lantus to avoid hypoglycemia, ssi 6. BPH: cont. tamsulosin 7. Neuropathy: cont. lyrica. 8. Constipation: miralax, colace, monitor. Full code. ppx: heparin HCP: son, ___ ___ ___ on Admission: vitamin c 500mg bid aspirin 81mg daily glyburide 5mg bid metformin 500mg bid humalog 8 units with meals lantus 60 units qhs lipitor 10mg daily lisinopril 2.5mg daily lyrica 50mg daily multivitamin daily tamsulosin 0.4mg daily toprol xl 100mg daily atrovent 2 puffs qid Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 2. Ascorbic Acid ___ mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 16. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain: This medication may make you drowsy. You should not drive while taking this medication. Disp:*60 Tablet(s)* Refills:*1* 17. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for hiccups. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) Metastatic pancreatic cancer 2) Possible pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with dyspnea. You were found to have a possible pneumonia. You were prescribed several new medications, including: 1) Levofloxacin 2) Oxycodone for breakthrough pain 3) Senna to prevent constipation 4) Colace to prevent constipation 5) Thorazine for hiccups Please take these as prescribed Followup Instructions: ___

{'cough': ['Secondary malignant neoplasm of lung', 'Pneumonia, organism unspecified'], 'hemoptysis': ['Secondary malignant neoplasm of lung'], 'dyspnea': ['Secondary malignant neoplasm of lung', 'Pneumonia, organism unspecified'], 'constipation': ['Constipation, unspecified'], 'weight loss': ['Malignant neoplasm of other specified sites of pancreas'], 'anterior chest wall mass': ['Secondary malignant neoplasm of mediastinum'], 'pain in neck and shoulders': ['Secondary malignant neoplasm of bone and bone marrow'], 'mental status changes': [], 'hypoglycemia': ['Diabetes with neurological manifestations, type II or unspecified type, uncontrolled'], 'nocturia': [], 'pressure like sensation in low abdomen': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins / fluconazole / Strawberry Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with asthma and bronchiectasis who presents with dyspnea, cough, and weakness, admitted for asthma exacerbation. Patient has been on Mass Health as her primary insurance. Over the past ___ years, she has lost coverage at the beginning of the year for various reasons and in the setting of being unable to afford and obtain her maintenance medications, she has had decomepnsation of her respiratory status. She lost her insurance in ___, and between then and sometime in the last 3 weeks when she was able to get it back, she has been unable to obtain her long acting inhalers (initially Breo --> Symbicort). She has had a number of ER visits to ___ due to respiratory decompensation. In addition, she has been seen by Dr. ___ primary care physician and has been started on two courses of steroids and antibiotics in the past month. Her most recent course was started on ___ with a course of 18 days of levofloxacin and prednisone. Patient reported progressive dyspnea and weakness over the past few days. Denies fevers or chills. She reports cough productive of clear sputum. Had musculoskeletal chest pain triggered by cough. She denies sick contacts. She does have a young grandson who is pre-___ in the home. She came to the ED for evaluation. In the ED, patient's vitals were as follows: T98.3, HR 81, RR 21, BP 132/69, SpO2 100% on RA. CBC without leukocytosis. BMP wnl. BNP slightly elevated at 148. Flu PCR negative. She was given duoneb x 1, 80 mg methylpred, and 500 cc LR. She was admitted to medicine for further work up and management. On arrival to the floor, patient reports interval improvement with ED interventions. Less coughing. Able to complete sentences now. Past Medical History: Asthma: secondary to second-hand smoke HTN Hypercholesterolemia (? reported in Atrius but denied by patient) GERD Vertigo: had one episode one year ago, CT was negative, improved with meclizine Osteoarthritis of knee Dermatitis, eczematous Mitral valve insufficiency Social History: ___ Family History: Mother & maternal grandmother with stroke. Father and daughter with cancer. Grandmother with CAD/PVD. Physical Exam: Admission Physical Exam: ======================== VS - ___ 2207 Temp: 98.2 PO BP: 154/80 HR: 87 RR: 18 O2 sat: 95% O2 delivery: RA GEN - NAD, speaking in hoarse voice but in complete sentences HEENT - NCAT NECK - supple, no LAD CV - rrr, no r/m/g RESP - diffuse expiratory wheezing with poor air movement ABD - soft, nt/nd, +bs EXT - no edema SKIN - no rashes NEURO - alert and oriented x 3 Discharge Physical Exam: ======================== VS: see Eflowsheets GEN - NAD, speaking in complete sentences HEENT - NCAT NECK - supple, no LAD CV - rrr, no r/m/g RESP - diffuse expiratory wheezing with good air movement ABD - soft, nt/nd, +bs EXT - no edema SKIN - no rashes NEURO - alert and oriented x 3 Pertinent Results: Admission Labs: =============== ___ 01:40PM BLOOD WBC-9.3 RBC-4.76 Hgb-13.1 Hct-40.9 MCV-86 MCH-27.5 MCHC-32.0 RDW-15.6* RDWSD-48.2* Plt ___ ___ 01:40PM BLOOD Neuts-79.9* Lymphs-15.2* Monos-3.3* Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.45* AbsLymp-1.42 AbsMono-0.31 AbsEos-0.02* AbsBaso-0.02 ___ 01:40PM BLOOD Glucose-122* UreaN-25* Creat-0.9 Na-139 K-4.5 Cl-101 HCO3-29 AnGap-9* ___ 05:26AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.2 Imaging: ======== CXR: No acute cardiopulmonary process. CT Chest: Very mild bronchiectasis in the right lower lobe. Residual secretions are noted inside the subsegmental bronchi in the left lower lobe. Discharge Labs: =============== ___ 06:15AM BLOOD WBC-16.0* RBC-4.46 Hgb-12.2 Hct-38.0 MCV-85 MCH-27.4 MCHC-32.1 RDW-15.7* RDWSD-48.6* Plt ___ ___ 06:15AM BLOOD Glucose-107* UreaN-25* Creat-0.8 Na-140 K-4.7 Cl-98 HCO3-29 AnGap-13 ___ 06:15AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.___ year old woman with a history of asthma and bronchiectasis who is here with exacerbation of respiratory issues. # Dyspnea: Presented with acute worsening of dyspnea. She has had multiple ED visits recently for the same issue, thought to be due to asthma exacerbations. On admission, CXR was negative for acute abnormalities. BNP was normal. She was noted to have a diffuse wheeze and was started on a steroid course (prednisone 60mg, as she had been taking 10mg daily at home as part of a taper). She was seen by pulmonology, who felt that the diagnosis of asthma was questionable given the lack of obstruction on PFTs (see pulmonary note from ___ for full details). They suspect that she may have vocal cord dysfunction. There may also be an element of GERD/aspiration, and post-nasal drip contributing to her symptoms, particularly since she reports that her cough is worse at night. In addition, pulmonary felt that there was a significant component of anxiety contributing to her dyspnea, which patient acknowledged may be the case. She also carries a diagnosis of bronchiectasis, but this was found to be very mild on CT chest. She was discharged on a rapid prednisone taper. She was continued on home Zyrtec, Montelukast, and flonase as well as symbicort. Omeprazole was increased to BID. ___, ANCA, and IgE sent per pulmonary recommendations and were pending at time of discharge. Pulmonary recommended outpatient ENT evaluation for vocal cord dysfunction, outpatient video swallowing study, and repeat outpatient PFTs. Patient reported that she would like to follow up with ___ pulmonary. An appointment was pending at time of discharge. # Leukocytosis: developed leukocytosis to 16 with no fever or infectious signs. Likely steroid effect # HTN : continued dyazide and amlodipine # GERD: continued omeprazole, which was increased to BID per pulmonary recommendations > 30 minutes spent on discharge coordination and planning Transitional Issues: ==================== - discharged on rapid prednisone taper - omeprazole and flonase increased to BID - ___, ANCA, and IgE pending at time of discharge - pulmonology recommending outpatient ENT evaluation for vocal cord dysfunction, video swallow, and repeat PFTs - patient reported that she wanted to follow up with ___ pulmonology. Appointment pending at time of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. ZyrTEC (cetirizine) 10 mg Oral qd 6. Montelukast 10 mg PO DAILY 7. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze 8. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral DAILY 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze 10. amLODIPine 2.5 mg PO DAILY 11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 12. LevoFLOXacin 750 mg PO Q24H 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY Discharge Medications: 1. PredniSONE 60 mg PO DAILY Tapered dose - DOWN RX *prednisone 10 mg 6 tablet(s) by mouth once a day Disp #*32 Tablet Refills:*0 2. Fluticasone Propionate NASAL 1 SPRY NU BID RX *fluticasone propionate 50 mcg/actuation 1 spry NAS twice a day Disp #*1 Bottle Refills:*0 3. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze 5. amLODIPine 2.5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Calcium Carbonate 500 mg PO DAILY 8. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral DAILY 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze 10. Montelukast 10 mg PO DAILY 11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 12. Vitamin D 1000 UNIT PO DAILY 13. ZyrTEC (cetirizine) 10 mg Oral qd Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Dyspnea GERD Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came in because your breathing was becoming worse. You were seen by the pulmonary doctors, who felt that there were several different things contributing to your breathing problems. They recommended increasing your omeprazole to twice a day. This medication treats acid reflux and acid reflux can sometimes cause breathing issues. You will also need to see an ear, nose and throat doctor as an outpatient and will need to have a video swallowing study. We are sending you home on a prednisone taper: ___: take 6 tabs (60mg) ___: take 6 tabs (60mg) ___: take 6 tabs (60mg) ___: take 4 tabs (40mg) ___: take 4 tabs (40 mg) ___: take 2 tabs (20mg) ___: take 2 tabs (20mg) ___: take 1 tab (10mg) ___: take 1 tab (10mg) ___: stop prednisone It was a pleasure taking care of you, and we are happy that you're feeling better! Followup Instructions: ___

{'dyspnea': ['Dyspnea', 'unspecified'], 'cough': ['Gastro-esophageal reflux disease without esophagitis', 'Bronchiectasis', 'uncomplicated'], 'weakness': ['Essential (primary) hypertension', 'Elevated white blood cell count', 'unspecified'], 'musculoskeletal chest pain': ['Adverse effect of glucocorticoids and synthetic analogues', 'initial encounter'], 'sick contacts': ['Patient room in hospital as the place of occurrence of the external cause', 'Personal history of nicotine dependence'], 'productive cough of clear sputum': ['Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: adhesive / Venomil Yellow Jacket Venom / Codeine / Vicodin / lisinopril Attending: ___ Chief Complaint: cystocele, stress urinary incontinene Major Surgical or Invasive Procedure: anterior colporrhaphy, suburethral sling, cystoscopy History of Present Illness: The patient is a ___, referred for gynecologic evaluation regarding vaginal prolapse and stress incontinence. The patient was originally managed with a pessary, which she wore for approximately ___ years. She eventually experienced some vaginal spotting and elected for a more definitive management in the form of surgery. She was referred for multichannel urodynamic testing, which confirmed that she has stress urinary incontinence with urethral hypermobility. Past Medical History: PMH: polymyalgia rheumatica, HTN, hypothyroidism, low back pain, SVD x4 PSH: TAH BSO, CCY, appx, carpal tunnel x2, temporal artery ligation Social History: ___ Family History: Her family history is siginficant for a sister with ___ cancer and unremarkable for Ovarian or Colon cancer. Physical Exam: Preoperative physical exam: Vaginal exam : External genitalia: no lesions or discharge urethral meatus: no caruncle or prolapse urethra: non tender, no exudate Internal exam: There was moderate/severe vaginal atrophy. Vagina was inspected and there were ulcerations absent # 3 ring w/ support was removed and NOT REINSERTED Discharge exam: Gen: NAD CV: RRR Lungs: CTAB Abd: soft, NT, ND GU: minimal spotting on pad, clear urine in foley Ext: WWP, calves nontender Brief Hospital Course: Ms. ___ was admitted to the gynecology service after undergoing a TVT EXACT sling procedure, anterior colporrhaphy and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 240 mL, voided 0 mL with 400 mL residual. 2. Instilled 300 mL, voided 0 mL with 350 mL residual. Her Foley catheter was replaced and she was instructed in its care. Her diet was advanced without difficulty and she was transitioned to oral pain medications. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. PredniSONE 5 mg PO DAILY 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*3 5. eszopiclone 3 mg oral HS 6. Hydrochlorothiazide 25 mg PO DAILY 7. Ibuprofen 600 mg PO Q8H:PRN Pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*1 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain Do not drive while taking this medication. RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 9. Acetaminophen 1000 mg PO Q6H:PRN pain Do not exceed 4000 mg per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*3 10. Nitrofurantoin (Macrodantin) 100 mg PO DAILY RX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth once a day Disp #*5 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: bladder prolapse stress urinary incontinence urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after undergoing an anterior repair and sling procedure. You have recovered well and are ready to be discharged. You are being discharged with a foley catheter in place. Please follow the instructions below: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks or until cleared at your post-operative appointment * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ office in ___ on ___ at 9:20am for catheter removal. Followup Instructions: ___

{'vaginal spotting': ['Cystocele'], 'stress urinary incontinence': ['Stress incontinence', 'Urethral hypermobility'], 'urethral meatus': [], 'vaginal atrophy': ['Cystocele'], 'urinary retention': ['Stress incontinence', 'Urethral hypermobility'], 'bladder prolapse': ['Cystocele']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Lisinopril Attending: ___. Chief Complaint: right knee pain Major Surgical or Invasive Procedure: right total knee replacement History of Present Illness: Mr ___ has had progressive right knee pain that has been refractory to conservative management. He elects for definitive treatment. Past Medical History: PMH: (per OMR) -stroke in ___ -question of a pinhole ventricular septal on prior cardiac imaging -HLD -Glaucoma -HTN -MV s/p repair w/ porcine valve per OMR as did not tolerate metal valve (details not clear from preliminary review in OMR) -aortic valve replacement with 25 mm ___ -OA -BPH -CEA on R with a saphenous vein patch w/ complication of a large hematoma and a small pseudoaneurysm -PVD -Lumbar stenosis with spondylolisthesis s/p laminectomy as well as L2 to S1 incision with drainage and debridement of infection and closure of left L3-4 dural opening -abdominal aortic aneurysm repaired in ___. -hearing loss as a child which was secondary to an ear infection and subsequent abscess. He has an approximate 50% hearing loss. He has 50% normal hearing with a hearing aid. -Cataracts bilaterally -R knee surgery -myocardial infarction in ___ with subsequent balloon angioplasty of his mid RCA. A stent was placed in the RCA in ___ -ventral hernia that was surgically repaired in the ___ -HF and AF per one note, but not listed in others Social History: ___ Family History: father w/ heart disease per OMR Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: 1. Transfused 1 unit autologous PRBCs in PACU 2. Geriatrics co-managing 3. On telemetry - SR with frequent PVCs. EKG - NSR. 4. Patient was very disgruntled during admission. Patient felt he was being sent to rehab too soon. Seen by Patient Advocate by patient request and CNS in addition to usual staff with resolution of the problem. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Mr ___ is discharged to rehab in stable condition. Medications on Admission: felodipine and finasteride, folate, hydrochlorothiazide, Vicodin for knee and back pain, metoprolol, simvastatin, spironolactone, terazosin, aspirin, vitamin D, and Prilosec. Discharge Medications: 1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 3 weeks. Disp:*21 syringe* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks: AFTER completing all lovenox injections, please take 325 mg aspirin twice daily with food for an additional 3 weeks. AFTER the additional 3 weeks, you may resume you home dose of 325mg aspirin daily. Disp:*42 Tablet(s)* Refills:*0* 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. eplerenone 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 13. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right knee osteoarthritis 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse (___) or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three (3) weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for an additional three weeks. ___ STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 11. ___ (once at home): Home ___, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT ROM - unrestricted Mobilize Treatments Frequency: dry, sterile dressing daily as needed for drainage wound checks ice and elevate staple removal at POD 17 Followup Instructions: ___

{'right knee pain': ['Osteoarthrosis'], 'stroke': ['Personal history of transient ischemic attack (TIA)', 'and cerebral infarction without residual deficits'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'glaucoma': ['Unspecified glaucoma'], 'hypertension': ['Unspecified essential hypertension'], 'heart valve transplant': ['Heart valve replaced by transplant'], 'hypertrophy of prostate': ['Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'], 'atherosclerosis of extremities': ['Atherosclerosis of native arteries of the extremities', 'unspecified'], 'hearing loss': ['Unspecified hearing loss'], 'cataract': ['Unspecified cataract'], 'coronary atherosclerosis': ['Coronary atherosclerosis of native coronary artery'], 'myocardial infarction': ['Old myocardial infarction'], 'angioplasty': ['Percutaneous transluminal coronary angioplasty status'], 'tobacco use': ['Personal history of tobacco use']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vancocin / Zosyn / ceftriaxone Attending: ___. Chief Complaint: Fever, Drug Rash Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o male with a recently complicated history of multiple right knee surgeries, most recently complex right knee revision including megaprosthesis ___, c/b infection, and Left rectus muscle free flap to right lower extremity on ___ and was discharged ___. In the past, he has had a prosthetic joint infection due to Proteus and CoNS, but during that last admission he has grown E. Coli, Enterococcus and Bacteroides. He was again admitted to ___ on ___ with fever to 102.7 at home. During this most recent hospitalization his fever was attributed to a drug reaction, thought to be from the zosyn. As a result his regimen was changed from daptomycin, metronidazole and ceftriaxone. He was discharged home on ___ after tolerating the regimen in the hospital. Yesterday however he noticed the start of a rash on his legs and arms that was erythematous and very pruritic. Today the rash worsened, has become more diffuse and he represented to the hospital for further evaluation. In the ED, initial vs were: 99.6, 108, 117/48, 16, 100% on RA. His labs showed a white count of 6.9 with 6% eosinophils, other labs were stable from his recent discharge. Exam was notable for fever and diffuse erythematous macular rash. He was given benadryl for presumed drug reaction and admitted for further evaluation. VS on transfer were: 102, 135/90, 103, 17, 100% on RA. On the floor initial VS were: 101.3, 116/44, 100, 20, 98% on RA. He currently only complains of extreme pruritis. Past Medical History: Prosthetic Joint Infections Hypertension Osteoarthritis Social History: ___ Family History: Positive for cancer, nonspecific Physical Exam: Admission Physical Exam: Vitals: 101.3, 116/44, 100, 20, 98% on RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, +S1/S2, ___ systolic/diastolic murmur heard throughout the precordium Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Right knee flap with some erythema, site with small amount of serosanguinous drainage, does not appear infected Skin: diffuse erythematous macular rash Discharge Physical Exam (Pertinent): Tm 99.0 Tc 97.2 BP 116/52 HR 76 RR 18 SpO2 100%/RA General: Alert, oriented, no acute distress CV: Regular rate and rhythm, +S1/S2, ___ systolic/diastolic murmur heard throughout the precordium Ext: Right knee flap with some erythema, site with small amount of serosanguinous drainage, does not appear infected Skin: no rash noted Pertinent Results: Admission Labs: ___ 10:30AM BLOOD WBC-6.9 RBC-4.10* Hgb-10.7* Hct-33.6* MCV-82 MCH-26.2* MCHC-32.0 RDW-17.3* Plt ___ ___ 10:30AM BLOOD Neuts-80* Bands-0 Lymphs-9* Monos-3 Eos-6* Baso-0 Atyps-2* ___ Myelos-0 ___ 10:30AM BLOOD Glucose-130* UreaN-12 Creat-1.2 Na-133 K-3.4 Cl-96 HCO3-23 AnGap-17 ___ 07:13AM BLOOD ALT-15 AST-21 AlkPhos-65 TotBili-0.5 ___ 07:13AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8 Blood cultures ___: No growth to date Discharge Labs: ___ 07:10AM BLOOD WBC-4.1 RBC-3.49* Hgb-9.3* Hct-28.4* MCV-81* MCH-26.7* MCHC-32.8 RDW-16.7* Plt ___ ___ 07:10AM BLOOD Glucose-94 UreaN-14 Creat-1.1 Na-137 K-3.2* Cl-101 HCO3-26 AnGap-13 Brief Hospital Course: Mr. ___ ia ___ y/o male s/p total knee replacement and multiple right knee surgeries now s/p Left rectus muscle free flap to right lower extremity complicated by infection with E. Coli, Enterococcus and Bacteroides recently discharged on daptomycin, ceftriaxone and metronidazole who presents with fever, rash and pruitis. Fever and rash improved on monotherapy of tigecycline, but pruitis remained and pt refused taking antibiotics. ID make recs to switch therapy to meropenem 500mg IV q6h and linezolid ___ mg q12h. ID further narrowed coverage to meropenem 500 mg IV q12h since he had completed a full two week treatment for enterococcus. #Drug Reaction: Fever and pruitis is likely from the ceftriaxone given his recent reaction to the Beta-Lactam zosyn. Right knee flap does not appear infected at this time, and his presentation is very similar to his recent drug reaction. Discussed pt with ID as to what to change his antibiotic regimen to given his recent allergic reactions and polymicrobial infection. ID recommended switch to tigecycline and stopping prior antibiotic regimen. Fever and rash improved on monotherapy of tigecycline, but pruitis remained and pt refused taking antibiotics. ID make recs to switch therapy to meropenem 500mg IV q6h and linezolid ___ mg q12h. ID further narrowed coverage to meropenem 500 mg IV q12h since he had completed a full two week treatment for enterococcus. Pt additionally received hydroxyzine for control of pruritis. #Prosthetic Joint Infection: No active signs of infections in right knee. Patient will continue on meropenem on discharge home. #Hypertension: blood pressure was well controlled on home HCTZ 25mg daily dose. Pt will follow up in the infectious disease clinic for antibiotic labs. Medications on Admission: 1. ceftriaxone 1 gram q24h 2. daptomycin 500 mg Q24H 3. aspirin 81 mg once a day. 4. acetaminophen 650 mg Q6H as needed for fever. 5. enoxaparin 30 mg Q12H 6. hydrochlorothiazide 25 mg once a day. 7. oxycodone 5 mg Tablet Sig: ___ Tablets Q4H as needed for pain. 8. metronidazole 500 mg Q8H Discharge Medications: 1. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. Disp:*qs * Refills:*0* 7. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Disp:*30 flushes* Refills:*0* 8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*24 Tablet(s)* Refills:*0* 9. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours). Disp:*120 Recon Soln(s)* Refills:*2* 10. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for itching. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Drug rash 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: Mr. ___, It was a pleasure taking care during your stay at ___ ___. You were admitted with a rash. This was likely the result of a drug reaction. Your antibiotics were changed and you improved. You are now ready for discharge. During the course of your hospitalization, the following changes were made to your medications: - STOPPED flagyl - STOPPED ceftriaxone - STOPPED daptomycin - STARTED Meropenem - STARTED Hydroxyzine You will need a few labs checked at your appointment next week because of your antibiotics. Followup Instructions: ___

{'Fever': ['Dermatitis due to drugs and medicines taken internally', 'Cephalosporin group causing adverse effects in therapeutic use'], 'Drug Rash': ['Dermatitis due to drugs and medicines taken internally', 'Cephalosporin group causing adverse effects in therapeutic use'], 'Pruritis': ['Other specified pruritic conditions', 'Dermatitis due to drugs and medicines taken internally'], 'Knee joint replacement': ['Knee joint replacement'], 'Hypertension': ['Benign essential hypertension'], 'Osteoarthritis': ['Osteoarthritis', 'unspecified whether generalized or localized', 'lower leg'], 'Aortic valve disorders': ['Aortic valve disorders'], 'Anemia of other chronic disease': ['Anemia of other chronic disease']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vancocin Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: Joint fluid aspiration and culture ___ History of Present Illness: ___ with HTN s/p multiple right knee surgeries, most recently complex right knee revision including megaprosthesis ___, c/b infection, and Left rectus muscle free flap to right lower extremity on ___. He was discharged ___. In the past, he has had PJI due to Proteus and CoNS, but during his last admission he has grown E. Coli, Enterococcus and Bacteroides. He is being followed by ID as an outpatient and is currently on a regimen of zosyn (via PICC) and PO rifampin. Pt presented to the ED today after a fever of 102.7 at home (takes his temp regularly). He denies any localizing signs/symptoms of infection including SOB, dysuria, headache/neck stiffness, abdominal pain, diarrhea, N/V, cough, or increased swelling or redness of the knee. He reports taking good PO intake. In the ED Ortho was consulted who felt no urgent intervention needed and will follow. CXR and UA were unremarkable. K+ was repleted, ESR/CRP added on, and pt was given nafcillin/ampicillin for possibility of endocarditis. ROS: Denies headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Hypertension OA of both knees Social History: ___ Family History: Positive for cancer, nonspecific. Physical Exam: Admission Exam: VS: T 98.7-99.6 BP 99-118/50-67 HR 91-100 RR ___ O2 Sat 96% RA GENERAL: NAD, affect somewhat blunted HEENT: NC/AT, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no JVD. HEART: RRR, harsh ___ systolic/diastolic murmur throughout the precordium, nl S1-S2. LUNGS: CTA bilat ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. Left sided vertical abdominal incision c/w recent rectus muscle graft c/d/i, no erythema or exudate EXTREMITIES: cool to touch, no c/c/e, 1+ peripheral pulses. There is a large muscle graft over the R knee which looks c/d/i. No tenderness or erythema/warmth. Right arm PICC is c/d/i without pain or erythema SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII intact, strength and sensation grossly intact Discharge Exam: VS: 98.5, 128/58, 88, 18, 100% RA GENERAL: NAD HEENT: NC/AT, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no JVD. HEART: RRR, harsh ___ systolic/diastolic murmur throughout the precordium, nl S1-S2. No splinters, oslers nodes, ___ lesions LUNGS: CTA bilat ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. Left sided vertical abdominal incision c/w recent rectus muscle graft EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. There is a large skin graft over the knee which looks c/d/i. No tenderness or erythema/warmth. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact Pertinent Results: Admission Labs: ___ 10:05PM SED RATE-58* ___ 10:05PM ___ PTT-28.1 ___ ___ 10:05PM NEUTS-74.5* LYMPHS-12.3* MONOS-6.0 EOS-6.5* BASOS-0.7 ___ 10:05PM WBC-3.6*# RBC-3.11* HGB-8.6* HCT-25.6* MCV-82 MCH-27.6 MCHC-33.5 RDW-16.7* ___ 10:05PM CRP-65.2* R Knee AP/Lat/Oblique (___): S/p right knee arthroplasty with hinge prosthesis, without evidence of loosening. Suspect joint effusion, though this is best corrrelated with physical exam. Small focus of subcutaneous emphysema noted. RUE Ultrasound (___): No evidence of DVT in the right upper extremity R Knee Ultrasound (___): In the medial right knee, subjacent to the flap, there is a hypoechoic irregular collection measuring approximately 2.4 cm in greatest depth. In the sagittal plane, this measures approximately 1.0 cm in greatest depth. In the distal lateral right thigh, there is a heterogeneous hypoechoic collection measuring approximately 1.8 x 3.5 cm in size, which is separate from the fluid on the medial side. CT Abd/Pelvis (___): 1. Prostatic hypertrophy with a hypodense peripheral zone, which is a nonspecific finding. 2. No evidence of a drainable periprostatic or intraprostatic fluid collection. 3. table renal and hepatic cysts. 4. No free fluid. R Knee Aspirate (___): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. Discharge Labs: ___ 05:50AM BLOOD WBC-4.7 RBC-3.28* Hgb-8.8* Hct-27.2* MCV-83 MCH-26.9* MCHC-32.4 RDW-17.2* Plt ___ ___ 05:50AM BLOOD Glucose-107* UreaN-10 Creat-1.1 Na-136 K-3.4 Cl-100 HCO3-26 AnGap-13 ___ 04:46AM BLOOD ALT-37 AST-45* CK(CPK)-79 AlkPhos-67 TotBili-0.___ y/o man with complicated right knee replacement history including multiple prosthetic joint infections s/p multiple revisions and washouts with recent muscle flap reconstruction presents from home with fever. In late ___, he was on Zosyn and Rifampin. He presented this hospitalization with fever. His knee was assessed by orthopedic surgery and thought not to be infected. Zosyn was stopped and the patient's fever resolved suggesting that he may have had a drug fever from Zosyn. Antibiotic regimen was adjusted to Daptomycin, Ceftriaxone, and Metronidazole which the patient tolerated well. ACTIVE PROBLEM LIST: # Drug Fever: Pt was on Zosyn for suppressive antibiotic coverage for PJI as outpatient and reported feeling febrile and experiencing chills, fever and severe pruritis with Zosyn infusions. He was documented to have fevers as an inpatient, not all of which coincided with Zosyn infusion. However, Zosyn was discontinued and the patient remained afebrile for the remainder of his hospital course. He had an extensive infectious workup and the R knee was exonerated as a possible source. Urine was clean and CXR was clear and blood cultures were negative at the time of discharge. There was concern for RUE DVT ___ inability to draw off the PICC, but RUE ultrasound was negative. Questionable prostatitis called on CT is unlikely given long term broad antibiotic coverage for all organisms that cause prostatitis and negative Gc/Ct assays. # History of R Knee prosthetic joint infections: Pt followed by ID; will require long term suppressive therapy to prevent recurrence of PJIs. Discharged on Daptomycin, Ceftriaxone, and Metronidazole, which the pt was tolerating well at the time of discahrge. He will follow up with Plastics and ID. INACTIVE ISSUES: # Anemia: Pt's Hct remained at baseline throughout his hospital course. He had an anemia workup as outpatient that revealed likely ACD, consistent with recurrent PJI infections # HTN: Pt was normotensive and hemodynamically stable throughout the hospital course. He was continued on his home HCTZ. # Leukopenia: Pt was leukopenic at the time of admission, resolved by discharge. Given the timecourse of his leukopenia, it is possible this was a manifestation of his systemic reaction to Zosyn. ## Transitional Issues: Pt discharged home on Daptomycin, Ceftriaxone, and Metronidazole. He will require follow up with PCP, ___ ___ and ID for his R knee. Medications on Admission: -aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). Disp:*45 Tablet, Chewable(s)* Refills:*0* -acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, HA, T>100 degrees: Max 12/day. Do not exceed 4gms/4000mgs of tylenol per day. -enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours). Disp:*60 syringes* Refills:*2* -hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). -rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* -oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. -piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 grams Intravenous Q8H (every 8 hours). -diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Medications: 1. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours). Disp:*30 gram* Refills:*0* 2. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). Disp:*30 Recon Soln(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 5. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). 6. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: - History of recurrent knee infection - Drug Fever (Zosyn) SECONDARY DIAGNOSES: - Hypertension - 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: Mr. ___-- It was a pleasure taking care of you at ___ ___. You were admitted with fevers. Given your history, there was concern that you had a worsening infection in your knee joint. You were evaluated by medicine doctors and ___. You had cultures taken from your knee, which did not show any signs of infection. Your antibiotics were changed and you improved. You are now stable and ready for discharge. During your hospital stay, the following changes were made to your medications: - STOPPED rifampin - STOPPED zosyn - STARTED daptomycin (to be given to you from home infusions) - STARTED ceftriaxone (to be given to you from home infusions) - STARTED flagyl (an oral antibiotic) Followup Instructions: ___

{'Fever': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Penicillins causing adverse effects in therapeutic use': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Unspecified essential hypertension': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Osteoarthrosis': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Leukocytopenia': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Anemia of other chronic disease': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Knee joint replacement': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins Attending: ___. Chief Complaint: left ___ digit MCP dislocation Major Surgical or Invasive Procedure: Open reduction of left ___ digit dislocation at MCP Joint History of Present Illness: ___ y/o p/w irreducible dorsal dislocation of SF MPJ. Pt. now s/p open reduction of MCP fracture. Pt being admitted O/N for monitoring. Past Medical History: PMH: HTN DMT2 - no insulin required diverticulosis hemrrhoids . PSH: TAH - for "benign tumor" Partial L colectomy ___ for acute GI bleed Breast Bx -benign L wrist surgery - "cyst" Central back area infected "cyst" s/p I&D Social History: ___ Family History: sister- h/o diverticulosis, GI bleeding, no surgeries required Physical Exam: GEN - Alert, oriented, no acute distress HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear NECK - supple, no JVD, no LAD PULM - CTAB, CV - RRR, ABD - soft, NT/ND, normoactive bowel sounds, no guarding or rebound EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally MSK- splint in place, no paresthesias, sensation intouch to light touch, warm well perfused. Motion limited by splint application SKIN - no ulcers or lesions Brief Hospital Course: The patient was admitted to the plastic surgery service on ___ and had a open reduction of left ___ digit MCP dislocation. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient was transitioned to oral pain medications and tolerated it well . . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Intake and output were closely monitored. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled Discharge Medications: 1. Atenolol 50 mg PO DAILY 2. GlyBURIDE 5 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Prazosin 2 mg PO BID 5. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: left ___ digit dislocation at MCP joint with volar plate interposition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: keep hand in splint until follow up on ___. Do not change dressing NWB left upper extremity Keep splint dry OK to shower tomorrow please resume all home medication take pain medication as indicated Followup Instructions: ___

{'irreducible dorsal dislocation': ['Closed dislocation of metacarpophalangeal (joint)'], 'HTN': ['Unspecified essential hypertension'], 'DMT2': ['Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled'], 'diverticulosis': ['Diverticulosis of colon (without mention of hemorrhage)']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Shellfish Derived Attending: ___. Chief Complaint: leg pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with severe, diffuse atopic dermatitis and secondary eczema herpeticum with multiple admissions to ___ due to severity of disease. Also with h/o bacteremia ___ skin lesions seeding spine with subsequent osteomyelitis of lumbar spine. He now presented to his PCP today with 1 week of worsening skin pustules on arms and legs which have since opened), multiple open wounds and now with right knee pain/swelling/redness/warmth. He has soft tissue swelling proximal medial thigh with substantial tenderness and right inguinal LAD. . His sx began one week ago when he got off the bus and had chills. Shortly after he developed R leg pain. The next morning he felt as though his leg had fallen asleep and then had pain radiating down to the leg to the knee which he describes as ___ pain and a raw soreness worsened with ambulation. He was not able to go to work all of last week and he rested to see if it would improve but it stayed the same. He also applied clobetasol cream which causes the rash to "dry up" with scaling skin. Given that his rash was not improving he scheduled an appt to see his PCP ___. No night sweats or repeat shaking chills except for 1 week ago. . In ER: (Triage Vitals: 99.6 96 115/69 18 100% with Tmax in Ed = 103) Meds Given: tylenol/ceftriaxone. Vancomycin sticker in ED paperwork but not checked off as given Fluids given: Radiology Studies:US consults called: none With abx given in ED the patient reports that his leg feels much better. . PAIN SCALE: ___ -> ___ with movement in R leg Past Medical History: BACK PAIN ECZEMA FOOD ALLERGIES -> shellfish -> lip swelling HSV1 SEASONAL ALLERGIES OSTEOMYELITIS Social History: ___ Family History: His father died of heart disease at ___. His mother has glaucoma Physical Exam: 1. VS T = 98, P 91, 16, 98% on RA 114/65 GENERAL: Well appearing pleasant male laying in bed. He is surrounded by family Nourishment: good Grooming: good Mentation: alert, speaking in 2. Eyes: [] WNL EOMI without nystagmus, Conjunctiva: clear 3. ENT [] WNL No lip lesions. Dry skin with desquamation noted on neck 4. Cardiovascular [X] WNL [X] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6, Location: [X] Edema RLE None [X] Edema LLE None RLE inner thigh with area of mild warmth and hyperpigmentation with swelling. No clear discrete fluctuant areas. Pus unable to be expressed. Mildly tender with deep palpation. 2+ DPP b/l [X] Vascular access [] Peripheral [] Central site: 5. Respiratory [X]WNL Integument [] WNL RUE with multiple excoriations, scabs, healing wounds with surrounding xerosis. B/L lower extremities with multiple areas of hyperpigmenation. Discrete swellng present on extensor surface of forearm without warmth nor erythema. Pertinent Results: ___ 12:40PM BLOOD WBC-25.1*# RBC-4.24* Hgb-12.8* Hct-39.5* MCV-93 MCH-30.2 MCHC-32.4 RDW-11.7 Plt ___ ___ 07:00AM BLOOD WBC-20.8* RBC-3.62* Hgb-11.6* Hct-33.7* MCV-93 MCH-32.1* MCHC-34.5 RDW-12.1 Plt ___ ___ 07:00AM BLOOD WBC-17.0* RBC-3.86* Hgb-12.2* Hct-36.9* MCV-96 MCH-31.6 MCHC-33.1 RDW-12.1 Plt ___ ___ 12:40PM BLOOD Glucose-92 UreaN-19 Creat-1.0 Na-131* K-4.9 Cl-93* HCO3-25 AnGap-18 ___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-136 K-5.1 Cl-102 ___ 07:00AM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-137 K-5.2* Cl-103 HCO3-26 AnGap-13 ___ 12:57PM BLOOD Lactate-2.2* ___ 3:24 pm SWAB LEFT LOWER LEG. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. Time Taken Not Noted Log-In Date/Time: ___ 4:37 pm Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 **FINAL REPORT ___ Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 (Final ___: UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN. Refer to culture results for further information. Reported to and read back by ___ ___ 1:08PM. DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final ___: UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN. Refer to culture results for further information. Time Taken Not Noted Log-In Date/Time: ___ 4:37 pm SWAB VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Pending): VARICELLA-ZOSTER CULTURE (Pending): Blood cultures: NGTD, pending Brief Hospital Course: ___ year old male with h/o severe atopic dermatitis requiring admissions for it in the past c/b osteomyelitis now presenting with rash, leukocytosis and fevers. # cellulitis: Ultrasound of right lower extremity in the ED was negative for abscess or DVT. Symptoms improved with IV antibiotics and pt was discharged on clindamycin to complete a course of antibiotics. # Eczema: Started mupirocin and clobetasol per derm recs. They would like him to f/u in derm office in ___. They have asked their scheduler to call the patient. Discharge Medications: 1. Hydrocortisone Cream 1% 1 Appl TP BID RX *hydrocortisone 1 % apply to face twice a day Refills:*2 2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID RX *clobetasol 0.05 % apply to arms and legs twice a day Refills:*2 3. Mupirocin Ointment 2% 1 Appl TP BID RX *mupirocin 2 % apply to open wounds twice a day Refills:*2 4. Clindamycin 300 mg PO Q8H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every eight (8) hours Disp #*21 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a skin infection (cellulitis). You were treated with antibiotics and your infection improved. You were seen by the dermatology doctors. ___ will call you to arrange a dermatology follow up appointment in a few months. Followup Instructions: ___

{'leg pain': ['Cellulitis and abscess of leg', 'except foot'], 'chills': ['Cellulitis and abscess of leg', 'except foot'], 'skin pustules': ['Cellulitis and abscess of leg', 'except foot', 'Impetigo'], 'open wounds': ['Cellulitis and abscess of leg', 'except foot', 'Impetigo'], 'right knee pain/swelling/redness/warmth': ['Cellulitis and abscess of leg', 'except foot'], 'soft tissue swelling': ['Cellulitis and abscess of leg', 'except foot'], 'tenderness': ['Cellulitis and abscess of leg', 'except foot'], 'eczema': ['Other atopic dermatitis and related conditions'], 'bacteremia': ['Other atopic dermatitis and related conditions'], 'osteomyelitis': ['Other atopic dermatitis and related conditions']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: E-Mycin Attending: ___. Chief Complaint: "I don't know" Major Surgical or Invasive Procedure: none History of Present Illness: ___ M with history of depression and polysubstance abuse brought in by police after found intoxicated in the park. At the time the patient stated he took 6 tramadol as well, in an effort to kill himself, though when sober, could only state "I don't know." The patient is very vague throughout the interview but does say that he has been feeling down lately and has " a lot of things on my mind." He notes that his mother is very ill and he is her primary caregiver. He also has been trying to stay sober, but has been unsuccessful. He denies any neurovegetative symptoms, AVH, HI or paranoia. When asked about SI, he just repeats "I don't know" and when pressed further on whether he thinks he is safe leaving the hospital he says, "I don't think so...I really don't know." He reports that he does not remember what happened in the park today other than getting picked up by the police, and he believes he took 6 or 7 tramadol. He said this was for his arthritis pain, but is not sure if he was also trying to kill himself. Past Medical History: PSYCHIATRIC HISTORY: History of depression, polysubstance abuse, alcohol dependence, PTSD and ADHD (per the patient). Multiple psychiatric admissions to ___, ___, ___, Deac 4, (>5 per the patient) for SI/SA and detox. The patient reports taking a bottle of Tylenol in ___, but cannot give any other history of suicide attempts. Per OMR, the patient has overdosed on cold tablets, soma + EtOH, and tried to drown himself in the ___ in ___. No history of assaultive behavior or HI. Current therapist: ___ at ___. No current psychiatrist PAST MEDICAL HISTORY: PCP ___ (ID) at ___: ___ -HIV pos since ___ -arthritis -seasonal allergies Social History: SUBSTANCE ABUSE HISTORY: Currently smokes < 1ppd, trying to quit. He drinks 1 pint of vodka daily for 2 days and then stops for a day and then goes back. Has multiple detox's in the past, last at ___ a few months ago. He was last sober in ___. No history of withdrawl seizures or DT's. The patient reports he last used cocaine "months ago" and denies marijuana or other drug use. SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.): The patient says he moved frequently as a child with his mom and his sister. He went to college in ___ and ended up getting a MA in ___. He worked many jobs until ___, when he started receiving SSDI. He currently lives with his friend ___ (___). Has a history of sexual abuse by his grandfather. He reports that he's been arrested in the past- his mother called the police and said she felt unsafe and wanted a restraining order against him, which later dropped. Family History: Mother- "something's going on" Multiple distant relatives with completed suicide. Physical Exam: MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE APPLICABLE) APPEARANCE & FACIAL EXPRESSION: disheveled man with dried blood over left eye wearing hospital gown POSTURE: lying in hospital bed BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS): no abnormal movements ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): vague SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.): normal in rate and prosody MOOD: "I don't know" AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.): dysthymic THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY, CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): linear THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS, DELUSIONS, ETC.): Denies AVH, HI, paranoia. Vague SI, no intent or plan. NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP, APPETITE, ENERGY, LIBIDO): none INSIGHT AND JUDGMENT: fair COGNITIVE ASSESSMENT: SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert ORIENTATION: oriented x 3 Pertinent Results: ___ 08:50AM GLUCOSE-124* UREA N-15 CREAT-0.7 SODIUM-139 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 ___ 08:50AM ALT(SGPT)-32 AST(SGOT)-32 ALK PHOS-92 TOT BILI-0.8 ___ 08:50AM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.1 ___ 08:50AM TSH-1.0 ___ 08:50AM WBC-5.6 RBC-4.15* HGB-13.5* HCT-39.1* MCV-94 MCH-32.5* MCHC-34.4 RDW-14.1 ___ 08:50AM PLT COUNT-278 ___ 09:20PM URINE HOURS-RANDOM ___ 09:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 09:20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 02:00PM GLUCOSE-90 UREA N-14 CREAT-0.6 SODIUM-143 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-16 ___ 02:00PM estGFR-Using this ___ 02:00PM ASA-NEG ___ ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02:00PM WBC-5.8 RBC-4.62 HGB-15.0 HCT-44.0 MCV-95# MCH-32.5* MCHC-34.2 RDW-14.3 ___:00PM NEUTS-45.6* LYMPHS-49.3* MONOS-3.3 EOS-1.2 BASOS-0.8 ___ 02:00PM PLT COUNT-___. Legal - The patient was transferred to Deac-4 on a ___, and was admitted on a CV. 2. Medical - The patient's only medical problem while on the unit was intermittent and persistent diarrhea. Per patient, this is a chronic condition that his PCP is aware of, and that he experiences shame because of. His PCP, ___ at ___, was unavailable during the ___ hospital stay, and the tests ordered on the patient's stool were negative: C.diff (negative), viral (negative) and acid fast (pending) cultures. He complained of hip pain, which he reported as chronic and adequately controlled with motrin. 3. Psychiatric - Throughout his hospital course, the patient denied suicidal ideation. He was continued on his home medications. He was encouraged to attend and participate in groups, especially in the substance abuse/dual diagnosis group. He was monitored on a CIWA scale and did not show evidence of ETOH w/d. Medications on Admission: -Norvir 100mg daily -Reyataz 300mg daily -Truvada 200/300 daily -Topamax 100mg daily -Seroquel 100mg QHS -celexa 40mg daily -tramadol 50mg BID Discharge Medications: 1. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal BID (2 times a day) as needed for nasal congestion. 8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Discharge Disposition: Extended Care Discharge Diagnosis: AXIS I: ETOH Dependence, mood disorder NOS AXIS II: Cluster B Traits AXIS III: HIV, arthritis AXIS IV: Problems related to chronic medical illness AXIS V: 55 Discharge Condition: Stable O: vit- T 98.4, HR 69, RR 17, BP 108/70, Pox 100% RA MSE: Patient is well groomed, appears stated age. Has scars above L eyebrow. Wearing casual clothes, and shorts. Eye contact intermittently poor and intense. Speech normal rate and volume. Mood "good". Affect labile. TF: linear, TC: denies SI, HI, AVH. I/J: fair, fair Discharge Instructions: 1. If you are having thoughts of wanting to hurt yourself or others, please call ___ or come to the Emergency Department immediately. 2. Please continue to take your medications as prescribed. 3. Please keep all your appointments with your outpatient treaters as detailed below. Followup Instructions: ___

{'feeling down': ['Unspecified episodic mood disorder', 'Other and unspecified alcohol dependence'], 'arthritis pain': ['Poisoning by opium (alkaloids)'], 'intoxicated': ['Other and unspecified alcohol dependence'], 'polysubstance abuse': ['Other and unspecified alcohol dependence', 'Tobacco use disorder'], 'suicidal ideation': ['Unspecified episodic mood disorder', 'Other and unspecified alcohol dependence'], 'seasonal allergies': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'history of depression': ['Unspecified episodic mood disorder'], 'PTSD': ['Posttraumatic stress disorder'], 'ADHD': ['Attention deficit disorder with hyperactivity']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___. Chief Complaint: RLE pain Major Surgical or Invasive Procedure: IVF filter placement ___ History of Present Illness: Ms. ___ is a ___ PMHx advanced Alzheimer's dementia, chronic HCV, autoimmune hepatitis, and AFib who presents from her SNF for RLE DVT. Per report from her SNF, the patient had been complaining of RLE pain. LENIs showed DVT after which the patient was transferred to ___. In the ED, initial VS 98.1, 84, 142/65, 16, 98% RA. Initial labs were unremarkable. CXR here showed no evidence of PNA. UA was grossly positive and the patient was given IV ceftriaxone, Lovenox 70 mg x 1 prior to transfer. Of note, the patient was most recently discharged from ___ in ___ for seizure activity and was found to have a 3 cm atypical meningioma. Per ___ discussion with the patient's niece, surgical intervention was deferred. Her course at the time was also notable for new paroxysmal AFib; given her CHADSVASC score of 4, anticoagulation was warranted. However, given her age, risk of fall, and her new intracranial lesion (high risk for venous bleed), anticoagulation was deferred. From further collateral information obtained from her SNF (Vero Health and Rehab of Mattapan) this evening, it is unclear why the patient was not started on anticoagulation for DVT treatment and why the patient was transferred to ___ for further evaluation. The ED attempted to reach out to the family re: utility of IVC filter placement in this setting, but was unable to contact the family. Upon arrival to the floor, the patient denies any chest pain or SOB. She has had a cough x 2 weeks; she has had no fevers. She is AOx2 to self and place (at baseline). She denies any dysuria, urinary incontinence or increased urinary frequency. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies vomiting, diarrhea, constipation. No recent change in bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - Alzheimer's; ADL impaired in preparing food, remembering to bathe, recalling faces. Lives at home but with extensive ___ and family support. - HCV, chronic, low viral load (last in OMR ___, 15 million copies) - Autoimmune hepatitis - HTN - atypical meningioma Social History: ___ Family History: Unable to obtain from patient as patient with memory deficits Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 98.7, 178/81, 80, 18, 99% on RA General: Alert, elderly female, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no appreciable m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, obese, distended, nontender, bowel sounds present. No suprapubic tenderness. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or pitting edema of BLE. TTP of RLE calf. Neuro: alert, oriented to name and place (knows she is in hospital, but unable to say which one), face symmetric, able to move all extremities Psych: normal affect and appropriately interactive Derm: no rash or lesions Pertinent Results: ADMISSION LABS ============== ___ 11:00PM GLUCOSE-94 UREA N-10 CREAT-0.8 SODIUM-141 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18 ___ 11:00PM LACTATE-1.5 ___ 11:00PM WBC-7.6 RBC-4.63 HGB-12.8 HCT-41.0 MCV-89 MCH-27.6 MCHC-31.2* RDW-14.5 RDWSD-46.3 ___ 11:00PM NEUTS-56.1 ___ MONOS-10.4 EOS-1.6 BASOS-0.4 IM ___ AbsNeut-4.28 AbsLymp-2.37 AbsMono-0.79 AbsEos-0.12 AbsBaso-0.03 ___ 11:00PM PLT COUNT-178 ___ 11:00PM ___ PTT-32.0 ___ ___ 10:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-LG ___ 10:00PM URINE RBC-2 WBC-21* BACTERIA-FEW YEAST-NONE EPI-<1 IMAGING/STUDIES =============== ___ CXR No evidence of pneumonia. OSH ___: RLE DVT FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal permanent infrarenal IVC filter. IMPRESSION: Successful deployment of permanent infrarenal IVC filter. Brief Hospital Course: Ms. ___ is a ___ PMHx advanced Alzheimer's dementia, chronic HCV, autoimmune hepatitis, and AFib who presents from her SNF for RLE DVT. # DVT. Diagnosed by LENIs at ___. Patient started on Lovenox in ED for anticoagulation. However, given intracranial lesion which is higher risk for bleeding, will discuss utility of IVC filter placement with HCP. After discussion with HCP ___ ___, decision made to place IVC filter and NOT anti coagulate given the patient's high risk for bleeding. She went for uncomplicated IVC filter placement on ___. She will not be anti coagulated going forward. # Asymptomatic bacteriuria: UA was positive and she was initially given antibiotics. However, there was no report of any symptoms to suggest UTI. Thus antibiotics were stopped. # Atypical meningioma. Recently seen on brain MRI in ___. Patient at the time was placed on Keppra for seizure prophylaxis. It is high risk for bleeding and that is partly why IVC filter placement was decided - Continued Keppra 500 mg BID # A. fib. Recent diagnosis of paroxysmal AFib. Despite CHADSVASC score of 4 warranting anticoagulation, systemic anticoagulation deferred due to age, risk of fall, and atypical meningioma at high risk for bleeding. - No rate-control # Autoimmune hepatitis. - Continued home prednisone # Hypertension. Stable. - Continued home nifedipine # Alzheimer's dementia. At baseline. - Continued home donepezil and memantine # CODE STATUS: DNR, DNI (confirmed by SNF, MOLST form completed # CONTACT: ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Donepezil 10 mg PO QHS 3. Memantine 21 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. NIFEdipine CR 30 mg PO DAILY 6. PredniSONE 5 mg PO DAILY 7. Vitamin E 400 UNIT PO DAILY 8. LevETIRAcetam 500 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Donepezil 10 mg PO QHS 3. LevETIRAcetam 500 mg PO BID 4. Memantine 21 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. NIFEdipine CR 30 mg PO DAILY 7. PredniSONE 5 mg PO DAILY 8. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute RLE DVT Alzheimer's dementia Autoimmune hepatitis HCV Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Patient admitted for evaluation of acute RLE DVT. Due to high bleeding risk, IVC filter was placed and patient will not be anti coagulated. Please resume all previous medications Followup Instructions: ___

{'RLE pain': ['Acute embolism and thrombosis of unspecified deep veins of right lower extremity'], 'cough': [], 'DVT': ['Acute embolism and thrombosis of unspecified deep veins of right lower extremity'], 'seizure activity': ['Dementia in other diseases classified elsewhere', 'Essential (primary) hypertension'], 'paroxysmal AFib': ['Paroxysmal atrial fibrillation'], 'atypical meningioma': ['Benign neoplasm of cerebral meninges'], 'autoimmune hepatitis': ['Autoimmune hepatitis'], 'HCV': ['Chronic viral hepatitis C'], "Alzheimer's dementia": ["Alzheimer's disease"]}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: Penicillins Attending: ___ Chief Complaint: right foot ulcer Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o DM M with a hx of presents hypertension and hypercholesteremia, who is well known to the podiatry service presents with a right plantar forefoot ulcer. He is a patient of Dr. ___ originally missed his appointment today and wanted to have his foot evaluated before the infection worsened. He presented today in athletic running shoes. Past Medical History: DM Type II Hypertension Hypercholesterolemia . PSH: Appendectomy Social History: ___ Family History: Father ___ - Type II Mother Cancer - ___ Hyperlipidemia Physical Exam: VSS, afebrile Gen: NAD, AAOx3, pleasant CV: RRR Pulm: CTAB Abd: soft, NT/ND RLE: DP and ___ pulses palpable. CFT brisk to all digits. Skin temp warm to warm proximal to distal. Ulcer encompassing plantar aspect of foot along metatarsal head level, most notably at ___ MPJ. Minimal surrounding erythema and edema. Does not probe deeply or track to the level of bone. No exudate. No fluctance. Gross sensation diminished. Pertinent Results: ___ 06:30AM BLOOD WBC-10.2 RBC-3.62* Hgb-10.0* Hct-29.8* MCV-82 MCH-27.5 MCHC-33.4 RDW-12.5 Plt ___ ___ 03:45PM BLOOD WBC-13.1* RBC-4.19* Hgb-11.5* Hct-34.9* MCV-83 MCH-27.5 MCHC-33.0 RDW-12.7 Plt ___ ___ 03:45PM BLOOD Neuts-72.5* ___ Monos-6.3 Eos-1.7 Baso-0.7 ___ 06:30AM BLOOD Plt ___ ___ 03:45PM BLOOD Plt ___ ___ 06:30AM BLOOD Glucose-120* UreaN-25* Creat-1.5* Na-137 K-4.5 Cl-100 HCO3-28 AnGap-14 ___ 03:45PM BLOOD Glucose-316* UreaN-26* Creat-1.6* Na-132* K-4.2 Cl-96 HCO3-26 AnGap-14 ___ 06:30AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.9 ___ 07:00AM BLOOD Vanco-19.9 ___ 06:30AM BLOOD Vanco-11.5 ___ 03:45PM BLOOD HoldBLu-HOLD ___ 03:50PM BLOOD Lactate-1.0 ___: R FXR: IMPRESSION: Plantar soft tissue ulcer at the level of the metatarsal heads with no radiographic evidence for osteomyelitis or soft tissue gas. ___: RLE US: IMPRESSION: No evidence of deep vein thrombosis in the right lower extremity. Brief Hospital Course: Mr. ___ presented to the Emergency Department at ___ after missing a scheduled appointment with Dr. ___ concern that his infection was worsening. He was admitted on ___ for a right foot infection. During his stay, he received IV antibiotics to fight the cellulitis and xrays were obtained and showed no osteomyelitis. The wound was lightly debrided at the bedside during his stay and he was fitted for a bivalve cast by an orthotech. He was given strict instructions on touch down weight bearing to the heel using a walker or crutches. Physical therapy worked with him while in the hospital and cleared him for home with such. Prior to discharge his vital signs were stable and neurovascular status intact. He understood all of his discharge instructions and is to follow up with Dr. ___ in approximately 1 week. Medications on Admission: omeprazole ec 20", simvastatin 40 qhs, glyburide 5', lisinopril 5', sildenafil 100 prn Discharge Medications: 1. Clindamycin 150 mg PO Q6H RX *clindamycin HCl 150 mg 1 capsule(s) by mouth every six (6) hours Disp #*40 Capsule Refills:*0 2. Aspirin 81 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Glargine 40 Units Breakfast Insulin SC Sliding Scale using REG Insulin 5. Lisinopril 5 mg PO DAILY 6. Omeprazole 20 mg PO BID 7. Simvastatin 40 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: right foot ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On your right side you are TOUCH DOWN WEIGHT BEARING TO THE HEEL IN A BIVALVE CAST AND CRUTCHES/WALKER for ___ weeks. You should keep this site elevated when ever possible (above the level of the heart!) Physical therapy worked with you in the hospital and gave instructions on weight bearing: please follow these accordingly. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. WOUND CARE: You will be getting every other day dressing changes by a visiting nurse with betadine paint to the ulceration and a dry sterile dressing. You may cleanse the foot with peroxide. Once the dressing is in place, avoid getting it wet. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for infection which will be taken every 6 hours. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___

{'right foot ulcer': ['Ulcer of other part of foot', 'Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled'], 'cellulitis': ['Cellulitis and abscess of foot', 'except toes'], 'hypertension': ['Unspecified essential hypertension'], 'hypercholesterolemia': ['Pure hypercholesterolemia'], 'smoking history': ['Personal history of tobacco use']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: Penicillins Attending: ___ Chief Complaint: Right foot ulcer Major Surgical or Invasive Procedure: ___ metatarsal head and proximal phalanx resection, closure History of Present Illness: This is a ___ y/o DM M who presents to Dr. ___ with an ulcer to the lateral aspect of the ___ met head of the R foot. He was directly admitted from clinic today to the surgical floor for IV antibiotics and will go to the OR on Thrusday for R foot debridement. He has had this ulcer for several months and it had been improving in size. He has finished a course of antibiotics for cellulitis at his his previous visit. He admits that his foot has become more painful over the last couple of days. He is currently in NAD, and denies f/c/n/v/sob. Past Medical History: PMH: - DM Type II with neuropathy - Hypertension - Hypercholesterolemia - Obesity PSH: - Appendectomy Social History: ___ Family History: Father - history of diabetes type 2 Physical Exam: PE on DISCHARGE: Vitals: Afebrile, VSS Gen: Pleasant, NAD CV: RRR Pulm: No respiratory distress Abd: Soft, NT, ND RLE: Bandage c/d/i right foot. CFT brisk to digits. AROM intact to digits. Protective sensation is diminished bil. Pertinent Results: ADMISSION LABS: ___ 07:50AM BLOOD WBC-7.6 RBC-3.43* Hgb-9.0* Hct-26.4* MCV-77* MCH-26.1* MCHC-34.0 RDW-13.3 Plt ___ ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-146* UreaN-28* Creat-1.6* Na-132* K-4.7 Cl-100 HCO3-25 AnGap-12 ___ 07:50AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.7 PERTINENT LABS: ___ 08:28PM BLOOD Vanco-20.8* Final Report STUDY: Right foot, ___. CLINICAL HISTORY: ___ man with right lateral foot pain. Rule out osteomyelitis. FINDINGS: Comparison is made to previous study from ___. Since the previous study, there has been bony destruction involving the majority of the fifth distal metatarsal as well as the base of the fifth proximal phalanx. There is overlying soft tissue swelling. Findings are highly suspicious for acute osteomyelitis. There is generalized demineralization. Degenerative changes of the first MTP joint is also identified. There is a large spur seen at the distal attachment of the Achilles tendon to the calcaneus. There is prominent soft tissue swelling and ankle joint effusion. IMPRESSION: Worsening of the bony destruction involving the fifth metatarsal distally and the base of the fifth proximal phalanx suspicious for osteomyelitis. These findings have been placed on the radiology reporting dashboard. DISCHARGE LABS: Brief Hospital Course: Mr. ___ was admitted to the hospital directly from clinic on ___ with a right foot infection requiring surgical debridement. He went to the operating room on ___ for debridement with closure. He tolerated the procedure well with no apparent complications. Please see the operative note for full details. While on the floor, he received IV antibiotics and his pain was well controlled. He remained hemodynamically stable and vitals were routinely checked. Prior to leaving, physical therapy worked with him and cleared him for home. He has follow up scheduled with Dr. ___ approximately 1 week. All questions were answered prior to discharge. Medications on Admission: omeprazole ec 20", simvastatin 40 qhs, glyburide 5', lisinopril 5', sildenafil 100 prn Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin 750 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 3. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #*40 Capsule Refills:*0 4. Glargine 40 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Lisinopril 5 mg PO DAILY 6. Omeprazole 20 mg PO DAILY:PRN Heartburn 7. Simvastatin 40 mg PO DAILY 8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4-6h Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R foot ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On your right side you are NON WEIGHT BEARING. You should keep this site elevated when ever possible (above the level of the heart!) Physical therapy worked with you in the hospital and gave instructions on weight bearing: please follow these accordingly. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. WOUND CARE: You will be getting every other day dressing changes by a visiting nurse with betadine paint to the ulceration and a dry sterile dressing. You may cleanse the foot with peroxide. Once the dressing is in place, avoid getting it wet. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for infection which will be taken every 6 hours. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___

{'Right foot ulcer': ['Diabetes with other specified manifestations', 'Ulcer of other part of foot'], 'Painful foot': ['Diabetes with other specified manifestations', 'Ulcer of other part of foot'], 'Cellulitis': ['Diabetes with other specified manifestations', 'Ulcer of other part of foot'], 'Bony destruction': ['Unspecified osteomyelitis', 'Other bone involvement in diseases classified elsewhere'], 'Soft tissue swelling': ['Unspecified osteomyelitis', 'Other bone involvement in diseases classified elsewhere'], 'Ankle joint effusion': ['Unspecified osteomyelitis', 'Other bone involvement in diseases classified elsewhere'], 'Degenerative changes': ['Other bone involvement in diseases classified elsewhere'], 'Large spur': ['Other bone involvement in diseases classified elsewhere'], 'Impaired protective sensation': ['Diabetes with neurological manifestations'], 'Hypercholesterolemia': ['Esophageal reflux'], 'Hypertension': ['Unspecified essential hypertension']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Spironolactone Attending: ___. Chief Complaint: - low back pain Major Surgical or Invasive Procedure: - none History of Present Illness: On admission: ___ y/o M with history of diastolic CHF, heart block s/p pacemaker, atrial fibrillation (on Coumadin) who presented with worsening low back pain x 3 days. Pain does not radiate and is worse with movement. Has had episodes of back pain in the past, but not this severe, managed with pain control and physical therapy in the past. Most recent episode was probably ___ yrs ago. Pain is different from sciatic back pain. He denies CP/worsening of his SOB, F/C/N/V, dysuria. . In the ED, vitals were WNL and imaging (CT abd/CT chest/CXR/L-spine X-ray) was negative for an acute process. He received Tylenol 1g po x 1 for pain, with no relief. . This morning, minimal pain at rest but has "spasms" with movement that are not relieved with morphine and Percocet. CT showed moderate to severe spinal stenosis worst at L4-L5. He denies any incontinence, weakness/numbness, other neurologic deficits. Past Medical History: - arthritis - chronic diastolic dysfunction - atrial fibrillation - h/o complete heart block s/p pacemaker - BPH - monoclonal gamopathy - basal cell and squamous cell carcinoma - sciatica - hypercholesteremia - hyponatremia Social History: ___ Family History: - positive for heart problems in parents and siblings Physical Exam: On admission: Vitals: T:96.6 BP:128/62 HR:60 RR:20 O2sat:97%RA Gen: comfortable at rest, some wincing with movement HEENT: oropharynx clear, MMM NECK: supple, no appreciable JVD CV: RRR, ___ systolic murmur LUNGS: CTAB ABD: soft, no TTP EXT: +TTP lower back, b/l, no TTP over spine, neg. straight leg raise, pulses 2+ b/l, no calf TTP NEURO: alert and oriented, responsive, sensation to light touch intact throughout, strength ___ lower extremities, DTR's 2+ b/l Pertinent Results: ___ WBC-10.0 Hgb-12.6 Hct-35.5 Plt ___ ___ WBC-8.0 Hgb-12.3 Hct-34.7 Plt ___ ___ WBC-6.7 Hgb-11.5 Hct-33.9 Plt ___ . ___ ___ PTT-48.9 ___ ___ ___ PTT-49.8 ___ ___ ___ PTT-58.3 ___ ___ ___ PTT-66.0 ___ ___ ___ PTT-66.2 ___ . ___ Glucose-128 UreaN-26 Creat-1.1 Na-129 K-4.4 Cl-97 HCO3-25 ___ Glucose-104 UreaN-19 Creat-1.0 Na-130 K-4.3 Cl-97 HCO3-27 ___ Glucose-90 UreaN-34 Creat-1.3 Na-130 K-4.7 Cl-95 HCO3-27 ___ Glucose-119 UreaN-31 Creat-1.2 Na-129 K-4.6 Cl-93 HCO3-28 . Urinalysis: unremarkable . SINGLE PA VIEW OF THE CHEST: IMPRESSION: 1. Cardiomegaly without evidence of overt pulmonary edema. 2. Bibasilar opacities likely reflect atelectasis. . AP VIEW OF THE PELVIS, AND TWO VIEWS OF THE LUMBAR SPINE: IMPRESSION: 1. No fracture or subluxation within the lumbar spine. 2. Severe lumbar spondylosis. 3. No fracture or dislocation within the pelvis. . CT CHEST/ABD/PELVIS: IMPRESSION: 1. No pulmonary embolism. 2. Multilevel degenerative changes within the lumbar spine result in moderate to severe spinal stenosis. MRI can be obtained for further evaluation. 3. 1-cm right thyroid nodule. Ultrasound could be obtained for further evaluation if clinically indicated. 4. Small pericardial effusion is slightly larger since ___, without evidence of tamponade. 5. Hepatic hypodensities likely represent cysts although are not fully characterized. Brief Hospital Course: *)Back pain: a thorough work-up did not reveal evidence of an acute process, although CT and X-ray did show moderate to severe spinal stenosis in the lumbar spine, which was likely contributory to his symptoms. An element of muscle spasm was also thought to be likely, based on his symptoms. He was given morphine and Percocet initially for pain control. He was transitioned to Percocet only, and low-dose Flexiril was added to aid with control of muscle spasm, as well as heat to the area. His symptoms continued to be significant and limiting to his progress with physical therapy. The Chronic Pain Service was consulted, and recommended a new medication regimen. He was given Toradol x 2 doses, and started on standing Tylenol, gabapentin, and tizanidine as well as oxycodone as needed. The following morning his symptoms had improved, and he was able to transition more easily in and out of bed. He was transferred to a rehabilitation facility for extended physical therapy. . *)Atrial fibrillation: also with a history of complete heart block with a pacemaker, rate-controlled on admission. His INR was found to be supra-therapeutic at 4.4, and his Coumadin was held for one day. On re-check, his INR continued to increase, so his Coumadin was stopped. Metoprolol was continued during his hospitalization. His INR will need to be followed, and Coumadin re-started once INR is less than 3. . *)Elevated creatinine: his creatinine was at his baseline at 1.1 on admission, with an increase to 1.3 after he received Toradol. This will need to be followed up with repeat labs; he did not receive any additional NSAIDs and was not discharged on any. On the day of discharge his creatinine had begun to trend back down. . *)Hypertension: BP was well-controlled on his home medication regimen. . *)Chronic diastolic heart failure: felt to be at baseline on admission. His home medication was continued. . *)BPH: finasteride and Flomax were continued during his hospitalization. . *)Hyponatremia: stable at baseline. Medications on Admission: - eplerenone 25mg every other day - finasteride 5mg daily - Lasix 20mg daily - Latanoprost 0.0005% - meclizine 12.5mg as needed - metoprolol 50mg twice daily - Flomax 0.4 twice daily - Valsartan 320mg daily - Coumadin as directed ___ - aspirin 81mg daily - coenzyme Q10 - vitamin D 400mg daily - folic acid - glucosamine 750mg daily - multivitamin - niacin 400mg daily - omega 3 fatty acid Discharge Medications: 1. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 11. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q6H (every 6 hours) as needed. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed. 17. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: - muscle spasm/low back pain - spinal stenosis . - arthritis - chronic diastolic dysfunction - atrial fibrillation - h/o complete heart block s/p pacemaker - BPH - monoclonal gamopathy - basal cell and squamous cell carcinoma - sciatica - hypercholesteremia - hyponatremia Discharge Condition: - improved/stable Discharge Instructions: You were admitted to the hospital for an episode of severe back pain. Imaging showed some narrowing of your spinal column, and no evidence of any other acute process. Your pain was thought to be musculoskeletal in origin. You were given medications to control your pain and relax your muscles, and were seen by Physical Therapy. You are going to a rehabilitation facility for additional help with physical therapy. Please follow up with your primary care doctor after you leave rehabilitation. . Changes to your medications: Added: Tylenol, gabapentin, tizanidine. Stopped: Coumadin (warfarin) Your Coumadin was stopped because a lab value that we use to track the proper dosing was high. This will need to be followed up at the rehabilitation facility and with your primary care doctor; once the lab value comes down, your Coumadin will need to be re-started. . Please call your doctor for the following: incontinence of stool or urine, weakness/numbness in your legs, inability to walk, severe or increasing pain that is not helped by medications, nausea/vomiting, fever, any new or concerning symptoms. Followup Instructions: ___

{'low back pain': ['Lumbago', 'Spinal stenosis', 'lumbar region', 'without neurogenic claudication'], 'atrial fibrillation': ['Atrioventricular block', 'complete'], 'chronic diastolic dysfunction': ['Chronic diastolic heart failure'], 'hyponatremia': ['Hyposmolality and/or hyponatremia'], 'muscle spasm': ['Other symptoms referable to back'], 'spinal stenosis': ['Spinal stenosis', 'lumbar region', 'without neurogenic claudication']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Left leg lesion Major Surgical or Invasive Procedure: 1. Excision of left lower extremity lesion 2. Partial local advancement closure left lower extremity. 3. Full-thickness skin graft from left groin 6 x 4 cm from left groin to left lower extremity. 4. Local advancement flap closure left groin defect 8 cm. 5. Vacuum-assisted closure dressing placement. History of Present Illness: ___ yo female who presents with about a 6 month history of a left shin mass. The mass is described as a small pimple that grew over the course of 6 months time. She was evaluated by a dermatologist who biopsied the mass and determined that it was benign but the pathology report is no present in the ___ medical record. She also experiences an episode of cellulitis at the area. She was evaluated in the ___ ED and was treated with Keflex. The cellulitis resolved. She now presents for removal of the mass. Past Medical History: Osteoarthritis Hypertension Hypercholestrolemia Colon polyp Left bundle branch block Social History: ___ Family History: Non-contributory Physical Exam: GEN: NAD HEENT: NCAT, EOMI, no LAD LUNGS: CTAB CARDIAC: RRR, no M/R/G ABD: +BS, NT/ND EXT: WWP SKIN: Lesion 2.5X2.5 cm with brown base, macerated center. No evidence of cellulitis, no drainage. On mid-tibia region Pertinent Results: PATH: SPECIMEN SUBMITTED: left leg lesion. Procedure date Tissue received Report Date Diagnosed by ___ ___. ___ DIAGNOSIS: Skin, left leg, wide excision (A-Q): Squamous cell carcinoma, invasive, well differentiated, completely excised. Note: The lesion has a crateriform (keratoacanthoma-like) architecture. Brief Hospital Course: The patient was admitted to the plastic surgery service on ___ and had: 1. Excision of left lower extremity lesion 2. Partial local advancement closure left lower extremity. 3. Full-thickness skin graft from left groin 6 x 4 cm from left groin to left lower extremity. 4. Local advancement flap closure left groin defect 8 cm. 5. Vacuum-assisted closure dressing placement. Skin lesion was found to be squamous cell cancer. The patient tolerated the procedures well. Neuro: Post-operatively, the patient had adequate pain control and tolerated PO pain meds. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. Pt urinating without Foley. ID: Post-operatively, the patient was started on IV Ancef. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#7, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Pt was evaluated by ___ and was able to walk stairs without assistance. ___ recommended a walker to assist when pt is not walking stairs. Medications on Admission: Omeprazole 20 QD Metoprolol 50 mg AM, 25 mg QHS Evista 60 mg QD ASA 81 mg QD Centrum Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Centrum Silver Tablet Sig: One (1) Tablet PO once a day: with food. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: no more than 4g total of acetaminophen (Tylenol) in 24 hours. 7. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain for 1 weeks: no more than 4g total Acetaminophen (Tylenol) in one day, one pill has 500mg Acetaminophen (Tylenol). Disp:*30 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 weeks: take this while you take Vicodin to keep from getting constipated. Disp:*14 Capsule(s)* Refills:*0* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation for 1 weeks: take this if you are using Vicodin to prevent constipation. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Squamous cell carcinoma Discharge Condition: Good Discharge Instructions: Physical therapy recommended that you use the walker that they gave you for assistance. You did well with stairs without any assistance. Please limit your walking to less than 15 minutes at a time. Keep your left leg elevated when you are sitting or are in bed. Home with ___ for wound care. ___ will come change your dressings and will help teach you and your caretakers how to change them. You do not need antibiotics. Do not take more than 4g Acetaminophen (Tylenol) in one day, both regular Tylenol and Vicodin contain Tyleno. Vicodin contains 500mg Tylenol in each pill. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Followup Instructions: ___

{'shin mass': ['Other malignant neoplasm of skin of lower limb, including hip'], 'cellulitis': ['Other malignant neoplasm of skin of lower limb, including hip'], 'pain': ['Other malignant neoplasm of skin of lower limb, including hip', 'Pure hypercholesterolemia', 'Unspecified essential hypertension', 'Osteoporosis, unspecified', 'Esophageal reflux']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing Attending: ___. Chief Complaint: Right lower leg ulcer and cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ with DM and newly diagnosed lupus. He was sent to the ED by his PCP for ___ ulcer & cellulitis x 2 wks. He claims that he scraped his leg with his cane and that it broke his skin 2 wks ago. His right lower leg is painful to contact. He denies fever and chills. He was hospitalized at ___ from last ___ to this ___ and treated with antibiotics per the patient. He was discharged ___ and seen by his PCP today, who decided to send the patient to the ED. Past Medical History: Diabetes, ? paroxysmal A-Fib, HTN, lupus, prostate CA, s/p brachy therapy ___ (___), s/p R TKR, s/p CCY ___ Social History: ___ Family History: Non-contributory Physical Exam: On Admission PE: 96.9 89 157/50 16 99%RA AAOx3 NAD no carotid bruit RR s1 s2 b/l rales soft ND NT, no pulsating mass b/l ___ edema, R>L ___ venous stasis ulcer, large; ant clean, post w/ dried eschar ___ cellulitis On discharge: Afebrile, VSS Gen: no acute distress Chest: RRR, lungs clear Abd: soft, nontender, nondistended Ext: B/L ___ edema (R>L), large venous stasis ulcer to right lower leg, erythema improved, large eschar on lateral aspect of right lower leg Pertinent Results: Admission labs: ___ 11:30PM BLOOD WBC-12.3* RBC-3.49* Hgb-9.7* Hct-30.7* MCV-88 MCH-27.7 MCHC-31.6 RDW-15.5 Plt ___ ___ 11:30PM BLOOD ___ PTT-27.2 ___ ___ 11:30PM BLOOD Glucose-303* UreaN-34* Creat-1.3* Na-143 K-4.0 Cl-107 HCO3-26 AnGap-14 ___ 11:30PM BLOOD ALT-22 AST-16 AlkPhos-58 TotBili-0.2 Discharge labs: ___ 06:40AM BLOOD WBC-9.0 RBC-3.40* Hgb-9.6* Hct-29.0* MCV-85 MCH-28.3 MCHC-33.1 RDW-16.2* Plt ___ ___ 06:40AM BLOOD Glucose-84 UreaN-25* Creat-1.1 Na-138 K-3.7 Cl-101 HCO3-30 AnGap-11 Plain films of right foot: No osteomyelitis Brief Hospital Course: Mr. ___ was admitted with a right lower extremitu ulcer and cellulitis on ___. A sample was sent for culture and he was started on intravenous antibiotics, Unasyn. The culture came back with > 3 colony types. He was switched to PO Bactrim on ___. He received dressing changes to both of his lower legs twice a day. The discharge and erythema improved on the antibiotics. A physical therapy consult was obtained and he was cleared for discharge. He will be allowed to ambulate only essential distances, such as to the bathroom, but his is to remain in bed or a chair with his legs elevated at all times. His legs are to wrapped in ACE wraps. He is being discharged to rehab to allow his right lower leg to demarcate and declare itself. He may need a skin graft or a revascularization procedure at some point in the future. He will follow up with Dr. ___ in 2 weeks to determine his treatment course. A rheumatology consult was obtained due to his recent diagnosis of lupus and they recommended a prednisone taper to 15mg daily. Medications on Admission: prednisone, lasix, coumadin Discharge Medications: 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (___). 3. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO 4X/WEEK (___). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 1 doses: Give 1 dose on ___. 8. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO daily (): Start on ___. 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Continue until follow up with Dr. ___. 10. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous once a day: Give at lunch. 11. Insulin Lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous every six (6) hours. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right lower leg ulcer and cellulitis Systemic lupus erythematosus Discharge Condition: Good Discharge Instructions: Call your physician or return to the Emergency Department if you experience: - fever > 101.5 - chills - increasing purulent drainage from your ulcers - increasing/spreading redness around your ulcers - increasing pain in your lower extremities that does not resolve - new onset chest pain or shortness of breath Your coumadin was restarted on ___. You must have your INR checked every day until it is therapeutic and then you can your INR checked weekly. You were diagnosed with Systemic lupus erythematosus on this admission. You were started on a prednisone taper. You will be on 15mg of prednisone daily. Followup Instructions: ___

{'Right lower leg ulcer': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Cellulitis': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Painful contact': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Fever and chills': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Erythema improved': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Large venous stasis ulcer': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Erythema': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Edema': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Lupus': ['Systemic lupus erythematosus']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R leg pain Major Surgical or Invasive Procedure: ORIF R femur ___ History of Present Illness: ___ c mild COPD, CKD (b/l Cre 1.2), and s/p R THA (___), transferred from ___ following slip and fall, with reported right distal femur fracture. The patient reports slipping on ice at ~7:30p on evening prior to presentation; she felt right knee buckle under her, and she fell on RLE. Immediate pain and inability to weight-bear. Denies prodromal symptoms; no HS/LOC or other injuries. Initially brought by ambulance to ___ ___, where imaging demonstrated reported distal femur fracture; transferred to ___ ED for further management. At time of interview, patient endorses right knee pain; no other injuries. Mild paresthesias over tips of right toes. At baseline, patient is active and ambulates without assistive device; she estimates that she could walk up ~8 stairs at a time. Past Medical History: COPD, no home O2 CKD (b/l Cre 1.2) HTN s/p R THA ___, ___ for acetab fx s/p laparoscopic gynecologic cyst excision (___) Denies any cardiac history; no echo in Atrius Social History: ___ Family History: nc Physical Exam: Vitals: 96.8 100 157/61 20 97% 4L Appears well CAM: Fluctuating Mental Status: no Inattention: no Disorganized Thoughts: no Altered consciousness: no Mini-Cog: A&Ox3 3 Object Recall: ___ Clock-Draw: pass Respirations non-labored RRR Abdomen soft, non-tender RLE: +swelling, TTP over knee No focal TTP over hip, ankle, foot No skin lacerations; very small, superficial abrasion over anterior knee No pain with log roll at hip Pain with any movement at knee Palpable DP pulse, symmetric bilaterally Dopplerable ___ pulse, symmetric bilaterally Sensation intact sural, saphenous, tibial, DP, SP distributions, though with mild paresthesias over all 5 toes Fires ___, TA, ___ LLE: No skin breaks / deformities / areas of TTP over hip / knee / ankle / foot Discharge PE: AVSS G:NAD RLE:Incision c/d/i NVID Pertinent Results: ___ 06:25AM BLOOD WBC-6.3 RBC-2.92* Hgb-8.2* Hct-26.2* MCV-90 MCH-28.3 MCHC-31.5 RDW-15.1 Plt ___ Rib series... Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF R femur, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TDWB in the RL extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: Losartan 25' Ca/Vit D Ambien prn Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Enoxaparin Sodium 30 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time 4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain Decrease dosage as soon as possible. 5. Senna 8.6 mg PO BID:PRN constipation 6. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R femur fracture Discharge Condition: Improved. AO3. TDWB RLE. Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet ACTIVITY AND WEIGHT BEARING: - TDWB RLE in unlocked ___ Physical Therapy: TDWB RLE in unlocked ___ Treatments Frequency: DSD to wound PRN. Followup Instructions: ___

{'R leg pain': ['Other closed fracture of lower end of femur'], 'Mild paresthesias over tips of right toes': ['Chronic kidney disease', 'unspecified'], 'Right knee pain': ['Other closed fracture of lower end of femur'], 'Swelling': ['Other closed fracture of lower end of femur'], 'TTP over knee': ['Other closed fracture of lower end of femur']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / ibuprofen / Novocain / lovastatin Attending: ___ Chief Complaint: Palpitations Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of AVNRT, HTN who presents w/ palpitations, SOB which had resolved prior to arrival to ED, and was admitted to ___ for workup. Pt noted that she has episodes of palpitations frequently, sometimes as much as 1x wk, and had a holter in ___ which did not show any e/o AVNRT. Diltiazem then switched to metoprolol/verapamil in ___ and pt felt that symptoms were greatly improved. However, over the last few weeks have had much longer lasting episodes, sometimes up to hours in duration. Pt called outpt cardiologist last ___ who rec'd 40mg verapamil to be taken prn in addition to TID dosing. Pt followed such intructions to good effect. Yesterday, pt had episode that lasted 4 hours from 4:30pm to 8:30pm, despite taking 40mg verapamil at 5:30pm. It then recurred at 9:30pm so pt took another 40mg verapamil and called EMS. She denied any preceeding ACS symptoms, but endorsed SOB during episode of palpitations. Pt routinely checks her pulse during such episodes, and noted that HR feels fast/regular, w/ occasional pauses. On ROS, pt denied any infectious symptoms (cough, fever, chills), or heart failure symptoms (orthopnea, wt gain). In the ED, initial VS were: 68 123/68 20 94% RA. Pt was not tachycardic in ED. Labs were significant for normal WBC/CHEM/UA/Trop. Pt was not given any medication and was admitted to ___ for further evaluation. Overnight, pt reports doing well. She still has occasional palpitations. Otherwise, no CP, light-headedness or SOB. Past Medical History: 1. Episodic cardiac arrhythmia 2. Hypertension 3. Hypercholesterolemia 4. Elevated calcium level (measured at 10.2 1 month ago) 5. Irritable bowel syndrome (periodic diarrhea) 6. Back pain 7. s/p ORIF L bimalleolar ankle francture (___) 8. osteoporosis Social History: ___ Family History: Patient's Father: coronary artery disease (died at age ___ Patient's Mother: heart valve dysfunction (specifics unknown) Patient's Daughter: parathyroid gland removed Physical Exam: On Admission: Vitals - T97.5, BP 159/75 P58, R20, O297RA GENERAL: NAD, sitting in bed, pleasant HEENT: MMM, supple neck CV: RRR no m/r/g, normal S1/S2 LUNGS: CTA b/l, no wheezes/rales/rhonchi ABD: Soft, NT, ND, normoactive BS EXT: Warm, well perfused, no edema NEURO: fluent speech, AOx3, no focal deficits At Discharge: VS: 97.5/97.5; 151-159/55-75; 53-58; 20; 95-97% RA GENERAL: WDWN F 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 xanthelasma. NECK: Supple with no JVD. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Trace pitting edema in ___, R>L. No cyanosis or clubbing. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Radial 2+ DP 2+ ___ 2+ Left: Radial 2+ DP 2+ ___ 2+ Pertinent Results: On Admission: ___ 11:36PM BLOOD WBC-7.5 RBC-4.31 Hgb-14.0 Hct-39.3 MCV-91 MCH-32.5* MCHC-35.7* RDW-14.4 Plt ___ ___ 11:36PM BLOOD Neuts-57.3 ___ Monos-6.7 Eos-1.8 Baso-0.4 ___ 11:36PM BLOOD Plt ___ ___ 11:36PM BLOOD Glucose-122* UreaN-15 Creat-0.8 Na-140 K-4.3 Cl-101 HCO3-25 AnGap-18 ___ 11:36PM BLOOD cTropnT-<0.01 On Discharge: ___ 10:34AM BLOOD WBC-4.8 RBC-3.99* Hgb-12.6 Hct-36.8 MCV-92 MCH-31.5 MCHC-34.2 RDW-13.9 Plt ___ ___ 10:34AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-141 K-3.8 Cl-100 HCO3-32 AnGap-13 ___ 10:34AM BLOOD cTropnT-<0.01 ___ 10:34AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.1 STUDIES: ___ CXR: IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: ___ PMH of AVNRT, HTN who presents w/ palpitations, SOB which had resolved prior to arrival to ED. Pt was monitored on telemetry overnight and had two short runs of narrow complex tachycardia. She was discharged with a plan to follow up with her primary cardiologist and consider possible EP study and ablation of AVNRT. No medication changes were made. Transitional Issues: -Follow up with primary cardiologist -Consider electrophysiology evaluation to consider possible EP study and ablation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO DAILY:PRN anxiety 2. Metoprolol Succinate XL 75 mg PO DAILY 3. Verapamil 40 mg PO Q8H 4. Aspirin 81 mg PO DAILY 5. Pravastatin 20 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lorazepam 0.5 mg PO DAILY:PRN anxiety 3. Metoprolol Succinate XL 75 mg PO DAILY 4. Pravastatin 20 mg PO QPM 5. Verapamil 40 mg PO Q8H Discharge Disposition: Home Discharge Diagnosis: Primary: Narrow complex tachycardia Secondary: Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ were admitted to ___ because of palpitations. ___ were observed overnight, and we did not see anything concerning while monitoring your heart. ___ should continue taking your home medications as prescribed. ___ should also follow up with your primary cardiologist and ___ should talk with her about the possibility of getting a study to look more closely at your heart rhythm and to possibly "ablate" . It was a pleasure to help care for ___ during this hospitalization, and we wish ___ all the best in the future. Sincerely, Your ___ Team Followup Instructions: ___

{'Palpitations': ['Paroxysmal supraventricular tachycardia'], 'Shortness of breath': ['Paroxysmal supraventricular tachycardia'], 'Hypertension': ['Unspecified essential hypertension'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Palpitations Major Surgical or Invasive Procedure: none History of Present Illness: HPI: The patient is a ___ year-old female with a history of episodic cardiac arrhythmia, hypertension, and hyperlipidemia, who presents for heart palpitations. Mrs. ___ was in her usual state of good health until 9am on the day of admission, when she experienced a "surging sensation" in her chest, with rapid heart rate, and a constant, dull ___ discomfort near her sternal angle, radiating to the ___ her back. She reports that the episode began while she was leaning over her sink, lasted ___ hours, and ended spontaneously. She reports a sensation of fatigue which began coincident with the cessation of palpitations. Mrs. ___ denies diaphoresis, dizziness, syncope, or shortness of breath (the patient can walk up 3 flights of stairs without dyspnea). She reports no recent fevers/chills or nausea/vomiting. The patient has experienced ___ previous episodes of arrhythmia over the past ___ years (most recent was 6 months ago), with chest discomfort and heart rate elevation similar to the current episode, leading to one previous hospitalization. The cardiac history is otherwise negative. During this episode, Mrs. ___ called EMS, and was brought by ambulance to ___. . In the ED, Mrs. ___ was asymptomatic, with T 97.3, P 54, BP 115/54, RR 18, and SaO2 95 on RA. An EKG was obtained, showing normal sinus rhythm and no signs of ischemia. Cardiac troponin level in the ED was 0.02, UA was negative, and CXR was normal. ASA (325 mg) was given, and Mrs. ___ was transferred to the floor for observation and further cardiac evalutation. Past Medical History: Past Medical History: 1. Episodic cardiac arrhythmia (The first episode of tachycardia/palpitations occurred a few years ago, and lasted for 1 hour, resulting in an admission to ___ in 3 additional episodes have occurred since this point. The most recent episode was 6 months ago, prompting evaluation by a cardiologist [Dr. ___, including echocardiogram and home telemetry, with normal results). 2. Hypertension 3. Hypercholesterolemia 4. Elevated calcium level (measured at 10.3 2 weeks ago) 5. Irritable bowel syndrome (periodic diarrhea) 6. Back pain Social History: ___ Family History: Family History: Patient's Father: coronary artery disease (died at age ___ Patient's Mother: heart valve dysfunction (specifics unknown) Patient's Daughter: parathyroid gland removed Physical Exam: PE: Vitals T 97.9 P 58 BP 125/67 RR 20 SaO2 99 (RA) . General: This is a healthy-appearing female, nontoxic appearing. On exam, she was conversational and in no apparent distress. Skin: Warm and well perfused, with good color. Nails without clubbing or cyanosis. No rash/petechiae/ecchymoses. HEENT: Head is normocephalic and aturaumatic. Sclera anicteric, conjunctiva pink. Oral mucosa pink, with good dentition (multiple metal fillings). Pharynx without exudates. Trachea midline. Neck supple. Pulmonary: Thorax is symmetric with good expansion. Chest clear to ascultation bilaterally. No rales/wheezes/rhonchi. Cardiac: Regular rate and rhythm. Nml. S1, S2. No murmurs/rubs/gallops. Lymphatic: No cervical or supraclavicular lymphadenopathy. GI: +Bowel sounds, abdomen soft, nontender, nondistended. No organomegaly. GU: Pelvic exam not performed Rectal: Rectal exam not performed Neuro: PEERLA, EOMI, TML, face symmetric, moving ___. Extremities: Warm and well perfused, radial pulse 2+, DP 2+ bilaterally. Mild tenderness to palpation over left ankle. Pertinent Results: Imaging: CXR-- No evidence of acute intrathoracic process. . (___) ___ Echocardiogram Reports: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No pulmonary hypertension or significant valvular disease seen. ___ 10:15PM CK(CPK)-59 ___ 10:15PM CK-MB-NotDone cTropnT-0.05* ___ 11:55AM GLUCOSE-106* UREA N-15 CREAT-1.0 SODIUM-142 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-33* ANION GAP-13 ___ 11:55AM estGFR-Using this ___ 11:55AM CK(CPK)-55 ___ 11:55AM cTropnT-0.02* ___ 11:55AM CK-MB-NotDone ___ 11:55AM CALCIUM-10.2 PHOSPHATE-3.3 MAGNESIUM-2.2 ___ 11:55AM WBC-4.9 RBC-4.49 HGB-15.0 HCT-41.4 MCV-92 MCH-33.3* MCHC-36.1* RDW-13.7 ___ 11:55AM NEUTS-50.1 LYMPHS-43.9* MONOS-4.4 EOS-1.0 BASOS-0.6 ___ 11:55AM PLT COUNT-254 ___ 11:30AM URINE HOURS-RANDOM ___ 11:30AM URINE GR HOLD-HOLD ___ 11:30AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG ___ 11:30AM URINE ___ WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 TRANS EPI-1 Brief Hospital Course: This is a ___ year-old female who presents with chest discomfort and palpitations. . # To address heart palpitations, the patient was put on continuous monitoring with Telemetry. Electrolytes were monitored frequently, and cardiac enzymes were checked q8hrs. Aspirin was given (81 mg, PO, Qdaily), and the patient was arranged for further ambulatory event monitoring with her cardiologist (Dr. ___, and outpatient follow-up. . # To address irritable bowel syndrome, home med Sucralfate 1gm daily was given . # To address the patient's hypertension, home med felodipine (2.5 mg, PO, Qdaily) was given. . # To address hypercholestrolemia, atorvastatin (20 mg, PO, Qdaily) was given. . # To address fluids/electrolytes/nutrition, the patient was given a regular diet, and electrolytes were repleted PRN (optimizing to mag 2.5 and K of 4.5). . # For DVT Prophylaxis, the patient was given Sub-cutaneous heparin. Medications on Admission: 1. Bisoprolol-HCTZ (5mg-6.25 mg, PO, Qdaily) 2. Lovastatin (20 mg, PO, Qdaily) 3. Sucralfate (1 g, PO, Qdaily) 4. Felodipine SR (2.5 mg, PO, Qdaily) 5. Aspirin (81 mg, PO, Qdaily) 6. Acidophilus (1 capsule, PO, Qdaily) 7. Vitamin C (1 capsule, PO, Qdaily) 8. Multivitamin (1 tab, PO, Qdaily) Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Palpitations Discharge Condition: Good Discharge Instructions: Return to the ED immediately if you experience - shortness of breath - heart palpitations - chest pain - loss of conciousness Followup Instructions: ___

{'surging sensation': ['Palpitations'], 'rapid heart rate': ['Palpitations'], 'dull discomfort near sternal angle': ['Palpitations'], 'radiating to the back': ['Palpitations'], 'fatigue': ['Palpitations'], 'diaphoresis': [], 'dizziness': [], 'syncope': [], 'shortness of breath': [], 'fevers/chills': [], 'nausea/vomiting': [], 'elevated calcium level': ['Pure hypercholesterolemia'], 'irritable bowel syndrome': [], 'back pain': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Fosamax Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Laparoscopic cholecystectomy History of Present Illness: ___ yo presents with abdominal pain. Pt reports on day prior to presentation she ate a fatty meal and noted onset of abdominal pain approximately 3 hours later. She has had persistent pain since then. The pain is epigastric with radiation to the RUQ and back, assoicated w/ nausea and 3 episodes of NBNB emesis. Pt had temp of ___ yesterday. Reports similar episodes of pain when eating fatting food for the past month that were less severe and self resolved. Denies chest pain, dyspnea, or cough. In ED RUQ showed stone is bile duct. Lipase ___. Pt given cipro/flagyl, zofran and morphine. ERCP and ACS notifed. On arrival to floor denies pain or nausea. ROS: +per HPI, 10 points reviewed and otherwise neg Past Medical History: osteoporosis Social History: ___ Family History: no history of gallstones or pancreatic cancer Physical Exam: VS: PAIN: GEN: nad, somnolent HEENT: mmm CHEST: ctab CV: rrr ABD: soft, tender epigastrium and RUQ, nabs EXT: no e/c/c NEURO: follows commands, answering questions appropriately Pertinent Results: ___ 05:45PM LACTATE-2.0 ___ 04:16PM ___ PTT-30.5 ___ ___ 03:50PM GLUCOSE-150* UREA N-17 CREAT-0.9 SODIUM-140 POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-26 ANION GAP-19 ___ 03:50PM ALT(SGPT)-742* AST(SGOT)-726* ALK PHOS-145* TOT BILI-5.0* ___ 03:50PM LIPASE-2223* ___ 03:50PM ALBUMIN-4.1 ___ 03:50PM WBC-22.3* RBC-4.78 HGB-14.7 HCT-42.9 MCV-90 MCH-30.8 MCHC-34.3 RDW-13.4 ___ 03:50PM NEUTS-93.3* LYMPHS-3.4* MONOS-3.0 EOS-0 BASOS-0.3 ___ 03:50PM PLT COUNT-270 RUQ US IMPRESSION: 1. Stone within the neck of the gallbladder but no evidence of cholecystitis. 2. Somewhat limited scan due to bowel gas. Heterogeneous liver concerning for underlying liver disease but no evidence of intra or extrahepatic biliary dilatation. Brief Hospital Course: After ED evaluation, patient was admitted for further evaluation. Once hospitalized, the patient had an ERCP which shwed sludge in the common bile duct, which was cleared by the procedure. Patient also had a RUQ US which showed cholelithiasis. Patient was assumed to have a passed gallstone and was brought to the operating room for gallbladder removal with Dr. ___. Operative report is as follows: The patient was brought to the operative theater. General anesthesia was induced. The patient was prepared and draped in the usual fashion. A time- out was now performed. We entered the abdomen through an infraumbilical smile incision, which was anesthetized, as all ports were, with 0.5% Marcaine. The incision was taken down bluntly to the linea ___. Linea ___ was elevated between ___ clamps and incised. We now penetrated the peritoneum bluntly with a single pass of a blunt ___ clamp. We now placed a 12 ___ type port and insufflated the abdomen to 15 mmHg. We now passed a 30 degree angled laparoscopic into the abdomen and explored. The right upper quadrant revealed the gallbladder was not particularly adherent to the surrounding tissues but was quite whitened, as typical of chronic cholecystitis. It also had a layer of rather fragile edematous tissues around it, which were moderately troublesome during the course of the case. We began the case by placing a 12 mm port in the epigastrium, and subsequently two 5 mm ports were placed in the subcostal regions in the mid clavicular and lateral clavicular lines. We now retracted cephalad on the gallbladder on its fundus and pulled the ampulla to the right. Using ___ as well as ___ dissection, we now suppressed the soft tissue off of the lateral edge of the cystic duct area, eventually defining the cystic duct lateral margin. We now slowly suppressed the soft tissue off of the cystic duct and allowed the cystic artery, which was lying fairly close over the cystic duct, to fall back to the patient's left by dividing some of its right-sided ramifications using cautery. This now enabled us to isolate the cystic artery high up and divided between 2 clips proximally and 1 distally. We now cleaned the remainder of the cystic duct and divided it between 2 clips proximally and 1 distally. We now commenced elevating the gallbladder off of the liver bed. Because of some dense adhesions in this area, a cholecystotomy was made, and we spilled some bile but there was not a lot of stone debris seen. All of this was irrigated free with a suction irrigator, and the right upper quadrant cleansed several times before we finished the case. We now completed dissecting the gallbladder off of the liver bed until it was attached only by the free edge of the liver. At this time, we examined the dissection area in great detail and were very satisfied with both hemostasis and the clips on the cystic duct. The attachments of the gallbladder and the free edge of liver were now lysed and the gallbladder pulled out through the epigastric port. At this time, we once more irrigated the abdomen and removed all irrigant and debris. We now removed the trocars sequentially and found a pesky bleeder on the epigastric trocar site. This was controlled with cautery from the right flank port site. When this was dry, we now once more irrigated and were satisfied with hemostasis throughout. The remainder of the ports were removed. We now closed the umbilical port using the 2 stay sutures of 0 Vicryl plus an intervening figure-of-eight Vicryl suture. This resulted in a very satisfactory closure. The skin wounds were anesthetized thoroughly with 0.5% Marcaine. The subcutaneous tissues and skin were closed with ___ Monocryl. Benzoin and Steri-Strips were applied. 2 x 2's and Tegaderm were applied. Procedure was terminated. She tolerated the procedure well and was extubated upon completion. She we subsequently taken to the PACU for recovery. She was transferred to the surgical floor hemodynamically stable. Her vital signs were routinely monitored and she remained afebrile and hemodynamically stable. She was initially given IV fluids postoperatively, which were discontinued when she was tolerating PO's. Her diet was advanced on the morning of ___ to regular, which she tolerated without abdominal pain, nausea, or vomiting. She was voiding adequate amounts of urine without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which she was able to do independently. Her pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On ___, she was discharged home with scheduled follow up in ___ clinic in 2 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Actonel *NF* (risedronate) 35 mg Oral ___ Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 3. Senna 1 TAB PO BID Constipation 4. Actonel *NF* (risedronate) 35 mg ORAL ___ 5. Docusate Sodium 100 mg PO BID Discharge Disposition: Home Discharge Diagnosis: gallstone pancreatitis 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 acute cholecystitis. You were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___

{'Abdominal pain': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Epigastric tenderness': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Nausea': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Vomiting': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Radiation of pain to back': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Elevated lipase': ['Acute pancreatitis'], 'Stone in bile duct': ['Calculus of gallbladder with other cholecystitis'], 'Sludge in common bile duct': ['Calculus of gallbladder with other cholecystitis'], 'Choledocholithiasis': ['Calculus of gallbladder with other cholecystitis'], 'Chronic cholecystitis': ['Calculus of gallbladder with other cholecystitis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dysphagia Major Surgical or Invasive Procedure: Gastric Band Removal History of Present Illness: The patient is a ___ woman who underwent a laparoscopic adjustable gastric band in year ___, with subsequent excellent weight loss. She had actually been doing very well, but developed acute onset of dysphagia and vomiting. Upper GI barium study demonstrated no passage of contrast through the band consistent with a prolapse. We discussed at length the nature of prolapse as well as the rationale for surgery. We also discussed options including band revision, band removal. She understood the potential risks as well as the expected outcomes and wished to have her band removed. We discussed possibly regain and she felt that her lifestyle changes would achieve a durable weight loss. Past Medical History: s/p lap band, GERD, seizure disorder ___ congenital malformation surgically corrected at ___. Last seizure ___, switched medication. Social History: ___ Family History: non-contributory Physical Exam: 98.3 97.4 58 122/68 16 98% RA GEN: Well appearing, well nourished CV: RRR ___ Resp: CTAB Abd: Soft, obese, non-tender, non-distended Ext: no evidence of edema, warm, well perfused wound: Clean, dry and intact Pertinent Results: ___ 03:05PM GLUCOSE-53* UREA N-8 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13 ___ 03:05PM ALT(SGPT)-14 AST(SGOT)-20 ALK PHOS-48 TOT BILI-0.5 ___ 03:05PM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.0 ___ 03:05PM WBC-7.0 RBC-4.46 HGB-13.3 HCT-37.9 MCV-85# MCH-29.7 MCHC-35.0 RDW-13.6 ___ 03:05PM NEUTS-74.4* ___ MONOS-3.5 EOS-1.0 BASOS-0.6 ___ 03:05PM PLT COUNT-232 Brief Hospital Course: The patient presented on ___ with dysphagia. Pt was evaluated by anaesthesia and taken to the operating room on ___ where a laparoscopic adjustable gastric band removal was performed. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the ward for observation. Neuro: The patient was alert and oriented throughout the hospitalization; pain was well controlled with acetaminophen and dilaudid. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: He was initially NPO because of post prandial dysphagia. Then started on clears, which was advanced sequentially to stage 4, and well tolerated. Patient's intake and output were closely monitored. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay; she was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a stage 4 diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Citalopram 30 mg PO DAILY FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Headache 2. Citalopram 30 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. LaMOTrigine 50 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Dysphagia Gastric Band Prolapse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Your band was removed, but that does not mean you have to abandon your efforts to improve your health. Take this opportunity and incorporate what you have learned from your health care team. Continue being active on a regular basis and follow these healthful guidelines (not diet!) for life long benefits. In the hospital, you will be on a stage 3 diet for healing. This diet includes all liquid, high protein, low sugar and low fat supplements. When you are discharged home, you may advance your diet as tolerated. Below are some helpful tips to continue your journey of eating well and healthy living. 1.Keep an eye on calories. 2.Always eat at a table. Avoid eating while driving, standing, sitting on the sofa, or lying in bed. 3.Eat slowly. Continue to take 30 minutes to eat a meal and chew your foods thoroughly. 4.Surround yourself with healthy foods. Clean out your cabinets of any “trigger” or “unsafe” foods. 5.Keep a food journal or track your intake on-line. Record what you eat, portion sizes, and the time you eat. You may want to include your mood and hunger level, as well. 6.Avoid skipping meals. Always eat at regular times to avoid overeating later in the day. 7.Listen to your body. Eat when you are physically hungry and stop when you are full. 8.Be active. Engage in at least ___ minutes of physical activity most (if not all) days of the week. 9.Regularly check your weight. Give yourself an acceptable range (i.e. 5 pounds). This prevents “slip ups” from becoming bigger problems down the road. 10. Make small changes. Set small, reasonable goals to keep on track. 11. Reward yourself. Treat yourself when you reach goals with a non-food treat (i.e. pedicure, movie). 12. Ask for support. Call the ___ nutrition clinic for follow-up at ___. Join Weight Watchers, talk to friends and family or contact a local dietitian. 13. Drink plenty of fluids. Stay hydrated. Fluids & Diet Fluid intake is extremely important the first month of your recovery. You must also take in enough liquids to prevent dehydration. Dehydration can cause nausea, fatigue, lightheadedness and dark urine. We recommend you track what you drink and eat each day. Most Frequent Problems Discomfort Abdominal soreness below your ribs on the left side is the most common site of tenderness after waking up. Despite this discomfort, it is very important that you get out of bed and take short walks. Dehydration Your most important job after surgery is drinking enough fluid. Dehydration is the most common reason to return to the hospital after surgery. Your goal is to drink 8 cups (64 oz) of fluid a day. You may not be able to drink this much fluid at first, but come as close as you can. Refer to your nutrition packet for more details. Wound Drainage & Infection It is important to care for your incisions to prevent infection. You will have small fiber tapes on your wounds. This should keep your wound dry and closed. Leave them on until they fall off by themselves. Do not put band aids, ointments, lotions or powder on your incisions. You may get your incisions wet but avoid scrubbing them. Pat them dry. It is not unusual for an incision to drain a little bloody fluid after you go home. If you have some drainage, dab the wounds with diluted hydrogen peroxide (hydrogen peroxide mixed half and half with water) and then cover with a dry gauze. Doing this twice a day will speed your recovery. Infections are uncommon and rarely serious after a laparoscopic operation. An infection will be red, warm, firm, and tender. The infected fluid will look more like pus than like blood. If you notice this please call the nurse at the Bariatric ___ Program to discuss your symptoms. Followup Instructions: ___

{'dysphagia': ['Other dysphagia'], 'vomiting': ['Other complications of gastric band procedure'], 'fever': ['Other complications of gastric band procedure'], 'pain': ['Other complications of gastric band procedure']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left posterior wall acetabular fracture status post MVC Major Surgical or Invasive Procedure: No surgeries performed History of Present Illness: REASON FOR CONSULT: Status post MVC with left posterior wall acetabular fracture HPI: ___ male w/ hx hepatitis C, substance abuse, ADHD, depression presents status post MVC in which he was the restrained front seat passenger. He was brought to an outside hospital where imaging showed a left acetabular fracture and he was transferred here. He does note predominantly left hip pain as well as some bumps and bruises elsewhere. Pain is predominantly on the left side of his body. He notes left leg pain but no numbness or tingling. Denies any chest pain, trouble breathing. Past Medical History: ARTHRALGIA BACK PAIN BIPOLAR DISORDER EXUDATIVE TONSILLITIS HEPATITIS C HEROIN ABUSE Social History: 1 pack/day smoker Endorses some alcohol use though he is vague, 1 sixpacks per week Has a history of heroin use as well as cocaine use. Notes he relapsed with cocaine a week ago. He is on Suboxone with his clinic at ___ in ___. Physical Exam: General: Well-appearing male in no acute distress. Right upper extremity: Skin intact, no deformity, soft, nontender forearm and wrist. He has full painless range of motion at the shoulder, elbow, wrist, digits. Motor intact to EPL/FPL/IO SILT axillary/radial/median/ulnar nerve distributions 2+ radial pulse, WWP Left upper extremity: Skin intact. No deformity Some scattered abrasions with one over the clavicle. He does note tenderness to palpation at the distal radius though he has good range of motion there. Soft, non-tender arm. Fires EPL/FPL/DIO. SILT axillary/radial/median/ulnar nerve distributions. 2+ radial pulse, WWP Right lower extremity: - Skin intact - No deformity, edema, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM at hip, knee, and ankle - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Right lower extremity: - Skin intact - No deformity, edema, ecchymosis, erythema, induration - Soft, tenderness to palpation at tibia and ankle - Fires ___. Able to flex and extend at the knee. - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left posterior wall acetabular fracture and was admitted to the orthopedic surgery service. The patient was treated nonoperatively and worked with physical therapy who determined that discharge to home with home ___ was appropriate. The patient was given anticoagulation per routine, and the patient's home medications were continued throughout this hospitalization. On the night of ___ patient was found apneic, satting in the 80%s, and unarousable. A CODE BLUE was called and multiple doses of Narcan were given. The patient was transferred to the TSICU. Utox upon arrival was floridly positive for multiple substances. Found to have drugs in rectum per TSICU staff that were believed to have been brought in by his friends. He was placed on a Narcan drip. He stayed in the TSICU until ___ largely for monitoring purposes. He was weaned from his Narcan drip and seen by addiction psych and chronic pain. Chronic pain suggested the patient go back onto his home regimen of Suboxone and Klonopin. Addiction psych provided final recommendations which included: Mr. ___ is a ___ year old male with opiate use disorder, on buprenorphine maintenance for 10 months. Recent relapse on opiates, which he attributes to "hanging with the wrong ___ He was inducted back on buprenorphine while hospitalized. He is ready to ___ home today. 1.Attempted to reach ___, psych NP at ___. She confirmed he is a patient there and missed his last appointment with her. 2.Plan to use remaining buprenorphine he has at home, to get to his next appt on ___. 3.Encouraged to attend his weekly therapy session and add recovery meetings that have helped him stabilize in the past. 4.He is not interested in IOP or PHP at this time. At the time of discharge the patient's pain was well controlled without additional narcotic pain medications other than his home burprenorphine. The patient was voiding/moving bowels spontaneously. The patient is touchdown weightbearing in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: Amphetamine-Dextroamphetamine Buprenorphine BuPROPion (Sustained Release) Citalopram ClonazePAM CloNIDine LamoTRIgine TraZODone Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Enoxaparin Sodium 40 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneously Nightly Disp #*30 Syringe Refills:*0 3. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % Apple one patch to area of pain Once daily PRN Disp #*25 Patch Refills:*0 4. Nicotine Patch 14 mg/day TD DAILY 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 6. Amphetamine-Dextroamphetamine 30 mg PO BID 7. Buprenorphine 8 mg SL DAILY 8. BuPROPion (Sustained Release) 200 mg PO BID 9. Citalopram 40 mg PO DAILY 10. ClonazePAM 1 mg PO BID 11. CloNIDine 0.1 mg PO BID 12. LamoTRIgine 200 mg PO BID 13. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left posterior wall acetabular fracture Discharge Condition: AVSS NAD, A&Ox3 LLE: No pain with log roll or gentle hip ROM Fires ___ SILT throughout WWP Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - TDWB LLE MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) You should continue to take your Suboxone and other medications as prescribed by Column Health. Please follow-up with them for ongoing prescriptions. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks Physical Therapy: TDWB LLE Treatments Frequency: No wounds or specific wound care instructions Followup Instructions: ___

{'Left posterior wall acetabular fracture': ['Displaced fracture of posterior wall of left acetabulum'], 'MVC': ['initial encounter for closed fracture'], 'Substance abuse': ['Opioid abuse', 'uncomplicated'], 'Apnea': ['Apnea', 'not elsewhere classified'], 'Poisoning by other opioids': ['Poisoning by other opioids', 'accidental (unintentional)', 'initial encounter'], 'Unspecified place in hospital': ['Unspecified place in hospital as the place of occurrence of the external cause'], 'ADHD': ['Attention-deficit hyperactivity disorder', 'unspecified type'], 'Bipolar disorder': ['Bipolar disorder', 'unspecified'], 'Joint pain': ['Pain in unspecified joint', 'Dorsalgia', 'unspecified'], 'Nicotine dependence': ['Nicotine dependence', 'cigarettes', 'uncomplicated'], 'Personal history of infectious and parasitic diseases': ['Personal history of other infectious and parasitic diseases']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Right colon cancer Major Surgical or Invasive Procedure: lap R colectomy History of Present Illness: ___ healthy male initially presenting with history of abdominal pain. Incidental findings on CT of a large mass 6.2 x 4.9 x 6.0 (TV x AP x CC) cm mass within the mid ascending colon consistent with malignancy. Colonoscopy workup also confirming adenocarcinoma. He presents for elective resection of his cancer. Past Medical History: None Social History: ___ Family History: One brother died of leukemia. Physical Exam: Vital Signs: Blood Pressure: 100/70, Heart Rate: 61, Weight: 202 Lbs, Height: 71 Inches, BMI: 28.2 kg/m2. HEENT: Anicteric. OP clear. TM's normal bilaterally. ___: Negative. COR: Regular, without concerning murmurs, ___, or rubs. LUNGS: Clear bilaterally without rales, ronchi, or wheezes. AB: Soft. No masses. No organomegaly. VASCULAR: DP pulses palpable bilaterally. No bruits. No JVP. SKIN: No concerning nevi noted. No concerning rash noted. NEURO: The cranial nerves are intact. Grossly non-focal. GU: Testes descended bilaterally. No nodules. No ___. Pertinent Results: ___ 07:46PM URINE RBC-187* WBC-29* Bacteri-NONE Yeast-NONE Epi-<1 URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed fecal flora. Clinical significance of isolate(s) uncertain. Interpret with caution. PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. ___ 07:05AM BLOOD WBC-10.8# RBC-3.97* Hgb-11.5* Hct-34.7* MCV-87 MCH-28.8 MCHC-33.0 RDW-12.9 Plt ___ ___ 01:00PM BLOOD CEA-1.9 Brief Hospital Course: Patient was admitted to Dr. ___ service on ___. He was taken to the operating room for a laparoscopic right colectomy. Patient tolerated the procedure without complications and taken to the PACU for monitoring. He was transferred to the floor for further recovery. His hospital course could be summarized as following: Neuro: Patient had sufficient pain control with Vicodin. Resp: No respiratory issues. Cardio: No hemodynamic issues. GI: Patient was kept NPO after his procedure with IVF. He was advanced to sips POD1. Diet was eventually advanced to regular on POD3 with return of bowel function. He will be discharged with a stool softener to be taken with narcotics. GU/FEN/Renal: Patient's urine output was monitored closely. His IV fluids were discontinued as he tolerated enough of his oral intake. ID: Patient with fever POD2 of 101.3. UA/UCx confirming UTI with proteus. Patient will be kept on a 5 day course of ciprofloxacin. Moreover, some erythema to surgical incision. Will discharge him with a 7 day course of cefadroxil for empiric coverage. Heme: Patient with subcutaneous heparin for DVT prophylaxis Dispo: Patient ambulating without any difficulty. He will be discharged home. Medications on Admission: None Discharge Medications: 1. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4-6H () as needed for pain for 2 weeks: Please do not take more than 4000mg of acetainophen in 24 hrs. Do not exceed 8 in 24 hrs. Disp:*45 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: for constipation while on narcotics. Disp:*60 Capsule(s)* Refills:*2* 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 4. Duricef 1 gram Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Right colon Cancer Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * 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 ___ 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. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips ___ days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: ___

{'abdominal pain': ['Malignant neoplasm of ascending colon'], 'mass within the mid ascending colon': ['Malignant neoplasm of ascending colon'], 'adenocarcinoma': ['Malignant neoplasm of ascending colon'], 'fever': ['Urinary tract infection'], 'erythema to surgical incision': ['Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Scheduled admission for chemotherapy with ___. Major Surgical or Invasive Procedure: ___ treatment. History of Present Illness: Patient is a ___ man with stage III colon cancer (T3, NO, MO) status post laparoscopic right colectomy. Pathology revealed a low grade tumor with ___ lymph nodes involved, clean margins. No LVI was noted. He started FOLFOX on ___. He is receiving oxaliplatin, leucovorin, and ___. Two days prior to admission was cycle 3, day 16. He is admitted today for observation during ___ treatment due to concern that this might be causing neurotoxicity and possible seizure activity (he was noted to have muscle twitching/cramping during infusion previously). The plan is for continuous EEG monitoring during ___ infusion today. On speaking with him today, he feels fine. He denies chest pain, shortness of breath, lightheadedness, dizziness, or confusion. He denies muscle cramps or twitching. Past Medical History: None. Social History: ___ Family History: One brother died of leukemia. Physical Exam: Vital signs: T 97.4, BP 108/75, HR 56, RR 18, sat 100% RA General: awake, alert, oriented, in no distress; lying comfortably in bed Heart: RRR, normal s1/s2 Lungs: clear bilaterally Abdomen: soft, non-tender Legs: non-edematous, well-perfused Neuro: AAOx3, moving all extremities Pertinent Results: ___ 09:56AM BLOOD WBC-5.7# RBC-4.53* Hgb-12.4* Hct-38.5* MCV-85 MCH-27.3 MCHC-32.2 RDW-15.1 Plt ___ ___ 09:56AM BLOOD Neuts-80.1* Lymphs-10.7* Monos-7.8 Eos-1.2 Baso-0.2 ___ 09:56AM BLOOD ___ PTT-23.9 ___ ___ 09:56AM BLOOD Glucose-132* UreaN-14 Creat-0.9 Na-138 K-3.7 Cl-102 HCO3-25 AnGap-15 ___ 09:56AM BLOOD ALT-93* AST-47* LD(LDH)-214 CK(CPK)-90 AlkPhos-71 TotBili-0.3 ___ 09:56AM BLOOD Albumin-3.8 Calcium-8.1* Phos-2.5* Mg-2.1 Brief Hospital Course: Patient underwent ___ treatment without complication. He was monitored on EEG during the infusion. The EEG was then reviewed by neurology. Per their report there was no evidence of seizure activity. The twitches he experienced during chemotherapy previously may be due to peripheral nerve damage (from either ___ or platinum), and neurology has recommended that he have an EMG as the next step in his evaluation. Medications on Admission: APREPITANT [EMEND] - 125 mg (1)-80 mg (1)-80 mg (1) Capsule, Dose Pack - 1 Capsule(s) by mouth daily as directed DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth BID x 3 days Starting the evening of chemotherapy LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for nausea ___ repeat x 1 if no effect WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth once a day continue daily while port is in IBUPROFEN [ADVIL] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: APREPITANT [EMEND] - 125 mg (1)-80 mg (1)-80 mg (1) Capsule, Dose Pack - 1 Capsule(s) by mouth daily as directed DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth BID x 3 days Starting the evening of chemotherapy LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for nausea ___ repeat x 1 if no effect WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth once a day continue daily while port is in IBUPROFEN [ADVIL] - (Prescribed by Other Provider) - Dosage uncertain Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Colon cancer Discharge Condition: Vital signs stable, afebrile. Discharge Instructions: You were admitted for treatment of colon cancer with ___ and monitoring on EEG for evidence of seizure activity. The treatment went without complication, and there was no seizure activity on EEG. . There have been no changes to your medications. . Please note your follow-up appointments below. Followup Instructions: ___

{'muscle twitching/cramping': ['Malignant neoplasm of ascending colon'], 'chest pain': [], 'shortness of breath': [], 'lightheadedness': [], 'dizziness': [], 'confusion': [], 'muscle cramps': ['Malignant neoplasm of ascending colon'], 'twitching': ['Malignant neoplasm of ascending colon']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Bactrim Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ yr old right handed gentleman who presents to Emergency Department after a fall off his bike with his helmet. He does complain of headaches and mild nausea. No weakness or paresthesia. Had a Head CT at ___ which shows a hyperdensity in the left frontal lobe. Currently he denies chest pain, dizziness, seizures. Past Medical History: Right arm ORIF Social History: ___ Family History: NC Physical Exam: On ___ Gen: comfortable, NAD. left forehead abrasion HEENT: Cranial defect left parietal area ___ FB by ___ FB Pupils: PERRL EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. 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, 4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Reflexes: 2+ symmetrical Toes downgoing bilaterally Coordination: normal on finger-nose-finger Stable gait and stance. upon discharge: ___ the patient is neurologically intact full strength and sensation the patient is alert and oriented to person,place, and time he ambulates with a steady gait independently there is no pronator drift face is symetric pupils are equal and reactive Brief Hospital Course: ___ patient presented to ___ Emergency department after a bike accident for evalaution. A CT head was done which showed small left frontal contusion under his known cranial defect. The patient was admitted to the floor and was neurologically intact. He exhibited full strength and sensation. The patient was alert to person/place/and time.The patient had minimal headache and was able to ambulate independently with a steady gait. The was scheduled for preadmission testing on ___ and had a scheduled Head CT for his futured surgery planned with Dr ___ ___ for ___. The patient was given direction to call the office to arrange for any additional preadmission testing prior to surgery. He was initiated on an antiseizure medication keppra 750 mg BID for is small left frontal constusion. Medications on Admission: None Discharge Medications: 1. LeVETiracetam 750 mg PO BID until follow up RX *Keppra 750 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q8H:PRN headache do not drive while taking this medication, do not operate heavy machinery RX *Co-Gesic 5 mg-500 mg ___ tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID stool softener please take while you are taking vicodin RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left Frontal contusion Discharge Condition: alert and oriented to person/place/time strength is full no pronator drift sensation intact pupils reactive/symetric speech clear hearing intact face symetric Discharge Instructions: •Take your pain medicine as prescribed. please take keppra 750 mg twice a day as seizure prophylaxis until you are seen in follow up. •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. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. 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: ___

{'headache': ['Other and unspecified cerebral laceration and contusion'], 'nausea': ['Other and unspecified cerebral laceration and contusion']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Bactrim / Keppra / zonisamide Attending: ___. Chief Complaint: Skull defect, eosinophilic granuloma Major Surgical or Invasive Procedure: Left craniotomy and cranioplasty History of Present Illness: Patient is a ___ year old gentleman who was found to have an eosinophilic granuloma requiring craniotomy and cranioplasty whose pre-operative course has been complicated by possible seziure activity, evalauted by neurology and transitioned from keppra to zonisamide. He presents electively for repair of his granuloma Past Medical History: Right arm ORIF Social History: ___ Family History: NC Physical Exam: T 98.3 BP 100/80 P ___ (supine) 130/80 100 (sitting) 100/80 100 (standing) R 16 KPS 90. Mental status is satisfactory in areas of alertness, orientation, concentration memory and language. Optic discs are sharp. On cranial nerve examination, eye movements are full, pupils are equal and reactive. Full visual fields. No facial weakness, no dysarthria. No tongue weakness. On motor examination, there is no weakness. Coordination is normal. Fine movements are satisfactory. Light touch and vibration is perceived well throughout. Reflexes are normoactive and symmetric. Gait and station are normal. On general examination, the oropharynx is clear, the lungs are clear, the heart is regular, the legs are without edema or tenderness. There is irregular left temporal skull defect with tenderness to touch. Brief Hospital Course: Patient presented electively ___ ___ for craniotomy and cranioplasty for eosinophilic granuloma. Medications on Admission: zonisamide Discharge Disposition: Home Discharge Diagnosis: Eosinophilic granuloma 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 have dissolvable sutures you may wash your hair. •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. •If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume after follow up •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 10.51° F. Followup Instructions: ___

{'seizure activity': ['Other convulsions'], 'tenderness to touch': ['Other specified acquired deformity of head'], 'eosinophilic granuloma': ['Other specified disorders of metabolism']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: slurred speech Major Surgical or Invasive Procedure: N/A History of Present Illness: History of Present Illness (per Dr. ___: The pt is a ___ Left handed woman who presents as a code stroke. She was in normal state of health when at 10 pm she suddenly developed acute onset of slurred speech. Along with this she states that she felt as though her whole left side of her body felt week from her arm to foot. These symptoms lasted about ___ min and resolved on there own except she still thinks her left arm is weak. This was witnessed by a friend who notified family first. At the time of eval her only symptoms were residual left side weakness feeling and just like it does not move in the right way. otherwise no sensory symptoms no vision symptoms. She normally drinks a "small" bottle of wine per day and today had 4 glasses of wine but not a full bottle. She denies ever suffering from withdraw symptoms. She smokes a pack a day and she states she has HLD and HTN but does not take meds for this. Past Medical History: Hypertension Hyperlipidemia Tobacco use Social History: ___ Family History: Her father had a history of MI in his ___. Physical Exam: Physical Exam (on arrival to hospital on ___: Vitals: T:98 P:70 R: 16 BP: 129/54 SaO2:98 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: Lungs CTA bilaterally. Barrel chest Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND Extremities: No edema bilaterally, 2+ DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. There were no semantic or phenomic paraphasic errors. Able to read without difficulty. Speech was mildly dysarthric. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI with 5 beat nystagmus at b/l lateral gaze. V: Facial sensation intact to light touch. VII: left facial to smile. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No tremor, asterixis noted. Strength was 5+ on the right and 5 on the left. there was give way component. There was some slow movements to RAM and Fine finger movements on the Left -Sensory: No deficits to light touch, extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 1 0 R 2 2 2 1 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Slightly slower with left FNF testing -Gait: not tested Pertinent Results: LABS: ___ 07:58AM CK(CPK)-150 ___ 07:58AM CK-MB-3 cTropnT-<0.01 ___ 07:58AM CHOLEST-214* ___ 07:58AM TRIGLYCER-110 HDL CHOL-56 CHOL/HDL-3.8 LDL(CALC)-136* ___ 07:58AM TSH-2.4 ___ 03:00AM URINE TYPE-RANDOM COLOR-Straw APPEAR-Clear SP ___ ___ 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 01:06AM GLUCOSE-104* UREA N-8 CREAT-0.7 SODIUM-142 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-27 ANION GAP-14 ___ 01:06AM estGFR-Using this ___ 01:06AM cTropnT-<0.01 ___ 01:06AM CALCIUM-9.4 PHOSPHATE-3.8 MAGNESIUM-2.3 ___ 01:06AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 01:06AM WBC-9.9 RBC-4.40 HGB-14.7 HCT-41.2 MCV-94 MCH-33.4* MCHC-35.7* RDW-12.8 ___ 01:06AM NEUTS-55.5 ___ MONOS-5.3 EOS-4.9* BASOS-0.9 ___ 01:06AM PLT ___ 01:06AM ___ PTT-27.9 ___ IMAGING: MRI w/o contrast Date: ___ FINDINGS: There is no evidence of acute infarct seen. There is no mass effect, midline shift or hydrocephalus identified. There are no significant focal abnormalities. Small areas of hyperintensity in both atrial regions of the ventricles on diffusion images are due to incidental small choroid plexus cysts. The suprasellar and craniocervical regions are unremarkable. The vascular flow voids are maintained. IMPRESSION: No significant abnormalities on MRI of the brain without gadolinium. No acute infarcts. CTA neck and head Date: ___ CTA HEAD: CTA of the head demonstrates normal vascular structures in the anterior and posterior circulation without stenosis, occlusion or an aneurysm greater than 3 mm in size. IMPRESSION: 1. No significant abnormality on CT head without contrast. 2. CT angiography of the neck demonstrates mild-to-moderate atherosclerotic disease at the left carotid bifurcation with less than 50% narrowing and calcified plaque. 3. No significant abnormalities on CT angiography of the head. ECHO Date: ___ IMPRESSION: Brief Hospital Course: Ms. ___ was admitted to the hospital on ___ with a chief complaint of slurred speech and left-sided numbness and weakness in her upper and lower extremities. On HD1, the patient was evaluated by the stroke felow who completed a full exam prior to any neurological imaging. She had a head CT without contrast that was negative for acute process based on the preliminarty read. She was admitted to the neurology service to rule stroke. She was initially ruled out for MI with serial tropinins. She received one dose of aspirin 325mg in the emergency department and this dose was decreased to ASA 81mg when she was transferred to an inpatient floor. A lipid panel was ordered and the patient was started on a statin. Her blood pressure was maintained between 140 and 180. She received smoking cessation counseling and was started on a nicotine patch. We also encouraged the patient to decrease her alcohol intake because it increases her risk of stroke. She was started on thiamine and folate due to her recent alcohol use. On HD2, the patient received an ECHO that was equivocal for showing a PFO. A TEE was recommended but not done. She was also discharged with a nicotine patch. Medications on Admission: None Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 2 weeks. Disp:*14 Patch 24 hr(s)* Refills:*1* 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Transient ischemic attack (TIA) Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospital admission. You were admitted after you developed left side numbness and slurred speech. During your admission, we completed a head CT and MRI scan that revealed no significant abnormalities. However, based on your clinical examination, we suspect that you had a transient episode with decreased blood flow to your brain. The neurologic deficits improved during your hospital stay. We encourage smoking and alcohol cessation to decrease your risk of stroke. Please follow up in 6 to 8 weeks with Dr. ___ discharge. His office phone number is as follows: ___. Followup Instructions: ___

{'slurred speech': ['Unspecified transient cerebral ischemia'], 'left side numbness': ['Unspecified transient cerebral ischemia'], 'left side weakness': ['Unspecified transient cerebral ischemia'], 'history of hypertension': [' Unspecified essential hypertension'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'tobacco use': ['Tobacco use disorder'], 'alcohol use': ['Other specified counseling']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abd Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of C-section p/w RUQ pain that started suddenly two hours ago, one hour after eating a cheeseburger. Pain is ___ and is RUQ and epigastric. + nausea. No vomiting. A few loose stools today. has not had this pain before. no fevers or chills, dysuria or flank pain. Denies recent acetaminophen, EtOH. Did have a tooth pulled a few days ago and has been taking amoxicillin. Of note, she reports going to the ___ ED ~1 month ago for abdominal pain, which she describes as esophageal discomfort after eating, and was given a medication for 1 week (she is unclear what) In the ED, initial VS were: 98.4 88 111/60 20 99% A RUQ US was obtained given concern for billiary colic and did not show any obstruction of gallbladder distention. Surgery was consulted as well and did not feel that her exam or labs were consistant with an acute biliary obstruction, but did raise concern for ulcer disease. LFTs were returned with a transaminitis in an AST>ALT pattern and no evidence of AP or bili elevation. She was given analgesics and anti-emetics and admitted to medicine. . VS on transfer: 72 118/52 18 99%. Currently, she is in NAD, feeling somewhat better than before. . After arrival to the floor, the patient reported improved symptoms. However, repeat LFT's were noted to be even more elevated. Broad work-up was started for various causes of hepatitis. However, prior to results being available, she left AGAINST MEDICAL ADVICE (see hospital course below). After this, she was contacted at home and agreed to return to the hospital to complete work-up. She was directly readmitted. Past Medical History: -Bipolar with several past psych admissions -hx of chlamydia infection -hx of panic disorder Social History: ___ Family History: Adopted, she does not know her biological family Physical Exam: Admission Exam: PHYSICAL EXAM: VS: 98.8 72 118/52 18 99% GENERAL: well appearing, NAD, AA female HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, JVD: LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, mildly tender in epigastrum/RUQ, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric . Discharge Exam: T 98 BP 90-100/50-70 HR ___ RR 16 O2 Sat 100% RA GENERAL: well appearing, NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, JVD: LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, mildly tender in RUQ, non-distended, liver edge palpable just below the R costal margin EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox3, CNs II-XII grossly intact, non focal PSYCH: Affect approproate, calm, goal directed, speech not pressured Pertinent Results: Labs: ___ 07:20PM BLOOD WBC-8.5 RBC-4.28 Hgb-13.0 Hct-40.7 MCV-95 MCH-30.5 MCHC-32.1 RDW-13.1 Plt ___ ___ 07:10AM BLOOD WBC-5.2 RBC-4.20 Hgb-13.0 Hct-40.9 MCV-97 MCH-31.0 MCHC-31.8 RDW-12.9 Plt ___ ___ 06:40AM BLOOD WBC-4.0 RBC-4.12* Hgb-12.5 Hct-39.1 MCV-95 MCH-30.4 MCHC-32.0 RDW-13.2 Plt ___ ___ 07:20PM BLOOD Neuts-73* Bands-0 ___ Monos-5 Eos-0 Baso-1 ___ Myelos-0 ___ 07:10AM BLOOD Neuts-66 Bands-4 ___ Monos-4 Eos-0 Baso-1 ___ Metas-1* Myelos-0 ___ 07:10AM BLOOD ___ PTT-31.7 ___ ___ 07:10AM BLOOD Plt Smr-NORMAL Plt ___ ___ 01:15PM BLOOD ___ PTT-34.1 ___ ___ 06:40AM BLOOD ___ PTT-34.1 ___ ___ 07:20PM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-141 K-3.6 Cl-101 HCO3-29 AnGap-15 ___ 07:10AM BLOOD Glucose-78 UreaN-11 Creat-0.8 Na-138 K-3.9 Cl-105 HCO3-27 AnGap-10 ___ 06:40AM BLOOD Glucose-101* UreaN-7 Creat-0.8 Na-140 K-4.0 Cl-108 HCO3-24 AnGap-12 ___ 07:20PM BLOOD ALT-169* AST-293* AlkPhos-64 TotBili-0.4 ___ 07:10AM BLOOD ALT-876* AST-750* LD(___)-607* CK(CPK)-237* AlkPhos-75 TotBili-0.6 ___ 01:15PM BLOOD ALT-760* AST-542* LD(LDH)-474* CK(CPK)-306* AlkPhos-90 TotBili-0.6 ___ 06:40AM BLOOD ALT-434* AST-180* AlkPhos-71 TotBili-0.4 ___ 07:20PM BLOOD Lipase-56 ___ 07:20PM BLOOD Albumin-4.6 ___ 07:10AM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.3 Mg-2.0 ___ 01:15PM BLOOD Iron-112 ___ 06:40AM BLOOD Albumin-4.0 Calcium-9.2 Phos-2.9 Mg-2.0 ___ 01:15PM BLOOD calTIBC-342 Ferritn-151* TRF-263 ___ 07:10AM BLOOD TSH-1.8 ___ 07:10AM BLOOD Free T4-1.2 ___ 07:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-PND HAV Ab-NEGATIVE IgM HAV-NEGATIVE ___ 08:33AM BLOOD AMA-PND Smooth-PND ___ 08:33AM BLOOD ___ ___ 07:10AM BLOOD IgG-1031 ___ 01:15PM BLOOD HIV Ab-NEGATIVE ___ 07:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:10AM BLOOD HCV Ab-NEGATIVE ___ 01:15PM BLOOD CERULOPLASMIN-PND . RUQ Ultrasound: The liver shows no evidence of focal lesions or textural abnormality. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The CBD measures 3 mm. The main portal vein is patent. The gallbladder is normal without evidence of stones or gallbladder wall thickening. Limited views of the right kidney are unremarkable. IMPRESSION: Normal right upper quadrant ultrasound. No gallstones or evidence of acute cholecystitis. Brief Hospital Course: Primary Reason for Admission: Ms ___ is a ___ y/o woman with no significant past medical history presenting with acute onset RUQ pain and transaminitis after eating a cheeseburger. . Active Problems: . # Acute Hepatitis: RUQ ultrasound was unremarkable without e/o cholecystitis or choledocolithiasis. There was no portal vein thrombus. Acetaminophen level was 0 on admission. No recent EtOH use, EtOH level also 0. Denies recent IV or intranasal drug use, though does have several tattoos. Serum and Urine tox screens were negative on admission. HIV negative. Autoimmune and infectious workup pending at time of d/c. Would note that she was adopted with known psychiatric comorbidities, which raises concern for Wilsons Disease. Ceruloplasmin also pending at time of d/c. Fe studies unremarkable. LFT's peaked and began to down-trend. At the time of d/c, her abd pain had resolved and she was tolerating a normal diet. # Psych: Ms ___ was extremely volatile during her admission. Social work was consulted and attempted to reassure the patient. This seemed to make things worse, and Ms ___ left the floor repeatedly on the morning of HD #1. Per RN, Ms ___ was overheard threatening to leave AMA and "take a bottle of pills." At that time, Psych was urgently consulted, though the patient would not cooperate with psych interview. She was noted to be future oriented and was felt to not be an acute suicide risk. After meeting with Psych, Ms ___ left the hospital AMA before the medical team was able to speak with her further. We then called Ms ___ and convinced her to return to ___ and she was directly readmitted. Per psych, she does not need 1:1 sitter or section and is safe for d/c from a psych perspective. # GERD: Ms ___ endorsed classical GERD symptoms, for which she was started on Omeprazole. EGD for similar symptoms in ___ was WNL. She should f/u with her PCP for possible ___ Pylori testing and ongoing management of GERD. . Transitional Issues: Code: Full HCP: None # Hepatitis: ___ f/u for Acute Hepatitis and GERD Medications on Admission: -Implanon 68 mg subdermal implant -lorazepam 0.5 mg BID (not currently taking) - amoxicillin (unknown dose) Discharge Medications: 1. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 2. IMPLANON *NF* (etonogestrel) ___ischarge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute Hepatitis Secondary Diagnosis: GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, It was a pleasure caring for you at the ___ ___. You were admitted for abdominal pain. We found that your liver function tests were abnormal. For this, we performed blood tests to help us understand what caused the damage to your liver. Many of these tests are still pending. Thankfully, your liver function has improved markedly over the course of your hosptial stay and you are now safe to go home. It will be importnat to follow up with your PCP and with the doctors at the ___ at ___. We also started you on a medication for acid reflux. You should take this every day. If your reflux symptoms to not improve, you should mention this to your PCP and liver doctor, as you may need another upper endoscopy. Thank you for allowing us to participate in your care. Followup Instructions: ___

{'Abd Pain': ['Acute Hepatitis', 'GERD'], 'epigastric': ['Acute Hepatitis', 'GERD'], 'nausea': ['Acute Hepatitis', 'GERD'], 'transaminitis': ['Acute Hepatitis'], 'bipolar': ['Bipolar disorder'], 'esophageal reflux': ['GERD'], 'cannabis abuse': ['Cannabis abuse'], 'dyschromia': ['Other dyschromia'], 'tobacco use': ['Personal history of tobacco use']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol Attending: ___ Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o bipolar, anxiety, substance abuse, and suicide attempt by overdose transferred from ___ on ___ with abdominal pain, nausea, diarrhea, and BRBPR. The patient was seen in the ___ on ___ for these complaints. Had normal CBC, chem, and LFTs, rectal was notable for ___ guiac postive stool, CT abd/pelvis prelim read was no acute pathology and the patient was discharged back to ___. The final read of the CT commented on mild stranding and thicken of the ascendign colon concerning for colitis. He was contacted by the ___ QI RN and returned for reevaluation. The patient has has been having these symptoms since ___. He initally presnted to ___ for evaluation of his abominal pain, nausea, and rectal bleeding and was diagnosed with pancreatitis. His symptoms contineud and he went back to ___ on ___ and diagnosed with hemorrhoids. Given persistance of symptoms he presented for eval to ___ as above. In the ___ intial vitals were: 8 98.5 86 136/78 16 100% RA - Labs including CBC, chem, and UA were unremarkable -Imaging: CT with abd/pelvis showed Mucosal hyperenhancement in the ascending colon with mild wall thickening and minimal stranding which may represent mild colitis. - Patient was given 2L NS, paroxetine 40mg, prazosin 1mg, percocet, zofran 4mg IV, flagyl 500mg, cipro 500mg, trazadone, and seroquel. He was supposed to be discharged back to ___ however the facility was not comfortable taking patient back given decreased PO intake. Vitals prior to transfer were: 98.4 74 110/70 16 100% RA On the floor is very sleepy after getting most of his ___ meds in the ___. He does report having about 20 BM daily, some small volume and some normal with BRBPR and clots. He also endorse tenesumus and acutally soiled himself on arrival to the floor. He continues to endorse abdominal pain ___, no nausea or vomitting. Also reports decreased PO intake for the past few day. No fevers, sweats or chills, or weight loss. Past Medical History: -Bipolar disorder with previous suicide attempt by OD req: ICU admission at ___ -Anxiety -Polysubstance abuse -Depression Social History: ___ Family History: No family history of IBD, Crohn's, UC, bowel disorders Physical Exam: ADMISSION PHYSICAL EXAM: VS: T97.6 128/59 72 18 97% RA GENERAL: NAD, sleepy but arousable HEENT: AT/NC, EOMI, MM CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: mild TTP bilateral upper quandrants, voluntary guarding no rebound, normoactive BS RECTAL: No hemmorrhoids. Brown stool guaiac negative. Normal rectal tone. Pain with rectal penetrance. EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: multiple tattoos DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: ___ 09:12PM BLOOD WBC-10.0 RBC-4.70 Hgb-14.1 Hct-41.5 MCV-88 MCH-30.0 MCHC-34.0 RDW-12.9 Plt ___ ___ 09:12PM BLOOD Neuts-71.8* Lymphs-17.8* Monos-8.0 Eos-2.1 Baso-0.3 ___ 09:12PM BLOOD ___ PTT-29.3 ___ ___ 09:12PM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-138 K-3.9 Cl-102 HCO3-24 AnGap-16 ___ 09:12PM BLOOD ALT-12 AST-14 AlkPhos-81 TotBili-0.3 ___ 09:12PM BLOOD Albumin-4.3 ___ 08:45AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.6 ___ 09:12PM BLOOD CRP-12.8* ___ 09:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:33PM BLOOD Lactate-1.5 ___ ECG: Sinus rhythm. Normal ECG. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 88 160 70 350/399 53 52 54 ___ CT ABD AND PELVIS WITH ORAL AND IV CONTRAST INDICATION: ___ man with bloody stools, evaluate for colitis or source of acute bleed. COMPARISON: None. TECHNIQUE: Contiguous axial MDCT images through the abdomen and pelvis with oral (Volumen)and intravenous contrast, with multiplanar reformats. FINDINGS: Lung bases are clear. There is no pleural effusion. Liver enhances homogenously without focal lesions. Gallbladder, spleen, pancreas, and adrenal glands are within normal limits. Kidneys enhance symmetrically without focal lesion or hydronephrosis. Stomach is distended with oral contrast but does not show wall thickening. The duodenal sweep is unremarkable. Proximal loops of small bowel are distended with oral contrast but do not show wall thickening or signs of obstruction. Distal small bowel loops are less distended. Prominent enhancement of the colon, ascending colon in particular, may relate to the phase of contrast; however, there is also mild thickening of the colonic wall and minimal fat stranding which could reflect colitis. The appendix is normal. There is no mesenteric or retroperitoneal lymphadenopathy. There is no intra-abdominal free fluid or free air. Bladder, seminal vesicles, and prostate are unremarkable. There is no pelvic free fluid. There is no inguinal or pelvic lymphadenopathy. Osseous structures are unremarkable. IMPRESSION: Mucosal hyperenhancement in the ascending colon with mild wall thickening and minimal stranding may represent mild colitis. DISCHARGE LABS ___ 11:15AM BLOOD WBC-7.0 RBC-4.46* Hgb-13.8* Hct-39.7* MCV-89 MCH-30.9 MCHC-34.7 RDW-13.0 Plt ___ ___ 07:15AM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-138 K-4.2 Cl-101 HCO3-29 AnGap-12 ___ 07:15AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.___ with extensive psychiatric history (bipolar, depression, suicide attempt by OD, substance abuse, on ___, presenting with one week of abdominal pain, bloody stools, diarrhea, and tenemsus, with mild ascending colitis on CT scan. # Acute colitis. Initially, he presented with bloody diarrhea for one week. He ad no family history of IBD, no prior GI history, no recent travel, no recent antibiotic use, and no sexual risk factors. He denied any anal intercourse. He was initially guaiac positive in the ___ on his first presentation, but was then negative the next day in the ___ and on admission to the floor. He was treated with IV fluids and IV ciprofloxacin pending stool studies. However, all stool studies were negative including C.diff, stool culture, Campylobacter, Salmonella, Shigella, and EHEC. He continued to have about 5 bouts of diarrhea a day, some watery brown and some with blood streaks. He was treated with oxycodone and Zofran for abdominal pain and nausea. Given his ongoing symptoms, GI was consulted. Reviewing the CT, he had some distention in the proximal small bowel and colitis only in the ascending colon, narrowing the differential to Yersinia vs Crohn's. Stool cultures have remained negative but Yersinia was pending at time of discharge. Patient was started on ciprofloxacin to complete total of 14 days (day ___, last dose ___. By day of discharge, patient was tolerating a low residue, lactose free diet with decreased sugars without vomiting. He is to f/u with GI outpatient for further evaluation re: colonoscopy. He complains of abdominal pain but this is likely component of colitis in addition to somatization of pain. Pain has been treated with oxycodone q4 PRN. ## CHRONIC ISSUES ## # Depression/bipolar. ___ with 1:1 sitter. Continue home seroquel, prazosin, trazadone and paroxetine # Back spasms. Stable. Continue home diazepam prn and Methocarbamol prn ### TRANSITIONAL ISSUES ### **PATIENT IS MEDICALLY STABLE. HE IS TOLERATING FULL MEALS AND HE HAS NO ASSOCIATED VOMITING. ABDOMINAL PAIN THAT HE COMPLAINS OF IS LIKELY A COMPONENT OF SOMATIZATION. HE CONTINUES TO HAVE INTERMITTENT BLOOD IN HIS STOOLS WHICH IS EXPECTED WITH COLITIS AND SHOULD RESOLVE WITH TIME.** TRANSITIONAL ISSUES - f/u Yersinia studies - Patient to f/u with GI - last dose ciprofloxacin ___ - QTC not prolonged during this hospitalization (Qtc___ on ___ though he is on multiple qtc prolonging medications. Should obtain repeat EKG qdaily X 5 days and stop daily EKGs if QTc is not prolonging. If Qtc is prolonged, consider d/c qtc prolonging medication - Patient was started on dicyclomine on discharge to help with abdominal cramping - 20mg QID should be continued for 7 days. After 1 week, may increase to 40 mg 4 times daily. Please stop medication after this period (total of 2 weeks). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prazosin 1 mg PO QHS 2. QUEtiapine Fumarate 200 mg PO QHS 3. TraZODone 200 mg PO HS 4. Paroxetine 40 mg PO DAILY 5. Methocarbamol 500 mg PO TID PRN back pain/spasm 6. DiphenhydrAMINE 50 mg PO QHS PRN insomnia 7. Diazepam 2.5 mg PO BID PRN back spasm 8. Mylanta 30 mL oral q4H PRN gastritis 9. Nicotine Polacrilex 2 mg PO Q1H:PRN cravings Discharge Medications: 1. Diazepam 2.5 mg PO BID PRN back spasm 2. DiphenhydrAMINE 50 mg PO QHS PRN insomnia 3. Methocarbamol 500 mg PO TID PRN back pain/spasm 4. Paroxetine 40 mg PO DAILY 5. Prazosin 1 mg PO QHS 6. QUEtiapine Fumarate 200 mg PO QHS 7. TraZODone 200 mg PO HS 8. Mylanta 30 mL oral q4H PRN gastritis 9. Nicotine Polacrilex 2 mg PO Q1H:PRN cravings 10. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days Last dose ___ RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every 12 hours Disp #*20 Tablet Refills:*0 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN breakthrough abd pain RX *oxycodone 5 mg 1 capsule(s) by mouth every 4 hours Disp #*18 Tablet Refills:*0 12. DiCYCLOmine 20 mg PO QID Duration: 7 Days Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: -Acute bloody diarrhea SECONDARY: -Depression -Anxiety -History of substance abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to take care of you at ___ ___. You were admitted to the hospital because of bloody diarrhea and were found to have inflammation of your colon. You were treated with IV fluids, antibiotics, and pain medications. You were evaluated by the Gastroenterology team. It is unclear what was causing inflammation of your colon but your symptoms improved. We have arranged for you to have a follow-up appt with Gastroenterology for further evaluation. We wish you a speedy recovery, Your ___ team Followup Instructions: ___

{'Abdominal pain': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Diarrhea': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Nausea': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Rectal bleeding': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Tenemsus': ['Infectious colitis', 'enteritis', 'and gastroenteritis'], 'Depression': ['Bipolar I disorder', 'most recent episode (or current) depressed', 'unspecified'], 'Anxiety': ['Anxiety state', 'unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: groin pain Major Surgical or Invasive Procedure: ___: Pipeline embolization of right ICA aneurysm History of Present Illness: ___ in ___ female well known to neurosurgery for ruptured aneurysm. She initially presented with a terrible headache in ___ and underwent emergent coil embolization of a ruptured right posterior communicating artery aneurysm on ___, at the time there was ___ II resolved. She presented for a follow-up angiogram on ___, that showed that there was some residual at the neck, similar to the appearance at the end of the case. She is felt to be a candidate for pipeline embolization. We talked about the risks and benefits of that procedure and the ability to not need to follow the aneurysm once it was proven gone follow-up after pipeline. She is interested in proceeding. Past Medical History: - ___ secondary to Right PCOMM aneurysm rupture (___) Social History: ___ Family History: no family hx of aneurysm Physical Exam: ON DISCHARGE: ============= ___ x 3. NAD. PERRLA. CN II-XII intact LS clear RRR Abdomen soft, NTND ___ BUE and BLE, no drift Groin site soft, without hematoma. Peripheral pulses intact Pertinent Results: Please refer to ___ for pertinent imaging and lab results. Brief Hospital Course: ___ is a ___ year old female with history of ___ secondary to right pcomm aneurysm rupture in ___ s/p emergent coil embolization. Recent angiogram demonstrates residual filling of aneurysm and patient returns now for elective pipeline embolization of the right pcomm artery aneurysm. #Right PCOMM Aneurysm Patient presented to pre-op area, was assessed by anesthesia and taken to the OR on ___ for right pipeline embolization of PCOMM aneurysm. Patient tolerate the procedure well. Please refer to formal op report in OMR for further intra operative details. Patient was successfully extubated and transferred to the PACU for post op care. She remained stable overnight. Due to her right groin pain US was done which was negative for pseudoaneurysm of hematoma. Patient was discharged home on ___. Medications on Admission: - clopidogrel 75 mg tablet, 1 tab PO daily - aspirin 325 mg tablet, 1 tab PO daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Docusate Sodium 100 mg PO BID 3. Senna 17.2 mg PO QHS 4. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 5. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Residual Right PCOMM aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. ___ Activity - ___ may gradually return to your normal activities, but we recommend ___ take it easy for the next ___ hours to avoid bleeding from your groin. - Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. - ___ make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. - Do not go swimming or submerge yourself in water for five (5) days after your procedure. - ___ make take a shower. Medications - Resume your normal medications and begin new medications as directed. - ___ may be instructed by your doctor to take one ___ a day and/or Plavix. If so, do not take any other products that have aspirin in them. If ___ are unsure of what products contain Aspirin, as your pharmacist or call our office. - ___ may use Acetaminophen (Tylenol) for minor discomfort if ___ are not otherwise restricted from taking this medication. - If ___ take Metformin (Glucophage) ___ may start it again three (3) days after your procedure. Care of the Puncture Site - ___ will have a small bandage over the site. - Remove the bandage in 24 hours by soaking it with water and gently peeling it off. - Keep the site clean with soap and water and dry it carefully. - ___ may use a band-aid if ___ wish. What ___ ___ Experience: - Mild tenderness and bruising at the puncture site (groin). - Soreness in your arms from the intravenous lines. - Mild to moderate headaches that last several days to a few weeks. - Fatigue is very normal - Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If ___ are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: - Severe pain, swelling, redness or drainage from the puncture site. - Fever greater than 101.5 degrees Fahrenheit - Constipation - Blood in your stool or urine - Nausea and/or vomiting - Extreme sleepiness and not being able to stay awake - Severe headaches not relieved by pain relievers - Seizures - Any new problems with your vision or ability to speak - Weakness or changes in sensation in your face, arms, or leg Followup Instructions: ___

{'groin pain': ['Cerebral aneurysm'], 'terrible headache': ['Cerebral aneurysm'], 'ruptured aneurysm': ['Cerebral aneurysm']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Insect Extracts Attending: ___ Chief Complaint: Post menopausal bleeding Major Surgical or Invasive Procedure: Total ___ hysterectomy, right salpingo-oophorectomy, omentectomy, and cystoscopy. History of Present Illness: ___ year-old gravida 0 who experienced postmenopausal bleeding that led to a pelvic ultrasound at ___ Ultrasound ___. This study dated revealed an endometrial polyp measuring 2.3 cm. This polyp had internal vascularity. The right ovary was well visualized and within it was a 1.8 cm complex cyst with multiple solid areas and areas of peripheral mural thickening and nodularity, some of which were vascularized. Notably, she has a history of bilateral borderline ovarian cancer and is status post a left salpingo-oophorectomy and right ovarian cystectomy in ___. Past Medical History: OB/GYN History: She is a gravida 0. She reports that her last Pap smear was about a year ago and was normal. She has never had an abnormal Pap smear. She denies any history of pelvic infections or STDs. - History of bilateral borderline ovarian cancers. She underwent an exploratory laparotomy, left salpingo-oophorectomy, right ovarian cystectomy, partial omentectomy in ___. Postoperatively, she has had no evidence of disease recurrence and has been followed with annual visits. - Menopause a few years ago but has had some concerns with osteoporosis and therefore began bioidentical hormones under the care of Dr. ___. She has stopped using these since the bleeding that she had. . Past Medical History: She reports a history of osteopenia. She denies any history of asthma, hypertension, cardiac disease, coronary artery disease, mitral valve prolapse, thromboembolic disorder, or cancer. She reports being up-to-date with mammograms, colonoscopies, and bone density evaluation. . Past Surgical History: As above. Social History: ___ Family History: She reports a maternal first cousin had breast cancer. Both her mother and her father had colon cancer but at old ages. Her mother had the disease at the age of ___, and her father had the disease diagnosed just prior to his death in ___. Physical Exam: Performed by Dr. ___ on ___: GENERAL: Appears stated age, no apparent distress. NECK: Supple. No masses. LYMPHATICS: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. CHEST: Lungs clear. HEART: Regular rate and rhythm. BACK: No spinal or CVA tenderness. ABDOMEN: Soft, nontender, nondistended. There is no mass. There is no hepato or splenomegaly. There is no fluid wave. EXTREMITIES: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. PELVIC: Normal external genitalia. Inner labial folds normal. Urethral meatus normal. Walls of the vagina are smooth. Apex is normal. Cervix is normal. Bimanual exam reveals a mobile uterus without mass or lesion. There is no cul-de-sac nodularity. Brief Hospital Course: Ms. ___ underwent a ___ right salpingo-oophorectomy, intraoperative pathology revealed borderline ovarian cancer and a total ___ hysterectomy, omentectomy, and cystoscopy was performed. She had a benign post-operative course and was discharged home on post-operative day #1 on oral pain medications, she was ambulating, tolerating a regular diet, and able to urinate without difficulty. Medications on Admission: None Discharge Medications: 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: Do not drive while taking this medication. Disp:*60 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: ___ Capsules PO BID (2 times a day) as needed for constipation: Take daily while taking narcotic to prevent constipation. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Borderline ovarian cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Followup Instructions: ___

{'Postmenopausal bleeding': ['Malignant neoplasm of ovary', 'Polyp of corpus uteri', 'Other specified disorders of female genital organs'], 'Endometrial polyp': ['Malignant neoplasm of ovary', 'Polyp of corpus uteri', 'Other specified disorders of female genital organs'], 'Complex cyst with solid areas': ['Malignant neoplasm of ovary', 'Other specified disorders of female genital organs'], 'Osteopenia': ['Disorder of bone and cartilage']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Vancomycin / Levofloxacin / Unasyn / Tigecycline / Meropenem / Metoprolol Attending: ___. Chief Complaint: Nausea; abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ gentleman with DM, HTN, CAD and recent FICU admission for necrotizing pancreatitis and pseudocyst is now admitted to the FICU for ___ drainage of enlarging pseudocyst. He was admitted from ___ for necrotizing pancreatitis that began in ___ and was complicated by shock, bacteremia, VAP, hypoxic respiratory failure requiring intubation and eventually tracheostomy. He had been discharged to rehab, and 2 days later his trach was removed and he was breathing fine on RA during the day, 1L NC st night. He awoke on the morning of presentation with nausea and abdominal pain, so he presented to the ED. It is epigastric, moving horizontally but not to the back, and is a deep pain. His pain is very similar to prior pancreatitis pain, but the nausea is new. No vomiting, no fever/chills. In the ED, initial vs were: T 97.1, HR 100, BP 122/62, RR 14, SaO2100%RA By the time of presentation his abdominal pain had subsided, and his exam was benign. He had a mild leukocytosis (11.1) and amylase was 112. His Cr was 1.6 (baseline 1.3) so he was hydrated with 1200cc IVF and Mucomyst (slowly, as patient has history of CHF), then sent for abdomen CT with contrast. This showed enlarging pancreatic pseudocyst, pelvic fluid collection smaller than on previous imaging, new small fluid collection anterior to pancreas as well as new small pseudocyst in pancreatic head. Upon returning from CT, he complained of ___ abdominal pain and he was given a total of 8mg IV morphine, and Zofran. He is tachycardic, but his blood pressures have been stable and he has no fever. Surgery is aware of the patient; they feel that there is no need for surgical intervention at this time. He is being admitted to the FICU with plans for ___ drainage of the pseudocyst. On the floor, the patient is without complaints. He has no abdominal pain. Not nauseous currently, but has no appetite. Does have an itchy rash that he has had since his last hospitalization that has been treated at rehab with antifungal powder and Benadryl. Review of systems: (+) Per HPI (nausea, abdominal pain, rash) (-) Denies fever, chills. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: 1. Necrotizing pancreatitis (___) - complicated by Enterococcus bacteremia, septic shock, hypoxic respiratory failure requiring intubation/trach (which was removed at rehab) 2. CABG ___ 3. DM II with neuropathy 4. CHF (EF 35-40% ___ TTE) 5. Hypertension 6. Hyperlipidemia 7. MSSA epidural abscess s/p laminectomy - ___ Social History: ___ Family History: Dad passed away from complications of CAD (MI in ___ and CHF. Mother had an MI in her ___. Sister with obesity, DM. Physical Exam: Vitals: T:96.9 BP:119/76 P:102 R: 17 O2:98%2L NC General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, normal S1 and S2, regular, no murmurs Abdomen: obese but nondistended; bowel sounds present; soft; non-tender; tenderness to very deep palpation of epigastrium; no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: rash on back near costal angles bilaterally - raised erythematous plaques with scale and satellite lesions Pertinent Results: ___ 01:40PM WBC-11.1* RBC-4.02*# HGB-11.7*# HCT-34.9*# MCV-87 MCH-29.0 MCHC-33.4 RDW-17.7* ___ 01:40PM NEUTS-82.9* LYMPHS-11.5* MONOS-3.7 EOS-1.4 BASOS-0.5 ___ 01:40PM PLT COUNT-372 ___ 01:40PM ___ PTT-22.8 ___ ___ 01:40PM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-74 AMYLASE-112* TOT BILI-0.4 ___ 01:40PM LIPASE-40 ___ 01:40PM GLUCOSE-119* UREA N-39* CREAT-1.6* SODIUM-137 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-31 ANION GAP-16 ___ 01:45PM LACTATE-1.1 ___ UA - rare bacteria ___ Urine Cx - pending ___ CT Abdomen/Pelvis with Contrast: IMPRESSION: 1. The large pancreatic body pseudocyst has continued to enlarge further across multiple prior studies. There is now possibly development of a satellite pseudocyst and/or adjacent small peripancreatic fluid collections as detailed above. 2. There is a relatively eccentric but traumatic wall thickening of the adjoining gastric body, pylorus, and proximal duodenum. This may be reactiv in nature if pancreatic enzymes continue to leach or also may represent a coincident gastritis. Correlate clinically. This may account for an acute pain as described. Not mentioned above, there may be a minimal amount of fluid tracking within the gastrohepatic ligament. 3. The relatively wide U-shaped pelvic collection previously described has decreased in size from the prior exam. The previously noted pigtail percutaneous drain is no longer present. 4. Persistent right pleural effusion with bibasilar atelectasis. Brief Hospital Course: 1. Pancreatic pseudocyst. CT imaging showed enlarging pancreatic pseudocyst. GI and surgery (Dr. ___ discussed options for drainage and initially determined that the best course was endoscopic drainage. However, during the hospitalization his pain improved and he remained stable, with no laboratory evidence of worsened pancreatitis. After discussion with patient, it was agreed to postpone the drainage, given risks involved, and reassess in about ___ weeks. Outpatient follow-up with CT, followed by appointment in Gastroenterology, was arranged. 2. Acute renal failure. Baseline is 1.3. It was felt that acute renal failure was likely prerenal on admission. He improved to baseline with hyudration. 3. Pleural effusion. Previously attributed to trans-diaphragmatic ascites. Not felt to represent CHF/cardiogenic volume overload. 4. Depression-- contniued on SSRI On ___ he was deemed appropriate for transfer to a rehab facility and this was arranged. Medications on Admission: -Aspirin 325 mg PO/NG DAILY -Diltiazem 120 mg PO/NG QID -Humalog Sliding Scale & Fixed Dose Lantus -Acetaminophen 325-650 mg PO/NG Q4H:PRN pain -Miconazole Powder 2% 1 Appl TP QID:PRN to folds -Citalopram Hydrobromide 10 mg PO/NG DAILY -Multivitamins W/minerals 1 TAB PO DAILY -Docusate Sodium 100 mg PO BID -Pancrelipase 5000 2 CAP PO TID W/MEALS -Famotidine 20 mg PO/NG Q24H -Heparin 5000 UNIT SC TID Discharge Medications: 1. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO four times a day. 2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Multivitamin,Tx-Minerals 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. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for to folds. 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. insulin per previous regimen Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pancreatic pseudocyst Discharge Condition: Fevers, worsened abdominal pain, nausea/vomiting Discharge Instructions: You were admitted with abdominal pain and found to have an enlarging pseudocyst. Initial plan was to drain this by a percutaneous (needle) procedure, but over the course of hospitalization your pain has improved and you have remained clinically stable, so the decision was made to postpone the procedure and reassess in approximately ___ days Followup Instructions: ___

{'nausea': ['Cyst and pseudocyst of pancreas'], 'abdominal pain': ['Cyst and pseudocyst of pancreas'], 'tachycardic': [], 'leukocytosis': [], 'itchy rash': [], 'fever/chills': [], 'cough/shortness of breath/wheezing': [], 'chest pain/chest pressure/palpitations/weakness': [], 'vomiting': [], 'diarrhea/constipation(changes in bowel habits)': [], 'dysuria/frequency/urgency': [], 'arthralgias/myalgias': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / Vancomycin / Levofloxacin / Unasyn / Tigecycline / Meropenem / Metoprolol Attending: ___. Chief Complaint: Pancreatic pseudocyst Major Surgical or Invasive Procedure: ___: EUS for drainage attempt History of Present Illness: Mr. ___ is a ___ year old male with recent history of necrotizing pancreatitis and an enlarging pancreatic pseudocyst. Patient was admitted from ___ for necrotizing pancreatitis complicated by shock, bacteremia, ventilator associated pneumonia, and hypoxic respiratory failure requiring intubation and eventually tracheostomy. He was readmitted from rehab on ___ with complaints of worsened abdominal pain and nausea and was found to have enlargement of his pseudocyst to 8.8 x 6.8 cm from 7.7 x 6.2 cm. Endoscopic and open surgical drainage of the pseudocyst were discussed with the patient with plans for endoscopic cyst-gastrostomy. However, his pain improved with no laboratory evidence of worsened pancreatitis and it was decided to postpone the drainage and reassess in 2 weeks. Repeat CT on ___ demonstrated stable appearance of the largest portion of pancreatic pseudocyst with a new locule at itssuperior aspect measuring 4.8 x 2.8 cm. Patient presented on ___ for endoscopic cyst-gastrostomy. EUS revealed a large blood vessel, possibly a splenic artery pseudoaneurysm, between the wall of the stomach and the pseudocyst and a moderate amount of debris within the cyst. Endo cyst-gastrostomy was deemed unsafe due to risk of infection and vascular injury and the procedure was aborted. Post-procedure, patient was complaining of abdominal pain, requiring IV pain medication for relief. Pancreaticobiliary surgery was reconsulted for possible open pseudocyst drainage. Patient's symptoms of pain and food intolerance due to fullness and nausea have been unchanged throughout this period, although improved with eating smaller portions. Past Medical History: 1. Necrotizing pancreatitis (___) - complicated by Enterococcus bacteremia, septic shock, hypoxic respiratory failure requiring intubation/trach (which was removed at rehab) 2. CABG ___ 3. DM II with neuropathy 4. CHF (EF 35-40% ___ TTE) 5. Hypertension 6. Hyperlipidemia 7. MSSA epidural abscess s/p laminectomy - ___ Social History: ___ Family History: Dad passed away from complications of CAD (MI in ___ and CHF. Mother had an MI in her ___. Sister with obesity, DM. Physical Exam: Vitals: T-98.6 HR-126 BP-130/82 RR-20 O2 Sat-96% RA Gen: Well appearing, NAD CV:RRR, Nl S1, S2 Resp: CTAB, no distress Abd: Soft, NT, ND, multiple ecchymoses (heparin related) Ext: No edema, scars on bilateral lower extremities from vein harvests Pertinent Results: ___ 09:00AM BLOOD WBC-6.2 RBC-3.79* Hgb-10.9* Hct-34.0* MCV-90 MCH-28.9 MCHC-32.2 RDW-16.8* Plt ___ EUS (___): - Pseudocyst was visualized and adjacent to the stomach. - Large blood vessel, possibly a splenic artery pseudoaneurysm, was visualized between the wall of the stomach and the pseudocyst. Additionally, a moderate amount of debris was seen within the cyst. Endo cyst-gastrostomy not deemed safe. - Normal upper eus to second part of the duodenum Brief Hospital Course: The patient with history of chronic pancreatitis and large pancreatic pseudocyst was admitted to the General Surgical Service for observation after attempted EUS cystgastrostomy. The procedure was aborted s/t possibly a splenic artery pseudoaneurysm, between the wall of the stomach and the pseudocyst and a moderate amount of debris within the cyst and high risk for vascular injury or infection. Patient was admitted overnight for pain control. On HD # 1, patient's diet was advanced to regular, pain was well controlled. Patient was evaluated by Dr. ___ scheduled for elective open cystgastrostomy or cystojejunostomy on next week. Patient was discharged back in Rehab in stable condition. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diabetic diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Diltiazem HCl 120 mg po q6h 2. Famotidine 20 mg Tablet daily 3. Vicodin 5 mg-500 mg Tablet po TID prn pain 4. Insulin Glargine 25 units SC at bedtimenr 5. Pancrelipase 5000- 2 Capsule(s) po TID with meals 6. Trazodone 50 mg Tablet po HS 7. Tylenol, Bisacodyl, Colace, Milk of Magnesia,Multivitamin Discharge Medications: 1. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydrocodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 4. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty Five (25) units Subcutaneous at bedtime. 9. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: ___ units Subcutaneous before meals and bedtime. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Chronic pancreatitis 2. pancreatic pseudocyst 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: Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: ___

{'abdominal pain': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis'], 'nausea': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis'], 'food intolerance': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis'], 'shock': ['Chronic pancreatitis'], 'bacteremia': ['Chronic pancreatitis'], 'ventilator associated pneumonia': ['Chronic pancreatitis'], 'hypoxic respiratory failure': ['Chronic pancreatitis'], 'intubation': ['Chronic pancreatitis'], 'tracheostomy': ['Chronic pancreatitis'], 'enlargement of pseudocyst': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis'], 'splenic artery pseudoaneurysm': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis'], 'debris within the cyst': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis'], 'pain medication': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis'], 'fullness': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis'], 'eating smaller portions': ['Cyst and pseudocyst of pancreas', 'Chronic pancreatitis']}

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Intractable headache Major Surgical or Invasive Procedure: Bilateral burr holes for evacuation of SDH History of Present Illness: ___ y/o male patient s/p hitting his head on the garage door on ___. He came to the ED and was admitted to neurosurgery for chronic bilateral SDH. He had two stable head CTs and was discharged stable. Patient returned to the ED on ___ with intractable heachache. Head CT showed a new acute aspect in the chronic SDH and was admitted to neurosurgery. Patient denies any new trauma and being on anticoagulation. Past Medical History: Left Bundle Branch Block HTN hyperlipidemia BPH Social History: ___ Family History: NC Physical Exam: BP:156 /91 HR:69 R 14 O2Sats 98 RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___ ___ symmetric reactive EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, Facial sensation intact and symmetric. VII- mild droop on left side, but strenghth intact VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch, propioception, and vibration bilaterally. mild sensory loss over left lateral leg to pain and temparature Reflexes: B T Br Pa Ac Right ___ 2 2 Left ___ 2 2 Toes downgoing bilaterally Coordination: mild dysmetria to finger-nose-finger on left side, and sluggish rapid alternating movements on left,clumsy heel to shin on left side EXAM ON DISCHARGE: Neurological exam non focal small bilateral linear incisions on either side of his head closed with staples Pertinent Results: CT HEAD W/O CONTRAST ___ 1. Mild increase in size of bilateral subdural collections, with an increase in the layering acute and subacute bleeds, suggesting rebleeding in the interval since the prior study. 2. Fluid opacification of the right mastoid air cells, recommended clinical correlation. CT HEAD W/O CONTRAST ___ Stable appearance to acute-on-chronic bilateral subdural hemorrhage. CT HEAD W/O CONTRAST ___ 1. New acute blood products in the right subdural collection. While the collection is stable in size, a portion of the fluid has been replaced by pneumocephalus. 2. Decreased size of the left subdural collection, with unchanged amount of the more acute blood products in its dependent portion. 3. Stable subdural hematoma along the tentorium and the falx. CT HEAD W/O CONTRAST ___ 1. Stable bilateral subdural collections representing evolving hematomas. Stable pneumocephalus consistent with recent post-surgical changes. 2. Stable subdural hemorrhage along the tentorium and falx. 3. No evidence of new hemorrhage or mass effect. Brief Hospital Course: Patient presented with intractable headaches and CT scan revealed bilateral chronic SDHs. Patient was admitted to neurosurgery for further workup. He denies any new trauma or anticoagulation. His repeat head CT on ___ was stable. On ___ patient was pre-oped for the OR for bilateral burr holes for evacuation of SDH. Patient was placed on steroids pre-operatively for headache which was discontinued after evacuation. Post op head CT scan was stable. Physical therapy has celared the patient safe to go home, repeat head CT showed some acute residual blood. He had issues with voiding and after failure to void x2 foley was left in place. He will follow-up with Dr. ___ PCP tomorrow in which these issues will be addressed. Medications on Admission: lipid lowering med ( cant recollect name) Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for headache. Disp:*40 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for seizure. Disp:*60 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/Temp>100/HA. Discharge Disposition: Home Discharge Diagnosis: Bilateral SDH Discharge Condition: Stable 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 only after staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. •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. •If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP’s office, but please have the results faxed to ___. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. •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: ___

{'Intractable headache': ['Subdural hemorrhage following injury without mention of open intracranial wound'], 'Left Bundle Branch Block': ['Other left bundle branch block'], 'HTN': ['Unspecified essential hypertension'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'BPH': ['Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: Gentamicin Attending: ___. Chief Complaint: L flank pain Major Surgical or Invasive Procedure: cystoscopy, L retrograde pyelogram, ureteral stent placement History of Present Illness: ___ 1.6 cm obstructing stone on the left with cranial outpatient. Patient reports that for the past several weeks and increasing left flank pain, seen by nephrology, recommended an ultrasound demonstrating obstructing stone with hydronephrosis. Creatinine noted to be elevated, referred here for evaluation. Patient's history of complicated nephrolithiasis on the contralateral side last year which was intervened upon by lithotripsy. Patient denies this time fevers or chills, no back pain. Patient reports that she has decreased appetite, however has no pain. CT scan in the ED demonstrated two obstructing L UPJ stones with hydro. Past Medical History: -Nephrolithiasis -Hypertension -Type II Diabetes Mellitus -Hyperlipidemia Social History: ___ Family History: Non-contributory Physical Exam: NAD abd soft, NT,ND no rebound or guarding no cva bilaterally Brief Hospital Course: Patient was admitted to Urology for pain control and observation. On HD2 the patient underwent a cystoscopy, L retrograde pyelogram and stent placement. Please see dictated operative note for details. Following the procedure the patient was tolerating aregular diet and voiding without any problems. She was discharged home the same day as her procedure with instructions to ___ with a BMP on ___. Patient will see Dr. ___ in ___ weeks for discussion about lithotripsy for her stones. Medications on Admission: amlodipine amlodipine 10 mg tablet 1 Tablet(s) by mouth once a day ___ Renewed ___, ___ 30 Tablet 5 ___ Care) atenolol atenolol 50 mg tablet 1 Tablet(s) by mouth once a day ___ Renewed ___, ___ 30 Tablet 5 ___ NP ___ Care) atorvastatin [Lipitor] Lipitor 20 mg tablet 1 Tablet(s) by mouth once a day ___ Renewed ___, ___ 30 Tablet 5 ___ NP ___ Care) nr diabeton 30 mg a day in the morning Medication is not available in the ___, brought from ___ (Prescribed by Other Provider) ___ Recorded Only ___, ___ ibuprofen ibuprofen 600 mg tablet 1 tablet(s) by mouth three times a day ___ ___, ___ 20 Tablet 0 ___ Care) lisinopril lisinopril 20 mg tablet one Tablet(s) by mouth once a day ___ Renewed ___, ___ 30 Tablet 5 ___ NP ___ Care) metformin metformin 1,000 mg tablet 1 Tablet(s) by mouth twice a day ___ Renewed ___, ___ 60 Tablet 5 ___ NP ___ Care) potassium citrate potassium citrate ER 10 mEq (1,080 mg) tablet,extended release 1 Tablet(s) by mouth twice a day Discharge Medications: same Discharge Disposition: Home Discharge Diagnosis: L renal stone Discharge Condition: stable Discharge Instructions: -Please have your blood drawn on ___ at ___. We have included a prescription for the blood draw with your discharge materials. -Expect to see occasional blood in your urine and to experience urgency and frequecy over the next month. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) Followup Instructions: ___

{'flank pain': ['Calculus of ureter', 'Hydronephrosis'], 'elevated creatinine': ['Acute kidney failure', 'Chronic kidney disease'], 'decreased appetite': ['Diabetes mellitus without mention of complication', 'type II or unspecified type'], 'no cva bilaterally': ['Unspecified essential hypertension', 'Other and unspecified hyperlipidemia'], 'soft abdomen': ['Obesity', 'unspecified', 'Body Mass Index 34.0-34.9', 'adult']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: Gentamicin Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None this admission, however, recent procedure ___: Cystoscopy, left retrograde pyelogram, left ureteroscopy, left laser lithotripsy and basket extraction of stone, and left ureteral stent exchange. History of Present Illness: ___ with h/o nephrolithiasis s/p L laser litho, stent placement today c/b post-op urinary retention requiring foley placement returning to the ED with fevers at home. In the ED patient with temp of 100.9 with chills. She was given 1gm ceftriaxone and admitted to urology for observation. Patient states that foley was draining well at home, although renal US in the ED demonstrated a partially full bladder. Thus, she was admitted for IV antibiotics and observation. Past Medical History: PMH: -Nephrolithiasis -Hypertension -Type II Diabetes Mellitus -Hyperlipidemia Allergies: Gentamicin PSH: Emergent left ureteral stent placement Left ureteroscopy, laser lithotripsy, basket extraction, stent exchange Social History: ___ Family History: Non-contributory Physical Exam: Afeb, VSS Wd Obese female ___ speaking, NAD Unlabored breathing Soft abdomen, nttp, no CVAT Stent string fastened onto pubic area Ext WWP, no edema Pertinent Results: ___ 06:40AM BLOOD WBC-8.8 RBC-3.62* Hgb-10.4* Hct-32.0* MCV-88 MCH-28.6 MCHC-32.4 RDW-15.1 Plt ___ ___ 08:05AM BLOOD WBC-15.6* RBC-4.12* Hgb-11.7* Hct-36.4 MCV-88 MCH-28.3 MCHC-32.0 RDW-15.1 Plt ___ ___ 09:40PM BLOOD WBC-14.1*# RBC-3.99* Hgb-11.4* Hct-34.6* MCV-87 MCH-28.7 MCHC-33.0 RDW-15.1 Plt ___ ___ 09:40PM BLOOD Neuts-90.5* Lymphs-5.0* Monos-2.9 Eos-1.2 Baso-0.4 ___ 06:40AM BLOOD Glucose-127* UreaN-17 Creat-1.5* Na-143 K-3.9 Cl-105 HCO3-27 AnGap-15 ___ 09:40PM BLOOD Glucose-201* UreaN-22* Creat-1.5* Na-140 K-4.3 Cl-104 HCO3-25 AnGap-15 Urine: GENERAL URINE ___ ___ ___ YellowHazy1.009 DIPSTICK U R I N A L Y S ISBloodNitriteProteinGlucoseKetoneBilirubUrobilnpHLeuks ___ 21:36 LGNEG100NEGNEGNEGNEG5.5LG MICROSCOPIC URINE EXAMINATIONRBCWBCBacteriYeastEpiTransERenalEp ___ 21:36 >182*>182*FEWNONE0 Urine culture: **FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. Brief Hospital Course: The pateint was admitted to Urology service for fevers after being recently discharged earlier that day from an outpatient procedure - left ureteroscopy, laser lithotripsy, basket removal, and stent exchange. No concerning intraoperative events occurred; please see dictated operative note for details. She received intravenous fluids and antibiotics (Ceftriaxone). On POD2, the Foley was removed after active voiding trial and post void residuals were checked. She was tolerating a regular diet, ambulating without difficulty. On POD3, her urine culture revealed <10,000 organisms. She was afebrile with stable vital signs. She was discharged home with 7 days of ciprofloxacin, and instructed to follow up with Dr. ___ stent removal in 3 days. Her creatinine was 1.5, and she was instructed to hold her metformin, unless her surgars are greater than 200. She was instructed to eat a diabetic diet, and to check her sugars regularly. She will follow up with her PCP office early this week. Medications on Admission: Metformin Amlodipine 10 mg PO DAILY Atenolol 50 mg PO DAILY Atorvastatin 20 mg PO DAILY Tamsulosin 0.4 mg PO DAILY Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain Metformin 1000 bid Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain,fever 2. Amlodipine 10 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO DAILY 6. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain 7. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: ADMISSION DIAGNOSIS: Post-operative fever PREOPERATIVE DIAGNOSES: Proximal left ureteral calculus approximately 8 mm in size, acute-on-chronic renal insufficiency, status post emergent ureteral stent placement. POSTOPERATIVE DIAGNOSES: 1 cm renal calculus. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent (if there is one). -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up AND your foley has been removed (if not already done) -You may or may not have passed all your stones ****Ureteral stent -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and if there is a Foley catheter is in place. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery. Also, if the Foley catheter and Leg Bag are in place--Do NOT drive (you may be a passenger). Followup Instructions: ___

{'Fever': ['Post-operative fever', 'Urinary tract infection'], 'Chills': ['Post-operative fever', 'Urinary tract infection'], 'Hypertension': ['Hypertensive chronic kidney disease'], 'Type II Diabetes Mellitus': ['Diabetes mellitus without mention of complication'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Nephrolithiasis': ['Calculus of kidney'], 'Urinary retention': ['Other specified retention of urine'], 'Acute kidney failure': ['Acute kidney failure'], 'Hydronephrosis': ['Hydronephrosis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right acetabular fracture Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ male presents with right hip pain. Patient was biking at about 3 pm today, got into an accident, went over the handlebars. He reports head strike while wearing helmet, no loss of consciousness. No head, neck, or back pain. Right hip pain with difficulty walking. He limped back home and was taken to urgent care where he underwent x-rays showing acetabular fracture. He was transferred to ___ for further care. Past Medical History: None Social History: ___ Family History: Non-contributory. Physical Exam: Exam on discharge: Right lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Pertinent Results: ___ 06:33PM WBC-10.9 RBC-4.83 HGB-14.6 HCT-41.7 MCV-86 MCH-30.1 MCHC-34.9 RDW-13.2 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right acetabular fracture and was admitted to the orthopedic surgery service. The patient was given a trial of non-operative management and worked with physical therapy. Repeat XRs were performed after mobilization with ___. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TDWB in the right lower extremity. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H Do not exceed 4g/day. 2. Diazepam 5 mg PO Q6H:PRN muscle spasm Do not drink alcohol, drive, or use heavy machinery while taking. 3. Docusate Sodium 100 mg PO BID 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain Do not drink alcohol, drive, or use heavy machinery while taking. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right acetabular fracture 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: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for an Orthopaedic injury. It is normal to feel tired or "washed out", and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touchdown weight bearing right lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___

{'right hip pain': ['Closed fracture of acetabulum'], 'head strike': ['Pedal cycle accident injuring pedal cyclist'], 'difficulty walking': ['Closed fracture of acetabulum']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Slurred speech. Major Surgical or Invasive Procedure: Two left burr holes and evacuation of subdural hematoma on ___. History of Present Illness: ___ y/o M hx CAD, HTN, HLD and stage V CKD on ASA 81 presents with word finding difficulty and lethargy over the past ___ weeks. Pt and family states that he has fallen twice that they can recall in that time frame and also few more times within the past year, last fall 2 days before presentation. Pt denies any LOC during these falls. Pt denies numbness weakness, nausea and vomiting, blurred vision, double vision, dizziness. Past Medical History: HTN Hyperlipidemia BPH- pt is ? s/p TURP (pt could not recall details) . Past Surgical Hx: R total knee replacement Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: O: T:98.0 BP: 132/79 HR: 71 RR:22 O2Sats:100% Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Neck: Supple. 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. frequent problems with word finding. Difficulty naming low frequency objects. mild dysarthria with frequent paraphasic errors. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields not tested. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Mild right facial droop. sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally. Coordination: normal on finger-nose-finger, rapid alternatinng movements. PHYSCIAL EXAMINATION ON DISCHARGE: Alert and oriented x3. Speech clear. Comprehension intact. CN II-XII grossly intact. Motor examination full strength throughout all four extremities. Incisions: Closed with nylon sutures. Clean, dry and intact without edema, erythema or discharge. Pertinent Results: CT Head: ___ Large left holohemispheric chronic SDH with subacute components, maximal thickness of 2.4cm with 1cm midline shift. CT Head: ___ Status post evacuation of left subdural collection with air and fluid now occupying the left subdural space. Although overall the midline shift has mildly decreased, there is a focal area of increased mass effect of the left frontal lobe caused by pneumocephalus. CT Head: ___ 1. Stable postoperative changes after evacuation of left subdural hematoma including a large amount of pneumocephalus. 2. No new hemorrhage. 3. Stable mass effect including 7 mm of subfalcine herniation. Brief Hospital Course: The patient was admitted to the ICU for close monitoring on the day of presentation, ___. She received a loading dose of Dilantin and was continued on Dilantin three times daily. On ___, the patient was taken to the operating room and underwent burr holes on the left for evacuation of the subdural hematoma. A post-operative head CT was obtained and showed post-operative changes and was negative for active hemorrhage. On ___, the patient remained neurologically stable. Subcutaneous Heparin was started for DVT prophylaxis. It was determined he would be transferred to the floor and evaluated by ___ and OT for dispo planning. On ___, the patient's urine culture was negative for growth and the IV Ceftriaxone was discontinued. A Head CT was obtained and was stable. He was evaluated by ___ who recommended discharge to rehabilitation. The case management team are screening him for facilities. On ___, the patient continued with urinary incontinence, which is his baseline. It was determined he would be discharged to rehabilitation later today. Medications on Admission: Asa 81 mg PO daily Doxazosin 8mg PO daily, Simvastatin 40mg PO daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain; fever Do not exceed greater than 4g Acetaminophen in a 24-hour period. 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Doxazosin 8 mg PO HS 5. Heparin 5000 UNIT SC TID 6. HydrALAzine ___ mg IV Q6H:PRN SBP >160 Goal SBP <160. 7. Ondansetron 4 mg IV Q8H:PRN nausea; vomiting 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Hold for sedation, drowsiness or RR <12. 9. Senna 8.6 mg PO BID:PRN constipation 10. Simvastatin 40 mg PO DAILY 11. LeVETiracetam 500 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Chronic Subdural Hematoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Craniotomy for Hemorrhage: •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. •Your wound was closed with sutures. 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. •If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may not resume this medication until cleared by the outpatient neurosurgery office. •You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow-up with laboratory blood drawing in one week. This can be drawn at your PCP’s office, but please have the results faxed to ___. You have been discharged on Keppra, an anti-seizure medication. Take this medication as directed. •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 101.5° F. Followup Instructions: ___

{'Slurred speech': ['Subdural hemorrhage following injury without mention of open intracranial wound', 'Aphasia'], 'Word finding difficulty': ['Subdural hemorrhage following injury without mention of open intracranial wound', 'Aphasia'], 'Lethargy': ['Subdural hemorrhage following injury without mention of open intracranial wound', 'unspecified state of consciousness'], 'Falls': ['Unspecified fall', 'Home accidents'], 'Dysarthria': ['Subdural hemorrhage following injury without mention of open intracranial wound', 'Dysarthria'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Urinary incontinence': ['Urinary incontinence'], 'Facial weakness': ['Facial weakness'], 'Knee joint replacement': ['Knee joint replacement'], 'Coronary atherosclerosis': ['Coronary atherosclerosis of native coronary artery']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Nausea, emesis and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year-old male with past medical history of ulcerative colitis s/p laparoscopic proctocolectomy, ileal pouch anal anastomosis with diverting loop ileostomy (___) with subsequent takedown (___) by Dr ___, presenting to the ED on ___ with a 24-hour history of persistent nausea and emesis. Patient states that he has not had a bowel movement or passed any gas since ___ hours ago (normally multiple bowel movements per day). He endorses persistent nausea and bilious emesis since waking up this morning, as well as moderate, pressure-like, abdominal pain, that he has been having intermittently for the past few months. He denies fever, chills, or bright red blood per rectum. Of note, patient stated that in the recent past, he has developed symptoms of "partial obstruction" where he feels constipated, distended, and nauseated. These episodes occur approximately once a month and last for about ___ hours before spontaneously resolving. Also, for the past few months, he had been experiencing occasional rectal and lower abdominal pain, especially when going to the bathroom at night, with some feeling of tightness in the rectum. On his last visit to his gastroenterologist two weeks ago (Dr ___, a possible explanation given to his symptoms was that of pouchitis, for which purpose a ___ had been arranged. Past Medical History: PMH: Ulcerative colitis PSH: ___- Laparoscopic proctocolectomy and mobilization of splenic flexure, ileal pouch anal anastomosis with diverting loop ileostomy. Social History: ___ Family History: He has 2 maternal cousins with underlying inflammatory bowel disease. He has one twin brother and one sister who are in good health. Maternal GF pancreatic cancer 56. Maternal GM breast post menopausal age ___. Paternal GF ? lung ca. Physical Exam: Vitals: VSS on discharge 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: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 09:40PM WBC-11.4* RBC-4.99 HGB-14.5 HCT-43.6 MCV-87 MCH-28.9 MCHC-33.1 RDW-14.7 ___ 09:40PM NEUTS-84.1* LYMPHS-5.6* MONOS-9.9 EOS-0.2 BASOS-0.2 ___ 09:40PM PLT COUNT-208 ___ 01:59PM LACTATE-1.6 ___ 01:49PM LACTATE-1.6 ___ 01:09PM ___ PTT-24.3* ___ ___ 12:50PM GLUCOSE-102* UREA N-14 CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16 ___ 12:50PM estGFR-Using this ___ 12:50PM ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-86 TOT BILI-0.7 ___ 12:50PM LIPASE-18 ___ 12:50PM ALBUMIN-5.3* ___ 12:50PM WBC-16.4*# RBC-5.68# HGB-16.5# HCT-49.6# MCV-87 MCH-29.0 MCHC-33.2 RDW-14.6 ___ 12:50PM NEUTS-89.3* LYMPHS-3.9* MONOS-6.3 EOS-0.3 BASOS-0.3 ___ 12:50PM PLT COUNT-230 Brief Hospital Course: Mr ___ presented to the ED on ___ with nausea, emesis and abdominal pain. Given his history of ulcerative colitis s/p laparoscopic proctocolectomy, ileal pouch anal anastomosis with diverting loop ileostomy (___) with subsequent takedown (___) by Dr ___ was admitted to the floor for conservative management of SBO. CT scan confirmed SBO with transition point at proximal pelvic anastomosis. In the ED he was made NPO, had an NGT placed and was maintained on IV fluids. After a brief and uneventful stay in the ED, the patient was transferred to the floor for further management. Neuro: The patient received IV pain control with good effect. Narcotic medications were avoided. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. GI: The patient was made NPO, had an NGT placed and received IV fluids. On HD#2 the patient passed gas and had BMs. The NGT was subsequently clamped with 0 residual output. GI was consulted; as per their recommendations the patient would be discharged on a low-residue diet and would follow up with his gastroenterologist Dr. ___ to determine the underlying cause of his condition (stricture versus inflammation). Diet was advanced which was initially well tolerated. For the rest of his stay, patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. GU:The patient voided without difficulty throughout his hospital stay. ID: The patient's white blood count and fever curves were closely watched for signs of infection. On admission his WBC was 16.4 which when repeated went down to 11.4. On ___, the patient was discharged to home. At discharge, he was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. He will follow-up in clinic. This information was communicated to the patient directly prior to discharge with verbalized understanding and agreement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LOPERamide 2 mg PO BID 2. Psyllium Wafer 1 WAF PO BID 3. Tamsulosin 0.4 mg PO HS 4. Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain do not take more than 3000mg of tylenol in 24 hours Discharge Disposition: Home Discharge Diagnosis: small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for a small bowel obstruction. You were given bowel rest and intravenous fluids and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. You should keep your appointment with Dr. ___ your ___ tomorrow. Please follow the instructions given to you by his office for the bowel prep. After this procedure, Dr. ___ also study the pouch. Please monitor your bowel function closely. If you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___

{'Nausea': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'Emesis': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)'], 'Abdominal pain': ['Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection)']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diverting loop ileostomy Major Surgical or Invasive Procedure: Ileostomy Takedown History of Present Illness: ___ with history of medically refractory UC s/p laparoscopic proctocolectomy, J-pouch loop ileostomy last month with course c/b SIRS reaction with spontaneous resolution now presenting for follow-up and discussion for ileostomy take-down. He has been doing well, eating well with a good appetite. He denies fevers or chills. He underwent routine pouch study last week, which did not demonstrate a leak. Past Medical History: PMH: Ulcerative colitis PSH: ___- Laparoscopic proctocolectomy and mobilization of splenic flexure, ileal pouch anal anastomosis with diverting loop ileostomy. Social History: ___ Family History: He has 2 maternal cousins with underlying inflammatory bowel disease. He has one twin brother and one sister who are in good health. Maternal GF pancreatic cancer 56. Maternal GM breast post menopausal age ___. Paternal GF ? lung ca. Physical Exam: Upon discharge: VS: Afebrile, VSS General: young white Caucasian male, in no acute distress HEENT: mucus membranes moist CV: regular rate, rhythm P: CTAB Abd: former ileostomy site clean, dry, intact without active drainage. Minimal expected post-operative erythema. Soft, appropriately tender. MSK: warm, well perfused Pertinent Results: ___ 06:00AM BLOOD WBC-6.6 RBC-4.42* Hgb-11.8* Hct-36.4* MCV-82 MCH-26.8* MCHC-32.5 RDW-17.3* Plt ___ ___ 06:00AM BLOOD Glucose-90 UreaN-7 Creat-0.7 Na-140 K-3.5 Cl-104 HCO3-26 AnGap-14 ___ 06:00AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.7 Brief Hospital Course: ___ was admitted to the inpatient Colorectal Surgery Service after ileostomy takedown. The patient was stable into post-operative day one. He did not have a foley catheter and was voiding without issue. He was advanced to clears, then to a regular diet the next day without issue. He was transitioned to oral pain medication with effective pain control. The day of discharge, the patient remained afebrile, with stable vital signs. He was ambulating without assistance, had return of bowel function and was tolerating a regular diet without issue. He verbalized understanding of his discharge instructions and was discharged home in good condition with follow-up. Medications on Admission: HYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 300 mg tablet. ___ tablet(s) by mouth every ___ hours as needed for pain LIDOCAINE - lidocaine 5 % Topical Ointment. Apply to affected area three to four per day as needed Medications - ___ FERROUS SULFATE [FERROUSUL] - FerrouSul 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider; ___) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H do not take more than 3000mg of tylenol in 24hrs, do not drink alcohol RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #*45 Tablet Refills:*0 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 3. Ferrous Sulfate 325 mg PO BID home regimen Discharge Disposition: Home Discharge Diagnosis: Ileostomy after surgical managment of Ulcerative Colitis 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 after an ileostomy takedown. You have recovered from this procedure well and you are now ready to return home. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery Please monitor your bowel function closely. Have had a bowel movement prior to your discharge. It is not uncommon after an ileostomy takedown to have frequent loose stool until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve. If you do not show improvement in these symptoms within ___ days please call the office for advice. You previously were taking imodium to slow your stool output with the ileostomy. If you find that you are having more than ___ bowel movements daily you can try a wafer also. Please call the Colorectal Surgery Office for advice. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have a small wound where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. The wound no longer requires packing with gauze packing strip. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. The staples will be removed at your follow-up appointment. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. ___. You may gradually increase your activity as tolerated but clear heavy exercise with Dr. ___. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___

{'fevers or chills': ['Ulcerative colitis'], 'good appetite': [], 'no acute distress': [], 'mucus membranes moist': [], 'regular rate, rhythm': [], 'CTAB': [], 'soft, appropriately tender': [], 'warm, well perfused': [], 'stable vital signs': [], 'ambulating without assistance': [], 'return of bowel function': [], 'tolerating a regular diet': [], 'pain controlled': ['Ulcerative colitis'], 'afebrile': ['Ulcerative colitis'], 'voiding without issue': []}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Pelvic mass Major Surgical or Invasive Procedure: laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy History of Present Illness: Ms. ___ is a ___ G1, P1 who underwent an abdominal ultrasound to evaluate for abdominal aortic aneurysm given her strong history of tobacco use by her primary care physician. That ultrasound revealed a large pelvic mass. She then underwent a CT scan on ___ which revealed a large mass within the pelvis measuring 9.9 x 12.2 x 10.3 cm with internal locules corresponding to the area of nodularity identified in ultrasound. The mass was intensely associated with the left ovary and closely abuts the uterine fundus. While there is no clear fat plane seen between the mass and uterus, it is believed to be of ovarian in origin rather than uterine. There are scattered sigmoid diverticula. No free fluid in the pelvis. Bladder and rectum are unremarkable and there are no enlarged pelvic or inguinal lymph nodes. She states that she has been asymptomatic from this mass. Today, she has no complaints. She denies any vaginal bleeding, abdominal pain, nausea, vomiting, change in bladder or bowel habits. Past Medical History: PAST MEDICAL HISTORY: Significant for breast cancer status post lumpectomy and adjuvant radiation, diabetes, hypertension, hypercholesterolemia, and depression. PAST SURGICAL HISTORY: Laparoscopic cholecystectomy and a right breast lumpectomy. OB AND GYN HISTORY: She is a gravida 1, para 1 with one spontaneous vaginal delivery. Her last menstrual period was when she was in her ___, menarche at age ___ with regular periods lasting four to five days. No history of abnormal Pap smears. Her last Pap was in ___, which was negative. No history of sexually transmitted infections, cysts or fibroids. Social History: ___ Family History: She denies any family history of GYN malignancies. Physical Exam: Pre-operative exam: GENERAL: Well-appearing, no acute distress. CARDIOVASCULAR: Regular rate and rhythm, no murmurs. LUNGS: Clear to auscultation bilaterally. BACK: No CVA or spinal tenderness. ABDOMEN: Soft, nontender, nondistended. No masses appreciated. No hernias. EXTREMITIES: No edema. LYMPHATICS: No supraclavicular or inguinal lymphadenopathy. PELVIC: Normal external female genitalia. Speculum exam revealed paracervix. No lesions present. Bimanual exam revealed a normal-sized uterus. Mass was difficult to appreciate secondary to body habitus. Rectovaginal exam revealed no nodularity or masses appreciated. Normal rectal tone. Exam on discharge: GENERAL: Well-appearing, no acute distress. CARDIOVASCULAR: Regular rate and rhythm, no murmurs. LUNGS: Clear to auscultation bilaterally. BACK: No CVA or spinal tenderness. ABDOMEN: Soft, nontender, nondistended. Incision clean, dry, intact EXTREMITIES: No edema. Non tender Pertinent Results: ___ 09:22AM BLOOD WBC-10.3# RBC-3.50*# Hgb-11.3*# Hct-33.3*# MCV-95 MCH-32.3* MCHC-33.9 RDW-14.8 Plt ___ ___ 09:22AM BLOOD Neuts-73.2* Lymphs-17.7* Monos-8.5 Eos-0.3 Baso-0.3 ___ 09:22AM BLOOD Glucose-232* UreaN-14 Creat-1.1 Na-141 K-4.6 Cl-103 HCO3-30 AnGap-13 ___ 09:22AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.2 CTA (___): 1. Worsening emphysema. 2. No pulmonary embolus. 3. Bibasilar atelectasis at the lung bases. 4. 3-mm nodule in the right middle lobe. Consider followup in six months to document stability. 5. Hepatic steatosis. CXR (___): No acute intrathoracic process. Brief Hospital Course: Ms. ___ underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and cystoscopy. Please see Dr. ___ ___ for full details. Post-operatively she was admitted to the gyn oncology service. On POD#1 Ms. ___ started to have some oxygen desaturations requiring oxygen via nasal cannula. CTA on ___ revealed worsening emphysema when compared to previously but no pulmonary emboli. CXR ___ did not reveal any acute intrathoracic process. She was started on chest physical therapy and albuterol and atrovent nebulizers. By POD#3 she was able to be weaned off of oxygen. Post-operatively her BPs and finger sticks were within normal limits. By POD#3 she was able to ambulate, tolerate a regular diet, control her pain with oral pain medications and void spontaneously. She was discharged in good condition on POD#3 with follow-up. Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 2 Tablet(s) by mouth daily GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet - 1 Tablet(s) by mouth twice a day LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth day METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth evening PAROXETINE HCL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth morning ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth evening Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by Other Provider; ___) - Dosage uncertain CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth morning OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation three times a day as needed for shortness of breath or wheezing. Disp:*1 * Refills:*0* Discharge Disposition: Home Discharge Diagnosis: large left ovarian cyst, pathology pending Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) x 6 weeks, no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. We will give you a prescription for an albuterol inhaler. You likely will need more medication or therapy for your lungs, please follow-up with pulmonology whom we have contacted on your behalf. Followup Instructions: ___

{'Pelvic mass': ['Other and unspecified ovarian cyst'], 'Abdominal aortic aneurysm': [], 'Vaginal bleeding': [], 'Abdominal pain': [], 'Nausea': [], 'Vomiting': [], 'Change in bladder or bowel habits': [], 'Breast cancer': ['Personal history of malignant neoplasm of breast'], 'Diabetes': ['Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled'], 'Hypertension': ['Unspecified essential hypertension'], 'Hypercholesterolemia': ['Other and unspecified hyperlipidemia'], 'Emphysema': ['Other emphysema'], 'Depression': ['Depressive disorder', 'not elsewhere classified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending: ___. Chief Complaint: Fatigue and palpitations at rest pre-op for AVR Major Surgical or Invasive Procedure: ___ :extraction of teeth #1,4,5,11,21,32 and cyst removal from right side of the mandible. History of Present Illness: ___ year old who presents for preoperative admission for bridge from coumadin to heparin with atrial fibrillation diagnosed in ___ and incidental finding of aortic stenosis. Underwent surgical evaluation for aortic valve replacement including cardiac catheterization that revealed no coronary artery disease and dental consultation that she needs six teeth extracted. Past Medical History: Severe Aortic ___ 0.7cm2), Hypertension, Paroxysmal atrial fibrillation, Left Ventricular hypertrophy, Arthritis, current tobacco use Social History: ___ Family History: Family History: father died ___ MI Physical Exam: Pulse: 63 Resp: 18 O2 sat: 98% B/P ___ Height: ___ Weight: 144.8 Lbs General: no acute distress Neuro: A&Ox3, non focal exam Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] MMM Neck: Supple [x] Full ROM [x] no JVD, Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: ___ SEM Abdomen: Soft[x] non-distended x] non-tender[x] +bowel sounds [x] Extremities: Warm [x] well-perfused [x] Edema: none Varicosities: None [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ ___ Right: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: murmur vs bruit Left: murmur vs bruit Pertinent Results: Admission labs ___ 06:18PM URINE ___ BACTERIA-FEW YEAST-NONE ___ 06:18PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM ___ 06:18PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 07:15PM ___ PTT-21.9* ___ ___ 07:15PM PLT COUNT-326 ___ 07:15PM WBC-7.7 RBC-4.78 HGB-14.0 HCT-41.0 MCV-86 MCH-29.2 MCHC-34.0 RDW-14.3 ___ 07:15PM %HbA1c-5.8 eAG-120 ___ 07:15PM ALBUMIN-4.6 CALCIUM-9.9 PHOSPHATE-4.5 MAGNESIUM-2.1 ___ 07:15PM CK-MB-2 cTropnT-<0.01 ___ 07:15PM LIPASE-22 ___ 07:15PM ALT(SGPT)-23 AST(SGOT)-16 LD(LDH)-131 CK(CPK)-45 ALK PHOS-89 AMYLASE-60 TOT BILI-0.4 ___ 07:15PM GLUCOSE-120* UREA N-22* CREAT-0.9 SODIUM-140 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13 Discharge labs ___ 04:50AM BLOOD WBC-4.4 RBC-4.60 Hgb-13.1 Hct-39.6 MCV-86 MCH-28.6 MCHC-33.2 RDW-14.1 Plt ___ ___ 11:17AM BLOOD PTT-58.3* ___ 04:50AM BLOOD ___ PTT-54.4* ___ ___ 04:50AM BLOOD Glucose-112* UreaN-9 Creat-0.6 Na-141 K-3.7 Cl-103 HCO3-29 AnGap-13 ___ 04:50AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.0 Radiology Report CHEST (PA & LAT) Study Date of ___ 3:04 ___ UNDERLYING MEDICAL CONDITION: ___ year old woman with Aortic stenosis Final Report CHEST: The heart is marginally enlarged. The lung fields are clear. No evidence of failure. Costophrenic angles are sharp. Radiology Report CAROTID SERIES COMPLETE Study Date of ___ 2:48 ___ -no carotid stenosis Brief Hospital Course: Patient was adnitted for hepirin bridge while awaiting Aortic valve replacement. During the preop workup it was noted that she needed dental extractions. She was brought to the operating room for extractions on ___. Following her extractions she spiked a fever to 102.3 and it was decided to delay her surgery until she had time to recover from her fever and extractions. She was restarted on Heparin and Coumadin. She was discharged home on ___. The patient was advised to go home with Lovenox bridge for Atrial fibrillation. She did not want to learn to give herself injections and was willing to accept the risk of resuming Coumadin w/o Lovenox bridge. She will followup with Dr ___ office ___ call her in the next several days to confirm new date for surgery and any further testing that may be indicated. Medications on Admission: Metoprolol 50", Wellbutrin XL 150', Warfarin 5 S/T/W/T/S, 7.5mg ___ Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal BID (2 times a day) for 1 days. Disp:*qs 1 day supply* Refills:*0* 4. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO every eight (8) hours for 5 days. Disp:*30 Capsule(s)* Refills:*0* 5. warfarin 1 mg Tablet Sig: resume pre admission schedule Tablet PO once a day: resume pre-admission schedule: 5mg Q S/T/W/T/S 7.5mg Q M/F. 6. Wellbutrin XL 150 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: s/p multiple teeth extractions PMH:Severe Aortic ___ 0.7cm2), Hypertension, Paroxysmal atrial fibrillation, Left Ventricular hypertrophy, Arthritis, current tobacco Discharge Condition: good Discharge Instructions: Take all medication as directed Oral rinses as directed by oral surgeon Followup Instructions: ___

{'Fatigue': ['Aortic valve disorders', 'Atrial fibrillation'], 'Palpitations at rest': ['Aortic valve disorders', 'Atrial fibrillation'], 'Severe Aortic ___ 0.7cm2': ['Aortic valve disorders'], 'Hypertension': ['Unspecified essential hypertension'], 'Paroxysmal atrial fibrillation': ['Atrial fibrillation'], 'Left Ventricular hypertrophy': ['Cardiomegaly'], 'Arthritis': [], 'current tobacco use': ['Tobacco use disorder'], 'Postprocedural fever': ['Postprocedural fever'], 'Other cysts of jaws': ['Other cysts of jaws']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin Attending: ___. Chief Complaint: Hyponatremia and Lethargy Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: The patient is an ___ y/o F with PMHx of HTN, HLD, hypothyroidism, and hyponatremia, who is presenting to the emergency department with hyponatremia. Per report, the patient had been seen by her PCP yesterday, where lab work was performed that showed a sodium of 120. She was sent to the ED for futher evaluation. Per ED report, the patient has a history of hyponatremia for which she takes salt tablets. However, she has been experiencing generalized malaise over the past week and has missed some of these tablets as a results. Her family also feels that she has recently been somewhat lethargic. . In the ED, initial vs were: T 98.0 P 75 BP 170/64 RR 16 O2 sat 100%. Patient was given 1L NS. . On arrival to the ICU, the patient's VS were BP: 203/67 P: 85 R: 16 O2: 96%RA. She endorsed feeling lethargic and under the weather since ___. During this time, she has had some generalized body aches and decreased PO intake. She also endorsed ___ weeks of non-productive cough. She also complained of some mild headaches and some mild intermittent shortness of breath. Her husband is sick with similar symptoms. . Review of systems: (+) Per HPI (-) Denies fever, chills. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies focal numbness, weakness, or tingling. Past Medical History: HYPERTENSION HYPOTHYROIDISM HYPERCHOLESTEROLEMIA HYPONATREMIA, suspected SIADH DIVERTICULOSIS LOW BACK PAIN, hx spinal stenosis CATARACTS ALLERGIC RHINITIS OSTEOPOROSIS GLAUCOMA ECZEMA GASTRIC ULCER SCOLIOSIS MEMORY LOSS HEMORRHOIDS s/p TAH/BSO for postmenopausal bleeding BLADDER PROLAPSE s/p suspension Social History: ___ Family History: Non-contributory. Physical Exam: Vitals: BP: 203/67 P: 85 R: 16 O2: 96%RA General: Alert, oriented to person and place HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur heard throughout Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: pneumoboots in place, no ___ edema appreciated Neuro: Moves all 4 extremities spontaneously. Non-focal neurologic exam. On Discharge: Mental status improved to oriented x3 and much more alert and interactive. Pertinent Results: Admission: ___ 04:00PM BLOOD WBC-9.3 RBC-4.73 Hgb-14.3 Hct-40.6 MCV-86 MCH-30.2 MCHC-35.2* RDW-13.3 Plt ___ ___ 04:00PM BLOOD UreaN-9 Creat-0.6 Na-120* K-4.1 Cl-85* HCO3-31 AnGap-8 Discharge: ___ 11:09AM BLOOD WBC-8.6 RBC-3.81* Hgb-11.7* Hct-32.9* MCV-87 MCH-30.8 MCHC-35.6* RDW-13.5 Plt ___ ___ 07:23AM BLOOD Glucose-101* UreaN-19 Creat-0.5 Na-128* K-3.6 Cl-96 HCO3-22 AnGap-14 ___ 07:23AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8 Miscellaneous: ___ 07:23AM BLOOD ___ PTT-24.3 ___ ___ 04:00PM BLOOD ALT-30 ___ 04:00PM BLOOD Triglyc-75 HDL-59 CHOL/HD-2.4 LDLcalc-70 LDLmeas-66 ___ 12:20AM BLOOD TSH-4.5* ___ 10:12AM BLOOD Free T4-1.4 CHEST (PA & LAT) Study Date of ___ 3:39 ___ REASON FOR EXAM: Cough, weakness and anorexia. Comparison is made with prior study ___. There is mild cardiomegaly. The aorta is elongated. There is probably a hiatal hernia. The lungs are hyperinflated, the hemidiaphragms are flattened suggesting COPD. Bibasilar opacities are consistent with atelectasis, left greater than right. Brief Hospital Course: ___ y/o F with PMHx of HTN, HLD, hypothyroidism, and hyponatremia, who is admitted with hyponatremia in the setting of lethargy and decreased PO intake. # Hyponatremia: Hypovolemic hyponatremia vs. SIADH. Likely a combination of the two with suspected SIADH per PCP notes as well as poor PO intake lately. She was given 3L of NS. Her sodium improved from 120 to 128 over two days and her symptoms and lethargy improved. She was continued on her home salt tabs. To ensure close monitoring she was discharged ___ with plan for a lab draw on ___ to evaluate for interval change of her sodium. Follow-up: - Sodium on ___ to be faxed to Dr. ___ at ___ # Anemia: After fluid resuscitation, her HCT dropped to 33.3. On recheck it was stable at 32.9. She was discharged with outpatient lab work to be checked on ___ to evaluate for change. Follow-up: - Hematocrit on ___ to be faxed to Dr. ___ at ___ # Cough/Myalgias/Lethargy: Likely viral illness. She was afebrile with no obvious pneumonia on CXR. Her flu swab had insufficient cells so a culture was added on. It was pending at the time of discharge. Follow-up: - Flu culture # Hypertension: Stable throughout her course. She was continued on her home valsartan dose of 320mg. # Hypothyroidism: Her TSH was checked (4.5) and T4 was normal. She was continued on her home levothyroxine dose of 75mcg. # Allergic Rhinitis: Continued fluticasone nasal spray # Transition issues: She was discharged with a plan to have sodium and hematocrit checked on ___ with results to be faxed to Dr. ___. Medications on Admission: Fluticasone Nasal Spray 50 mcg, 2 sprays each nostril daily Levothyroxine 75 mcg daily Nystatin Powder Nystatin-Triamcinolone Cream Simvastatin 40 mg daily Sodium Chloride Tabs 1 gram daily Valsartan 320 mg daily Aspirin EC 81 mg daily B Complex Vitamins Calcium Carbonate Calcium Citrate-Vitamin D2 Docusate Sodium 100 mg daily Loratadine 10 mg daily Discharge Medications: 1. Outpatient Lab Work Please check sodium and hematocrit ___. Please fax results to Dr. ___ at ___: ___ 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. nystatin-triamcinolone 100,000-0.1 unit/g-% Cream Sig: One (1) appl Topical twice a day as needed for Rash. 9. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO once a day. 11. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 12. B Complex Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 13. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. ___, It was a pleasure taking part in your care. You were admitted to ___ with increased lethargy and generally feeling unwell. You were found to have a low salt level in your blood which can cause these symptoms. We gave your IV fluids, and limited the amount you should drink as well as put you back on your salt tablets. Your salt level increased and you felt much improved. We did not make any changes to your medications. Please take your medications as prescribed. Please have blood work drawn on ___ to be sent to Dr. ___. Followup Instructions: ___

{'Hyponatremia': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Lethargy': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Generalized malaise': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Body aches': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Decreased PO intake': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Non-productive cough': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Mild headaches': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Mild intermittent shortness of breath': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with past medical history of follicular lymphoma in CR and recurrent UTI presenting with fall and 2 days of fatigue. She is very active normally, yesterday during practice for a play she felt very fatigued and not herself. She has been going to the bathroom more frequently than usual, denies dysuria. Early this morning she woke up to urinate and felt very lightheaded, tried walking back to the bed and fell down to the ground, hit the back of her head, denies losing consciousness. Brought to ED, head and neck CT, CXR unremarkable. U/A was mildly positive, she was given IV cipro. Past Medical History: 1. Follicular lymphoma in CR s/p bendamustine and rituxamab 2. Lumbar spinal stenosis status post XLIF (extreme lateral interbody fusion). 3. Cervical spinal stenosis. 4. Recurrent urinary tract infections with chronic cystitis. 5. Hypertension. 6. History of breast cancer requiring a lumpectomy, chemotherapy and radiation 7. History of migraine headaches. 8. History of right upper extremity "nerve damage" following a surgical procedure of the right shoulder 9. History of left shoulder shingles. 10. Moderate aortic regurgitation and aortic root dilatation with an EF of 60%. Social History: ___ Family History: Migraines in mother and daughter. Unknown cancer in paternal grandparents. Physical Exam: Admission Physical Exam: T: 97.3 HR 77 BP 146/76 RR 18 100% RA Gen: NAD, resting comfortably in bed HEENT: EOMI, PERRLA, MMM, OP clear CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, NT, ND +BS Ext: no c/c/e Neuro: CN II-XII intact, ___ strength throughout Discharge Physical Exam: T: 97.8 HR 73 BP 149/78 RR 20 99% RA Gen: NAD, resting comfortably in bed HEENT: EOMI, PERRLA, MMM, OP clear CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, NT, ND +BS Ext: no c/c/e Neuro: CN II-XII intact, ___ strength throughout Pertinent Results: ___ 06:00AM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD ___ 06:00AM URINE RBC-0 WBC-7* BACTERIA-MANY YEAST-NONE EPI-0 TRANS EPI-<1 ___ 03:00AM GLUCOSE-110* UREA N-17 CREAT-0.8 SODIUM-134 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-20* ANION GAP-22* ___ 03:00AM ALT(SGPT)-26 AST(SGOT)-45* ALK PHOS-58 TOT BILI-0.3 ___ 03:00AM LIPASE-57 ___ 03:00AM ALBUMIN-4.9 CALCIUM-10.2 PHOSPHATE-3.3 MAGNESIUM-1.8 ___ 03:00AM WBC-13.8*# RBC-4.81 HGB-15.7 HCT-44.9 MCV-93 MCH-32.7* MCHC-35.1* RDW-13.5 CT head: IMPRESSION: Atrophy. No evidence of fracture, hemorrhage or infarction. CT C-spine: IMPRESSION: 1. No evidence of fracture. 2. Severe degenerative changes, mildly progressed since ___. 3. 9mm right thyroid nodule increased in size from prior, a non emergent thyroid ultrasound can be obtained if clinically indicated. 4. Enlarged descending thoracic aorta measuring up to 3.4 cm. ECG: sinus rhythm RBBB, no ST-T wave abnormalities, no change from prior Brief Hospital Course: ___ year old female with past medical history of follicular lymphoma in CR and recurrent UTI presenting with fall and 2 days of fatigue. 1. UTI: Mildly positive urinalysis with increased urinary frequency. No history of resistent infections. -Continue PO cipro for 3 day course. -Urine culture pending on discharge, will call if growing resistant organism. 2. Fall: Likely due to infection and dehydration, no concerning findings on ECG, no loss of consciousness. CT head and C-spine showing no acute abnormlities. ___ was consulted and she was able to ambulate using rolling walker without dizziness or significant difficulties. Home ___ was recommended. 3. Migraines: Continue Tylenol 4. FEN/PPX: regular diet, heparin SC, ___ protocol DNR/DNI HCP: ___ (daughter) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. cranberry extract unknown oral daily 3. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 3. cranberry extract 1 tablet ORAL DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted after a fall and found to have a urinary tract infection and dehydration. You were started on ciprofloxacin for the infection. You were given IV fluids for the dehydration. Followup Instructions: ___

{'fatigue': ['Other chronic cystitis', 'Dehydration'], 'fall': ['Other chronic cystitis', 'Dehydration', 'History of fall'], 'urinary frequency': ['Other chronic cystitis', 'Dehydration'], 'lightheaded': ['Other chronic cystitis', 'Dehydration'], 'headache': ['Migraine']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bee Pollens Attending: ___. Chief Complaint: RLE erythema Major Surgical or Invasive Procedure: none History of Present Illness: ___ yr old with no past medical hx presenting with RLE erythema and abrasion s/p rollerblading accident with impact on pavement two days prior. Onset of erythema from foot, ankle, to distal shin yesterday. No change since yesterday. Full range of motion and pain only with palpation of abrasion which he cleaned with peroxide. Increased drainage from the site, without purulence or fluctuance. No fevers, nausea, vomiting or chills. Given erythema to ED. . In the ED, initial vs were - 98.4, 65, 121/56, 18, 97% RA. On exam superficial abrasion to right anterior ankle. Positive pulses. Patient was given tetanus booster. Able to Ambulate without pain. Pain to palpation along ankle. One gram of vancomycin given. Took blood cultures prior. Wound culture was sent in ED. Admitted for parenteral antibiotics. . ROS: (+) 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, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. . Past Medical History: none Social History: ___ Family History: Patient states no diseases run in family Physical Exam: VS:120/72, 98.5, 22, 99%RA 74 Gen: NAD HEENT: OP clear, EOMI Neck: No JVD, no thyromegaly, no LAD Cor: RRR no m/r/g Pulm: CTAB Abd: +BS, NTND, No HSM Extrem: RLE with abrasion on ankle, no fluctuance, erythema along dorsum of foot extending 4 cm to shin. Marked with pen. 1+ edema of ankle. No tenderness to palpation focally. Scab along shin. Full range of motion. 2+ pedal pulses. Abrasion on left palm, no fluctuance. Pertinent Results: ___ 08:20PM WBC-12.0* RBC-4.32* HGB-13.5* HCT-36.1* MCV-83 MCH-31.2 MCHC-37.4* RDW-12.5 . ___ 08:20PM PLT COUNT-174 . ___ 08:20PM GLUCOSE-120* UREA N-15 CREAT-1.0 SODIUM-140 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-29 ANION GAP-___ellulits: Cellulitis s/p fall. Patient with no past medical history therefore no predisposing conditions, no previous episodes of MRSA. No evidence of systemic toxicity. No evidence of joint involvement. No clear evidence of fracture. Mild leukocytosis likely from cellulitis. Improved with overnight IV antibiotics. Patient was sent home with 7 day course of Keflex to be completed on ___. Medications on Admission: none Discharge Medications: 1. Keflex ___ mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Right leg cellulitis Discharge Condition: good, vss, afebrile, on room air Discharge Instructions: You came to the hospital for redness and swelling around an abrasion on your R foot. You were given antibiotics and there does not appear to be any problems with your ankle joint. . Please take the full course of antibiotics. You may take tylenol for pain. . Call your doctor or return to the ED if you have fevers/chills, increaseing redness, swelling, purulent discharge from the wound, or for nausea, vomitting, diarrhea, or other concerns. Followup Instructions: ___

{'erythema': ['Cellulitis and abscess of leg', 'except foot'], 'abrasion': ['Late effect of superficial injury', 'Late effects of accidental fall']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Cephalosporins / Sulfa (Sulfonamide Antibiotics) / penicillin G / ampicillin / codeine / erythromycin base / tetracycline Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: ___: Left chest needle decompression and Left pigtail catheter placement History of Present Illness: ___ unwitnessed fall down ___ steps while intoxicated. Was seen at ___ ED, had Ct chest that showed multiple left sided rib fractures involving ___, 10th ribs and as well as left PTX without evidenc eof tension. patient also had normal Ct head and c spine as well. The patient was subsequently transferred here for further management. on arrival to Ed, patient became hypoxic to 75% while on 15L NRB, had left sided needle decompression with, per Ed report, a rush of air. A pigtail catheter was also placed at that time. Patient was subsequently admitted to the Tsicu. Past Medical History: Past Medical History: - EtOH abuse - HTN - psych history Past Surgical History: - TAH - c-section - laparoscopy - tonsillectomy - vein stripping Social History: ___ Family History: noncontributory Physical Exam: FOCUSED PHYSICAL EXAMINATION: VITALS: T , HR 95, BP 127/58, RR 20, 96% O2sat 5L GENERAL: NAD HEENT: nonicteric, wnl HEART: RRR LUNGS: decreased breath sounds, left pigtail catheter BACK: no rashes, no scars ABD: soft, non-tender MSK/EXT: no edema Pertinent Results: ___ 04:30AM BLOOD WBC-7.9 RBC-3.47* Hgb-11.6* Hct-34.2* MCV-99* MCH-33.3* MCHC-33.8 RDW-14.1 Plt ___ ___ 06:54AM BLOOD WBC-9.2 RBC-3.92* Hgb-12.6 Hct-38.1 MCV-97 MCH-32.1* MCHC-33.0 RDW-14.4 Plt Ct-UNABLE TO ___ 08:00PM BLOOD WBC-16.7* RBC-4.25 Hgb-13.9 Hct-41.2 MCV-97 MCH-32.7* MCHC-33.6 RDW-14.3 Plt ___ ___ 08:00PM BLOOD ___ PTT-28.2 ___ ___ 04:30AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-134 K-4.2 Cl-99 HCO3-30 AnGap-9 ___ 03:33AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-134 K-4.6 Cl-101 HCO3-22 AnGap-16 ___ 08:14PM BLOOD Glucose-135* Lactate-3.8* Na-140 K-4.6 Cl-102 ___ 05:11AM BLOOD Lactate-1.6 Imaging: CT chest: Small left pneumothorax, and nonhemorrhagic pleural effusion with adjacent atelectasis. Multiple left-sided rib, nondisplaced fractures involving the second through sixth ribs laterally CT head: negative ___ CXR: 1. No pneumothorax. 2. Interval increase in left-sided pleural effusion, which is now small to moderate size. Brief Hospital Course: ___ multitrauma, transfer from OSH status post fall down 14 stairs, +ETOH. Injuries include left sided pneumothorax, left anterior ___ rib fractures and left posterior ___ fractures, who became hypoxic in the ED and is status post left chest needle decompression and pigtail placement. The patient was admitted to the TSICU for continuous oxygen saturation monitoring, pain control, CIWA, serial chest xrays, and close respiratory monitoring/pulmonary toilet. Acute Pain Service was consulted and an epidural was placed for pain management. ON HD1, the patient self-discontinued her chest tube. A post-pull cxr did not reveal any new or increasing pneumothorax. On HD2, the epidural was removed and the patient was converted to oral pain medication. The patient was hemodynamically stable and transferred out of the TSICU to the floor. On HD3 Physical therapy evaluated the patient and felt she was safe to return home without any services. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. She had follow-up scheduled in the ___ clinic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO QID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H pain 2. Gabapentin 800 mg PO QID 3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain 4. Docusate Sodium 100 mg PO BID 5. Ibuprofen 800 mg PO Q8H pain RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*0 6. Lidocaine 5% Patch 1 PTCH TD QAM left rib site RX *lidocaine-menthol [LidoPatch] 4 %-1 % 1 PTCH Qam Disp #*15 Patch Refills:*0 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q3h Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1. Left anterior ___ rib fractures 2. Left post ___ rib fractures 3. Left pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ after sustaining injuries from a fall. You you fractured your fractured multiple ribs on the left side and injured your lung, requiring a chest tube be placed. You were admitted for pain control, close respiratory monitoring, and chest tube management. The chest tube has been removed and your pain is under control with oral analgesia. Your vital signs are stable, and you are medically cleared for discharge home to continue your recovery. Please note the following discharge instructions: * Your injury caused rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily (e.g Colace and/or Senna) and increase your fluid and fiber intake if possible. If you do not have a bowel movement in the next couple of days, you can take a laxative such as Milk of Magnesia or Miralax as needed. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). It was a pleasure taking care of you Your ___ team Followup Instructions: ___

{'Fall': ['Accidental fall on or from other stairs or steps'], 'Rib fractures': ['Closed fracture of seven ribs'], 'Pneumothorax': ['Traumatic pneumothorax without mention of open wound into thorax']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: CC: Arm weakness s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: HPI: ___ fell in bathroom today and hit his neck, no LOC, did not hit his head, remembers the event clearly. He initially had total paralysis, and was seen initially at ___. Within a short while, he regained strength in his lower extremities, but had persistent weakness of LUE, proximal>distal, and RUE, though not as bad. He denies bowel or bladder symptoms. Past Medical History: HTN DM2 History of hyperkalemia Gout Social History: ___ Family History: ___ has significant diabetes with complications Physical Exam: PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL 2 to 1 bilaterally EOMs:intact Neck: some ttp posterior neck Back: no stepoffs or tenderness Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT ___ G R 4 4 4 4 4 5 5 5 5 5 L 3 4- 4- 4- 4- 5 5 5 5 5 Sensation: Intact to light touch, mildly decreased in L ulnar distrubtion. Reflexes: B Pa Right 2 2 Left 2 2 Toes downgoing bilaterally Rectal exam normal sphincter control Pertinent Results: CT: Head: no infarct, no hemorrage, normal NECK: Base of Odontoid fx ___ 09:38PM GLUCOSE-203* UREA N-26* CREAT-0.8 SODIUM-133 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16 ___ 09:38PM WBC-13.4* RBC-3.74* HGB-10.6* HCT-30.4* MCV-81* MCH-28.3 MCHC-34.9 RDW-13.9 Brief Hospital Course: Pt was admitted to neurosurgery service. His initial CT showed fracture at the base of the odontoid. He underwent subsequent MRI showing cord contusion. He was maintained in hard collar. He was seen by wound care nurse for left toe ulcer - recommended dry gauze dressing daily. He was found to have UTI on UA and started on antibiotics. His arm strength improved while here. ___ evaluated pt and suggested acute level rehab. Prior to D/C Pt has no neurological deficits, non-focal exam with c-collar in place for fx at the base of the odontoid. He will follow-up with Dr. ___ in 4 weeks. Medications on Admission: Medications prior to admission: asa 81', insulin glargine, Pantoprazole 40',Lisinopril 5', metformin, hctz, glyburide 5' Discharge Medications: 1. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Insulin Glargine Subcutaneous 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days: through ___. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: ___ ___ Discharge Diagnosis: C1 fracture diabetes foot ulcer UTI Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES · Do not smoke · No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. · Limit your use of stairs to ___ times per day · You are required to wear cervical collar at all times · You may shower briefly without the collar · Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort · Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. · Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation · Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: · Pain that is continually increasing or not relieved by pain medicine · Any weakness, numbness, tingling in your extremities · Any change in your bowel or bladder habits Followup Instructions: ___

{'Arm weakness': ['Closed fracture of first cervical vertebra'], 'Neck pain': ['Closed fracture of first cervical vertebra'], 'Fall': ['Unspecified fall'], 'Foot ulcer': ['Ulcer of other part of foot'], 'Hypertension': ['Unspecified essential hypertension'], 'Diabetes': ['Diabetes mellitus without mention of complication'], 'Gout': ['Gout'], 'Osteoarthrosis': ['Osteoarthrosis']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year-old male with PMH notable for Asperger syndrome/Autism spectrum who presents as a direct transfer from OSH (___) for L-sided weakness, L-sided hemi-spasticity, L-sided hyper-reflexia and involuntary L-sided muscle contractions. Mr. ___ was in his usual state of health until 2 days prior to admission (evening of ___ when he developed intermittent, mild R-sided headache, light-headedness and light-sensitivity. He reports he had several brief episodes of headache which self-resolved. He was able to sleep that night, however woke up on ___ with persistent right-sided headache and generalized malaise. He describes the headaches as a ___ with regards to severity, localized to his R temple and associated with photophobia. He describes the sensation of traffic lights on the street being excessively bright, and notes that he normally does not have a history of headaches prior to this. The headaches and malaise persisted through ___, at which point the patient asked his father to drive him into work. He works at a desk job and was able to work for approximately 3 hours from 6pm-9pm but noted progressive numbness in his LUE and LLE (up to his knee) over this time period. At the end of this time period (approximately 9pm on ___, patient LLE/LUE numbness progressed to ___ LLE/LUE weakness where he remembers he distinctly could not stand up from his chair. This sensation persisted, and was followed by his leg shaking violently, followed by shoulder jerking. Patient was able to ask for help from his colleagues but otherwise does not clearly remember the ensuing time period following the onset of these symptoms, however he does remember being assessed in the ambulance by the paramedics, which he was told was about 20min after the onset of his symptoms. Following this event, he continued to have left upper and lower extremity weakness, and was brought to ___ for further evaluation. Patient was questioned without his parents in the room to obtain additional history. Of note, Mr. ___ recently started this new job. He reports mild stress associated with work but does not believe this is impacting his daily functioning or pathological. He further denies any recent illness. Denies recent upper respiratory symptoms, fevers/chills, and diarrhea. Denies any history of prior episodes of weakness, denies any prior history of periods of visual loss. No recent drug use; he did use marijuana at ___. He reports feeling happy at home with no stressors apart from this recent job. He is not sexually active. No recent travel. Denies any unusual ingestions. At ___, he states that his L-sided weakness slowly improved. His examination per his OSH records was notable for weakness of the left arm and leg (documented only as ___ in L upper extremity, and "unable to straight leg raise" in the L lower extremity), L sided hemispasticity, L sided hyperreflexia, and possible fasciculations. For further workup, he had a CTA head/neck which was unremarkable. He had an unremarkable initial lab workup as well, with normal basic metabolic panel, LFTs, and CBC. Serum tox screen was negative for salicylates, acetaminophen and ethyl alcohol. He was evaluated by the neurologist at ___ who expressed concern for transverse myelitis and recommended transfer to ___ for further evaluation. On neuro ROS, the pt denies current headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Past Medical History: Asperger syndrome/Autism spectrum Social History: ___ Family History: - ___ Sister has a history of uncontrolled right-sided tremors/dystonia with no clear diagnosis beginning at ___, followed by Dr. ___ at ___. - Mother with history of Anxiety. - No fam hx of seizures, strokes or neurologic malignancies Physical Exam: Vitals: T:99.9 BP: 103/52 P:70 RR:17 SaO2: 99% General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Speech fluent, no dysarthria. Follows midline and appendicular commands. Cranial Nerves: EOM full with conjugate gaze, no nystagmus. Face symmetric, tongue midline. V1-V3 equal to light touch. Hearing intact. Motor: Normal tone and bulk +Intermittent spasms of his LLE and LUE that disappear with distraction Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 5 5 5 5 ___ 5 5 R 5 ___ 5 5 5 5 5 5 5 5 5 Sensory: intact to light touch bilateral -DTRs: ___ Tri ___ Pat L 3 3 3 2 R 3 3 3 2 Plantar response was flexor bilaterally. Coordination: No intention tremor, no dysmetria. Heel-knee-shin was jerky, tremulous on left but smooth throughout. Gait: Able to bear weight bilateral. Negative Romberg. Pertinent Results: ___ 09:19PM GLUCOSE-100 UREA N-12 CREAT-0.9 SODIUM-140 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15 ___ 09:19PM ALT(SGPT)-8 AST(SGOT)-12 CK(CPK)-60 ALK PHOS-82 TOT BILI-0.5 ___ 09:19PM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-2.1 ___ 09:19PM VIT B12-448 ___ 09:19PM %HbA1c-5.0 eAG-97 ___ 09:19PM RHEU FACT-<10 CRP-0.3 ___ 09:19PM TSH-3.8 ___ 09:19PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 09:19PM WBC-4.9 RBC-5.12 HGB-15.4 HCT-44.7 MCV-87 MCH-30.1 MCHC-34.5 RDW-11.9 RDWSD-38.5 ___ 09:19PM PLT COUNT-242 ___ 09:19PM ___ PTT-29.6 ___ MRI Brain ___ IMPRESSION:1. No concerning intracranial lesions identified. 2. No acute infarction or hemorrhage. MRI Spine ___ IMPRESSION: 1. No definite cord signal abnormalities identified. Slight apparent increased STIR signal abnormality along the upper cervical cord, is likely artifactual in etiology, as no correlate was seen on the axial T2 weighted images. No concerning enhancing lesions are seen. Brief Hospital Course: ___ was admitted to ___ after he developed left sided weakness while at work on ___ evening. At ___ there was concern that he could have acute flaccid myelitis, so he was transferred to ___ for further evaluation and treatment on ___. Upon arrival to ___, history and exam was confirmed. Briefly on ___ evening he drove home from work and noted that his left side felt odd and that he was more sensitive to the headlights. ___ evening he still felt weak on his left side, so his Dad drove him to work when at approximately 9pm during his work break he felt as if he was unable to stand. He then developed left sided shaking of his extremities and a right temporal headache. After the weakness started, he had some left sided paresthesias that started in his foot and ascended upwards. During this episode which last 20minutes, he never lost consciousness, he just became very anxious. EMS was called and he was brought to ___. At ___, a MRI spine was completed that was normal. He was evaluated by Physical Therapy was deemed stable for discharge home with outpatient physical therapy with a rolling walker, as well as outpatient neurology follow up. Transitional Issues: Recommend Cognitive Behavior Therapy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Stress Induced Weakness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were transferred from ___ to the Neurology Service at ___ for evaluation of your left sided weakness. Your exam was reassuring and you continued to show improvement in your strength and function. You had a MRI of the brain and spine that did not show any abnormalities. Overall, your evaluation was normal and reassuring. Your doctors think that your episode was likely due to stress. Neurologic symptoms can sometimes be due to non-neurologic issues. It is an increasingly well recognized condition. There is a website: ___/ that offers a lot of helpful information regarding these conditions and issues. While it will not all apply to you, it may be helpful. It is not uncommon for people under new or different stresses to respond differently, including with Functional Neurology Symptoms. The diagnosis was supported by both your very normal and reassuring Neurologic examination and imaging. It is important that you follow with neurology to help guide you. Dr. ___ Dr. ___ both saw you in the hospital) will see you in clinic in ___. Additionally, outpatient therapy and psychiatry follow-up is often critical in helping you with this issue long term. You were examined by physical therapy who you were safe to go home, but recommended outpatient physical therapy to continue to encourage improvement. Thank you for allowing us to participate in your care, ___ Neurology Followup Instructions: ___

{'left sided weakness': ['Weakness'], 'intermittent spasms of his LLE and LUE': ['Abnormal reflex'], 'right-sided headache': ['Other reactions to severe stress'], 'light-headedness': ['Other reactions to severe stress'], 'light-sensitivity': ['Other reactions to severe stress'], 'numbness in his LUE and LLE': ['Weakness'], 'L sided hemi-spasticity': ['Abnormal reflex'], 'L sided hyper-reflexia': ['Abnormal reflex'], 'possible fasciculations': ['Abnormal reflex'], 'Asperger syndrome/Autism spectrum': ["Asperger's syndrome"]}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: s/p Fall, rib fractures Major Surgical or Invasive Procedure: ___ Right thoracostomy tube placement History of Present Illness: ___ who presents after a fall out of bed. She does not remember the circumstances of the fall, but found herself on the floor with terrible pain in her right side. She denied head trauma. Her daughter reports a subacute decline over the past several months, with worsening confusion and occasional inappropriate behavior (walking around naked). She recently moved to a new ___ living facility. The daughter is concerned that she is more depressed than she had previously been. She denies any palpitations, lightheadedness, dizziness, or other associated symptoms. In the ED, she was found to have multiple rib fractures, with other negative imaging. She was admitted for pain control. All systems were reviewed and are negative except as above. Past Medical History: - Breast cancer - Sciatica - Dyspepsia - Uterine prolapse - T12 compression fracture - Osteopenia - Hypothyroidism - Depression/Bipolar disorder - IBS - Mitral valve prolapse - Hearing loss Social History: ___ Family History: Noncontributory Physical Exam: Upon admission: VITALS: T97.4F, BP 138/63, HR 72, RR 16, Sat 94%RA GENERAL: Well appearing, no acute distress HEENT: EOMI, PERRL, OP clear without lesions NECK: No cervical lymphadenopathy, no JVD, no carotid bruit CARD: RRR, normal S1/S2, no m/r/g RESP: CTA bilaterally, no wheezes/rales/rhonchi; ecchymoses and tenderness to light palpation over right-sided ribs bilaterally ABD: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly RECTAL: Guaiac negative in ER BACK: No spinal tenderness, no CVA tenderness EXT: No clubbing/cyanosis/edema, 2+ DP pulses NEURO: CN II-XII, A&O x 3, Strength ___ in both upper and lower extremities bilaterally, no sensory deficits, gait not tested PSYCH: Appropriate, normal affect Pertinent Results: ___: 14.2 PTT: 30.0 INR: 1.2 Na 141 K 3.8 Cl 105 HCO3 25 BUN 17 Creat 0.8 Gluc 106 CK: 257 MB: 4 Trop-T: <0.01 WBC 8.5 N:69.5 L:19.9 M:9.8 E:0.5 Bas:0.3 Hgb 12.4 Hct 38.1 Plt 237 MCV 95 U/A: SpecGr 1.018, tr leuk, tr bld, 15 ket, 6 WBC, 2 RBC, no bacteria STUDIES: ECG: No prior for comparison. NSR at 77bpm. Head CT: 1. No intracranial hemorrhage, with global atrophy and mild chronic microvascular infarction. 2. No displaced skull fracture. 3. Opacified right maxillary sinus. CXR: 1. Right-sided rib fractures. Consider dedicated rib series. 2. No pneumothorax. 3. T12 compression deformity, age indeterminate, in the absence of prior films. Correlate clinically Hip films: This exam is WNL. There is no fracture or dislocation. Sacroiliac joints and hips are normal. There is no focal lytic or sclerotic lesion. The bones are mildly demineralized. There is no abnormal soft tissue calcification or radiopaque foreign body. Shoulder films: There is no fracture or dislocation of the shoulder. There are degenerative changes at the acromioclavicular joint. There is mild demineralization. There is no focal lytic or sclerotic lesion. A tubular structure is seen overlying the right upper chest probably artifact on skin. No abnormal periarticular soft tissue calcification. The right lung is normal. Rib films: Multiple rib fractures. ___ 08:10AM CK(CPK)-254* ___ 08:10AM cTropnT-<0.01 ___ 04:50AM ___ PTT-30.0 ___ ___ 03:00AM GLUCOSE-106* UREA N-17 CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 ___ 03:00AM CK(CPK)-257* ___ 03:00AM WBC-8.5 RBC-4.04* HGB-12.4 HCT-38.1 MCV-95 MCH-30.7 MCHC-32.5 RDW-15.3 ___ 03:00AM PLT COUNT-237 Brief Hospital Course: She was admitted initially to the Medicine service on ___. A Trauma consult was obtained on ___ because questionable hemothorax, right pleural effusion and hematocrit drop from 38.5 to 29.7. A right thoracosotmy was placed by Surgery and remained in for several days. The chest tube was pulled on ___ in the late afternoon. Post removal films showed peristent right apical pneumothorax. A repeat chest film was obtained which showed virtually the same findings. She is on nasal oxygen at 2 liters; her saturations have been in mid 90's. She was noted intermittently with elevated blood pressure felt likley due to pain from her rib fractures. Her pain was managed with standing Tylenol and prn Oxycodone; a Lidoderm patch was also added. This regimen appeared to be effective. She was started on a bowel regimen. Her home medications were restarted. She was started on a regular diet and tolerated this. She was evaluated by Physical therapy and is being recommended for rehab after her acute hosital stay. Medications on Admission: - Levothyroxine 75mcg daily - Omperazole 20mg BID - Gabapentin 300mg TID - Dorzolamide-timolol 1 gtt ___ BID - Depakote 750mg QHS - Citalopram 20mg daily - Multivitamin daily - Calcium, vitamin D - Alendronate 70mg weekly ___ Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Dorzolamide-Timolol ___ % Drops Sig: One (1) Drop Ophthalmic BID (2 times a day): ___. 7. Divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every ___. 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 14. Tylenol ___ mg Tablet Sig: Two (2) Tablet PO every ___ hours. 15. Oxycodone 5 mg/5 mL Solution Sig: Five (5) ML's PO Q4H (every 4 hours) as needed for pain. 16. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: s/p Fall Multiple right rib fractures Right hemothorax Pneumothorax Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Followup Instructions: ___

{'terrible pain in her right side': ['Closed fracture of four ribs'], 'subacute decline': ['Bipolar I disorder', 'most recent episode (or current) depressed'], 'worsening confusion': ['Bipolar I disorder', 'most recent episode (or current) depressed'], 'inappropriate behavior': ['Bipolar I disorder', 'most recent episode (or current) depressed'], 'multiple rib fractures': ['Closed fracture of four ribs'], 'right hemothorax': ['Traumatic hemothorax without mention of open wound into thorax'], 'pneumothorax': ['Pneumothorax'], 'elevated blood pressure': ['unspecified'], 'pain from her rib fractures': ['Closed fracture of four ribs'], 'constipation': ['unspecified']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: This ia a ___ yo right handed male who presented to the ED after having a fall a few hrs before presenation. He reports that he fell from stairs about 10 ft. He slipped and hit his chin and head. He did not lose the consciousness. He denies seizures, weakness, nausea, emesis, chnage in vision, dizziness. Past Medical History: ADD, DM, GERD, Depression, trigeminal neuralgia PSH- diverticulitis, abd hernia repair, 3 brain surgeries for TGN ___ ___ Social History: ___ Family History: father had heart attack Physical Exam: On admission: O: T:98 BP:149 /91 HR:103 R 14 O2Sats 100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___ ___ reactive symmetric EOMs- Full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V- sensation decreased over left half of face ( baseline) VII: Facial strength . VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right ___ 2 1 Left ___ 2 1 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On discharge:*** Pertinent Results: ___ 12:40AM GLUCOSE-165* UREA N-13 CREAT-1.0 SODIUM-143 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13 WBC-13.7* RBC-4.85 HGB-14.5 HCT-42.9 MCV-88 MCH-29.9 MCHC-33.8 RDW-13.8 NEUTS-70.5* ___ MONOS-3.8 EOS-3.9 BASOS-0.5 PLT COUNT-236 Ct Head ___: 1. Right temporal subgaleal hematoma, with underlying tiny focal 2- to 3-mm subdural hematoma, but without skull fracture. 2. Post-operative changes noted with right temporo-occipital craniectomy and dilation of the CSF space overlying the left cerebellum; correlation with prior surgical history recommended. 3. Minimal calcification along left carotid siphon, remarkable for the patient's age. 4. Paranasal sinus mucosal disease, with slight increase in mucosal thickening lining the maxillary sinuses compared to ___. Ct C-spine ___: 1. Reversal of the normal cervical lordosis, without acute fracture or paraspinal hematoma seen. 2. Posterior disc osteophyte at C4-5 causes moderate narrowing of the central canal. 3. Left posterior fossa surgical changes as noted above and seen on CT head, as well as paranasal sinus mucosal disease. Ct Head ___: Brief Hospital Course: Mr. ___ admitted to ___ for observation of ___. He was neurologically intact on ___ at time of admission. He received Dilantin with load for seizure prophylaxis. Imaging of his left hand and wrist showed triquetrum fracture. Plastic surgery placed a splint and arranged follow up. Repeat CT imaging of his brain showed no enlargement of SDH. He did have some neck pain but there was no fracture on CT imaging. He remained neurologically stable. He was discharged to home on ___ Medications on Admission: adderall, metformin, welbutrin, tylenol, prilosec, Discharge Medications: 1. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Scalp Hematoma Subdural hematoma Triquetral fracture Cervical stenosis Discharge Condition: Stable Discharge Instructions: General Instructions •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. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. •You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to ___. • 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. Followup Instructions: ___

{'Fall': ['Accidental fall on or from other stairs or steps'], 'ADD': ['Attention deficit disorder without mention of hyperactivity'], 'DM': ['Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled'], 'GERD': ['Esophageal reflux'], 'Depression': ['Depressive disorder', 'not elsewhere classified'], 'Trigeminal neuralgia': ['Trigeminal neuralgia'], 'Subdural hematoma': ['Subdural hemorrhage following injury without mention of open intracranial wound'], 'Triquetral fracture': ['Closed fracture of triquetral [cuneiform] bone of wrist'], 'Cervical stenosis': ['Spinal stenosis in cervical region']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Fruit Extracts / Chocolate Flavor / Strawberry Attending: ___. Chief Complaint: angina, pulmonary edema Major Surgical or Invasive Procedure: coronary artery bypass x 2 (LIMA-LAD, SVG-diagonal), aortic valve replacement (23mm ___ tissue) ___ History of Present Illness: The patient recently had an increasein his anginal symptoms and underwent echo and stress test with his cardiologist. Additionally he developed cough, shortness of breath and pink frothy sputum, so he presented to the ED where he was treated for pulmonary edema and admitted for further workup. Cardiac catheterization revealed three vessel disease. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: no Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CAD s/p cath at ___ ___: 30% LMCA, 60% proximal LAD, LCx with 60% stenosis, RCA completely occluded proximally. This was managed medically. - Mild AS on cath ___ 3. OTHER PAST MEDICAL HISTORY - PVD - TIA, s/p left CEA ___ and known total occlusion of the ___ right ICA at its origin - Tonsillectomy - Anxiety Depression - ADD - MVA x2 c/b chronic back pain - Constipation causing impactions - Gerd - Hyperlipidemia - hypertension Social History: ___ Family History: Father had a CABG in his ___, lived into his ___. No other family history of cardiac disease. Physical Exam: Pulse:68-regular Resp: 20 O2 sat: 99 on RA B/P Right: 127/72 Left: Height: 71 inches Weight:169 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur3/6 harsh systolic ejection murmur radiates to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema1+ Varicosities: bilateral None []chronic venous stasis changes Neuro: Grossly intact [x] Pulses: Femoral Right:cath site-2+ no hematoma Left:2+ DP Right:trace Left:1+ ___ Right:1+ Left:trace Radial Right:2+ Left:2+ Carotid Bruit Right: murmur Left:murmur Pertinent Results: ___ 03:53AM BLOOD WBC-14.5* RBC-2.99* Hgb-9.5* Hct-27.8* MCV-93 MCH-31.9 MCHC-34.2 RDW-14.0 Plt ___ ___ 05:40AM BLOOD WBC-13.4* RBC-3.21* Hgb-10.1* Hct-30.1* MCV-94 MCH-31.5 MCHC-33.5 RDW-14.1 Plt ___ ___ 02:46PM BLOOD ___ PTT-34.6 ___ ___ 05:40AM BLOOD Glucose-114* UreaN-29* Creat-1.5* Na-140 K-3.9 Cl-103 HCO3-27 AnGap-14 PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. 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 arch is mildly dilated. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: Patient is AV paced, on low dose neo. A prosthetic aortic valve is in place with no leak and no AI. Residual mean gradient 16. Good biventricular systolic fxn. Aorta intact. Dr. ___ was notified in person of the results in the operating room. Brief Hospital Course: The patient was admitted and brought to the operating room on ___ where he underwent AVR, CABG as detailed in the operative report. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in critical but stable condition for observation and recovery. POD 1 found the patient extubated, alert and oriented and breathing comfortably. He was hemodynamically stable, weaned from vasopressor support. He did display some confusion on POD 1, however, this cleared. The patient was transferred to telemetry. Chest tubes and pacing wires were discontinued without complication. The physical therapy service was consulted for assistance with post-operative strength and mobility. The patient had some dental work prior to surgery, and post-operatively, his crown fell off while eating. The patient was started on amoxicillin and advised to continue this until he sees his dentist. Dr. ___ was consulted via telephone and agrees with this plan. Post-op course was essentially uneventful and the patient was cleared by Dr. ___ discharge home on POD 4. Medications on Admission: ASA 81mg daily simvastatin 40mg daily ezetimibe 10mg daily lasix 20 mg q ___ atenolol 50 mg daily omeprazole 20 mg daily venlafaxine 100 mg bid methylphenidate 20 mg bid ginko biloba 60 mg bid Plavix - last dose:300 mg ___ am Discharge Medications: 1. Venlafaxine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for Reconstitution Sig: Two (2) PO Q12H (every 12 hours) as needed for lost crown for 2 weeks: **take until further instructed by dentist**. Disp:*56 * Refills:*0* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 12. 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* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: aortic stenosis coronary artery disease Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Followup Instructions: ___

{'angina': ['Coronary atherosclerosis of native coronary artery'], 'cough': [], 'shortness of breath': ['Aortic valve disorders'], 'pink frothy sputum': ['Aortic valve disorders'], 'dyslipidemia': ['Other and unspecified hyperlipidemia'], 'hypertension': ['Unspecified essential hypertension'], 'history of drug use': [], 'smoking history': [], 'hypoechoic lesion': [], 'CAD s/p cath': ['Coronary atherosclerosis of native coronary artery'], 'mild AS': ['Aortic valve disorders'], 'PVD': ['Atherosclerosis of native arteries of the extremities with intermittent claudication'], 'TIA, s/p left CEA': ['Personal history of transient ischemic attack (TIA)'], 'anxiety depression': ['Dysthymic disorder'], 'ADD': [], 'MVA x2 c/b chronic back pain': [], 'constipation causing impactions': [], 'gerd': ['Esophageal reflux'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending: ___ Chief Complaint: Heroin Overdose Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a ___ y/o F admitted after heroin overdose. The pt reports a past history of heroin abuse with recent relaps six months ago. Pt went to rehab at ___ in ___ approx 1 week ago for 7 day stay but felt her rehab stay didn't address her addiction issues. She reports being treated with librium and clonidine. She completed her rehab stay two days ago. She says that due to ongoing stress within her marriage she again used heroin earlier today. She reports that after feeling her inital rush after her injection she began reacting poorly and feeling like she was going to pass out. The people around her called EMS. Upon EMS arrival she became concerned about possessing additional heroin and she swallowed her other bag in her possession, states less than 1gm of heroin. The patient denies any attempt to harm herself. Denies fear of domestic violence. She was found unresponsive on a basketball court by EMS. On arrival to ED vitals T 97.8, HR 80, RR 12 BP 120/61, SaO2 %NRB. She was responsive to verbal stimuli. She received naloxone X 4 in the ED. She was admitted to the ICU as she was having continued episodes of somnolence. . On arrival to the FICU the patient was awake and alert. She was able to ambulate from the transport gurney to the bedside without difficulty. Vitals stable. Pt was cooperative with questioning and expressed an interest in obtaining outpatient therapy. Denies use of other illicit drugs. Past Medical History: Hepatitis C - reports due to tatoo, no prior treatment Heroin abuse - states her addiction began after she was given percocet and oxycodone for back pain s/p MVC many years ago. Had previously been clean for ___ years prior to relapsing 6 months ago Social History: ___ Family History: unknown patient is adopted Physical Exam: Gen: alert, oriented X3, NAD CV: RRR, no MRG Resp: CTAB, no WRR Abd: soft, NT/ND NABS Ext: no edema Skin: tatoo left shoulder, no needle tracks Pertinent Results: ___ 02:21PM WBC-12.0* RBC-4.71 HGB-14.3 HCT-41.4 MCV-88 MCH-30.3 MCHC-34.4 RDW-14.1 ___ 02:21PM NEUTS-53.1 ___ MONOS-4.4 EOS-1.0 BASOS-0.7 ___ 02:21PM PLT COUNT-362 ___ 02:21PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG ___ 02:21PM GLUCOSE-147* UREA N-22* CREAT-1.0 SODIUM-146* POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-26 ANION GAP-19 ___ 02:21PM CALCIUM-10.0 PHOSPHATE-7.3* MAGNESIUM-2.3 ___ 08:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 08:35PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG ___ 10:00PM URINE HOURS-RANDOM ___ 03:48AM BLOOD ALT-59* AST-43* AlkPhos-56 TotBili-0.5 ___ CXR FINDINGS: There is relative ___ of the lungs with no consolidation or edema evident. The mediastinum is unremarkable. The cardiac silhouette is top normal for size. Minimal left basilar atelectasis is evident with a slightly elevated left hemidiaphragm. There is no pleural effusion or pneumothorax. The visualized osseous structures are unremarkable. IMPRESSION: No acute pulmonary process. Brief Hospital Course: The pt is a ___ F admitted with heroin overdose. Heroin Overdose - pt w/ respiratory depression in ED requiring narcan. On arrival to ICU this has resolved. Need for recurrent narcan may be related GI absorption of swallowed heroin. It was unclear whether the bag of heroin ingested had ruptured and she had absorbed the drug. Toxicology was contacted and they stated safest would be to start the patient on golytely until the heroin bag passes or her stool output is clear and to monitor her in a medical setting until this is complete. She signed out against medical advice, understanding the risks of this including GI obstruction, heroin overdose or death. Discharged with recommendations to follow up with her PCP for help with a drug rehab program. upon discharge no signs of heroin intoxication or withdrawal, the patient has capacity to make this decision. She denies any thoughts of suicide. Polysubstance abuse - pt with recent relapse despite rehab stay. Urine tox positive for cocaine, benzos and opiates. Pt reports benzo screen positive due to librium use at rehab. Hep C - pt reports stable LFTS followed as outpatient. Recommend continued outpatient management. Medications on Admission: Medications: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Heroin Overdose Discharge Condition: Against Medical Advice. Vitals stable. Normal Mental Status. No signs of heroin withdrawal or intoxication. Discharge Instructions: You were admitted for a drug overdose. You stated that you ingested a bag of heroin, it is important that you be monitored in a medical setting in case the bag ruptures and you absorb this heroin. You stated that you understand the risks of leaving including heroin overdose, intestinal obstruction, or even death and that you are willing to take the risks and leave Against Medical Advice ("AMA"). Please call your doctor or return to the emergency room immediately if you have abdominal pain, difficulty breathing, constipation, nausea, lethargy or if you begin to feel the effects of the heroin you have ingested. Followup Instructions: ___

{'Heroin Overdose': ['Poisoning by heroin'], 'Opioid abuse': ['Opioid abuse'], 'Cocaine abuse': ['Cocaine abuse']}

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending: ___. Chief Complaint: Left renal stone Major Surgical or Invasive Procedure: ESWL, left ureteral stent placement History of Present Illness: ___ with 1.5cm L UPJ stone. Past Medical History: lower back pain Social History: ___ Family History: non-contributory Brief Hospital Course: The patient was admitted to the Urology service after undergoing ESWL and left ureteral stent placement. His pain was controlled with oral pain medications. He was tolerating a regular diet. He was ambulating without assistance, and voiding without difficulty. He is given explicit instructions to call Dr. ___ ___ follow-up. Medications on Admission: None Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for bladder spasm. 6. phenazopyridine 100 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 3 days. Discharge Disposition: Home Discharge Diagnosis: Left renal stone Discharge Condition: Stable A+OX3 ambulates independently Discharge Instructions: -No vigorous physical activity for 2 weeks. -Expect to see occasional blood in your urine and to experience urgency and frequecy over the next month. -You may have already passed your kidney stone, or it may still be in the process of passing. You may experience some pain associated with spasm of your ureter. This is normal. Take Motrin as directed and take the narcotic pain medication as prescribed if additional pain relief is needed. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) -Make sure you drink plenty of fluids to help keep yourself hydrated and facilitate passage of stone fragments. -You may shower and bathe normally. -Do not drive or drink alcohol while taking narcotics -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Resume all of your home medications, unless otherwise noted. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: ___

{'lower back pain': ['Calculus of kidney', 'Lumbago'], 'pain': ['Calculus of kidney', 'Other acute postoperative pain'], 'urgency and frequency': ['Calculus of kidney', 'Stricture or kinking of ureter']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Amoxicillin / Nitrofurantoin / Augmentin / Cipro / Penicillins / Codeine Attending: ___. Chief Complaint: right knee pain Major Surgical or Invasive Procedure: complex right total knee replacement - rotating hinge History of Present Illness: Ms ___ has had progressive right knee pain that has been refractory to conservative management. She has radiographic evidence of severe osteoarthritis and a physical exam consistent with multi-directional instability. She elects for definitive treatment. Past Medical History: asthma and depression Social History: ___ Family History: n/c Physical Exam: well appearing, well nourished ___ year old female alert and oriented no acute distress RLE: -dressing-c/d/i -incision-c/d/i -+AT, FHL, ___ -SILT -brisk cap refill -calf-soft, nontender -NVI distally Pertinent Results: ___ 08:10AM BLOOD WBC-8.9 RBC-3.56*# Hgb-9.5*# Hct-29.0*# MCV-81* MCH-26.7* MCHC-32.8 RDW-15.5 Plt ___ ___ 08:10AM BLOOD Glucose-116* UreaN-14 Creat-0.5 Na-134 K-4.0 Cl-102 HCO3-26 AnGap-10 Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms ___ is discharged to rehab in stable condition. Medications on Admission: sertraline, flaxseed, naproxen, and cranberry Discharge Medications: 1. Sertraline 75 mg PO DAILY 2. Lorazepam 1 mg PO BID 3. Acetaminophen 650 mg PO Q6H standing dose 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC DAILY 6. Senna 1 TAB PO BID 7. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right charcot knee right knee osteoarthritis right knee multi-directional instability 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out at first follow up appointment two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in two (2) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. ___ STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed AT FIRST POST OP APPOINTMENT in two (2) weeks. 11. ___ (once at home): Home ___, dressing changes as instructed, wound checks. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ___ brace locked ___ degrees at all time x 4 weeks. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: ROM - ___ ___ x 4 weeks WBAT Mobilize frequently Treatments Frequency: dry, sterile dressing changes daily and as needed for drainage wound checks ice and elevate TEDs Followup Instructions: ___

{'right knee pain': ['Osteoarthrosis', 'Knee joint replacement'], 'asthma': ['Asthma', 'unspecified type'], 'depression': ['Depressive disorder', 'not elsewhere classified'], 'multi-directional instability': ['Osteoarthrosis', 'Knee joint replacement'], 'severe osteoarthritis': ['Osteoarthrosis', 'Knee joint replacement']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Amoxicillin / Nitrofurantoin / Augmentin / Cipro Attending: ___ Chief Complaint: incisional hernia Major Surgical or Invasive Procedure: Open mesh incisional hernia repair. History of Present Illness: ___ woman who is status post a laparoscopic cholecystectomy and she has developed an incisional hernia at the umbilical port site. It has grown slowly, but surely grown to a massive size, and she now has entrapped omentum and a large hernia sac and needs this repaired. She has no evidence of bowel obstruction. Past Medical History: OA, obesity, umbilical hernia Social History: ___ Family History: n/c Physical Exam: AVSS Gen: NAD, cooperative Chest: no resp distress CV: RRR Abd: soft, tender ___, incision - c/d/i, abdominal binder in place. JP drain in place, sero-sang output. Extrem: warm, well perfused Pertinent Results: ___ 08:15PM URINE RBC-9* WBC-35* Bacteri-MANY Yeast-NONE Epi-16 TransE-<1 ___ 08:15PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 08:15PM URINE Color-Straw Appear-Hazy Sp ___ ___ - Urine Cx pending Brief Hospital Course: The patient was admitted to the Colorectal Surgical Service after operative repair. After a brief, uneventful stay in the PACU, the patient arrived on the floor with a regular diet, on IV fluids and antibiotics, and Dilaudid PCA for pain control. The patient was hemodynamically stable. Neuro: The patient received IV Dilaudid with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. UA was sent on POD1 as patient was having urinary frequency. The result appeared consistent with contaminated specimen and patient denied having any buring or dysuria. Urine culture was pending at time of discharge. JP drain was left in place and patient received adequate teaching on drain management. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Anxiety. Discharge Medications: 1. citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Anxiety. 3. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: incisional hernia Discharge Condition: Stable, Alert and Oriented. Ambulating safely. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. You may keep the binder on as you wish for comfort. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, and bring these recordings to your follow up appointment. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___

{'tender ___, incision - c/d/i': ['Incisional ventral hernia with obstruction'], 'Abd: soft': ['Incisional ventral hernia with obstruction'], 'JP drain in place, sero-sang output': ['Incisional ventral hernia with obstruction']}

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Amoxicillin / Codeine Attending: ___. Chief Complaint: left knee osteoarthritis Major Surgical or Invasive Procedure: ___ - Complex primary left total knee arthroplasty with stems and total stabilizer tibial insert History of Present Illness: ___ with left knee pain from osteoarthritis who failed conservative management. Past Medical History: OA, obesity, umbilical hernia Social History: ___ Family History: n/c Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength ___ * SILT DP/SP/T/S/S * Toes warm Pertinent Results: ___ 07:10AM BLOOD WBC-9.8 RBC-3.35* Hgb-9.5* Hct-29.1* MCV-87 MCH-28.3 MCHC-32.6 RDW-13.9 Plt ___ ___ 06:15AM BLOOD Glucose-114* UreaN-9 Creat-0.4 Na-133 K-4.3 Cl-99 HCO3-24 AnGap-14 ___ 06:15AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.0 Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable. She followed standard knee pathway but she required an unlocked ___ brace at all times given her complex knee surgery. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior hip precautions. Medications on Admission: celexa 60, ativan, naprosyn Discharge Medications: 1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 3 weeks: Please continue lovenox for 3 wks. Once lovenox is finished take aspirin 325mg twice daily for 3 wks. Disp:*21 syringes* Refills:*0* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 3 weeks: take for 3 wks once you're done with the lovenox. Disp:*42 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for Pain. Disp:*90 Tablet(s)* Refills:*0* 5. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Anxiety. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: left knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 11. ___ (once at home): Home ___, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Wear your ___ brace unlocked for 2months. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Weight bearing as tolerated on the operative extremity. CPM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Treatments Frequency: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. Followup Instructions: ___

{'left knee pain': ['Osteoarthrosis'], 'umbilical hernia': ['Obesity']}