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Admission Date: [**2117-9-11**] Discharge Date: [**2117-9-17**] Date of Birth: [**2082-3-21**] Sex: F Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 2195**] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: 35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy, nephropathy, HTN, gastroparesis, CKD and retinopathy, recently hospitalized for orthostatic hypotension [**2-3**] autonomic neuropathy [**Date range (1) 25088**]; DKA hospitalizations in [**6-12**] and [**7-12**], now returning w/ 5d history of worsening nausea, vomiting with coffee-ground emesis, chills, and dyspnea on exertion. Last week she had a fall and hit her right face. she also had 1 day of diarrhea, which resolved early last week. Found to be in DKA with AG 30 and bicarb 11. . In the ED inital vitals were 09:00 0 98.2 113 181/99 22 100% RA. K 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) She is on her 3rd L NS. Insulin srip at 5 units/hr. On home at 22 levemir in am and 12 at with difficult to control sugars. BPs have been high. Given 30 mtroprolol tartrate in ED. She was started on an insulin drip at 5 units/hr and 3L NS boluses. Also aspirin 325mg PO and Morphine 4mg IVx1 for pain. CXr was clear. EKG NAD. . Review of systems: otherwise negative. Past Medical History: Type 1 diabetes mellitis w/ neuropathy, nephropathy, and retinopathy - 2 episodes of DKA in [**6-12**] and [**7-12**] HTN - 5 years gastroparesis - 1.5 years CKD - stage III, baseline Cr 2.4-2.5, proteinuria L1 vertebral fracture - [**2117-7-17**] Systolic ejection murmur Social History: Patient lives at home in [**Location (un) **] with her 8 y/o daughter and boyfriend. She has no history of EtOH, tobacco, or illicit drug use. She is currently unemployed and seeking disability. Family History: Both parents have HTN and T2DM. Grandfather had an MI in his 40s. Physical Exam: GEN: Awake, alert, and oriented HEENT: PERRLA. MMM. no JVD. neck supple. No cervical LAD Cards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard best at the L upper sternal border. Pulm: CTABL with no crackles or wheezes. Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**] sign Extremities: wwp, no edema. radials, DPs, PTs 2+. Skin: no rashes or bruising. no skin tenting. Neuro: CNs II-XII intact. Upper extremities: Power [**5-6**] bilaterally. Le: left power: 4.5/5 right: power [**3-6**]. Bilateral symmetric, reduced sensation distal LE to ankles. Pertinent Results: Admission Labs: [**2117-9-11**] 09:22AM WBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466* LIPASE-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5 GLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9 CL-101 CO2-11* LACTATE-1.9 Discharge Labs: [**2117-9-16**] 07:10AM WBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298 Glucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23 AnGap-14 Calcium-8.7 Phos-3.5 Mg-2.0 Radiology: CXR: No evidence of pneumonia or other pathological abnormalities. No pleural effusions. No pulmonary edema. Normal size of the cardiac silhouette. Microbiology: Urine culture negative, blood cultures no growth to date, stool for C.difficile negative Brief Hospital Course: 35 yo F with HTN & poorly controlled type I DM, c/b neuropathy, gastroparesis, nephropathy ?????? CKD, retinopathy presents with DKA and hypertension SBP to 200s. . # Diabetic ketoacidosis: Patient controls diabetes at home with Humalog SS and long acting Levemir. Sugars at home recently have been in 250s. In the ED, glucose was 466. UA was +ve for ketones ?????? corrected to 200s, but rose again to 300s. She was treated with an insulin drip which was transitioned to subq when she tolerated POs. Her electrolytes were repleted and she received aggressive volume resuscitation. [**Last Name (un) **] saw her and gave sliding scale recommendations which were implemented. No source for DKA found, beleived to be [**2-3**] gastroparesis. Nausea managed with ativan, compazine, and promethazine. She was discharged on her home Insulin and sliding scale with instructions to follow-up with [**Last Name (un) **]. # HTN: Hypertensive with SBP in 190s initially, attributed to DKA, as she has experienced in the past. As she improved her blood pressures normalized and she was re-started on her home Lopressor and Midodrine regimen. # Coffee grounds emesis: Emesis started off as clear, then with prolonged wretching, she started having coffee-grounds vomiting. This had also occurred on prior admissions for DKA with associated vomiting. Her hematocrit remained stable and her hematemesis self-resolved, and so work-up was deferred to the outpatient setting. # Acute on chronic kidney disease, Stage III: Patient's Cr on admission was 2.7, trending down to 2.1-2.3 following fluids, consistent with her known CKD secondary to diabetic nephropathy. Medications on Admission: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous every AM. 3. Levemir 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 4. Humalog 100 unit/mL Solution Sig: sliding scale as directed Subcutaneous four times a day: Please use sliding scale as directed by MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **]. 5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): take in the evening. 6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for nausea. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily): Please take only 1 capsule daily (30 mg) for first 2 weeks of treatment. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for pain. 10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4) hours: Can hold while sleeping. Disp:*270 Tablet(s)* Refills:*2* Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO Once Daily at 6 PM. 5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Levemir 100 unit/mL Solution Sig: As directed by [**Last Name (un) **] units Subcutaneous As directed. Discharge Disposition: Home Discharge Diagnosis: Diabetic keotacidosis Hematemesis (blood in your vomit) Hypertension Chronic renal insufficiency 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 DKA, hypertension, and blood in your vomit. You were initially treated in the ICU with an insulin drip, and your blood sugars improved. Your blood pressure medications were adjusted to better control your blood pressure while you were in DKA, but you were re-started on your home regimen at discharge. The blood in your vomit was likely secondary to mechanical trauma from repeated wretching, but you should follow-up with your primary care doctor to discuss whether you should undergo further evaluation such as an upper endoscopy. Given your complaints of chronic cough and heartburn, you should also discuss beginning a trial of a proton pump inhibitor such as Nexium or Prilosec to see if this helps your symptoms. Your insulin regimen was adjusted by the [**Last Name (un) **] team while you were here. You should continue to follow-up with them with any questions or concerns regarding your insulin management. Followup Instructions: Please call Dr.[**Last Name (STitle) 805**]' office to schedule a follow-up appointment within 7-10 days of discharge. Her office number is [**Telephone/Fax (1) 85219**]. You should also continue to follow-up with your [**Last Name (un) **] doctors as needed.

Admission Date: [**2150-4-17**] Discharge Date: [**2150-4-21**] Date of Birth: [**2090-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12174**] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: EGD Right IJ CVL History of Present Illness: Mr. [**Known lastname 52368**] is a 59M w HepC cirrhosis c/b grade I/II esophageal varices and portal gastropathy (last EGD [**3-/2150**]), who p/w coffee-ground emesis and melena x2 days. . Pt was in his USOH until about 2-3 days PTA, when he began experiencing intermittent nausea. He had 2-3 episodes of coffee-ground emesis and 1 episode of tarry black stool in the morning of admission. He reports some lightheadedness which is not new, but denies frank hematemesis, BRBPR, abdominal pain, fever, chills, significant increases in his abdominal girth. He denies drinking or medication non-compliance. He also reports taking naproxen for back pain 2-3 times a day in the recent past. . In the ED, his vitals were 97.4, 93/41, 69, 18, 100% on RA. He was given 4L NS IV, protonix 40mg IV, started on an octreotide drip. He had guaiac positive brown stool on rectal exam. He was seen by the liver fellow in the ED who felt this was unlikely a variceal bleed and recommended work up for infection. An NG tube was attempted, however, patient was unable to tolerate it in the ED. Abdominal ultrasound was done which showed a patent portal vein, scant ascites but not enough to tap. BP dropped to 80/34, pt transferred to MICU for hemodynamic monitoring. . In the MICU, pt was given 3 pRBC, Hct bumped from 21.3 to 28. Started on norepinephrine gtt for a few hours, but BP stabilized. On transfer to the floor, remains hemodynamically stable. Feels good, denies tarry or bloody BMs, emesis. Past Medical History: HCV Cirrhosis (tx with interferon x2 with no response) Portal Gastropathy Grade II Esophageal varices HTN Social History: He lives alone. He is drinking alcohol, usually one session per week. He has four to five drinks per session. He was told to completely abstain from alcohol, effective as of today. He smokes about 20 cigarettes per day. Family History: NC Physical Exam: ON ADMISSION: VS: T95.9 HR 71 BP 83/36 RR 11 96% 2L NC Gen: somnolent, oriented x 3, unable to assess for asterixis given somnolence HEENT: PERRLA, EOMI Neck: supple, JVP at angle of jaw (fluid bolus running wide open) CV: RRR s1 s2 no appreciable murmur Lungs: CTAB Abd: distended, non tender, no rebound or guarding, bowel sounds positive Ext: 1+ pitting edema bilaterally Skin: warm, diaphoretic, no rash or lesions noted Pertinent Results: LABS ON ADMISSION: [**2150-4-17**] 01:30PM BLOOD WBC-17.9*# RBC-2.78* Hgb-8.5* Hct-26.0* MCV-94 MCH-30.6 MCHC-32.7 RDW-20.6* Plt Ct-186 [**2150-4-17**] 01:30PM BLOOD Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2 Baso-0.9 [**2150-4-17**] 02:13PM BLOOD PT-17.7* PTT-34.5 INR(PT)-1.6* [**2150-4-17**] 01:30PM BLOOD Glucose-92 UreaN-51* Creat-1.3* Na-131* K-5.7* Cl-104 HCO3-21* AnGap-12 [**2150-4-17**] 01:30PM BLOOD ALT-126* AST-260* LD(LDH)-426* AlkPhos-157* TotBili-3.3* [**2150-4-17**] 06:41PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.9 . LABS ON DISCHARGE: [**2150-4-21**] 05:00AM BLOOD WBC-10.7 RBC-2.94* Hgb-9.6* Hct-27.0* MCV-92 MCH-32.6* MCHC-35.6* RDW-21.2* Plt Ct-110* [**2150-4-21**] 05:00AM BLOOD PT-17.4* PTT-35.6* INR(PT)-1.6* [**2150-4-21**] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-132* K-4.4 Cl-99 HCO3-25 AnGap-12 [**2150-4-21**] 05:00AM BLOOD ALT-113* AST-210* AlkPhos-111 TotBili-3.6* [**2150-4-21**] 05:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7 . OTHER LABS: [**2150-4-18**] 06:25AM BLOOD CK-MB-9 cTropnT-<0.01 [**2150-4-17**] 06:41PM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-<0.01 [**2150-4-17**] 01:30PM BLOOD Lipase-85* . URINE: [**2150-4-17**] 11:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2150-4-17**] 11:01PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2150-4-17**] 11:01PM URINE RBC-63* WBC-7* Bacteri-NONE Yeast-NONE Epi-<1 . MICROBIOLOGY: Blood, urine cultures - negative H.pylori serum antibody - negative . CARDIOLOGY: . TTE ([**4-18**]): Conclusions The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic LV systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. . EKG ([**4-17**]): Sinus rhythm Prolonged QT interval is nonspecific but clinical correlation is suggested No previous tracing available for comparison Intervals Axes Rate PR QRS QT/QTc P QRS T 70 160 96 462/479 70 55 52 . GI: EGD ([**4-20**]): 1. Varices at the lower third of the esophagus and middle third of the esophagus. 2. Erythema and erosion in the antrum and pylorus compatible with non-steroidal induced gastritis. 3. Bleeding from a pyloric ulcer in the pylorus compatible with non-steroidal induced ulcer (injection, thermal therapy). 4. Normal mucosa in the duodenum. 5. Otherwise normal EGD to third part of the duodenum . RADIOLOGY: . CXR ([**4-17**]): The prominent bulge to the right heart border could be due to pericardial effusion, _____ cyst, and enlarged right atrium. There is no mediastinal vascular engorgement to suggest cardiac tamponade. Pulmonary vasculature is normal. The lungs are clear and there is no pleural effusion. Overall heart size is normal. Right jugular line ends at the junction of the brachiocephalic veins. No pneumothorax or pleural effusion. . ABD U/S ([**4-17**]): IMPRESSION: 1. No son[**Name (NI) 493**] evidence for portal venous thrombosis. Portal vein flow is hepatopetal and wall-to-wall. 2. No significant ascites. A sliver of perihepatic ascites. 3. Persistent coarsened echotexture of the liver consistent with known history of cirrhosis. 4. Splenomegaly Brief Hospital Course: Mr [**Known lastname 52368**] is a 59M w HCV cirrhosis w grade II esophageal varices admitted w coffee-ground emesis and melena concerning for UGIB, s/p MICU stay for hypotension. . # UGIB: Pt did not have any more bleeds while in hospital. EGD revealed erythema and erosion in the antrum and pylorus compatible with non-steroidal induced gastritis. Pt did remember taking increased doses of naproxen for backache. Started on pantoprazole 40mg PO BID for one week with repeat endoscopy scheduled in one week ([**4-30**]). Recommended to take tylenol (max daily dose of 2gm) for pain instead of NSAIDs. Blood pressure meds were held at first, given MICU admission for hypotension, but were restarted on discharge. . # HCV Cirrhosis: appears to be progressing to liver failure, with elevated INR at 1.6, decreased albumin at 2.6, tbili slightly elevated at 3.6, and chronic LE edema. Pt was continued on prophylactic medications. . # FULL CODE Medications on Admission: FUROSEMIDE 20mg daily LISINOPRIL 10 mg daily SPIRONOLACTONE 100 mg daily Discharge Medications: 1. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane PRN (as needed). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-15**] hours as needed: no more than 6 tablets of regular strength tylenol per day. 8. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 1 weeks. Disp:*qs * Refills:*0* 9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 1 weeks: then take 1 tablet daily. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. 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* 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Peptic ulcer GI bleed Discharge Condition: asymptomatic Discharge Instructions: You were admitted for bleeding from an ulcer in your stomach. This ulcer is at least partially caused by naproxen. You should stop taking naproxen and take only tylenol for pain. You should not take any NSAIDS for pain including ibuprofen, naproxen, aleve, motrin, aspirin, toradol, or advil. It is okay to take tylenol but do not take more than 4 extra strength tylenol a day (2gram daily maximum). . The following medication changes were made: Do not take naproxen Take pantoprazole 40 mg twice daily for one week. Then take 40 mg daily. . You are scheduled to get a repeat endoscopy next week. Prior to the procedure do not have anything to drink or eat after midnight. . Please return to the ER if you have any chest pain, lightheadeness, fever, chills, bloody or black stools or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-4-30**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-4-30**] 1:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2150-5-7**] 11:00 Completed by:[**2150-4-24**]

Admission Date: [**2108-4-6**] Discharge Date: [**2081-4-7**] Date of Birth: [**2059-5-7**] Sex: F Service: O MED CHIEF COMPLAINT: Dyspnea. HISTORY OF PRESENT ILLNESS: This is a 48 year old African American female with a history of multiple myelomas being admitted for respiratory distress. The patient has been recently discharged one week ago from outside hospital ([**Hospital3 7900**]) for respiratory distress. Back at [**Hospital3 7362**], she was given nebulizer, antibiotics and steroids. She also had elevated INR and was given medication to lower INR although there was no evidence of bleeding. Last night, she reports having increased difficulty with breathing. She has also had a cough. She denies any fever or chills. The patient admitted to decreased p.o. intake but has been recently sedimentary. She denies any swelling of the legs. The patient had noted some wheezing but then took her Albuterol inhaler without any effect. She has been on a Prednisone taper but reports that she has been coughing up thick sputum. She went to her primary care provider today but could not say a sentence so was sent to the Emergency Department. In the Emergency Department, she was tachypneic and wheezing with heart of 120 and blood pressure of 127/82. She received Solu-Medrol and continued with nebulizer treatment. She improved, but seemed to be tiring. Her ABG was done and showed pH of 7.41; PCO2, 40; PO2, 92. She can speak in full sentences but still just making wheezing. She is requiring continued nebulizer treatment but denies any chest pain, nausea, vomiting, diarrhea or abdominal pain. She feels weak in general. PAST MEDICAL HISTORY: 1. Multiple myeloma diagnosed in [**2107-12-9**], with increase protein in bone marrow biopsy. She is to receive Decadron 40 mg q d every other week. 2. Pulmonary embolism, [**2108-1-2**]. 3. Asthma. No PFTs ..................... 4. History of steroid psychosis. 5. Pneumonia requiring intubation in [**2107-12-9**]. MEDICATIONS UPON ADMISSION: 1. Coumadin 2.5 mg p.o. q d. 2. Serevent two puffs q.i.d. 3. Albuterol inhaler one to two puffs q 6 hours prn. 4. Dexamethasone 10 mg p.o. q d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Socially, she lives with her children and works at home as a home health aid. She has twenty years of two pack a day smoking history but quit in [**2107-12-9**]. She drinks an occasional alcohol. FAMILY HISTORY: Family history shows father died of an myocardial infarction. Sister with ovarian cancer. PHYSICAL EXAMINATION UPON ADMISSION: Temperature, 96.6; heart rate, 122; blood pressure, 127/82; respiratory rate, 24; O2 saturation, 99%. Head, eyes, ears, nose and throat, pupils are equal, round, and reactive to light and accommodation and extraocular movements intact. No accessory muscles are being used. Neck is supple without lymphadenopathy. Pulmonary, diffuse wheezing with bibasilar crackles with the left greater than right. Cardiac, regular rate and rhythm with normal S1 or S2. No murmurs or thrills noted. Abdomen is soft, nontender, nondistended with normal active bowel sounds. Extremities, no edema, cyanosis or clubbing noted. Neurologically, the patient is somnolent but oriented x 3. No focal defects are noted. LABORATORIES UPON ADMISSION: White count, 9.6; neutrophils, 66%; lymphocytes, 5%; bandemia, 21%; monocytes, 1%. Sodium, 131; potassium, 4.4; chloride, 92; bicarbonate, 24. BUN, 14; creatinine, 0.8. Glucose, 131. INR, 1.3. PTT, 29.1. ABG, 7.41; PCO2, 40; PO2, 92. HOSPITAL COURSE: 1. Pulmonary - Dyspnea secondary to chronic obstructive pulmonary disease/emphysema under this hospital course. Briefly, the patient received BIPAP, ...................., intravenous Solu-Medrol, nebulizer treatment and inhaler treatment while in the Intensive Care Unit. She was able to be weaned off of the oxygen back to room air, sating to about 93 or 94 percent. Though her chest x-rays show hyperinflation and no signs of infection, she was given five days worth of Zithromax. An echocardiogram was to rule out any cardiac wheezes which then showed an ejection fraction of greater than 55%, mild right ventricular dilation and mild pulmonary arterial pressure. Pulmonary function tests were performed showing obstructive pattern with FEC of 2.56 which is 93% of the predicted and FEV1 of 0.9 which is 43% of the predicted in FEV1 to FEC ratio of 46%. When the patient was transferred to the Medical Floor, a CT was performed showed no evidence of a pulmonary embolism but did show signs of emphysema. Sputum cultures were sent and showed no growth of any organism. Alpha antitrypsin was sent out but is still pending. 2. Pulmonary Embolism - The patient was continued on Coumadin for an INR between 2 and 3. Since she was subtherapeutic, she was started on Lovenox until she became therapeutic on the Coumadin. 3. Psychiatry - Anxiety. The patient was quite anxious during the hospital course. Psychiatry was called to consult and recommended that she be on Risperidone at 0.25 mg q hs. The patient did well on this medication. 4. Oncology - Multiple myeloma. A protein electrophoresis was done showing a monoclonal IGG capa gammaglobulinopathy (60% of the total protein in [**2108-1-8**], but now is 66% of total protein on [**2108-4-9**], despite q weekly Dexamethasone treatment. Bone marrow biopsy was done revealing 70 to 80 percent plasma cells. Given these findings, the patient was then transferred to the [**Hospital Ward Name 516**] for start of chemotherapy with Vincristine, ................... and Decadron in preparation for bone marrow transplant to be done. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**First Name3 (LF) 30667**] MEDQUIST36 D: [**2108-4-17**] 15:47 T: [**2108-4-17**] 15:46 JOB#: [**Job Number 30668**]

Admission Date: [**2145-3-31**] Discharge Date: [**2145-4-7**] Date of Birth: [**2071-6-4**] Sex: F Service: SURGERY Allergies: Penicillins / Dilantin Attending:[**First Name3 (LF) 301**] Chief Complaint: Severe abdominal and back pain Unable to take oral intake. No flatus or bowel movement. Abdominal distention. Major Surgical or Invasive Procedure: Exploratory Laparotomy Lysis of adhesions Small Bowel Resection Jejunosotomy History of Present Illness: Ms [**Known lastname **] is a 73 year old female with a history of multiple abdominal surgeries, pancreatitis and previous SBO. She presented to the Emergency Department on [**2145-3-30**] with complaints of [**11-10**] abdominal pain, radiating to her back that began in the morning. She complains of distention, inability to have a bowel movement, inability to take oral intake, no fever, chills or diarrhea. Past Medical History: Chronic Pancreatitis Migraines Surgical history: Pancreatic diversion, cholecystectomy, appendectomy, small bowel obstruction. Social History: Married, lives with husband who is a retired pediatric infectious disease doctor. Family History: Father: deceased, leukemia Brother: colon cancer Physical Exam: T: 97.9 HR: 79 BP: 153/60 RR: 22 Spo2 100% on RA Constitutional: in pain Head/Eyes: mucous membranes dry ENT/Neck: neck supple Chest/Respiratory: Clear to auscultation Bilaterally GI/Abdominal: Tender to light palpation. Multiple well healed scars + guarding, hypoactive bowel sounds GU: no costovertebral angle tenderness Musculoskeletal: WNL Skin: Dry Neuro: alert & oriented Pertinent Results: [**2145-3-30**] 09:15PM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-139 K-3.8 Cl-103 HCO3-25 AnGap-15 [**2145-3-31**] 10:26AM BLOOD WBC-12.3*# RBC-4.01* Hgb-12.3 Hct-37.1 MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259 [**2145-3-30**] 09:15PM BLOOD ALT-12 AST-22 AlkPhos-89 Amylase-169* TotBili-0.3 [**2145-4-2**] 06:15AM BLOOD Amylase-107* [**2145-3-31**] 10:26AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.6 [**2145-3-31**] 12:44AM BLOOD Lactate-3.1* [**2145-4-2**] 02:10PM BLOOD Lactate-1.9 [**2145-3-30**] 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG . ABDOMEN (SUPINE & ERECT) IMPRESSION: Nonspecific bowel gas pattern without evidence of obstruction. . CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST IMPRESSION: 1. High grade small-bowel obstruction. Unusual configuration of a loop of small bowel in the mid abdomen is concerning for closed loop obstruction. There is a moderate amount of free fluid within the abdomen. 2. Ill-defined opacity in the right middle lobe representing infection or BAC and should be further evaluated with PET CT. 3. Thickening of the first portion of the duodenum, of uncertain clinical significance. . CHEST (PORTABLE AP) [**2145-4-2**] 1:51 PM IMPRESSION: Right lower lobe airspace opacity, which could represent pneumonia in the appropriate clinical setting. Small bilateral pleural effusions. Followup to assure resolution is recommended. . CT Chest [**2145-4-2**] IMPRESSION: 1. New right lower lobe pneumonia. Small bilateral pleural effusion and left basilar atelectasis. 2. Ill-defined opacity in the right middle lobe representing either infection or BAC and should be further evaluated once acute issues resolve. 3. No evidence of pulmonary embolus or aortic dissection. 4. Small mediastinal and axillary lymph nodes, which do not meet CT criteria for pathologically enlargement. CXR [**2145-4-6**] IMPRESSION: 1. Improving airspace consolidation in the right lower lung field consistent with resolving pneumonia. 2. Small bilateral pleural effusions. Brief Hospital Course: Ms [**Known lastname **] was admitted through the emergency room on [**2145-3-31**] and taken to the operating room. She underwent an uncomplicated exploratory laparatomy for small bowel resection, jejunosotomy and lysis of adhesions, see op report for details. She was stabilized in the PACU, and transferred to SICU on POD#1. She was extubated, her pain was well controlled with morphine PCA, she remained NPO with NGT and foley catheter. She was initiated on Cefazolin/Flagyl x 24 hours. POD#2 she developed confusion and decreased oxygen saturation, requiring 3L nasal cannula. Narcotics were stopped, CXR and CT of chest were obtained and revealed right lower lobe pneumonia, see pertinent results for details. Vanc/Levo/Flagyl were initiated as well as an ID and medicine consult. She was transferred to SICU. POD#[**4-4**] she remained in SICU, her mental status and respiratory status improved. POD#4 her NGT was removed and she was transferred to [**Hospital Ward Name 121**] 9, she was weaned to room air. Her pain was well controlled with tylenol and small doses of oxycodone. POD#5 she reported flatus followed by multiple loose stools. Stool for C diff was negative. She was started on sips, and tolerated it easily. POD#6 she tolerated clear liquids but no longer wanted to take antibiotics due to frequent stools. CXR was repeated which showed resolving pneumonia. She tolerated a regular diet in the evening without difficulty. Infectious disease team recommended completion of 7 days of Levofloxacin. Clips were removed on POD#7, she was discharged home in stable condition with antibiotics, pain medication and all appropriate follow up appointments. Medications on Admission: Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume your home dose of trileptal Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*7 Tablet(s)* Refills:*0* Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume your home dose of trileptal Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Internal hernia with necrotic jejunum Pneumonia Discharge Condition: good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**11-15**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. If you have a problem with constipation, you should take a stool softener, Colace 100 mg twice daily as needed. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2145-4-20**] 2:00 You have an appointment to see Dr. [**Last Name (STitle) **] on Friday, [**2145-4-23**] at 3:30. Phone #: [**Telephone/Fax (1) 2723**]. Please see your primary care physician regarding follow up from your CT scan within 1 month. Your CT results and Discharge summary will be faxed to her. Completed by:[**2145-4-7**]

Admission Date: [**2162-5-16**] Discharge Date: [**2162-5-21**] Date of Birth: [**2101-7-30**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2162-5-17**]: CABGx4 LIMA-> LAD, RSVG-> Diagonal, Posterior Descending Artery, Obtuse marginal [**2162-5-19**]: Right Atrial lead placement History of Present Illness: 60yo man with known coronary disease (AMI in [**2143**] and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**2155**]). Doing well until last week when he developed angina initially with exertion then progressed to rest angina. Each episode was releived with SL NTG, no episode lasting more than 5 minutes. He presented to cardiologist for treatment. He was admitted to MWMC, a cardiac catheterization revealed 3 vessel disease. He was transferred to [**Hospital1 18**] for coronary bypass grafting. Cardiac Catheterization: Date: [**2162-5-11**] Place: MWMC -LAD- chronic total occlusion proximally(distal filling via collaterals) -RCA- chronic total occlusion of non-dominant RCA 90% -LCx- new complex 90% stenosis of prox LCx involving the bifurcation of the LCx proper and large OM2. Old stent in LCx is widely patent -mod LV systolic dysfx, with anterior, apical, and infero-apical AK and reduced EF 30% LVEDP 36mmHg No valvular dz Past Medical History: CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]) Cardiomyopathy- EF 35-45% depending on study Ventricular tachycardia s/p AICD [**8-/2155**] Atrial flutter s/p ablation [**8-/2155**] Hypertension Dyslipidemia Insulin dependent diabetes Mellitus Obesity Conduction disease-LAFB Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**] Left leg claudication Right thigh tumor s/p radiation and excision [**2141**]'s Social History: Race: caucasian Last Dental Exam: Lives with: wife Occupation: [**Name2 (NI) 56028**] owns company Tobacco: 2ppd x20 yrs quit [**2143**] ETOH: occaisional Family History: Father died 50yo cirrhosis, mother died 42yo MI Physical Exam: Pulse: 58 Resp: 16 O2 sat: 97%-RA B/P Right: 124/76 Left: Height: 5'[**62**]" Weight: 259 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema -none Varicosities: None [x]. Well healed right vein harvest site. Neuro: Grossly intact Pulses: Femoral Right: +2 Left:+2 DP Right:+2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit none Right: +2 Left:+2 Pertinent Results: [**2162-5-17**]: Prebypass The left atrium is dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the apex and septum. Overall left ventricular systolic function is mildly depressed (LVEF=30-35%). The estimated cardiac index is depressed (<2.0L/min/m2). Focal abnormalities are seen in the mid and apical anteroseptal wall, apical anterior wall, mid and apical inferoseptal wall, apical inferior wall. NO thrombus was seen in LV apex. Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened with focal calcification of the non-coronary cusp which moves poorly. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-3**]+) mitral regurgitation is seen. There is no mitral valve prolapse or flail segments. There is no pericardial effusion. Postbypass The patient is A-paced and on a phenylephrine infusion. Biventricular systolic function is unchanged. Mitral regurgitation remains mild-to-moderate. The thoracic aorta is intact post decannulation. [**2162-5-20**] 05:00AM BLOOD WBC-10.9 RBC-3.73* Hgb-11.2* Hct-31.7* MCV-85 MCH-30.1 MCHC-35.4* RDW-13.9 Plt Ct-114* [**2162-5-20**] 05:00AM BLOOD Glucose-151* UreaN-19 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-28 AnGap-11 [**2162-5-16**] 05:00PM BLOOD ALT-66* AST-55* LD(LDH)-206 AlkPhos-73 TotBili-0.3 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2162-5-17**] where the patient underwent Coronary artery bypass graft x 4. See operative note for details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The Electrophysiology team was consulted now due to non capturing atrial lead after permanent pacemaker was initially interrogated and epicardial wires were removed. Ventricular lead and ICD were functioning appropriately. The right atrial lead was revised on [**5-19**] without complication. He is to follow up the device clinic at [**Hospital1 **] in 2 weeks - operative note was given to patient to bring to follow up appointment. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Lisinopril was restarted for better blood pressure. The patient was transferred to the telemetry floor for further recovery. Chest tubes were discontinued without complication on post operative day 3. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the sternal and pacer pocket wound was healing and pain was controlled with oral analgesics. He is to continue on 1 week of antibiotics per EP s/p atrial lead placement. The patient was discharged home with VNA services in good condition with appropriate follow up instructions. All follow up appointments were arranged. Medications on Admission: Lisinopril 20' Atenolol 100' Vytorin [**10/2131**] QHS Fenofibrate 200' ASA 325' NTG-sl/PRN Insulin-NPH 22u QAM/24u QPM- followed by [**Last Name (un) **] Insulin- Humalog SS MVI Calcium 600' Plavix - last dose:[**2162-5-12**] Allergies: NKDA Discharge Medications: 1. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*1* 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*0* 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice a day: Take 22 units in AM and 24 units in PM. Disp:*QS 1 month * Refills:*0* 16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]),Cardiomyopathy- EF 35-45% Ventricular tachycardia s/p AICD [**8-/2155**], Atrial flutter s/p ablation [**8-/2155**], Hypertension, Dyslipidemia,Insulin dependent diabetes Mellitus, Obesity, Conduction disease-LAFB, Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**], Left leg claudication, Right thigh tumor s/p radiation and excision [**2141**]'s Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] on [**6-10**] at 1:45pm [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) 1295**] on [**6-14**] at 3:30pm EP [**Hospital 19721**] Clinic at [**Hospital1 **] in [**1-3**] weeks: Call for appointment - [**Telephone/Fax (1) 6256**] Wound check appointment in [**Hospital **] Medical office building [**Telephone/Fax (1) 170**] Date/Time:[**2162-5-26**] 12:00 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 27187**] in [**4-6**] weeks [**Telephone/Fax (1) 3658**] Follow up with [**Hospital **] [**Hospital 982**] Clinic to be arranged by patient **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2162-5-24**]

Admission Date: [**2177-8-29**] Discharge Date: [**2177-9-12**] Date of Birth: [**2156-2-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: Helmeted motocyclist who hit tree Major Surgical or Invasive Procedure: [**2177-8-29**] 1. Irrigation and debridement down to and inclusive of bone, right open femur fracture. 2. Retrograde intramedullary nailing with Synthes 11 x 360 nail. 3. Open reduction and internal fixation of patella fracture with K-wires and figure-of-8 tension band construct. [**2177-9-4**] Tracheostomy IVC filter [**2177-9-12**] PICC right bascilic vein History of Present Illness: 21 y.o. male helmeted moped rider who struck a tree with reported GCS of 6 on the scene. Patient was transported to OSH and noted to have a right sided open femur fracture. He received antibiotics and was intubated prior to transfer. Patient was transported and had radiographic studies performed that showed right femur fracture, SAH, grade II liver lac, pulmonary contusions, and small PTX. Patient reportedly received 1 unit of pRBCs in the ED and was placed into a traction splint on RLE. Past Medical History: None Social History: tobacco none ETOH none Family History: Non-contributory. Physical Exam: 96.9 130 150/97 20 100% intubated and sedated HEENT - L eye abrasions, pupils nonreactive bilaterally CTA b/l rapid HR, regular rhythm SNDNT pelvic fracture + palpable distal pulses Pertinent Results: [**2177-8-29**] 04:35AM BLOOD WBC-17.7* RBC-4.76 Hgb-15.2 Hct-45.5 MCV-96 MCH-32.0 MCHC-33.5 RDW-13.2 Plt Ct-314 [**2177-8-30**] 12:50AM BLOOD WBC-7.6 RBC-2.73* Hgb-9.0* Hct-25.0* MCV-92 MCH-32.8* MCHC-35.9* RDW-13.5 Plt Ct-188 [**2177-8-31**] 01:49AM BLOOD WBC-9.4 RBC-2.42* Hgb-7.8* Hct-21.7* MCV-89 MCH-32.1* MCHC-35.9* RDW-14.5 Plt Ct-148* [**2177-9-1**] 03:13AM BLOOD WBC-9.2 RBC-2.87* Hgb-9.0* Hct-25.6* MCV-90 MCH-31.6 MCHC-35.3* RDW-15.0 Plt Ct-128* [**2177-9-2**] 01:40AM BLOOD WBC-7.7 RBC-2.78* Hgb-8.8* Hct-24.6* MCV-88 MCH-31.5 MCHC-35.7* RDW-15.4 Plt Ct-164 [**2177-9-3**] 12:53AM BLOOD WBC-8.9 RBC-2.94* Hgb-9.3* Hct-26.2* MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-220 [**2177-9-4**] 01:08AM BLOOD WBC-7.7 RBC-2.99* Hgb-9.5* Hct-27.3* MCV-91 MCH-31.7 MCHC-34.7 RDW-15.5 Plt Ct-313 [**2177-9-5**] 02:32AM BLOOD WBC-8.4 RBC-2.91* Hgb-9.0* Hct-26.9* MCV-92 MCH-30.9 MCHC-33.5 RDW-15.6* Plt Ct-412 [**2177-9-6**] 01:58AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.0* Hct-26.5* MCV-93 MCH-31.6 MCHC-34.0 RDW-15.2 Plt Ct-418 [**2177-9-7**] 02:12AM BLOOD WBC-14.4* RBC-3.00* Hgb-9.3* Hct-27.6* MCV-92 MCH-30.9 MCHC-33.7 RDW-14.7 Plt Ct-556* [**2177-9-8**] 01:59AM BLOOD WBC-14.7* RBC-3.25* Hgb-10.0* Hct-29.7* MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-748* [**8-29**] CT head - Multiple foci of parenchymal hemorrhage as well as small amount of likely subarachnoid hemorrhage. The location of some of these foci at the [**Doctor Last Name 352**]-white matter interface is concerning for diffuse axonal injury CT Cspine - No fracture or traumatic malalignment in the cervical spine CT torso - Extensive pulmonary contusions, worse on the right than the left. Hepatic lacerations with a small amount of abdominal and pelvic free fluid of intermittent density. Bilateral rib fractures. Right femur/knee xrays - There is a mid shaft femoral fracture with mild varus angulation of the distal fragment relative to the proximal. There is also medial subluxation by ~ 1 cortical width. [**9-2**] MRI cspine - Edema in the interspinous ligaments from C3-C4 through C7-T1, without evidence of distraction. lobal central canal narrowing due to congenital short pedicles. This is slightly exacerbated by a disc bulge at C3-4. No cord signal abnormality. Moderate right C4-5 neural foramen narrowing due to uncovertebral osteophytes. [**9-3**] Bilateral LE LENIs - No deep venous thrombosis involving the right or left lower extremity. LUE LENI - No deep venous thrombosis in the left upper extremity. [**9-7**] CT Abdomen/Pelvis - Right pleural effusion with associated compressive atelectasis. Considerable improvement in the appearance of the right lobe of the liver laceration. Small amount of free fluid in the pelvis. Fractures of the left first and right fourth and fifth ribs. Fracture of the right transverse process of T1. Brief Hospital Course: The patient was admitted to the trauma ICU. [**8-29**] - Patient was admittd to the ICU. He was taken to the operation room with ortho for ORIF of his right femur (see operative report for full details). Neurosurgery was consulted and an ICP was placed. He was started on dilantin and q1 hour neurochecks. [**Date range (1) 58392**] - The patient was transfused 4u PRBC for a decreasing Hct. He had a right femur hematoma which was expanding but his limb was soft and there was no fear of compartment symdrome. His Hct stabilized. Head CT was stable. [**9-1**] - His ICP was discontinued and neurosurgery signed off. Head CT was stable. [**9-2**] - MR of head and c-spine were performed. [**9-3**] - Bilateral LE and LUE LENIs were performed which demonstrated no DVT. [**9-4**] - The patient went the OR with the acute care service for tracheostomy and IVC filter placement. [**9-6**] - Patient dc'ed his dophoff tube twice. [**9-7**] - A CT A/P was done because of persistent fevers and rising white count. No source for his fevers was identified. Patient was put to trach collar. [**9-8**]: Awake, off-versed, following commands. Passed S&S for regular diet and Passy [**Last Name (un) 87596**] Valve. BAL cultures grew MRSA, kept only on Vanc now. Patient ready to be transferred to floor, waiting for a bed. ` Following transfer to the Surgical floor he continued to make slow progress. His trach tube was plugged with a PMV and he tolerated it well. After confirming no aspiration by video swallow he was tolerating a regular diet with thin liquids. The Physical Therapy and Occupational Therapy services followed him on a daily basis to increase his mobility and increase cognitive abilities. His memory is decreased and he occasionally has some confusion but is improving each day. He has a PICC line placed on [**2177-9-12**] for IV antibiotics and will require Vancomycin thru [**2177-9-16**] for MRSA pneumonia. He has minimal secretions but is undergoing nebulizer treatments. Potentially his IVC filter can be removed but Dr. [**Last Name (STitle) **] will re evaluate in a few weeks therefore he will need to return to the [**Hospital 2536**] Clinic. He will also follow up in the Neuro cognitive clinic with Dr. [**First Name (STitle) **] following his discharge from rehab. After a lonfg hospitalization he was transferred to rehab on [**2177-9-12**] for further therapy with the goal to return home soon. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for temp > 101.5. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for abrasions. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg Intravenous every eight (8) hours: thru [**2177-9-16**]. 10. Morphine Concentrate 20 mg/mL Solution Sig: Fifteen (15) mg PO Q2H (every 2 hours) as needed for pain. 11. HYDROmorphone (Dilaudid) 1-2 mg IV Q2H:PRN pain Please use for breakthrough only after PO/NG MSIR. 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: S/P scooter v tree 1. Left eye abrasion 2. Rib fractures right [**5-5**], left 1 3. Bilat pulmonary contusions 4. Grade 2 liverlaceration 5. Open right femur fracture 6. Right thigh laceration 7. Right patellar fracture 8. Right metatarsal neck fracture [**3-7**] 9. Small SAH 10.Right TP fracture T1 11.[**Doctor First Name **] 12.Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital with multiple injuries following your accident including head trauma, rib fractures, knee fracture and liver laceration. * You have made alot of progress but will need further rehabilitation before you can return home. * You are now breathing well on your own with your trach tube plugged and hopefully it will be removed as you improve. * Continue to work with physical therapy to increase your mobility. Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 1 month, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**3-5**] weeks Call the Vascular Surgery Clinic at [**Telephone/Fax (1) 1237**] for an appointment in 2 weeks with Dr. [**Last Name (STitle) **]. Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up appointment in 6 weeks with Dr. [**First Name (STitle) **]. You will need a Head CT prior to your appointment. The secretary can book that for you. Call Dr. [**First Name (STitle) **] in the Neuro cognitive Clinic at [**Telephone/Fax (1) 1690**] for an appointment after your discharge from rehab Completed by:[**2177-9-12**]

Admission Date: [**2177-3-12**] Discharge Date: [**2177-3-22**] Date of Birth: [**2109-6-26**] Sex: M Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 1505**] Chief Complaint: exertional angina Major Surgical or Invasive Procedure: [**2177-3-14**] Coronary ARTERY BYPASS GRAFTING x3 with: Left Internal Mammary Artery to Left Anterior Descending Artery, Saphenous Vein Graft to Obtuse Marginal Artery, Saphenous Vein Graft to Posterior Descending Artery History of Present Illness: 67 year old man with known coronary artery disease-s/p stents x 6(2004x5 and [**11-21**]) who developed exertional angina while walking [**3-9**]. Angina resolved w/ rest after few minutes. Angina recurred [**3-11**], patient was brought to [**Hospital **] Med Ctr where enzymes were negative. He had cardiac catheterization which showed: tapering distal LM,70% osteal LAD,90% mid RCA. LVEF 60% by LVgram. He was then transferred to [**Hospital1 18**] for surgical management of his coronary artery disease. At the time of transfer he was pain free. Past Medical History: Coronary artery disease(PCI/stents x6), Hypertension, HYPERCHOLESTEROLEMIA, CA- Left vocal cord(RT/chemo)[**3-20**] PSH:Left knee arthroscopy, Left chest Portacath Social History: Works as administrator at [**University/College 33918**]. Married, 2 children. Tob: Former smoker, quit 30 yrs ago. ETOH: Drinks a few beers or cocktails per night. No drugs Family History: Brother: MI at 60, uncle: MI at 50 Mother: htn Physical Exam: Pulse: Resp: O2 sat: B/P Right:130/72 Left: 128/72 Height: 70" Weight:175# General:WDWN, NAD Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x]glasses Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur n Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:n Left:n Pertinent Results: Admission Labs: [**2177-3-12**] 04:05PM PT-11.7 PTT-23.8 INR(PT)-1.0 [**2177-3-12**] 04:05PM PLT COUNT-199 [**2177-3-12**] 04:05PM NEUTS-78.7* LYMPHS-9.6* MONOS-5.6 EOS-5.6* BASOS-0.5 [**2177-3-12**] 04:05PM WBC-6.9 RBC-3.93* HGB-14.0 HCT-38.2* MCV-97# MCH-35.6* MCHC-36.6* RDW-13.5 [**2177-3-12**] 04:05PM %HbA1c-5.2 eAG-103 [**2177-3-12**] 04:05PM ALBUMIN-4.1 MAGNESIUM-1.7 [**2177-3-12**] 04:05PM ALT(SGPT)-36 AST(SGOT)-24 LD(LDH)-148 ALK PHOS-100 TOT BILI-2.0* [**2177-3-12**] 04:05PM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-137 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [**2177-3-12**] 04:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2177-3-12**] 04:33PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 Discharge Labs: Radiology Report CHEST (PORTABLE AP) Study Date of [**2177-3-17**] 7:29 AM Final Report: Comparison with study of [**3-15**], all of the monitoring and support devices have been removed except for the left subclavian catheter and the right IJ sheath. With the chest tube removed, there is no evidence of pneumothorax. Residual opacification at the left base is consistent with atelectasis and effusion. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Borderline normal RV systolic function. AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: No MS. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions Focused Intraoperative TEE during chest exploration for post-operative bleeding. Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Borderline normal RV free wall function. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. Brief Hospital Course: Mr [**Known lastname 732**] was transferred fro [**Hospital **] Med Ctr for surgical management of his coronary artery disease. After the usual pre-operative workup he was brought to the operating room for coronary artery bypass grafting on [**2177-3-14**]. Please see the operative report for details. In summmary he had: Coronary Artery Bypass Grafting x3 with Lwft Internal Mammary Artery to Left Anterior Descending Artery, Saphenous Vein Graft to Obtuse Marginal Artery, and Saphenous Vein Graft to Posterior Descending Artery. His cardiopulmonary bypass time was 51 minutes with a crossclamp time of 39 minutes. He tolerated the operation well and post-operatively was transferred to the cardiac surgery ICU in stable conditio. He remained hemodynamically stable in the immediate post-op period. He woke from anesthesia neurologically intact and was extubated on the operative day. On POD1 he continued to have significant drainage from his chest tubes and was brought back to the operating room for mediastinal exploration-no source of bleeding was found. He tolerated this procedure well and was again returned to the cardiac surgery ICU in stable condition. He recovered from anesthesia and was extubated shortly after the surgery was completed. He remained hemodynamically stable throughout this period. All tubes lines and drains were removed per cardiac surgery protocol. On POD 3 he was transferred from the ICU to the stepdown floor for continued post-op care and recovery. Physical therapy worked with the patient to advance his activities of daily living and to improve strength and endurance. POD # 4, Pt develope some drainage from his sternal incision. He was started on IV Vancomycin. Betadine was cleanse TID was started. from POD # [**4-19**], pts wound improved. He is to be discharged on PO keflex x 10 days. His wound on DC is without drainage. On POD 10 was discharged home with visiting nurses. He is to follow up with Dr [**Last Name (STitle) **] in 3 weeks, He has a sternal check [**3-26**] on [**Hospital Ward Name **] 6. He is to follow up with his cardiologist, appt made, He was also instructed to follow up with his PCP. Medications on Admission: Lisinopril 20mg daily, Lipitor 80mg daily, Plavix 75 mg [**Last Name (LF) **], [**First Name3 (LF) **] 325mg daily, Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. [**Last Name (un) 1724**] Lisinopril 20mg daily,EcASA 325mg daily,Lopressor 25mg [**Hospital1 **],Plavix 75mg daily,NTG prn,Lipitor 80mg daily 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. potassium chloride 8 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day for 7 days. Disp:*14 Tablet Extended Release(s)* Refills:*0* 9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Disp:*40 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Bypass Grafting x3 PCI/stents(6) PMH: Hypertension, HYPERCHOLESTEROLEMIA, CA- left vocal cord(RT/chemo)[**3-20**] PSH:lt knee arthroscopy, LT chest Portacath Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] on [**2177-4-10**] at 9AM at [**Hospital1 **] Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] on [**2177-4-16**] at 3PM Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) 488**] J. [**Telephone/Fax (1) 8036**] in [**4-15**] weeks You have a wound check scheduled for [**5-26**] at 1000 hrs, please come to [**Hospital Ward Name **] 6 at this scheduled time. Thw midlevelers will look at your wound to see if this is stable. **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication Goal INR First draw Results to phone fax Completed by:[**2177-3-22**]

Admission Date: [**2188-5-24**] Discharge Date: [**2188-5-30**] Date of Birth: [**2132-11-19**] Sex: M Service: MEDICINE Allergies: Ampicillin / Thorazine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Trach change Mechanical ventilation History of Present Illness: Mr. [**Known lastname 89172**] is a 55 yo man with PMH significant for Downs Syndrome, MRSA pneumonia and respiratory failure in [**10/2187**] resulting in tracheostomy which was reversed [**2188-5-13**], who is transferred from s/p intubation at [**Hospital1 **] in [**Location (un) 1110**] today. Patient had been predominantly in rehab since developing MRSA pneumonia in [**10/2187**] (first [**Last Name (un) **] and then [**Hospital 5279**] Rehab Centers) and presented to [**Hospital1 **] from rehab for respiratory distress. He had been started on Rocephin [**5-22**] for presumed pneumonia at Rehab in setting of labored breathing. Patient was intubated at [**Hospital1 **] for labored breathing, accessory muscle use. Per report, there may have been some failed attempt in OSH ED to re-open his tracheostomy prior to intubation. . At OSH, patient received, levoquin 750mg @ 03:25, Vancomycin 1g @ 5:09 for pneumonia. He was ordered for 4L NS and received at least 2.5L. CXR and CT Chest appeared to show some fluid overload. Patient was difficult to maintain on sedation; blood pressure dropped on propofol, so patient was briefly on dopamine until sedation was switched to versed boluses prn, which he tolerated well. Trach site had some serosanguinous fluid leakage, so it was covered with guaze and tegaderm. Respiratory therapist in ED confirmed no air leakage while on the ventilator. Patient was transfered to [**Hospital1 18**] for further management. . In ED, initial VS were as follows: 99.9 (Rectal temp) 101 174/100 22 98% on ventilator with 100%FiO2. He was given 1amp D50 for a blood sugar of 69. He also received 250cc of IVF and 2.5mg bolus of IV versed for sedation while ventilated. EKG showed sinus tach with rate 103. CXR showed fluid overload with possible consolidation, so CTA of chest was done to further characterize ?consolidation and rule out PE. CTA showed no signs of PE and confirmed RUL and RML pneumonia, as well as fluid filled esophagus, suggesting aspiration. CT also showed moderate left and small right effusions, but no pulmonary edema. Vitals in ED prior to transfer to ICU were as follows: 99.8F HR 91 BP 92/53 RR 16 O2sat100% cpap FIO2 60%, PS 10, PEEP 5. . On arrival to the unit, patient is mechanically ventilated and appears comfortable. He is accompanied by his sister who was able to corroborate the above story. Of note, the patient is non-verbal at baseline but does make some signs, only eats icecream and [**Last Name (un) **] tea by mouth (for pleasure) and is otherwise fed through tube feeds. . Past Medical History: - Downs Syndrome - MRSA Pneumonia complicated by tracheostomy [**10/2187**] - reversed [**2188-5-13**] - C Diff Colitis - [**2188**] - Pseudomonas Colitis - [**2188**] - dx by colonoscopy, tx w cipro through G-tube - Adrenal Insufficiency - Seizure History, per sister this [**Name2 (NI) 89173**] with hospitalization in [**11-3**] - on keppra - Hx transaminitis - presumed to be secondary to antiepileptics - Hx of HBV - Membranoproliferative Glomerulonephritis Social History: Lives at Group Home, but has spent significant amount of time at Rehab since [**10/2187**] and presented from [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **]. [**Last Name (NamePattern1) 6961**] are his guardians, but his sister [**Name (NI) **] is also very involved in his care and finances. Family History: NC Physical Exam: ADMISSION EXAM: GEN: Comfortable appearing, opens eyes to command HEENT: ETT in place. NECK: Tegaderm placed over anterior neck; difficult to assess opening in skin. No drainage or erythema. CV: RRR, no murmur LUNGS: Rhonchi anteriorly R>L, CTAB laterally on both sides ABD: Soft, non-tender but distended. Central G-tube covered with gauze with tube feeds draining around opening. Ostomy erythematous, raw. No erythema on surrounding skin. EXT: LE cachectic, No LE edema. DISCHARGE EXAM: GEN: Comfortable appearing, opens eyes to command, not in distress HEENT/Neck: EOMI, trach in place with sputum surrounding, mild erythema around site CV: RRR, no murmur LUNGS: Rhonchi anteriorly, CTAB laterally on both sides ABD: Soft, non-tender but distended. Central G-tube covered with gauze. Mildly erythematous around opening. EXT: LE cachectic, No LE edema. Pertinent Results: ADMISSION LABS: . [**2188-5-24**] 11:50AM PT-18.8* PTT-31.4 INR(PT)-1.7* [**2188-5-24**] 11:50AM URINE RBC-28* WBC-7* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 [**2188-5-24**] 11:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2188-5-24**] 11:50AM WBC-11.7* RBC-2.84* HGB-10.5* HCT-31.6* MCV-111* MCH-37.1* MCHC-33.4 RDW-18.9* [**2188-5-24**] 11:50AM GLUCOSE-69* UREA N-54* CREAT-1.0 SODIUM-136 POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-10 [**2188-5-24**] 12:00PM LACTATE-2.0 . DISCHARGE LABS: . [**2188-5-30**] 03:56AM BLOOD WBC-8.1 RBC-2.32* Hgb-8.9* Hct-26.7* MCV-115* MCH-38.5* MCHC-33.5 RDW-17.4* Plt Ct-130* [**2188-5-30**] 03:56AM BLOOD Glucose-83 UreaN-29* Creat-1.1 Na-135 K-3.7 Cl-108 HCO3-24 AnGap-7* [**2188-5-30**] 03:56AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.5* [**2188-5-30**] 03:56AM BLOOD Vanco-25.0* . MICRO: C. diff negative Urine culture - no growth Blood culture x2 - no growth to date IMAGING: CXR [**2188-5-24**]: 1. Endotracheal tube terminating at the carina. 2. Mild pulmonary interstitial edema. 3. Right upper zone opacity may reflect aspiration pneumonitis or developing pneumonia. CT-A [**2188-5-24**]: IMPRESSION: 1. RUL and RML pneumonia, possible due to aspiration since the esophagus is fluid filled and dilated. 2. No PE. 3. Moderate left and small right effusions, but no pulmonary edema. 4. Mediastinal lymphadenopathy 5. Acute left 7th rib fracture. G/GJ/GI TUBE CHECK FINDINGS: Supine radiographs demonstrate jejunostomy tube with tip at the junction of the distal duodenum or proximal jejunum. Contrast is seen passing distally in the jejunum without evidence of leak. Bowel gas pattern is normal without evidence of leak. Imaged portion of the lungs are clear. Surgical clips are noted overlying the base of the heart. IMPRESSION: Jejunostomy tube in appropriate position with normal passage of contrast without evidence of leak. Brief Hospital Course: 55M with hx of Downs Syndrome, MRSA pneumonia c/b respiratory failure and tracheostomy, s/p tracheostomy reversal 10d prior to admission, transferred to [**Hospital1 18**] for hypoxic respiratory failure [**2-27**] RUL/RML aspiration PNA . # Aspiration PNA/respiratory distress: PE was ruled out as potential cause of respiratory distress. Imaging demonstrated RUL/RML pneumonia secondary to aspiration, as well as airway narrowing at site of prior tracheostomy. Likely secondary to aspiration, as patient was also noted to have fluid filled esophagus on CT scan. Patient was treated with hospital acquired and community acquired pneumonia with Vancomycin, Levoquin and Cefepime (8-day course). Cultures of urine and blood from OSH showed no growth. Aspiration may have been related to overflow at g-tube site. Tube feeds were initially held, and G tube study was ordered which showed jejunostomy tube in appropriate position with normal passage of contrast without evidence of leak. Patient on steroids at home for adrenal insufficiency, was not on PCP prophylaxis at home so bactrim daily was started. Patient was arranged to be transferred to [**Hospital Ward Name 517**] ICU service for extubation and potential IP intervention at site of airway narrowing. IP found an 0.8 cm focal area of stenosis with dynamic collapse at 2nd tracheal ring. The granulation tissue was debrided and IP replaced percutaneous trach through existing stoma. Patient will need evaluation for tracheal resection/reconstruction at IP o/p f/u in 2 weeks. Post-procedure CXR showed multifocal PNA, unchanged bilateral effusions, trach in appropriate position. Patient remained stable with new trach in place and did well prior to discharge. His last day of levaquin and cefepime will be on [**2188-5-31**]. . # Recent history of colitis: Reported recent history of both C.diff and Pseudomembranous colitis. Patient with with several episodes of lose stool. C. diff was checked and was negative. . # Down syndrome/Anxiety: At baseline, pt nonverbal. Pt was restarted on home dose of ativan given evidence of anxiety and aggitation w/groups of people while intubated. . # Adrenal Insufficiency: History unclear but patient currently on prednisone 20 daily - patient has not had outpatient endocrine evaluation. As per [**Hospital 228**] rehab facility steroids were started to treat low sodium. Patient currently with normal blood pressures. Steroid dose tapered to 10mg daily for 1 week with outpatient follow up of electrolytes. Patient started on PCP prophylaxis, which he should remain on if he is going to continue steroids long term. Patient will follow-up with endocrinology for further work-up of possible renal insufficiency. OSH records were faxed to endocrinology department when appointment was made. . # Hx of seizure disorder: Reportedly first seizure [**11-3**] at time of hospitalization with MRSA pneumonia. Continued home dose of Keppra. . #FEN: Concern for leaking at J tube site. Tube feeds were held as concern for leaking at feeding tube. Surgery was consulted and sutured the tube in place with clamp. Dressing in place over tube site. . # Prophylaxis: SubQ heparin, Famotidine . # Contact: [**Name (NI) 6961**] = guardians, [**Name (NI) 449**] and [**Name (NI) **] ([**0-0-**]), Sister [**Name (NI) **] [**Telephone/Fax (1) 89174**]. . # Code Status: FULL CODE (Confirmed with family) Medications on Admission: Prednisone 20mg daily Omeprazole 20mg [**Hospital1 **] Keppra 500mg [**Hospital1 **] (do not crush) Ativan 0.25-0.5mg via PEG Q8h PRN (for moderate to severe anxiety) Duonebs prn wheezing oxycodone Zinc Bacitracin ointment Bowel Regimen prn Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 1110**] Discharge Diagnosis: Primary diagnosis: Subglottic stenosis Hosptial acquired pneumonia . Secondary diagnoses: ? Adrenal insufficiency Down's syndrome Seizure disorder Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Mental Status: Confused - sometimes. (baseline) Discharge Instructions: It was a pleasure to participate in your care Mr. [**Known lastname 89172**]. You were admitted to [**Hospital1 18**] for evaluation of respiratory failure. You were found to have narrowing of your trachea. You were taken to the OR to have a procedure to replace tracheostomy. You were also treated for a pneumonia. . There was concern for your G tube not working appropriately. Surgery evaluated you and fixed your J tube. . You were started on steroids at your outpatient facility as you had low sodium. We decreased your dose of steroid and started you on Bactrim to prevent a type of lung infection called PCP. [**Name10 (NameIs) **] will have you follow-up with endocrinology here to further evaluate if you need to take steroids. . MEDICATION CHANGES: START Cefepime 2gm Q24 for one more day START Levofloxacin 750mg daily for one more day START Bactrim SS daily for prophylaxis for PCP DECREASE Prednisone to 10mg daily Followup Instructions: Department: Thoracic Multi [**Hospital 4094**] Clinic When: TUESDAY [**2188-6-10**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Thoracic Multi [**Hospital 4094**] Clinic When: TUESDAY [**2188-6-10**] at 3:00 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES - Endocrinology When: WEDNESDAY [**2188-6-11**] at 3:15 PM With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2188-6-10**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2188-6-10**] at 3:00 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2188-6-11**] at 3:15 PM With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2188-5-30**]

Admission Date: [**2176-8-29**] Discharge Date: [**2176-9-6**] Date of Birth: [**2121-2-13**] Sex: M Service: MEDICINE Allergies: Penicillins / Keflex Attending:[**First Name3 (LF) 1928**] Chief Complaint: Upper extremity weakness Major Surgical or Invasive Procedure: C5-C6 anterior cervical decompression and fusion, C1 tumor removal History of Present Illness: 55-year-old man with diabetes mellitus type 2, hypertension, severe peripheral [**First Name3 (LF) 1106**] disease s/p R SFA stent angioplasty and L SFA stent placement, congenital pulmonic valve stenosis, CAD s/p BMS stents, diastolic CHF, atrial fibrillation s/p ablation on warfarin, stage 3 diabetic nephropathy, intradural tumor compressing his spinal cord at C1/C2, who was admitted on [**2176-8-29**] to neurosurgery for anterior cervical decompression at C5/6 fusion ([**8-29**]) and extradural tumor removal of C1 intradural tumor ([**8-30**]). The patient was post-operatively managed in the ICU with a dexamethasone taper. He developed a small subdural hematoma ([**8-30**]) with no new neurologic symptom. Aspirin and heparin SC were restarted. Clopidogrel, for L SFA stent, is scheduled to be restarted on POD#5, [**2176-9-4**], and warfarin, for atrial fibrillation, to be restarted on [**2176-9-9**]. Patient was extubated on [**9-1**], and is coming off a furosemide drip for dCHF. [**Month/Day (4) **] is following the patient for a mottled right foot and his recent [**Month/Day (4) 1106**] procedures. Patient's other medical issues diabetes, HTN, CKD (Cr 1.1), atrial fibrillation (HRs 70s-80s), CAD s/p stent and "chronic hyponatremia" (Na 138) have been stable. Transfer is requested for ongoing management of diastolic CHF. On evaluation in the SICU before transfer, patient was sleeping but arousable, complaining of old back pain and of constipation. Vital signs were stable with O2 saturation 98% on 3L. Past Medical History: (1) Type 2 diabetes mellitus, requiring insulin, and the complications from years of poor glycemic control: -hypertension -severe peripheral [**Month/Day (4) 1106**] disease -peripheral neuropathy -pressure, venous stasis, and neuropathic ulcers on his right and left lower extremities -stage 3 diabetic nephropathy -renal insufficiency (baseline creatinine 1.5 to 1.7) (2) Atrial fibrillation status post ablation [**2169**] and [**2174**], on coumadin (3) Congenital pulmonic valve stenosis status post two childhood surgeries -history of RV failure -history of peripheral edema and anasarca (4) Chronic hyponatremia (5) Chronic low back pain status post car accident (6) Spinal cord meningioma compressing his spinal cord at C1/C2 (7) COPD (8) Coronary artery disease status post stenting [**2169**] (bare metal stent by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] ([**Telephone/Fax (1) 8725**])) and repeat stenting at [**Hospital1 18**] in [**2174**] (bare metal stent - see d/c summary [**2175-2-7**]) (9) MI in [**2161**] Social History: The patient is married and has two adult sons who do not live at home. He lives in [**Hospital1 1474**], MA. His wife works 60 hours a week, and he is left at home for most of the day. He has been bedbound for several years. A visiting nurse can only come once a week to change the dressings on his lower extremity ulcers. His sons struggle with alcoholism and heroin abuse. His younger son has recently threatened suicide and homicide (against the patient's wife), a source of much stress at home. He used to work as a "bouncer" and in construction, and enjoyed riding his motorcycle. The patient says he tries to keep a positive attitude about his condition. He says he feels depressed, but says he is not interested in therapy or medication for depression. He has not seen his primary care physician [**Last Name (NamePattern4) **] 2 years because he will only travel in an ambulance but his PCP's office is in touch with the patient and wife weekly. -[**Name2 (NI) **] has a 2 pack per year smoking history for "several years" -He drinks alcohol occasionally, and has never had a problem with alcoholism -He denies recreational or IV drug use Family History: Heart disease in unspecificed family members. Physical Exam: Physical exam on admission: Gen: obese, deconditioned, pain with movement of extremities. Extrem: B LE edema Neuro: Mental status: Awake and alert, cooperative with exam. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Motor: Patient with severe bilateral wasting of muscles of hand. UE's: FI's:[**2-1**] WE 4+/5 Grip 4+/5 Bi4+/5 Tri 4+/5. RLE: [**1-4**] PF/DF 0/5 LLE: IP3/5 PF/DF 0/5 Pertinent Results: [**2176-8-29**] 12:10PM GLUCOSE-94 UREA N-42* CREAT-1.2 SODIUM-133 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14 [**2176-8-29**] 12:10PM estGFR-Using this [**2176-8-29**] 12:10PM WBC-7.6 RBC-3.91* HGB-9.7* HCT-30.5* MCV-78* MCH-24.9* MCHC-31.9 RDW-13.6 [**2176-8-29**] 12:10PM PLT COUNT-206 IMAGING STUDIES: # C-spine Xray [**8-29**]: Single lateral view of the cervical spine obtained portably in the OR, labeled #1. C1 through the C4/5 disc space is visualized. The C5 vertebral body is faintly seen -- bony structures lower than this are obscured by overlying soft tissues. However, surgical markers are seen overlying the anterior aspects of the C4-5 and C5-6 disc spaces, from an anterior approach. Support tubing and temperature probles noted. # C-spine CT [**2176-8-29**]: 1. New interval C5-C6 anterior fusion with intervertebral disc spacer, no immediate hardware complication. Post-surgical changes in the soft tissue with subcutaneous emphysema mostly in the right submandibular region. 2. Mass at C1 level with associated cord compression consistent with known meningioma better described on recent MRI. 3. Soft tissue thickening at the right lung apex, not fully characterized on the current CT. In comparison with CT neck from [**2176-8-9**], it has increased in size. CT chest is recommended to evaluate this further, if clinically warranted. # Head CT [**2176-8-30**]: 1. New interval left frontal subdural hyperdense extra-axial fluid collection with new interval subdural subfalcine extra-axial hyperdense fluid collection, indicating subdural hemorrhage, likely post-surgical but clinical correlation recommended. 2. Pneumocephalus with distribution at the basilar cisterns, mostly at the left sylvian fissure, and bifrontally at the falx, likely post-surgical, and additionally in the posterior fossa near the site of the occipital craniotomy. 3. Post-surgical changes with left craniotomy at the occipital bone and laminectomy at C1 with subcutaneous emphysema and hyperdense products, likely post-surgical. 4. Soft tissue hyperdensity at the posterior parietal, occipital soft tissue region, could be small post-surgical hematoma. . # C-spine MRI [**2176-8-31**]: Status post resection of C1 extradural tumor, likely meningioma with expectorated postoperative changes. No large intraspinal hematoma seen. There remains some persistent narrowing of the spinal canal at C1 level with indentation on the posterior aspect of the spinal cord. Continued followup recommended. Mild spinal cord atrophy could be secondary to chronic myelomalacia. . # LE arterial Duplex [**2176-9-3**]: The peak systolic velocity involving the native right common femoral artery is 104 cm/sec. Velocities within the superficial femoral artery range from 85 to 234 cm/sec and that within the popliteal artery on the right, is 25 cm/sec. On the left, peak systolic velocity within the common femoral artery is 132 cm/sec, SFA, velocities range from 146-75 cm/sec and that within the popliteal artery is 85 cm/sec. IMPRESSION: Findings as stated above which indicate widely patent common femoral, superficial femoral and popliteal arteries bilaterally. . PATHOLOGY: # C1 tumor [**2176-8-30**]: Cervical medullary junction tumor: Meningioma, psammomatous subtype (WHO Grade I). The tumor is composed of meningothelial cells with numerous psammoma bodies and collagen deposition with no typical features or mitotic activity. Brief Hospital Course: 55-year-old man with diabetes mellitus type 2, severe peripheral [**Month/Day/Year 1106**] disease, CAD, diastolic CHF, atrial fibrillation, presented for planned anterior cervical decompression at C5-6 and removal of C1 meningioma. # Cervical myelopathy and meningioma: Patient underwent anterior cervical decompression and C5/6 fusion on [**2176-8-29**] and removal of C1 meningioma on [**2176-8-30**]. The patient was post-operatively managed in the ICU with a dexamethasone taper. He developed a small subdural hematoma on [**2176-8-30**] with no new neurologic symptom. Per neurosurgery recommendations, aspirin and heparin SC were restarted. Clopidogrel, for recent left SFA stent, was restarted on POD#5, [**2176-9-4**], and warfarin, for atrial fibrillation, is to be restarted on [**2176-9-9**]. Of note, there was some concern that he had developed LE weakness after his procedure, but after re-evaluation with the neurosurgery team they felt that his strength in his legs were his baseline and this was not a change. He continued to work with PT during his hospitalization. # Diastolic heart failure: The patient experienced an acute exacerbation of his diastolic heart failure likely secondary to significant fluid administration during surgery. He was placed on a furosemide gtt in the SICU, which was transitioned to his home dose of lasix on the floor. At discharge he was slightly under his admission weight of 115kg with O2 sats in the mid 90's on room air. # Peripheral [**Date Range **] disease. The patient recently underwent bilateral SFA angioplasties and Left SFA stenting. In preparation for his neurosurgery, the plavix was held pre-procedure and was subsequently re-started on [**2176-9-4**]. He underwent bilateral arterial ultrasound on [**2176-9-3**] which demonstrated patent SFA and femoral arteries. # Atrial fibrillation: The patient was not in atrial fibrillation during his hospitalization. Given his need for neurosurgery his coumadin was held. It is scheduled to be restarted 10 days post-procedure ([**2176-9-9**]). He was well rate controlled at the time of discharge. # DM II. The patient's insulin regimin was adjusted to 50 units of insulin glargine nightly with humalog insulin sliding scale and achieved good control of his blood sugars (FSBS 100-180). # Pressure ulcers. The patient has a 2x2cm right heel full thickness ulcer that was without odor or drainage. A right dorsum small 1x1cm partial thickness ulcer. Wound care nursing consult was obtained. Pressure ulcer care was performed by repositioning, skin cleansing and conditioner application, and cover with ABD and kerlex. # Coping. The pt expressed to some staff members that his mood was poor and he was not coping well after his surgery. He never expressed suicidal ideations. He further expressed that he was extremely frustrated with his hospitalization and his inability to walk and function independently. Discussed the possibility of talking to psychiatrists in the hospital, but he declined. He felt that if these feeling persisted he would pursue further psychiatric care. A number for psychiatric services was provided to him on discharge. # Chronic pain syndrome: The patient was continued on his home regimen of dilaudid 4mg PO Q3H:prn # Chronic hyponatremia. The patient had a history of chronic hyponatremia although his sodium remained between 130-140 during this admission. Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID: PRN as needed for constipation. 2. Furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection [**Hospital1 **] (2 times a day): Hold for SBP<100. 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100 or HR<60. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 8. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily): Please apply to leg wounds per wound care orders. thank you! . 9. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation q6H: PRN as needed for shortness of breath or wheezing. 11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain: Hold for RR<12 or sedation. 12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO q6H: PRN as needed for itching. 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) g PO BID: PRN as needed for constipation. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: hold for diarrhea. 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 18. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for dry mouth, sore throat. 19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Please apply to upper forehead and scalp for seborrheic dermatitis (day 1 = [**2176-8-11**]). Also, please apply to wound on left shin for overlying fungal infection(day 1 = [**2176-8-15**]). Thank you! . 20. Glycerin (Adult) Suppository Sig: One (1) Suppository Rectal PRN (as needed) as needed for constipation. 21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for headache: Hold for somnolence. 22. Heparin drip Heparin IV Sliding Scale (please see included scale): Diagnosis: DVT/A-fib, Patient Weight: 114.76 kg, Initial Bolus: 0 units IVP, Initial Infusion Rate: 1450 units/hr, Target PTT: 60 - 100 seconds, . PTT <40: 4600 units Bolus then Increase infusion rate by 450 units/hr, PTT 40 - 59: 2300 units Bolus then Increase infusion rate by 250 units/hr, PTT 60 - 100*:, PTT 101 - 120: Reduce infusion rate by 250 units/hr, PTT >120: Hold 60 mins then Reduce infusion rate by 450 units/hr, 23. Insulin sliding scale Glargine 46 units at bedtime; Humalog sliding scale per included sliding scale. Discharge Medications: 1. Hydroxyzine HCl 25 mg/mL Solution Sig: One (1) Intramuscular Q6H (every 6 hours) as needed for pruritis. 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4 hours). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-1**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO Q3hr:prn. 13. simvistatin 10mg Qday 14. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily). 15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 16. Outpatient Lab Work Chem 10 to monitor electrolytes and creatinine while taking lasix 17. Turn and reposition off back prn and limit sit time to 1hour at a time using pressure redistribution cushion. Cleanse skin with wound cleanser or NS then pat dry nad apply aquafor to gluteals and legs and feet daily 18. For heel and lateral foot ulcer apply thin layer of duoderm wound gel, cover dorsum and lateral wound with adaptic and heel with gauze followed by ABD pad, wrap iwth kerlix and change daily 19. headrest to occiput with frequent repositioning 20. please remove sutures from posterior neck on tuesday [**9-10**] [**2175**] 21. Please start warfarin on [**2176-9-9**] (post op day 10) and monitor INR prn 22. check weight Qday Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Cervical myelopathy C1 tumor with cervical myelopathy Acute on chronic diastolic heart failure Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to [**Hospital1 18**] on [**2176-8-29**] for worsening upper extremity weakness due to your spinal tumor. You underwent an operation to remove the tumor. You also underwent an operation to decrease the pressure on the spinal cord in your neck. You will need to have the staples out from your surgical site on [**2176-9-10**], which they will do at your rehab facility. An appointment was made for you to follow up with Dr. [**Last Name (STitle) **] in 6 weeks. Please return to the Emergency department for fever, chills, difficulty breathing, worsening upper extremity weakness, or worsening symptoms. Followup Instructions: 1. [**Last Name (STitle) **] LAB [**Hospital1 18**] [**Hospital Unit Name **], [**Location (un) **] [**Location (un) **] surgery Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2176-9-26**] 3:15 2 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD LM [**Hospital Unit Name **], [**Location (un) **] [**Location (un) **] surgery Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2176-9-26**] 4:15 3. Dr. [**Last Name (STitle) 47032**] [**Name (STitle) **] address: [**Doctor First Name **] [**Hospital Unit Name **] [**Location (un) 470**] [**Hospital Unit Name **] phone: [**Telephone/Fax (1) **] appointment: [**2176-10-8**] 1:15PM 4. Psychiatry Clinic [**Hospital1 18**] Psychiatry Clinic Please call the bottom number to schedule an appointment if your mood is sad or you are not taking pleasure in life: [**Telephone/Fax (1) **]

Admission Date: [**2138-6-9**] Discharge Date: [**2138-6-12**] Date of Birth: [**2111-2-28**] Sex: M Service: Cardiothoracic Surgery PREOPERATIVE DIAGNOSIS: 1. Bicuspid aortic valve. 2. Dilated aorta. 3. Aortic insufficiency. HISTORY OF PRESENT ILLNESS: The patient has had a heart murmur since childhood and found to have a bicuspid aortic valve on echocardiogram, and recently had an increase in the size of the ascending aorta. Otherwise, the patient denies any other medical problems. [**Name (NI) **] did have surgery in [**2124**] for an undescended testicle. SOCIAL HISTORY: Denies a smoking history. Occasional alcohol, maybe once per week. FAMILY HISTORY: Noncontributory. MEDICATIONS ON ADMISSION: Prophylactic antibiotics. ALLERGIES: No known drug allergies. LABORATORY ON ADMISSION: Preoperative vital signs were a heart rate of 78, blood pressure 102/68, respiratory rate of 18. He was a healthy, 27-year-old male. Lungs were clear. Heart had a 3/6 systolic ejection murmur. Otherwise, the examination was within normal limits. HOSPITAL COURSE: So, on [**2138-6-9**], the patient underwent homograft aortic root replacement, resection, and grafting proximal aortic arch. He underwent general anesthesia. There were no intraoperative complications. Postoperatively, the patient was transferred to the recovery room on a nitroglycerin drip in normal sinus rhythm. He was transferred from the recovery room to the Intensive Care Unit, and on postoperative day one was transferred to the floor, where he continued with an uncomplicated postoperative course. The patient did experience some tachycardia with a heart rate of around 117. For this tachycardia the patient's beta blockers were increased, and he did respond. His beta blockers were increased to 75 mg p.o. b.i.d. Potassium was repleted. The patient was diuresing about 4 liters per day. The patient had very good pain control. He was ambulating around the halls without difficulty on his own. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home with prescription. No services needed. MEDICATIONS ON DISCHARGE: 1. Lopressor 75 mg p.o. b.i.d. 2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 40 mEq p.o. q.d. times five days. 3. Iron sulfate 325 mg p.o. t.i.d. 4. Percocet 5 one to two tablets p.o. q.6h. p.r.n. 5. Aspirin 81 mg p.o. q.d. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 8344**] MEDQUIST36 D: [**2138-6-12**] 23:01 T: [**2138-6-13**] 18:17 JOB#: [**Job Number 13750**]

Admission Date: [**2142-11-30**] Discharge Date: [**2142-12-10**] Date of Birth: [**2084-5-2**] Sex: M Service: MEDICINE Allergies: Percocet / Bactrim Ds / Lisinopril Attending:[**First Name3 (LF) 898**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 25925**] is a 58 yo m w/ multiple sclerosis and seizure disorder who presented to an OSH for delusions and AMS x 2 days. At OSH, he was noted to have a Na of 124. He does have a history of hyponatremia; he had a Na of 117 in [**2-27**] but had been in the mid 130s since then. He has seen nephrology. At the OSH, he had an approx 45sec generalized tonic clonic seizure, received 1mg Ativan, and transferred to the ED at [**Hospital1 18**]. He also has a history of seizures especially in the setting of infection and hyponatremia. It is unclear if he has had seizures without an inciting event. He is currently being weaned off of Keppra and Gabapentin and is being started on Tegretol. In the ER, his VS were: 97.5; 189/105; 78; 16; 95% 3L. He was given 2L of NS. Given that he has had AMS in the setting of infection and is known to have chronic UTIs [**12-24**] indwelling suprapubic catheter and neurogenic bladder, blood and urine cultures were obtained as well as a CXR. He had a urine culture from [**11-28**] that grew pseudomonas and his CXR showed a possible infiltrate and he was treated with vancomycin and cefepime. A head CT was negative. Past Medical History: MS - since [**2119**], progressive, quadriplegic, neurogenic bladder with suprapubic catheter, restrictive PFT's History of Aspiration PNAs Esophageal Ulcer - [**12-24**] NSAIDs, [**2139**], small bowel bx negative Recurrent UTIs CHF (EF > 65% with moderate LVH in '[**39**]) HTN Legally Blind Social History: He is married 32 years and lives with his wife at home. He has three children and three grandchildren. He was a professor [**First Name (Titles) **] [**Last Name (Titles) 25949**] engineering at [**University/College 25932**], but retired on disability after the [**2128**] spring semester due to his MS. [**Name13 (STitle) **] is wheelchair-bound. He denies tobacco, alcohol, and recreational drug use. Has personal care assistant. Family History: Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother has diabetes. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2142-11-29**] 10:47PM BLOOD WBC-6.4 RBC-3.99*# Hgb-11.8*# Hct-33.1* MCV-83# MCH-29.7 MCHC-35.7* RDW-15.0 Plt Ct-235# [**2142-12-10**] 05:50AM BLOOD WBC-8.8 RBC-3.54* Hgb-10.8* Hct-31.0* MCV-88 MCH-30.5 MCHC-34.7 RDW-15.3 Plt Ct-424 [**2142-12-7**] 05:50AM BLOOD PT-13.6* PTT-34.1 INR(PT)-1.2* [**2142-11-29**] 10:47PM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-126* K-4.5 Cl-88* HCO3-29 AnGap-14 [**2142-11-30**] 06:58AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-125* K-4.6 Cl-90* HCO3-28 AnGap-12 [**2142-11-30**] 12:40PM BLOOD Na-128* [**2142-11-30**] 09:45PM BLOOD Na-127* [**2142-12-1**] 07:40AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-131* K-4.0 Cl-93* HCO3-29 AnGap-13 [**2142-12-1**] 03:00PM BLOOD Glucose-101 UreaN-16 Creat-0.8 Na-131* K-4.5 Cl-94* HCO3-30 AnGap-12 [**2142-12-2**] 05:45AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-133 K-4.6 Cl-95* HCO3-28 AnGap-15 [**2142-12-2**] 04:10PM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-131* K-4.9 Cl-93* HCO3-27 AnGap-16 [**2142-12-3**] 06:20AM BLOOD Glucose-121* UreaN-21* Creat-1.2 Na-131* K-4.3 Cl-93* HCO3-28 AnGap-14 [**2142-12-3**] 05:40PM BLOOD Glucose-115* UreaN-25* Creat-1.3* Na-134 K-4.4 Cl-96 HCO3-27 AnGap-15 [**2142-12-4**] 07:18AM BLOOD Glucose-101 UreaN-23* Creat-0.8 Na-135 K-4.0 Cl-98 HCO3-27 AnGap-14 [**2142-12-5**] 05:30AM BLOOD Glucose-83 UreaN-21* Creat-0.7 Na-135 K-3.9 Cl-96 HCO3-26 AnGap-17 [**2142-12-6**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-134 K-4.2 Cl-97 HCO3-28 AnGap-13 [**2142-12-7**] 05:50AM BLOOD Glucose-102 UreaN-21* Creat-0.8 Na-137 K-4.2 Cl-97 HCO3-26 AnGap-18 [**2142-12-8**] 07:00AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-27 AnGap-14 [**2142-12-9**] 06:30AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-140 K-4.0 Cl-101 HCO3-28 AnGap-15 [**2142-12-10**] 05:50AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-140 K-4.5 Cl-102 HCO3-26 AnGap-17 [**2142-11-29**] 10:47PM BLOOD Osmolal-260* [**2142-11-30**] 12:40PM BLOOD Osmolal-264* [**2142-12-8**] 07:00AM BLOOD ALT-23 AST-16 LD(LDH)-213 AlkPhos-87 TotBili-0.2 [**2142-12-10**] 05:50AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.4 U/A [**11-28**]: nit +, LE +, WBC 55, RBC 6, Epi 1, bact few U/A [**11-29**]: sm bld, 100 prot/gluc; WBC [**1-24**], RBC [**1-24**], Epi [**1-24**], bact mod U/A [**12-2**]: sm LE, WBC 10, RBC 2, Epi 1, bact none U/A [**12-5**]: 30 prot, 10 ket, lg LE; WBC 99, RBC 11, Epi 1, bact few U/A [**12-6**]: 30 prot, mod LE; WBC 22, RBC 8, Epi 3, bact none U/A [**12-8**]: neg leuk CULTURES: BCx [**11-29**] x2: neg BCx [**12-2**] x2: neg UCx [**11-28**]: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML UCx [**11-29**] pseudomonas UCx [**12-2**] yeast Ucx [**12-5**] neg Ucx [**12-6**] yeast Ucx [**12-8**] neg c.diff neg x 2 - CXR from [**12-2**]: Patchy opacity at left base again noted, but the significance in the setting of low inspiratory volumes is uncertain. - CTA from [**12-2**]: No PE. Scattered patchy ground-glass opacities may represent expiratory state with air trapping. - Renal u/s from [**12-2**]: No evidence of abscess, hydronephrosis or mass - abd xray from [**12-3**]: non-specific bowel gas pattern, stool throughout colon, no free air - abd xray from [**12-4**]: Stool- and air-filled loops of large and small bowel consistent with ileus. - Liver u/s from [**12-5**]: Hypoechoic right hepatic mass, measuring up to 4.2 cm in size - CT abd: prelim read: Arterially enhancing liver lesion cannot be fully characterized, may represent adenoma, FNH, or less likely HCC. Brief Hospital Course: 58 yo male w/ progressive multiple sclerosis was admitted for AMS and seizure after having a 45s GTC at the OSH that responded to 1mg Ativan. He had a negative head CT but was found to have a Na level of 126. He has been hyponatremic in the past and this has often caused changes in his mental status. In the ED, he was treated with 2L NS for concern of hypovolemic hyponatremia. At that time, his urine osm was 423 and serum osm was 263. He also had a CXR and there was prelim concern for pneumonia which can cause an ADH like effect (the final read was neagtive). Neurology was consulted for his AMS and seizure and they felt that his hyponatremia was likely related to recent initiation of carbamezapine for sensory illusions. Carbamezapine has a known ADH like effect and can cause hyponatremia. Following discontinuation of carbamezapine along with fluid restriction, his Na increased. After several days, the pt appeared slightly dehydrated so his fluid restriction was lifted. By time of discharge, his serum Na was 140. . In the past, his seizures have been instigated by an underlying infection. However, upon admission he was afebrile and did not have a leukocystosis. The most likely source was either pneumonia or a UTI. He has a suprapubic catheter [**12-24**] neurogenic bladder and on the day prior to admission, he had a urine sample that grew pseudomonas, a bacteria he has had in the past. He has also had several pneumonias in the past, most likely [**12-24**] frequent aspirations and his first CXR was concerning for lung infiltrate. He was treated with one dose of vancomycin and cefepime for pneumonia. Ultimately, repeat CXR and a CTA were both negative for pneumonia. . Because of his pseudomonal bacteriuria, he was started on ciprofloxacin. A urine culture drawn prior to abx inititian also grew pseudomonas. Because he was afebrile and did not have a leukocytosis and there was thought that it may actually have been colonization as opposed to infection. However, he was treated with a full course of cipro for a complicated UTI. His catheter was changed and all other cultures remained negative. . On admission, the pt was afebrile and hypertensive to 180-200. However, shortly after arriving on the floor, he had an episode of hypotension down to the 70's systolic. During this time he was mentating well, he did not have any complaints, denied chest pain, headache, and visual changes. IVFs were given, however the hypotension did not initially respond, however came up eventually prior to getting to the ICU. This labile blood pressure was most likely secondary to the patient's autonomic dysfunction secondary to his SPMS. Other considerations were infection or possible sepsis, however the patient was continued to be afebrile. Blood and urine cultures were negative. He was monitored in the ICU for 24 hours with stable swings in BP which were asymptomatic and consistent with autonomic dysfunction. Changed clonidine dosing from 0.2mg [**Hospital1 **] to 0.1mg TID. Maintained other blood pressure medications at home doses. . The next day, he was transferred out of the MICU and returned to the floor. Shortly after arrival, he developed a fever. More blood and urine cultures were sent and all were negative. Pneumonia had been ruled out and his UTI was being treated with a medication that was appropriate per sensitivities. He had a CTA which was negative for PE. However, he was started on meropenem and was treated for 2 days. He was still slightly febrile but his meropenem was discontinued for concern of drug fever. He defervesced without any further treatment. . However, his mental status continued to fluctuate despite being afebrile, no obvious source of infection, and he was eunatremic. He was occasionally aggressive and would say that he was being murdered or kidnapped. Neurology was reconsulted but did not feel that his symptoms were related to the keppra and they did not think he was having subclinical seizures. He continued to have repetitive shaking moves of his head but he was conscious and able to speak during these episodes. Also, despite the Keppra, he continued to have sensory illusions, mostly centered around the feeling of having a bowel movement (when he actually was not). . During the work up for a source of infection and source of AMS, he had a CTA which revealed a liver lesion. He had an ultrasound and a multiphase liver CT to further describe the lesion because he cannot have an MRI [**12-24**] an implanted baclofen pump. Mr [**Known lastname 25925**] and his family decided to not biopsy the lesion at this time but it was not ruled out completely for malignancy, although unlikely. During this work up he also had KUB that was concerning for ileus but he continued to have BMs so he was kept on a regular diet. . Prior to discharge, his mental status had not completely returned to baseline but he was alert and oriented x 3 and was no longer aggressive towards staff. No definite etiology was elucidated and it was hypothesized that this could be a result of the progression of his established disease. Medications on Admission: BACLOFEN 2,000 mcg/mL Kit -pump BRIMONIDINE Dosage uncertain CARVEDILOL - 25 mg Tablet [**Hospital1 **] CARBAMEZAPINE - 100mg [**Hospital1 **] CLONIDINE - 0.2 mg Tablet [**Hospital1 **] CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream tid FENTANYL - 12 mcg/hour Patch 72 hr FUROSEMIDE - 40 mg Tablet qd IPRATROPIUM-ALBUTEROL prn LACTULOSE prn MINOCYCLINE - 100 mg Tablet [**Hospital1 **] MODAFINIL [PROVIGIL] 50 [**Hospital1 **] OMEPRAZOLE 20 [**Hospital1 **] OXYBUTYNIN CHLORIDE - 15 mg qhs SIMVASTATIN - 40 mg qd TRAVOPROST1 drop L eye once a day ACETAMINOPHEN prn ASCORBIC ACID 500 [**Hospital1 **] BISACODYL hs CALCIUM 500 mg Tid CRANBERRY 475 mg Capsule [**Hospital1 **] ERGOCALCIFEROL (VITAMIN D2)400 [**Hospital1 **] MINERAL OIL prn OMEGA-3 FATTY ACIDS [**Hospital1 **] PSYLLIUM [METAMUCIL] prn SENNA - 8.6 mg Tablet prn Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Oxybutynin Chloride 5 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 12. Simvastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days: through [**2142-12-13**]. 16. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 19. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) inh Inhalation twice a day as needed. 20. TRAVATAN Z 0.004 % Drops Sig: One (1) Ophthalmic once a day: To Left eye. 21. Cranberry 475 mg Capsule Sig: One (1) Capsule PO twice a day. 22. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO twice a day. 23. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1) Tablet PO twice a day. The patient has an allergy listed to ACE Inhibitors, and was therefore not discharged on an ACE Inhibitor. This will be communicated to PCP. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1. Multiple Sclerosis 2. Urinary Tract Infection, complicated 3. Hyponatremia . Secondary: 1. Chronic Diastolic CHF Discharge Condition: Stable vital signs. Discharge Instructions: You were admitted with altered mental status and found to have low sodium and a urinary tract infection. You were started on antibiotics for your urinary tract infection (cipro) to complete a 2 week course. Your sodium corrected after adjusting your medications and reducing your water intake. . You were found to have an abnormality in your liver. You had a CT scan and the results are pending final interpretation. We have provided a phone number below so that you can schedule an appointment in [**Hospital **] clinic. It may be necessary to reimage the liver or take a biopsy of the lesion seen on CT scan. . Your medications have changed. You were switched from tegratol to keppra. Please review your most recent medication list and take only these medications, and discard any old medications not on this list. . Please return to the hospital if you develop fevers, chills, or worsening symptoms. Followup Instructions: 1. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2143-1-8**] 1:30 . 2. [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-1-15**] 4:00 . 3. [**Hospital **] CLINIC at [**Hospital1 18**]: ([**Telephone/Fax (1) 2233**] Completed by:[**2142-12-13**]

Admission Date: [**2109-8-17**] Discharge Date: [**2109-10-16**] Date of Birth: [**2054-10-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: B/L ankle fractures, s/p fall Major Surgical or Invasive Procedure: [**8-18**] . 1. Closed reduction of left pilon fracture. 2. Application of multi-planar external fixator left lower extremity. 3. Closed treatment of calcaneus fracture with mild amount of manipulation. 4. External fixation of Right Pilon fracture . [**8-30**] Adjustment of external fixator of R pilon fracture . [**9-17**] ORIF right intra-articular distal tib-fib fracture R History of Present Illness: 54 year old Spanish speaking male, in the US on vacation, with a questionable PMH of liver disease presents after jumping?falling? out a window. Per his daughter he was drinking alcohol with his son and reported feeling that someone was out to kill him. He locked himself in a second-story bedroom and was later found by his daughter crawling outside. He was initially seen at [**Hospital3 **] and found to have opiates and cocaine on UA in the emergency department there. He was transported to [**Hospital1 18**] with b/l ankle fractures. Per family, the pt has been confused at home. In [**Name (NI) **], pt was aggitated and received haldol and ativan. He was later somnolent. EKG demonstrated atrial flutter with HRs in 110-140's, rate controlled in the ED with IV diltiazem. Patient is a poor historian, most information obtained from his daughter ROS: + b/l ankle pain, -CP, -SOB, -Abdominal pain Past Medical History: "Gets yellow" High ammonia HTN questionable anginal history depression, family states he see a psychiatrist Social History: EtOH abuse, polysubstance abuse, one ppd for mayn years Urine positive for cocaine and opiates in ED Not married Daughter is involved in care Family History: Noncontributory Physical Exam: Vitals: 96.7 140/90 76 16 99% on 2L NPO/1000 Physical Exam: General: sleepy but arousable, oriented to place and person, able to name the months of the year forwards, but not backwards, not oriented to current month/year HEENT: icteric sclerae, dry MM, + c-collar CVS: irregular rate, tachy, no murmurs/rubs/gallops appreciated Pulm: CTA b/l, no wheezes, rales or rhonchi Abd: soft, NT, mild hepatosplenomegaly, +BS Ext: b/l ankle splints, mild bruising over b/l knees, - for asterixis GU: + foley Pertinent Results: CT C-Spine: negative for fracture Left tib/fib: Comminuted fracture of the calcaneus. Dense sliver of bone along the medial aspect of the proximal fibula, seen only on a single view. This could represent additional calcification of the intraosseous ligament, a small cortical fracture fragment, or a foreign body. Right tib/fib: Comminuted, intraarticular, impacted, and displaced fractures of the distal tibia as well as fracture of the distal fibula as detailed above. . CT bilat LE 1. Comminuted intra-articular distal right tibial fracture. 2. Comminuted distal right fibular fracture with displacement. 3. Comminuted left calcaneal fracture. . RUQ U/S: FINDINGS: The liver is coarse in echotexture without evidence of focal lesion. The gallbladder is not distended due to nonfasting stage. No evidence of gallstones. No evidence of intra- or extra-hepatic biliary ductal dilatation and the common duct measures 3 mm. The pancreas is not well visualized due to bowel gas. There is no evidence of free fluid. The main portal vein is patent with antegrade flow. IMPRESSION: No evidence of cholecystitis. . Head CT ([**8-21**]) IMPRESSION: No evidence of acute intracranial pathology, including no sign of intracranial hemorrhage. . CXR ([**8-21**]) No previous studies for comparison. Low lung volumes. Heart size is difficult to evaluate in this semi-upright AP film. There could be some LVH but no evidence for CHF and the lungs are clear. Questionable slight impression on the right margin of the tracheal air column which can be better evaluated by standard PA and lateral chest films when condition permits. . Chest CT ([**8-23**]): 1. No juxtatracheal mass or left upper lobe lesion as questioned on chest radiograph report. 2. Three foci of ground glass, right upper lobe, not detectable on routine radiographs, a nonspecific finding. Six- month CT follow up is recommended to look for change, because bronchoalveolar cell carcinoma, though unlikely, cannot be excluded. 3. Borderline size mediastinal and hilar lymph nodes should be checked on followup CT. 4. Mild atherosclerotic coronary artery calcification. Chest CTA ([**8-24**]): 1. No pulmonary embolism. 2. Relatively unchanged appearance of multiple ill-defined opacities and tiny nodules in the right upper lobe. Follow-up stated on the examination from 1 day prior is again recommended. 3. New foci of opacification present at the lung bases compared to examination from one day prior likely related to aspiration. Layering debris present within the right main stem bronchus most suggestive of aspiration as well. Clinical correlation is recommended. 4. Recommend advancing NG tube at least 4-5 cm. The current position elevates the risk of further aspiration. . CT RLE with contrast ([**8-24**]): IMPRESSION: Comminuted distal tibial and fibular fractures with intra- articular involvement of the tibial plafond and lateral displacement of the talus with respect to the tibia. Posterior displacement of the distal fibular fragment. . CT LLE without contrast ([**8-24**]) Comminuted left calcaneal fracture. Lentiform area of fluid attenuation at the skin on the posterolateral aspect of the left foot. The significance of the latter finding is uncertain, but may be due to a skin blister or possibly dressing material within the cast. Clinical correlation requested. . CXR ([**8-26**]) 1. NG tube could be advanced several centimeters for standard positioning, as described in prior exams. 2. New perihilar opacities, likely due to acute aspiration in the superior segments. . Head CT ([**9-3**]) IMPRESSION: There is no evidence of hemorrhage or CT evidence of acute infarct. . CT abd/pelvis ([**9-22**]): IMPRESSION: No CT evidence of pyelonephritis or abscess within the abdomen/pelvis. . CT LLE without contrast ([**9-26**]) 1. Markedly comminuted fracture of the calcaneus with wide distraction and dispersal of the fracture fragments as above. 2. Non-displaced fractures of the sustentaculum tali and of the middle facet of the talus. 3. No fracture identified of the medial malleolus. 4. Non-displaced fractures of the anterior aspect and of the inferior aspect of the lateral malleolus. 5. Non-displaced fracture of the cuboid. 6. No fracture identified of the navicular. 7. No other fractures identified within the remainder of the mid foot or the forefoot. 8. Lateral subluxation of the peroneal tendons with respect to the fibula. 9. Probable tear of the anterior talofibular ligament. . Echo ([**9-26**]): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Brief Hospital Course: During course of hospitalization, pt was put on CIWA scale for EtOH withdrawal and given thiamine, folate and a multivitamin, his AFib with RVR was initially treated with metoprolol, then diltiazem, his high ammonia levels were treated with lactulose. His b/l ankle fractures were followed by orthopedics. The patient was severely agitated on more than one occassion during this hospitalization, requiring three codes puples to be called as well as requiring restraints for protection of both the patient and the staff. The patient was originally sent from the floor to the MICU with delirium of unknown cause and severe agititation. He required increased amounts of sedation and was returned to the floor after a NG tube was placed. Once returned to the floor, the patient required less sedation, was taken off of any benzodiazipines and only intermittently needed restraints. The patient remained somnolent and delerious. He pulled out his NG tube. He was also febrile and rhoncorous on the floor. He was initially treated with vancomycin and flagyl, which was changed to azithro/ceftriaxone/flagyl. He was scheduled to return to the OR for revision of his right external fixation. In preop holding, he was found to be hypoxic and sent to the MICU. MICU COURSE: Morning of [**8-28**], patient scheduled to return to OR for revision of externally fixated RLE. Upon transport to PACU, patient became more somnolent and had reported "agonal breathing". O2 sats 83% on 2LNC and NRB applied with O2 sats to 100%. BP in 90s/60s, HR in 80s, RR 17-19. ABG drawn: 7.38/58/90. During stay in MICU, patient coughed up large amount of thick sputum with improved respiratory status. Surgery postponed and patient transferred to MICU for further monitoring. In the MICU, respiratory status has remained stable with Sp02 in the high 90s on room air. Pt is hemodynamically stable in chronic a-flutter. Called out to floor on [**8-29**]- no further intensive care needs identified. In the MICU, patient was started on Zosyn and restarted on Vancomycin wiht marked improvement in his respiratory status. Within a few days of returning to the floor, Vancomycin and zosyn were stopped as CXR showed resolution of questionable aspiration pneumonia - this was felt to be more likely pneuomonitis which resolved. . After the MICU, patient's delirium started to improve, but then worsened when he returned to the OR for removal of external fixation. He developed fevers to 102F post-operatively which likely worsened delirium. Source of fevers unclear - of note patient had recently developed VRE in his urine but infectious disease did not feel this was an active infection. he received three days of antibiotics (daptomycin and then linezolid). When these were stopped he became afebrile and delirium began to lift. . #Aggitation was mostly controlled with haldol. Zyprexa was tried for two weeks but it did not seem to help acute aggitation. QTc was monitored while patient was on antipsychotics and was stable at approximately 420-440msec. Overall etiology of delirium has remained unclear but was thought to be multifactorial due in part to chronic alcohol use, hepatic encephalopathy, benzodiazepine use, and post-operative delririum. Although spanish-speaking 1:1 sitters and interpreters were employed as much as possible, language also likely contributed to persistance of delirium. Delirium has completely resolved patient is now restraint and sitter free. All haldol has been stopped. He has past the period of etoh withdrawal. It is recommended that patient follow up with alcohol abuse counseling. . #Afib/flutter While febrile, his afib/flutter was complicated by more frequent episodes of rapid ventricular rate. This was controlled with IV metoprolol when needed but also by increasing PO metoprolol and diltiazem. Treating fever with tylenol also seemed to help. He was briefly put on therapeutic lovenox for atrial fibrillation, but this was stopped as he was not felt to be eligible by CHADS criteria and also because of high fall risk. Patient was transitioned off of beta blockers and placed on Diltiazem 120mg daily. . #Urinary retention patient failed several voiding trials. He also pulled out his foley on several occasions, causing hematuria. Intermittent straight catheterization was tried to reduce infection risk of long-term indwelling foley. However given delirium and aggitation this was untenable. This resolved with reductions in haldol. Patient now able to void freely on his own. History of VRE on urine culture, but no signs of infection, dyruria, increased urinary frequency. There is no evidence based literature or other clinical indications to treat this asymptomatic bacteuria at this time. . #Fractures patient followed by orthopedics during admission. L ankle fractures treated with casting, however repeat plain films and CT scan 4-6 weeks post-op showed fractures which were not initially visualized. Orthopedics felt casting was still appropriate and that there was no indication for surgery. R pilon fracture managed initially with external fixation system because of skin breakdown making internal fixation difficult. One month into hospitalization ex-fix removed and tibial and fibular plates were placed. He is to remain Non-weight bearing for a total of one month after his hospital discharge. Patient has completed the necessary course of lovenox.He has a follow up appointment scheduled with his orthopaedic surgeon Dr. [**Last Name (STitle) **] for [**11-28**] at 1030am, at [**Hospital3 **] [**Hospital Ward Name **], [**Location (un) 1385**] of the [**Hospital Ward Name 23**] building. . Transfer to [**Hospital **] Rehab Hospital. Medications on Admission: Diltiazem 180 mg one daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:*30 Tablet, Chewable(s)* Refills:*0* 5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*1* 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary: 1) Bilateral Lower Extremity fractures a. Closed left tibial plafond fracture/pilon fracture. b. Dislocation left tibiotalar joint. c. Right calcaneus fracture, intra-articular 2) Persistent agitated delirium ?????? resolved 3) Aspiration Pneumonitis - resolved 4) Alcoholism ?????? continuous 5) Delirium Tremens 6) Polysubstance Abuse (cocaine, opiates, alcohol) 7) Atrial Fibrillation/Atrial Flutter 8) Abnormal CT chest ?????? follow-up ([**2111-1-5**]) recommended 9) Liver Failure ?????? presumed secondary to alcoholism (No evidence for HBV or HCV infection) a. Thrombocytopenia presumed secondary to thrombopoitin deficiency. No evidence for splenomegaly on imaging. 10) Elevated AFP level ?????? etiology as yet undetermined Secondary: 1) Hypertension 2) Urinary retention ?????? resolved 3) Bactiuria ?????? asymptomatic, colonized with Vancomycin resistant enterococcus Contact information: [**First Name8 (NamePattern2) **] [**Known lastname 1794**] (daughter): [**Telephone/Fax (1) 74301**] [**Female First Name (un) 74302**] & [**First Name9 (NamePattern2) 74303**] [**Known lastname 1794**](son) cell [**Telephone/Fax (1) 74304**] For Follow-up: 1) Repeat CT scan of chest in [**2111-1-5**] to f/u 3 foci of ground glass in the RUL as well as borderline mediastinal and hilar lymphadenopathy 2) Assess etiology of elevated alpha-fetoprotein 3) Further evaluate etiology of pancyctopenia ?????? consider bone marrow aspirate as well as HIV testing Discharge Condition: Stable, Non-weight bearing in both legs for one month starting [**10-15**] Discharge Instructions: You were transferred to [**Hospital1 18**] emergency room after a large fall. You were found to have bilateral ankle fractures. You had a CT scan of your head which did not show any acute bleed. When you came into the emergency room your heart rate was fast, and you were given medications to help slow it down. . On [**8-18**] you had an operation on your left leg for a heel and ankle fracture, you had several pins placed in your left leg. Your left leg was then casted. . On [**8-30**] you had an operation on your R tibula fibula fracture that stabilized the leg externally. . On [**9-17**] you had an operation on your right tibula and fibula and screws were placed to help your leg heal. . During your hospital stay. You were very confused and placed on many psychiatric medications, you became very agitated at times,and had to be restrained at times. This has resolved you are no longer on any psychiatric medications. . While in the hospital you developed some breathing problems. [**Name (NI) **] spent time in the intensive care unit, because there was some worry that you might have a pneumonia, you were started on antibiotics, but your breathing problems improves, and your chest xray improved. It was thought that you did not have a pneumonia and the antibiotics were normal. . You were also found to have some bacteria in your urine called VRE, because you were not having, any burning with urination. The infectious disease doctors thought that the bacteria should not be treated. . You are being transferred to a rehab facility. It is important that while at that rehab facility you, follow up and get counseling for your problems with alcohol abuse. . You have follow up appointments schedule with both orthopaedics and a new primary care physician. [**Name10 (NameIs) **] is important that you follow up with both of these appointments. . It is also important that you do not put any weight on your legs for next month. Please return to the hospital or the emergency room if your condition worsens in any way. You had an abnormal chest x-ray/CT scan and should have this repeated in [**2111-1-5**] to make sure you don't have lung cancer. Your blood counts were low but stable during your hospitalization. You should see a Hematologist (Blood Doctor) about this and consider testing for HIV. You had an elevation of a marker in your blood called AFP (alpha fetoprotein). The significance of this is not know. It may be related to your underlying liver disease but should be further evaluated by a specialist. You should absolutely refrain from further use of alcohol, cocaine or any illicit drugs not explicitly prescribed to you by a physician. Ten??????as una exploraci??????n anormal [**Doctor First Name **] pecho x-ray/CT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 7214**] esto repetido en diciembre de [**2110**] para cerciorarse de t?????? no [**Last Name (un) 7214**] pulm??????n c??????ncer. Tus cuentas de sangre [**Doctor First Name **] [**First Name9 (NamePattern2) 74305**] [**Last Name (un) **] [**First Name9 (NamePattern2) 74306**] [**Last Name (un) 33761**] tu hospitalizaci??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7213**] [**Last Name (un) **] a un hemat??????logo (el doctor [**Last Name (Titles) **] [**Last Name (Prefixes) 74307**]) sobre esto y considerar el probar para el VIH. Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP (alfa fetoprotein). [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 74308**]??????n de esto no es saber. Puede ser relacionado con tu enfermedad [**Doctor First Name **] higado [**First Name9 (NamePattern2) 74309**] [**Last Name (un) **] debe ser m??????s futuro evaluado por un especialista. [**Last Name (un) 7213**] refrenarse absolutamente [**Doctor First Name **] uso adicional [**Doctor First Name **] alcohol, de [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????na o de cualquier droga il??????cita prescritos no expl??????citamente a ti por un m??????dico. Followup Instructions: Ten??????as una exploraci??????n anormal [**Doctor First Name **] pecho x-ray/CT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 7214**] esto repetido en diciembre de [**2110**] para cerciorarse de t?????? no [**Last Name (un) 7214**] pulm??????n c??????ncer. Tus cuentas de sangre [**Doctor First Name **] [**First Name9 (NamePattern2) 74305**] [**Last Name (un) **] [**First Name9 (NamePattern2) 74306**] [**Last Name (un) 33761**] tu hospitalizaci??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7213**] [**Last Name (un) **] a un hemat??????logo (el doctor [**Last Name (Titles) **] [**Last Name (Prefixes) 74307**]) sobre esto y considerar el probar para el VIH. Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP (alfa fetoprotein). [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 74308**]??????n de esto no es saber. Puede ser relacionado con tu enfermedad [**Doctor First Name **] higado [**First Name9 (NamePattern2) 74309**] [**Last Name (un) **] debe ser m??????s futuro evaluado por un especialista. [**Last Name (un) 7213**] refrenarse absolutamente [**Doctor First Name **] uso adicional [**Doctor First Name **] alcohol, de [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????na o de cualquier droga il??????cita prescritos no expl??????citamente a ti por un m??????dico. Please follow up with Dr. [**Last Name (STitle) **] from orthopedic surgery you have an appointment scheduled for [**2112-11-28**]:30 am, [**Location (un) 1385**] of the [**Hospital Ward Name 23**] building on the [**Hospital Ward Name **] of [**Hospital1 771**]. Please call [**Telephone/Fax (1) 9769**] if would like to change this appointment. Please follow up with your new primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15259**] on [**2109-11-19**] at 3pm in the [**Hospital Ward Name 23**] Center on the [**Location (un) **] of the [**Hospital Ward Name 516**] [**Hospital1 1170**]. You had an abnormal chest x-ray/CT scan and should have this repeated in [**2111-1-5**] to make sure you don't have lung cancer. Your blood counts were low but stable during your hospitalization. You should see a Hematologist (Blood Doctor) about this and consider testing for HIV. You had an elevation of a marker in your blood called AFP (alpha fetoprotein). The significance of this is not know. It may be related to your underlying liver disease but should be further evaluated by a specialist.

Admission Date: [**2170-9-19**] Discharge Date: [**2170-9-25**] Date of Birth: [**2099-5-27**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion and fatigue Major Surgical or Invasive Procedure: [**2170-9-19**] Coronary artery bypass graft x 4 (Left internal mammary artery to diagonal, saphenous vein graft to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) History of Present Illness: 71 year old male who presented to his PCP for [**Name Initial (PRE) **] routine visit with complaints of recent onset fatigue, dyspnea on exertion, exertional throat discomfort and left arm. He denied any rest pain but reports the discomfort and dyspnea occur with minimal activities such as showering. He was found to be hypertensive and was started on Atenolol 25mg daily. His EKG was normal and he was sent for a nuclear stress test. He underwent a nuclear stress test on [**2170-8-1**] which revealed inferolateral ischemia and a moderate inferior, inferolateral, and posterolateral perfusion abnormality. He is now refereed for cardiac catheterization. He is now being referred to cardiac surgery for revascularization. Past Medical History: Hypertension Right rotator cuff tear Compound fracture of left arm/plated as a child Benign colon polyps Arthritis s/p right rotator cuff repair s/p repair if left arm fracture, plated Social History: Race:Caucasian Last Dental Exam:"a very long time ago", does not recall when Lives with:Wife Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (3) 74913**] Occupation:self employed painter Cigarettes: Smoked no [x] Other Tobacco use:denies ETOH: stopped drinking in [**12-20**] Illicit drug use:denies Family History: No premature coronary artery disease Physical Exam: Pulse: 56 Resp:13 O2 sat:97/RA B/P Right:173/82 Left:164/76 Height:5'9" Weight:200 lbs General: NAD, WG, WN Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none_ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: no bruits Pertinent Results: [**2170-9-25**] 06:35AM BLOOD WBC-10.9 RBC-2.94* Hgb-9.3* Hct-26.3* MCV-89 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-261 [**2170-9-24**] 06:20AM BLOOD WBC-13.4* RBC-3.27* Hgb-10.1* Hct-28.7* MCV-88 MCH-31.0 MCHC-35.3* RDW-14.2 Plt Ct-197 [**2170-9-25**] 06:35AM BLOOD Na-139 K-4.0 Cl-99 [**2170-9-24**] 06:20AM BLOOD Glucose-118* UreaN-26* Creat-0.9 Na-139 K-4.0 Cl-98 HCO3-31 AnGap-14 [**2170-9-23**] 05:00AM BLOOD UreaN-25* Creat-0.9 Na-137 K-4.3 Cl-99 Brief Hospital Course: Mr. [**Known lastname **] was a same day admit and on [**9-19**] was brought to the operating room where he underwent a Coronary artery bypass graft x4 (left internal mammary artery to the diagonal and saphenous vein grafts to the left anterior descending, obtuse marginal, and posterior descending arteries) with Dr.[**First Name (STitle) **]. CARDIOPULMONARY BYPASS TIME:104 minutes. CROSS-CLAMP TIME:93 minutes. Please see operative report for further surgical details. Following surgery he was transferred to the CVICU intubated and sedated in critical but stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated without incident. He weaned from pressor support and beta blocker/Statin/Aspirin and diuresis was initiated. Chest tubes and epicardial pacing wires were removed per protocol. POD#1 he was transferred to the step-down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. During his postoperative course he developed atrial fibrillation and was treated with beta blockers and amiodarone. Anticoagulation was initiated with Coumadin. He developed a phlebitis from IV Amio and was placed on a course of Keflex x 7 days. This was slowly improving. His pulmonary status waxed and waned with a strong productive cough and wheezing, which improved by the time of discharge. He continued nebulizer treatments. CXR showed small bilateral pleural effusions with atelectasis, no infiltrate or density. His pulmonary status slowly improved by his day of discharge. On POD 4 he developed a tender erythematous right knee and was treated with colchicine for presumed gout. This had improved by the time of discharge and the colchicine was discontinued. On POD 6 he was afebrile, ambulating with assistance, tolerating a full po diet and his wounds were healing well. On POD 6 he was discharged to Lifecare Center of [**Location 15289**] in stable condition. All follow up appointments were advised. Medications on Admission: ATENOLOL 25 mg Daily ASPIRIN 325 mg daily FISH OIL-DHA-EPA 1,200 mg-144 mg-216 mg Daily MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [A THRU Z HIGH POTENCY] 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet Daily NAPROXEN SODIUM [ALEVE]PRN Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 1 week then 200 [**Hospital1 **] x 1 week then 200 mg daily directed by caridologist. 8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for coughing . 14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: For right arm phlebitis. 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. 16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 14 days. 17. warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once): Give 4 mg on [**9-26**] then as directed for INR goal 2.0-2.5 for A fib. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 4 Past medical history: Hypertension Right rotator cuff tear Compound fracture of left arm/plated as a child Benign colon polyps Arthritis s/p right rotator cuff repair s/p repair if left arm fracture, plated Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] on [**10-29**] at 1:15pm, #[**Telephone/Fax (1) 170**] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] on [**9-25**] at 2:00pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **]. Nikolaos Michalacos in [**4-17**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Patient to be given 4 mg Coumadin on [**2170-9-25**] Goal INR 2.0-2.5 First draw [**2170-9-26**] Please arrange follow up with PCP or cardiologist prior to discharge from rehab [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2170-9-25**]

Admission Date: [**2191-7-13**] Discharge Date: [**2191-7-15**] Date of Birth: [**2191-7-13**] Sex: M Service: NEONATOLOGY HISTORY: Baby [**Name (NI) **] [**Known lastname 1661**] was born at 39 weeks gestation to a 32-year-old gravida 1, para 0 now 1 woman. The mother's prenatal screens were blood type O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, and group B strep negative. The infant not crying and was intubated and no meconium was suctioned from below the cords. He was given a brief period of bag and mask ventilation with good responses. Apgars were 8 at two minutes and 9 at five minutes. His birth weight was 3885 grams, his birth length was 20 [**1-19**] inches, and his birth head circumference was 34 cm. The transferred to the Newborn Intensive Care Unit at four hours of age for hypoglycemia. His blood dextrose stick was 36. PHYSICAL EXAMINATION: Reveals a vigorous, non-dysmorphic, term-appearing infant. Anterior fontanel open and flat, cranial molding present, small caput posteriorly, palate intact. Respirations unlabored, lung sounds clear and equal. Heart was normal heart sounds and no murmur. Femoral and brachial pulses +2 and equal. Soft abdomen with no masses. Normal external male genitalia with both testes descended. Symmetric tone and reflexes. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The infant has remained in room air throughout his Newborn Intensive Care Unit stay. He has had no apnea, bradycardia or desaturations. 2. Cardiovascular: He has remained normotensive throughout his Newborn Intensive Care Unit stay. There are no cardiovascular issues. 3. Fluids, electrolytes and nutrition: The infant required supplemental intravenous fluid, from which he weaned successfully at 28 hours of age, maintaining euglycemia with feedings of Enfamil 20 on an ad lib schedule, taking approximately one ounce every three to four hours. His last blood glucose at the four hour mark was 59. 4. Gastrointestinal: The infant has been passing meconium. 5. Sensory: Hearing screening was performed with automated auditory brain stem responses, and the infant passed in both ears on [**2191-7-15**]. 6. Psychosocial: The parents have been involved in the infant's care during his Newborn Intensive Care Unit stay. DISCHARGE STATUS: The infant is being discharged to the Newborn Nursery. CONDITION ON DISCHARGE: His condition is good at the time of discharge. PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**Last Name (STitle) 43003**] [**Name (STitle) 17494**] of [**Hospital3 **] Medical Center, telephone number [**Telephone/Fax (1) 17663**]. CARE RECOMMENDATIONS: 1. Feedings: Enfamil 20 on an ad lib schedule. 2. Medications: The infant is discharged on no medications. 3. A state screening has not been drawn yet. 4. The infant has not yet received the hepatitis B vaccine. DISCHARGE DIAGNOSIS: 1. Resolved hypoglycemia 2. Term male infant [**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**] Dictated By:[**Last Name (NamePattern1) 37333**] MEDQUIST36 D: [**2191-7-15**] 01:36 T: [**2191-7-15**] 02:18 JOB#: [**Job Number 43004**]

Admission Date: [**2142-12-23**] Discharge Date: [**2142-12-30**] Date of Birth: [**2070-6-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: Right upper quadrant pain Major Surgical or Invasive Procedure: [**2142-12-23**]: ERCP with sphincterotomy and stent placement [**2142-12-28**]: cholecystectomy History of Present Illness: This is a 72 year-old female with a history of mild mental retardation, who presents with RUQ that started this AM. Pt with some back pain. Pt went to [**Hospital1 **] and was found to have a fever of 102.9 and elevated LFTs. RUQ u/s with concern for stone in CBD. WBC was 9.4 and 56% bands, tbili 8.7, dbili 5.3 and she was given levo/flagyl, tylenol, and IVF and transfered to [**Hospital1 18**] with presumed cholangitis. She is orientated to person and "hospital". Lives at home. In the ED, VS on arrival were 97.3 82 132/74 20 96% 2L NC. Pt was given IVF, unasyn, zofran, and morphine. Labs showed WBC of 31, lactate 3.2, and bili of 7.7 with elevated LFTs. ERCP and surgery were consulted. ERCP wanted pt in [**Hospital Unit Name 153**] for ERCP tonight. Surgery requested u/s and CT abd with contrast. CXR with concern for LLL PNA, but no resp sx. RUQ u/s prelim showed: gallstones, no evidence of acute cholecystitis. Angiomyolipoma in left upper pole, 1.5cm. CT prelim showed: No intrahep bil dil. Slight enhancement of the normal caliber cbd, cbd raises the possibility of cholangitis. Pulmonary bronchiectasis. Pt was admitted to surgery in [**Hospital Unit Name 153**]. VS on transfer were 98 66 104/39 16 99% 2LNC. Pt went for an ERCP that showed pus in the bile duct with a small stone causing obstruction. There was also a stricture 1/3rd of the way in the CBD. Malignacy can not be ruled out. A stent was placed that will need removal in 3 weeks. Pt was given 3 liters LR by the time she arrived post procedure in the [**Hospital Unit Name 153**] including her ER IVF. Past Medical History: -Mild mental retardation -Arthoscopy of knee -Hysterectomy -Low plts at [**Hospital1 2025**] [**2129**], dx with ITP -Cataract surgery -Right 3rd nerve palsy -Esophageal web, with food obstruction removed in past Social History: Lives with her sister, brother-in-law, and mother. [**Name (NI) **] tobacco or etoh use. Ambulates independently. Enjoys watching the TV and news and Today show. Family History: no bleeding or plt disorders Physical Exam: Vitals: 98.8 87 97/36 13 94%RA GEN: Well-appearing, no acute distress HEENT: mild sclera ictericus, MMM, OP Clear NECK: JVP at 5-6cm, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, soft SEM at Rt 2nd ICS, radial pulses +2 PULM: Lungs with coarse crackles at right bsea with decreased BS at left base and few crackles ABD: Soft, NT, ND, +BS, no HSM, no masses, neg Murphys EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person and time, and "hospital". Moving all ext, right third nerve palsy (in abduction at rest and no elevation past midline and no adduction) and pupil is asymetric offcenter but contract; CN otherwise grossly intact. SKIN: Mild jaundice Pertinent Results: Admission labs- [**2142-12-23**] 04:54PM BLOOD WBC-31.3* RBC-5.04 Hgb-13.2 Hct-38.0 MCV-75* MCH-26.1* MCHC-34.7 RDW-13.9 Plt Ct-162 [**2142-12-23**] 04:54PM BLOOD Neuts-57 Bands-30* Lymphs-6* Monos-2 Eos-0 Baso-0 Atyps-2* Metas-3* Myelos-0 [**2142-12-23**] 04:54PM BLOOD PT-16.0* PTT-27.9 INR(PT)-1.4* [**2142-12-23**] 04:54PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-141 K-3.4 Cl-108 HCO3-20* AnGap-16 [**2142-12-23**] 04:54PM BLOOD ALT-263* AST-184* AlkPhos-172* TotBili-7.7* [**2142-12-23**] 04:54PM BLOOD Lipase-14 [**2142-12-24**] 12:08AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.7 [**2142-12-23**] 05:08PM BLOOD Lactate-3.2* [**2142-12-23**] Liver US : Gallstones, without gallbladder wall thickening or pericholecystic fluid to suggest acute cholecystitis. No biliary dilation. [**2142-12-23**] CT Abd/pelvis : 1. No intrahepatic biliary ductal dilatation, no gallstones, the gallbladder is normal in appearance. 2. Slight mural hyperenhancement of the nondilated common hepatic and common bile duct - can be seen with cholangitis. 2. Diverticula, no evidence of diverticulitis. [**2142-12-23**] ERCP : Esophageal web Periampullary diverticulum Successful biliary cannulation. A single stricture that was 6 mm long was seen at the middle third of the common bile duct. There was an irregular appearance to the lining of bile duct, likely secondary to cholangitis. Sucessful sphincterotomy performed Small 4mm stone was extracted. Pus was seen exiting the bile duct. Successful plastic biliary stent placement Otherwise normal ercp to third part of the duodenum Possible Mirizzi's versus tumor as a cause of stricture. [**2142-12-26**] CXR ; 1. New small-to-moderate right-sided pleural effusion with parenchymal opacity which could probably be explained by compressive atelectasis, although pneumonia is an additional differential consideration. 2. Similar left lower lung opacity which is a more chronic finding. [**2142-12-28**]: INDICATION: CBD stricture of unclear etiology. Evaluate for pancreatic mass. COMPARISON: CT of the abdomen [**2142-12-23**] and ERCP [**12-23**], [**2142**]. TECHNIQUE: Multidetector helical scanning of the abdomen was performed prior to and following the administration of 200 cc of IV Optiray contrast. Coronal, sagittal, volume-rendered and MIP reformats were displayed. CTA OF THE ABDOMEN: Left lower lobe bronchiectasis and small bilateral pleural effusions are unchanged from prior exam. There is pneumobilia and a common bile duct stent in place traversing the mid CBD stricture seen on ERCP. There is no soft tissue surrounding the CBD to definitively suggest a biliary malignancy. There is mild intrahepatic biliary ductal dilation. There is an 8-mm low-density lesion within segment V/VI of the liver (3A:43), which is too small to characterize but likely a cyst. No intrahepatic lesions. The portal vein is patent. The hepatic arterial anatomy is conventional. The pancreas enhances homogeneously and there is no evidence of a pancreatic mass. The superior mesenteric artery and vein are patent and normal in caliber and course. There is a prominent 12 mm portal hilar lymph node (3B:110), likely reactive. There is also a 13-mm precaval node (3B:119). The spleen, gallbladder, and adrenal glands are normal. The kidneys enhance and excrete contrast symmetrically with multiple subcentimeter hypoattenuating lesions which are too small to characterize but likely cysts. A 16-mm exophytic fat-containing left renal lesion is consistent with an angiomyolipoma (3A:66). There is a left extrarenal pelvis. No ascites. No mesenteric adenopathy. The small bowel loops are normal. There are moderately extensive colonic diverticula. The bones are mildly osteopenic and there are degenerative changes, however, no concerning lytic or sclerotic lesions. IMPRESSION: Mild biliary dilation and stent within the CBD, with no pancreatic or biliary mass identified. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 18394**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18395**] DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**] Approved: SAT [**2142-12-29**] 10:56 PM Brief Hospital Course: This is a 72 year-old female with a who presented with acute cholangits and was transfered for a ERCP and surgery evalaution. # Acute Cholangitis: Pt has elevated LFTs and bili with RUQ pain and fever of 102.9 at OSH. She was transfered for ERCP and surgery eval. Pt had appearance of sepsis due to WBC from 9.4 with 56% bands at OSH to WBC of 31.3 and 30% bands in [**Hospital1 18**] ER and fevers. ERCP showed stone obstruction with drainage of pus, and stent was placed. Pt was admitted to the [**Hospital Unit Name 153**] post procedure and remained NPO. Her LFTs started to down trend post ERCP. 2 hours post ERCP she developed some hypotension with BP dropping from mid 90s to 70s. She was mentating and making urine. She was given IVF bolus with LR and her BP improved to 90-100. She was given IVF as needed to maintain UO and SBP>90. She had no further abd pain post procedre. She continued on tx with unasyn. [**2142-12-23**] OSH blood cx are growing GNR 2/4 bottles as of [**2142-12-24**] at 9AM. She was transferd to the SICU per request of the surgery team. # CBD Stricture: On ERCP pt was found to have a stricture of unclear cause. She then had a pancreatic protocol CTA, which showed Mild biliary dilation and stent within the CBD, with no pancreatic or biliary mass identified. # Cholelithiasis: Following ERCP and sphincterotomy with stone extraction, pt clincally stabilized and her LFTs gradually returned to [**Location 213**]. At this point, she was taken to the operating room for definitive management of her cholelithiasis. Pt was found to have acute suppurative cholecystitis and laproscopic cholecystectomy was performed. She recovered uneventfully from this procedure. # Atrial fibrillation: She developed RAF to 150 on [**2142-12-25**] and was given IV lopressor and subsequently Diltiazem with conversion to NSR. No further episodes. # Possibe PNA: no clear resp sx or hypoxia. CT Abd showed some lower lung fields with pulm bronchiectasis, which may expalin the ER findings on her CXR. She has a 3 liter oxygen requirment which is likely from IVF given in setting of sepsis. Following transfer to the Surgical floor she continued to make good progress. She remained free of any arrhythmias and was gradually weaned off of oxygen with adequate saturations. She was up and ambulating independently and voiding without difficulty. Her diet was gradually advanced to regular and well tolerated. Medications on Admission: Multivitamin Discharge Medications: 1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 2 days. Disp:*6 Tablet(s)* Refills:*0* 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 3. multivitamin Tablet Sig: One (1) Tablet PO once a day. 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*25 Tablet(s)* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: Take while using oxycodone to avoid constipation. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: cholangitis choledocholithiasis gram negative bacteremia paroxsymal atrial fibrillation 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 abdominal pain due to a stone in your bile duct. You underwent ERCP with stent placement. * You had a surgery and your gallbladder was removed. * You should continue to eat a regular diet and stay well hydrated. * Take the antibiotics as prescribed. * You had an irregular heartbeat for a short time when you were in the ICU. It normalized with a medication called lopressor. You will continue that until Dr. [**Last Name (STitle) 39288**] evaluates you in thge office. * If you develop any more abdominal pain or any other symptoms that concern you, please call your doctor or return to the Emergency Room. * You will need to have the stent removed later on. Please call the number below to schedule an appointment. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also 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. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**12-27**] weeks. Call the GI unit at [**Telephone/Fax (1) 1983**] to schedule an appointment for a repeat ERCP with stent removal in 3 weeks. Call Dr. [**Last Name (STitle) 39288**] for a follow up appointment in 2 weeks.

Admission Date: [**2185-4-17**] Discharge Date: [**2185-5-2**] Date of Birth: [**2185-4-17**] Sex: F Service: Neonatology HISTORY: [**First Name4 (NamePattern1) 14552**] [**Known lastname **], twin #2, was born at 34-2/7 weeks gestation to a 40-year-old gravida 3, para 2 now four woman by spontaneous vaginal delivery. The mother's prenatal screens were blood type O+, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, and group B Strep unknown. This pregnancy was achieved in-[**Last Name (un) 5153**] fertilization resulting in dichorionic-diamniotic twin. The mother received betamethasone at 23 weeks gestation due to cervical shortening. The pregnancy was also complicated with hypertension and urinary tract infection x2 with an unknown organism, and mother was also a chronic smoker. The labor ensued after spontaneous rupture of membranes 12 hours to delivery of twin #1. This twin emerged vigorous. Apgars were eight at one minute and eight at five minutes. The birth weight was 2,125 grams, the birth length 44.5 cm, and the birth head circumference 31.5 cm. All parameters in the 25-50th percentile for gestational age. ADMISSION PHYSICAL EXAM: Reveals a vigorous preterm infant. Anterior fontanel is soft and flat. Sutures are proximated. Positive bilateral red reflex. Mild subcostal-intercostal retractions, and some positive grunting. Breath sounds are equal. Heart was regular, rate, and rhythm, no rhythm. Pink and well perfused. Soft abdomen with positive bowel sounds, three vessel umbilical cord. Normal preterm female genitalia, femoral pulses +2, and a nonfocal neurological examination. HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant initially had some grunting flaring and retracting which resolved by a few hours of life. She had some occasional episodes of desaturation in the first two days of life, and has had no further apnea, bradycardia, or desaturation. On examination, her respirations are comfortable. She has always remained on room air throughout her NICU stay. Cardiovascular: The infant has remained normotensive throughout her NICU stay. There are no cardiovascular issues. Fluids, electrolytes, and nutrition: At the time of discharge, her weight is 2,180 grams, her length is 45 cm, and her head circumference is 31.5 cm. Enteral feeds were begun on day of life #1 and advanced without difficulty to full volume feeding by day of life #2. At the time of discharge, she is eating on an adlib schedule of 24 calories/ounce of breast milk or Enfamil and breast feeding when the mother is present. Gastrointestinal: She had one bilirubin drawn on day of life #3 that was total 6.4 and direct 0.3. She never required phototherapy. Hematology: At the time of admission, the hematocrit was 46.8. She has never received any blood product transfusion during her NICU stay. Infectious disease: [**Doctor First Name 14552**] was started on ampicillin and gentamicin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours when the blood cultures were negative, and the infant was clinically well. Neurology: There are no neurological issues. Audiology: Hearing screening was performed with automated auditory brain stem responses, and the infant passed in both ears. Psychosocial: Parents were very involved in the infant's care throughout their NICU stay. The infant is being discharged in good condition home with her parents. PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] in [**Hospital1 1562**], telephone #[**Telephone/Fax (1) 49156**]. CARE AND RECOMMENDATIONS AFTER DISCHARGE: 1. Feedings: 24 calories/ounce of breast milk or Enfamil and breast feeding to maintain consistent weight gain. MEDICATIONS: 1. Iron sulfate (25 mg/ml of elemental iron) 0.2 cc po q day. The infant has passed the car seat oxygenation test. State newborn screens were sent on [**4-21**] and [**2185-5-1**]. The infant has not yet received any immunizations in our attempt to keep the twins on the same immunization schedule and her twin has not yet reached the 2 kg weight recommendation for the first hepatitis B vaccine. RECOMMENDED IMMUNIZATIONS: 1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with plans for daycare during RSV season, with a smoker in the household, or with preschool siblings, or 3) with chronic lung disease. 2. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENTS FOR THIS INFANT: 1. The [**Hospital6 407**] of [**Hospital3 **], telephone #1-[**Telephone/Fax (1) 46331**]. 2. Lactation consultant at the Learning Center at [**Hospital1 **], telephone #[**Telephone/Fax (1) 47507**]. DISCHARGE DIAGNOSES: 1. Prematurity at 34-2/7 weeks. 2. Twin #2. 3. Status post transitional respiratory distress. 4. Sepsis ruled out. [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**] Dictated By:[**Last Name (NamePattern1) 37333**] MEDQUIST36 D: [**2185-5-2**] 15:03 T: [**2185-5-2**] 06:58 JOB#: [**Job Number 49158**]

Admission Date: [**2199-12-3**] Discharge Date: [**2199-12-19**] Date of Birth: Sex: M Service: CHIEF COMPLAINT: Hypoxia HISTORY OF PRESENT ILLNESS: This is a 33 year old male with no significant past medical history who initially presented to the [**Company 191**] Outpatient Clinic on [**11-27**] with four days of high fevers (103 degrees F), nonproductive cough, malaise, diffuse myalgias, mild resting dyspnea, no exposure to ill contacts. On [**2199-11-27**] his vital signs in the office were temperature 99.5, blood pressure 120/85, heartrate 113 and respiratory rate 20, oxygen saturation 89% on room air. Weight was 238 lbs. Nonspecific pulmonary examination was appreciated at the time. He was prescribed Levaquin 500 mg p.o. q.d. and discharged to home. He represented to his outpatient [**Hospital 191**] Clinic on [**2199-12-3**] complaining of persistent fever to 102 degrees F, weakness, bilious emesis, worsening dyspnea, and nonproductive cough. Vital signs in the office were temperature 97.3, blood pressure 108/70, respiratory rate 20, heartrate 108, oxygen saturation 70% on room air. No wheezes were noted on examination. He was given 1 gm of Ceftriaxone and sent to the Emergency Department where he received normal saline and 1 gm of Vancomycin. He denied pleuritic chest pain. He has no risk factors for human immunodeficiency virus. He denies a history of seizure disorder, alcohol use, recent somnolence, or symptoms of gastroesophageal reflux disease. He was transferred to the Intensive Care Unit on arrival. PAST MEDICAL HISTORY: No significant past medical history or surgical history. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Levofloxacin 500 mg p.o. q.d. SOCIAL HISTORY: Originally from [**Male First Name (un) 1056**]. A bus driver, lives with his wife and daughter, no alcohol, no elicit drug use. Rare alcohol use. FAMILY HISTORY: Father had diabetes mellitus. PHYSICAL EXAMINATION ON ADMISSION: General, moderately obese, sitting up in bed, no accessory muscle use. Vital signs, temperature 99.0, heartrate 92, blood pressure 137/74, respiratory rate 16, oxygen saturation 100% on 100% nonrebreather. Head, eyes, ears, nose and throat, pupils equal, round and reactive to light, extraocular muscles intact, anicteric, oropharynx clear, fair dentition. Neck, no lymphadenopathy. Chest, rhonchi, right greater than left, no crackles, no wheezes. Normal I to E ratio, no egophony, no fremitus, no dullness to percussion. Cardiac, regular rate and rhythm, no murmurs, rubs or gallops. Abdomen, obese, normoactive bowel sounds, nontender, nondistended, no masses. Neurological, cranial nerves II through XII grossly intact. Alert and oriented times three. Conversant appropriately. Strength 5/5 in all extremities. LABORATORY DATA: Laboratory findings on admission revealed white blood cell count 8.4, 73% neutrophils, 0 bands, 19 lymphocytes, 6 monocytes, hematocrit 43.8, platelets 104, MCV 83, RDW 13.0, sodium 137, potassium 3.4, chloride 92, bicarbonate 29, BUN 13, creatinine 0.8, glucose 129. Arterial blood gases on 100% nonrebreather, PH 7.49, carbon dioxide 39, oxygen 77. Imaging: [**2199-11-27**], chest x-ray, normal, no acute cardiopulmonary process. Chest x-ray [**2199-12-3**], (on admission), patchy right upper lobe, right middle lobe infiltrate and diffuse right greater than left interstitial pattern, normal mediastinum, no effusion. HOSPITAL COURSE: A 33 year old male with no past medical history originally admitted to the Intensive Care Unit with hypoxia, bilateral pneumonia, received Ceftriaxone and Azithromycin, and then Doxycycline was added since he had a parakeet at home (he also has rats at home). He underwent a bronchoscopy and had a computed tomographic angiography of the thorax which demonstrated right middle lobe and right lower lobe pulmonary emboli with a question of infarction. He was subsequently heparinized. His human immunodeficiency virus test was negative. He received Bactrim and steroids for a few days but were stopped when his human immunodeficiency virus test came back negative. A hypercoagulability workup was pending when he arrived on the floor in stable condition. On arrival to the floor he was clinically improving on the heparin drip, Ceftriaxone, Azithromycin, and Doxycycline. The further studies that were obtained while in the Intensive Care Unit included [**First Name8 (NamePattern2) **] [**Doctor First Name **] which was negative, an ANCA which was negative, hepatitis panel which was negative. LENIS demonstrated no deep vein thrombosis, a thrombosis of the right lesser saphenous vein, echocardiogram was obtained as well on [**12-6**], that demonstrated an ejection fraction of 50%, a mildly dilated right ventricle and mild tricuspid regurgitation. The chest computerized tomography scan mentioned above was on [**12-4**] and that demonstrated multiple small pulmonary emboli (right lower lobe and right middle lobe) and bilateral atypical pneumonias. Workup for the organism of said pneumonia was undertaken. He had negative viral culture, negative Chlamydia, negative leptospirosis, negative C. Psittaci and negative mycoplasmas. Blood cultures were negative as well. He was maintained on Azithromycin and completed a 14 day course for his pneumonia. The Doxycycline was withdrawn. He completed a ten day course of Ceftriaxone. Regarding the pulmonary emboli, he remained hemodynamically stable on a heparin drip throughout his admission. A repeat computerized tomography scan of the thorax demonstrated bilateral expanded heterogenous soft tissue densities within the rectus abdominis muscle ? hematomas, partial resolution of bilateral perihilar ground-glass opacities, left SVC, however, no pulmonary emboli. Given the discrepancy between the [**12-4**] and [**12-11**], computerized tomography scans, it would be very difficult to prove that there were no pulmonary emboli on the [**12-4**] film. The decision to anticoagulate him for three to six months and then to pursue further evaluation was made. Regarding his anticoagulation workup, the patient had a positive anticardiolipin IgM (46.9). This is an intermediate range value. The IgG anticardiolipin value was 1.6. The patient had a normal PTT on admission. While we can not make the diagnosis of anticardiolipin syndrome on a single value, the finding stands as nonspecific, however, the anticardiolipin panel will have to be repeated in six weeks. The patient was subsequently continued on anticoagulation for pulmonary emboli. His heparin drip was discontinued by discharge where he was bridged to Coumadin with Lovenox. Regarding the rectus hematomas noted on computerized axial tomography scan, this finding is commonly seen in the setting of anticoagulation. The patient concurrently had fevers maximally to 101 degrees F. There was concern perhaps the fevers may be attributable to the hematoma or a local infection thereabouts. He was started on Clindamycin in conjunction with the Infectious Disease Consult Service's recommendations. He completed a ten day course of Clindamycin. Finally, the patient was noted to have a drop in his hematocrit during his anticoagulation. He was guaiac negative. There was no other source for bleed identified. It is likely he bled into the abdominal hematoma attributing for the drop in hematocrit. The patient was also intermittently hyponatremic during his stay, likely secondary to syndrome of inappropriate antidiuretic hormone secondary to the thoracic processes (namely bilateral pneumonia, pulmonary embolisms) on this admission. DISCHARGE DIAGNOSIS: 1. Bilobar pneumonia with atypical fevers 2. Pulmonary embolus 3. Rectus hematoma 4. Anticardiolipin antibody IgM positive 5. Hyponatremia 6. Anemia FOLLOW UP: The patient will follow up with his primary provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] the week following discharge. MEDICATIONS ON DISCHARGE: He will be discharged on Lovenox bridge to Coumadin. He was also discharged on Clindamycin to complete his ten day course. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Name8 (MD) 17844**] MEDQUIST36 D: [**2200-5-7**] 17:14 T: [**2200-5-7**] 19:08 JOB#: [**Job Number **]

Admission Date: [**2140-11-11**] Discharge Date: [**2140-11-24**] Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a scheduled admission by aortic aneurysm repair. This is an 81 year old woman with a history of hypertension, who had recurrent pericarditis and pleuritis requiring percutaneous drainage in [**2137**]. An echocardiogram in [**2137-12-13**], showed normal left ventricular function with a dilated aortic root of 48mm, mildly thickened aortic valve with mild aortic regurgitation. Follow-up in [**2140-9-12**], with echocardiogram showed an ejection fraction of 60% with dilated aortic root at 55mm, mild aortic sclerosis, mild aortic regurgitation, and bilateral atrial enlargement. Cardiac catheterization done on [**2140-10-26**], showed an ejection fraction of 80% with normal wall motion, severe aneurysmal dilatation of the ascending aorta into the arch, recurrent dilatation in the descending aorta with no dissection, 1+ aortic regurgitation, normal coronaries. PAST MEDICAL HISTORY: 1. Hypertension. 2. Raynaud's disease. 3. Phlebitis. 4. Osteoporosis. 5. Tonsillectomy. 6. Spinal fusion. 7. Umbilical hernia repair. 8. Appendectomy. 9. Cholecystectomy. 10. Total abdominal hysterectomy. MEDICATIONS ON ADMISSION: 1. Metoprolol 100 mg twice a day. 2. Hydrochlorothiazide 25 mg once daily. 3. Lisinopril 10 mg once daily. 4. Enteric Coated Aspirin 81 mg once daily. 5. Centrum Silver one once daily. 6. Calcium 600 once daily. 7. Nexium 40 mg once daily. ALLERGIES: Stated allergy to Codeine which caused bad abdominal cramps and adhesive tape which causes a rash. SOCIAL HISTORY: The patient lives at home with her husband. [**Name (NI) 1139**] one half pack per day times eighteen years, quit forty-five years ago. Alcohol one drink per day, none times the past four weeks. PHYSICAL EXAMINATION: At the time of preadmission testing, the heart rate is 74 beats per minute, blood pressure 148/80, respiratory rate 18, oxygen saturation 96% in room air, height four feet eleven inches, weight 106 pounds. In general, she appears younger than stated age in no acute distress. Skin - no breaks or rashes. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Pharynx is clear. The neck is supple with no jugular venous distention, no bruits, carotid pulses are 2+ bilaterally. The chest is clear to auscultation bilaterally. The heart is regular rate and rhythm, no murmurs, rubs or gallops. The abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly, well healed surgical scars. Extremities without cyanosis, clubbing or edema. Left upper extremity with nodularity at old intravenous site near the left wrist. No varicosities in the lower extremities. Neurologically, the patient is alert and oriented times three, grossly intact. Pulses - femoral not indicated. Dorsalis pedis 1+ bilaterally. Posterior tibial not detected. Radial 2+ bilaterally. No carotid bruits bilaterally. HOSPITAL COURSE: As stated previously, the patient was a direct admission to the operating room on [**2140-11-11**], at which time she underwent a supracoronary ascending aortic graft with a resuspension of the aortic valve. Please see the operative report for full details. The patient tolerated the operation well and was transferred from the operating room to Cardiothoracic Intensive Care Unit. Circ arrest time was eleven minutes. At the time of transfer, the patient had Milrinone at 0.4 mcg/kg/minute, Amiodarone at 1 mg per minute, Neo-Synephrine no dose indicated and Propofol, also no dose indicated. The patient did well in the immediate postoperative period. Her anesthesia was reversed. She was weaned from the ventilator. In the morning of postoperative day one, she was successfully extubated. On postoperative day number one, her cardioactive medications were begun to be weaning beginning with Amiodarone and Milrinone. By postoperative day two, the patient was maintained with minimal amounts of Amiodarone, Milrinone and Nipride. On postoperative day two, the patient's Milrinone was discontinued. Her Amiodarone was changed to p.o. Her Nipride was discontinued with initiation of beta blockade. Her chest tubes were removed. She was maintained in the Cardiothoracic Intensive Care Unit for monitoring of her hemodynamic and pulmonary status. On postoperative day three, the patient continued to do well. She remained hemodynamically stable. She was transferred from the Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 121**] Two for continuing postoperative care and cardiac rehabilitation. Once on the floor, it was noted that the patient had gone into sustained atrial fibrillation with a heart rate of 100 to 110, hemodynamically tolerated well. She was seen by the electrophysiology service and was maintained on her p.o. Lopressor as well as her p.o. Amiodarone and continued to be monitored on the floor. Over the next two days, the patient was in and out of atrial fibrillation. She remained hemodynamically stable throughout these periods. On postoperative day five, it was noted that the patient had a drop in her hematocrit with guaiac positive stools. She was seen by the gastroenterology service. At that time, she was also transferred back to the Cardiothoracic Intensive Care Unit for close monitoring. The patient underwent a KUB which was read as normal. She also had stools sent for Clostridium difficile which were negative. She was empirically started on Flagyl at that time. The patient remained in the Intensive Care Unit for the next several days to monitor her gastrointestinal status to make sure that she had no further guaiac positive stools. On postoperative day seven, she was again transferred to the floor for continuing postoperative care. Prior to transfer from the Intensive Care Unit, it was noted that the patient had some left upper extremity swelling. She underwent ultrasonography of her upper extremities at that time to rule out a thrombosis. Ultrasound showed a right internal jugular and cephalic thrombus. Following transfer, the vascular service was consulted and they recommended oral anticoagulation with Coumadin, which was begun at that time. Over the next several days, with the exception of intermittent atrial fibrillation, the patient had an uneventful hospital course. She was again seen by the electrophysiology service given her episodes of atrial fibrillation, the last episode lasting greater than 24 hours. The patient was additionally begun on Heparin given the duration of this episode of atrial fibrillation. The patient was scheduled for a direct current cardioversion, however, prior to cardioversion, the patient spontaneously converted to normal sinus rhythm. On postoperative day twelve, it was decided that if the patient remained in a rate controlled rhythm for the next 24 hours, she would be stable and ready to be transferred to rehabilitation. At the time of this dictation, the patient's physical examination is as follows; vital signs revealed temperature 98.2, heart rate 71, sinus rhythm, blood pressure 147/68, respiratory rate 20, oxygen saturation 98% in room air. Weight preoperatively was 50 kilograms and at transfer to rehabilitation is 53 kilograms. Laboratory data on [**2140-11-23**], white blood cell count 11.7, hematocrit 34.5, platelet count 219,000. Prothrombin time 15.0, partial thromboplastin time 25.0 with Heparin off. INR is 1.5. Sodium is 129, potassium 4.8, chloride 95, CO2 29, blood urea nitrogen 16, creatinine 0.8, glucose 183. The patient is alert and oriented times three, moves all extremities, follows commands. Respiratory revealed scattered rhonchi. Cardiac is regular rate and rhythm with no murmur. The sternum is stable and incision with Steri-strips open to air, clean and dry. The abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities are warm and well perfused with no edema. Right upper arm with minimal edema which has been resolving over the last several days. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. twice a day. 2. Amiodarone 200 mg p.o. three times a day times one week and then 200 mg p.o. once daily times one month. 3. Metoprolol 100 mg twice a day. 4. Lasix 20 mg once daily times ten days. 5. Potassium Chloride 20 meq once daily times ten days. 6. Prilosec 40 mg p.o. once daily. 7. Heparin 600 units per hour to keep partial thromboplastin time 40 to 60 until INR is therapeutic. 8. Warfarin to maintain an INR between 2.0 and 2.5. The patient received 2 mg of Coumadin two days prior to discharge and no Coumadin on one day prior to discharge and 2 mg of Coumadin on the night before discharge. We will check the INR in the morning and dose Coumadin on the day of transfer to rehabilitation center. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Status post supracoronary ascending aortic graft with a resuspension of the aortic valve. 2. Hypertension. 3. Raynaud's disease. 4. Phlebitis. 5. Osteoporosis. 6. Status post tonsillectomy. 7. Status post spinal fusion. 8. Status post umbilical hernia repair. 9. Status post inguinal hernia repair. 10. Status post appendectomy. 11. Status post cholecystectomy. 12. Status post total abdominal hysterectomy. DISCHARGE STATUS: The patient is to be discharged to [**Location 50742**]. FO[**Last Name (STitle) **]P: She is to have follow-up with Dr. [**First Name (STitle) **] in two to three weeks and follow-up with Dr. [**Last Name (STitle) 1159**] in one month and follow-up with Dr. [**Last Name (Prefixes) **] in one month. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2140-11-23**] 16:44 T: [**2140-11-23**] 18:31 JOB#: [**Job Number 50743**]

Admission Date: [**2164-4-23**] Discharge Date: [**2164-4-27**] Date of Birth: [**2096-1-7**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: [**2164-4-23**] Coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery and the obtuse marginal artery. History of Present Illness: 68 year old male has a history of an MI about 25 years ago. He has been treated with medication since then. He has been doing well over the years until about 3 weeks ago when he started to notice some diaphoresis, shortness of breath and right sided chest discomfort that has occurred with exertion such as yard work or taking out the trash. His symptoms resolve with rest. He also had one episode of chest pain, diaphoresis and back pain that occurred at rest after a large meal. This episode lasted a little longer than the other episodes and prompted the patient to contact Dr. [**Last Name (STitle) 1270**]. He was sent for a stress echo which was abnormal and referred for a cardiac catheterization. He is was found to have three vessel disease and is now being referred to cardiac surgery for revascularization. Past Medical History: diabetes type II -diagnosed [**2160**]; controlled on oral agents hyperlipidemia hypertension MI [**2138**] psoriasis Social History: Race:Caucasian Last Dental Exam:[**1-/2164**] Lives with:Wife Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 90854**] Occupation:Retired from the FDA as a field investigator and consultant Cigarettes: Smoked no [] yes [x] Hx:smoked 2ppd for 28 years and quit [**2138**] Other Tobacco use:denies ETOH: < 1 drink/week [x] [**12-27**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- unknown-adopted Physical Exam: Pulse:61 Resp:16 O2 sat:100/RA B/P Right:138/86 Left:135/74 Height:6'2" Weight:230 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] _____ Varicosities: (L)LE superficial varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit -none appreciated, pulses Right:2+ Left:2+ Pertinent Results: [**2164-4-23**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to distal inferoseptal and anteroseptal walls. Overall left ventricular systolic function is mildly depressed (LVEF= 50-55 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is in sinus rhythm. The patient is on no inotropes. Biventricular function is unchanged. Mitral regurgitation is unchanged. The aorta is intact post-decannulation. [**2164-4-27**] 04:44AM BLOOD WBC-11.7* RBC-3.00* Hgb-9.8* Hct-28.3* MCV-94 MCH-32.5* MCHC-34.5 RDW-14.0 Plt Ct-323 [**2164-4-27**] 04:44AM BLOOD Plt Ct-323 [**2164-4-27**] 04:44AM BLOOD Glucose-121* UreaN-22* Creat-1.0 Na-139 K-3.8 Cl-102 HCO3-28 AnGap-13 [**2164-4-27**] 04:44AM BLOOD Mg-2.3 COMPARISON: [**2164-4-25**] at 10:45 a.m. FINDINGS: As noted previously, there is a similar-sized left apical pneumothorax. The left chest tube has been removed in the interim. Left basilar atelectasis remains. The cardiac silhouette and mediastinal contours are unchanged. Median sternotomy wires are unchanged. IMPRESSION: Unchanged small left apical pneumothorax, status post left chest tube removal. Brief Hospital Course: Mr. [**Known lastname **] 68 yr old male with history of MI developed worsening chest pain, underwent cath which revealed significnat CAD. He was seen by the cardiac surgery service and accepted for CABG. He was a same day admit and on [**4-23**] was brought directly to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. He was weaned from Neo overnight and was started on beta-blocker POD#1. He was diuresed towards his preoperative weight. POD#1 he transferred to the step down unit for further monitoring. He continued to progress well on the floor. Physical Therapy was consulted for evaluation of his strength and mobility. The remainder of his postop course was essentially uneventful. He was cleared for discharge to home with VNA services on POD#4. Follow-up appts arranged. Medications on Admission: ATENOLOL 50 mg Daily LIPITOR 20 mg Daily PLAVIX 75 mg Daily (started on [**2164-4-14**]), LD [**4-17**] DILTIAZEM HCL 240 mg Daily ENALAPRIL MALEATE takes 10mg qam, 5mg qhs HYDROCHLOROTHIAZIDE 25 mg Daily METFORMIN 1,000 mg [**Hospital1 **] NITROGLYCERIN 0.4 mg Tablet PRN Aspirin 325mg Daily Centrum Silver Multivitamin 1 tablet daily Discharge Medications: 1. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 2 weeks. Disp:*60 Tablet Extended Release(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). Disp:*1 * Refills:*2* 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: diabetes type II -diagnosed [**2160**]; controlled on oral agents hyperlipidemia hypertension MI [**2138**] psoriasis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Wound Check: [**2164-5-8**] 10:00 Surgeon: Dr. [**Last Name (STitle) **] on [**2164-5-31**] @ 1pm Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**] [**Telephone/Fax (1) 1144**] Date/Time:[**2164-5-15**] 10:30 **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2164-4-27**]

Admission Date: [**2115-2-22**] Discharge Date: [**2115-3-19**] Date of Birth: [**2078-8-9**] Sex: M Service: MEDICINE Allergies: Vicodin Attending:[**First Name3 (LF) 4891**] Chief Complaint: Post-cardiac arrest, asthma exacerbation Major Surgical or Invasive Procedure: Intubation Removal of chest tubes placed at an outside hospital R CVL placement History of Present Illness: Mr. [**Known lastname 3234**] is a 36 year old gentleman with a PMH signifciant with dilated cardiomyopathy s/p AICD, asthma, and HTN admitted to an OSH with dyspnea now admitted to the MICU after PEA arrest x2. The patient initially presented to LGH ED with hypoxemic respiratory distress. While at the OSH, he received CTX, azithromycin, SC epinephrine, and solumedrol. While at the OSH, he became confused and subsequently had an episode of PEA arrest and was intubated. He received epinephrine, atropine, magnesium, and bicarb. In addition, he had bilateral needle thoracostomies with report of air return on the left, and he subsequently had bilateral chest tubes placed. After approximately 15-20 minutes of rescucitation, he had ROSC. He received vecuronium and was started on an epi gtt for asthma and a cooling protocol, and was then transferred to [**Hospital1 18**] for further evaluation. Of note, the patient was admitted to LGH in [**1-4**] for dyspnea, and was subsequently diagnosed with a CAP and asthma treated with CTX and azithromycin. Per his family, he has also had multiple admissions this winter for asthma exacerbations. . In the [**Hospital1 18**] ED, 35.3 102 133/58 100%AC 500x20, 5, 1.0 with an ABG 7.16/66/162. He had a CTH which was unremarkable. He then had a CTA chest, afterwhich he went into PEA arrest. Rescucitation last approximately 10-15 minutes with multiple rounds of epi and bicarb, with ROSC. He was then admitted to the MICU for further management. . Currently, the patient is intubated, sedated, and parlyzed. Past Medical History: Asthma Dilated cardiomyopathy Multiple admissions for dyspnea this winter ([**1-26**]). Anxiety/depression CKD HLD Obesity HTN Social History: Unknown Family History: Unknown Physical Exam: ADMISSION: VS: 35.9 124 129/67 99% AC 480x24, 5, 1.0 Gen: ETT in place, intubated, sedated. HEENT: ETT in place. CV: Tachy S1+S2 Pulm: Poor air movement bilaterally. Diffuse wheezes bilaterally. Abd: S/D hypoactive BS Ext: 1+ edema bilaterally Neuro: Unresponsive. . Discharge: 98.5 102/65 76 20 95-98% RA In cage bed to prevent patient from falling out of bed. Occasionally calling out. Lungs clear without wheezes. Pertinent Results: Labs on Admission: [**2115-2-22**] 08:50AM BLOOD WBC-19.5* RBC-4.76 Hgb-14.9 Hct-44.3 MCV-93 MCH-31.4 MCHC-33.7 RDW-12.9 Plt Ct-201 [**2115-2-22**] 08:50AM BLOOD PT-14.1* PTT-25.9 INR(PT)-1.2* [**2115-2-22**] 08:50AM BLOOD Glucose-306* UreaN-21* Creat-1.2 Na-144 K-4.1 Cl-111* HCO3-28 AnGap-9 [**2115-2-22**] 08:50AM BLOOD Albumin-3.4* Calcium-6.2* Phos-5.5* Mg-2.2 [**2115-2-22**] 09:32AM BLOOD calTIBC-320 Ferritn-1129* TRF-246 [**2115-2-22**] 07:17AM BLOOD Type-ART pO2-162* pCO2-66* pH-7.16* calTCO2-25 Base XS--6 Intubat-INTUBATED . Labs on Discharge [**2115-3-18**] 11:34AM BLOOD Type-ART pO2-95 pCO2-33* pH-7.54* calTCO2-29 Base XS-5 Intubat-NOT INTUBA [**2115-3-5**] 05:35AM BLOOD ALT-49* AST-23 AlkPhos-53 TotBili-0.9 [**2115-3-19**] 04:45AM BLOOD Glucose-73 UreaN-25* Creat-1.4* Na-133 K-4.1 Cl-95* HCO3-21* AnGap-21* [**2115-3-19**] 04:45AM BLOOD WBC-12.4* RBC-4.47* Hgb-14.3 Hct-41.3 MCV-93 MCH-32.0 MCHC-34.6 RDW-13.3 Plt Ct-352 [**2115-3-19**] 04:45AM BLOOD Neuts-56 Bands-0 Lymphs-38 Monos-3 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 . CXR (in MICU): Mr read - cardiomegaly, RIJ in SVC, ETT 4.5 cm above carina. Blunting of costophrenic angles bilaterally with low lung volumes. Loss of retrocardiac diagphragm and bilateral opacities (L>R) . CXR: 1. NG tube at 7.2 cm above the carina. [**Month (only) 116**] consider advancing for optimal placement. 2. Severe cardiomegaly with globular shape. In the absence of prior comparison, the differential is broad, including moderate pericardial effusion, mediastinal hemorrhage, or acute cardiac failure. Recommend clinical correlation. . CTH: My read, no acute bleed . CTA Chest: 1. No evidence of pulmonary embolism, although evaluation of subsegmental branches is limited. 2. Moderate cardiomegaly without pericardial effusion. 3. Bilateral dependent atelectasis. 4. Multiple nondisplaced rib fractures on the right, some of which are subacute. Also possible subtle nondisplaced fractures of the left ribs. 5. Nondisplaced acute sternal fracture in addition to a subacute nondisplaced sternal fracture. . TTE: The left atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. LV systolic function appears depressed (ejection fraction ? 30 percent) with regional variation. There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . ECG (post-arrest): Sinus with 1:1 conduction. LAA. LAD, RBBB, LAFB. STD in V4-V6. . ECG (pre-arrest): Sinus with 1:1 conduction. LAD, bifascicular block. No lateral STD. . ECG (OSH, unclear pre/post arrest): Sinus with 1:1 conduction. Bifascicular (RBBB, LAFB) block. STD in V5-6. . EEG [**2-27**] IMPRESSION: This is an abnormal video EEG telemetry due to the slow and disorganized background of 6.5 Hz with bursts of generalized slowing that showed no clear reactivity. These findings indicate a severe encephalopathy. This may be consistent with the patient's history of anoxia; however, toxic/metabolic disturbances, infection, and medication effects are also among the most frequent causes of encephalopathy. No clear epileptiform discharges or seizures were seen. LUMBAR SPINE [**2115-3-11**] CLINICAL INFORMATION: Evidence of fracture, seizure, fall, low back pain. FINDINGS: Three views of the lumbar spine demonstrate mild narrowing of the left femoroacetabular joint. There is mild scoliosis of the thoracolumbar spine. The ventricular lead of a pacemaker is identified. No fracture of L2 through L5 is identified. However, there is a compression fracture of L1, with compression of the superior endplate, and a sclerotic fracture line. Given the mechanism of fall, if there is acute pain referable to L1, then this would be considered an acute finding. There is no apparent retropulsion of the posterior margin of L1 into the spinal canal. No other fractures are identified at this time. Facet joints are aligned. There is early calcification of the aorta. IMPRESSION: Compression fracture of L1 with anterior wedge deformity, likely an acute finding. No other fractures identified. EKG: Normal sinus rhythm. Complete right bundle-branch block with left anterior fascicular block. Diffuse ST-T wave changes laterally. CT Head: COMPARISON: [**2115-2-22**]. TECHNIQUE: Non-contrast axial images were obtained through the brain. FINDINGS: There is no intracranial hemorrhage, edema, or loss of [**Doctor Last Name 352**]/white matter differentiation. Ventricles and sulci are normal in size and configuration. The basilar cisterns are not compressed. Paranasal sinuses demonstrate fluid in the sphenoid air cells and right posterior ethmoid air cell, likely related to prolonged hospitalization. Mastoid air cells are well aerated. IMPRESSION: No evidence of acute intracranial abnormalities. Brief Hospital Course: Mr. [**Known lastname 3234**] is a 36 year old gentleman with a PMH signifciant with dilated cardiomyopathy s/p AICD, PE not on anticoagulation, asthma, and HTN admitted to an OSH with dyspnea now the transferred to [**Hospital1 18**] MICU after PEA arrest x2. # PEA arrest and subsequent anoxic brain injury.: Suspect that original OSH PEA arrest due to hypoxemia or acidosis, with [**Hospital1 18**] ED PEA arrest due to acidosis with admission pH 7.16 on arrival. TTE with evidence of RV failure to suggest PE. LVEF 30% with known dilated cardiomyopathy. He was cooled per protocol. Initially, his EEG was concerning without evident brain activity. On hospital day 3, there was only comatose activity and his prognosis was guarded. However, the patient was able to be weaned off the vent and over the course of the next three days his mental status improved. He was alert, oriented to place and day of the week and moving all 4 extremities. He became more interactive on transfer to the floor, was initially speaking in spanish and English and not always making sense but then started responding more appropiately and following commands. On hospital day 11 he had a witnessed grand mal seizure and was given ativan and started on Keppra with neurology consult. His mental status was worse for 24 hours after the seizure but then he slowly returned to his recent baseline. He was somewhat aggitated so his Keppra was switched to Topiramate. He had a subsequent seizure on [**3-18**] with LUE tonic clonic activity and impaired consciousness but this resolved spontaneously after 1-2 minutes. He was contineud on topamax per neuro recommendations. OT and PT were consulted and worked with the patient as he will likely require a long rehabilitation course. At the time of discharge the patient was alert, oriented (though not always to date), following commands but impulsive with poor motor planning leading to several falls. Neurology notes indicate the patient has the potential toimprove from a neurologic standpoint. He also may have recurrent seizures which should be treated with ativan IV or IM and do not neccessarily indicate patient needs to return to hospital unless they continue for greater than 5 minutes or he has multiple recurrent seizures or complications such as aspiration. -patient will be on Topiramate 25mg PO BID until [**3-22**] PM then increase to 50mg po BID for seven days then increase to 75mg [**Hospital1 **] ongoing. -patient will follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) **] in his s/p arrest neurology clinic -patient will require intensive PT and OT in an anoxic brain injury unit. . # Respiratory failure: Believed to be due to status asthmaticus, although inciting event unclear. [**Name2 (NI) 227**] multiple cardiac arrests, also a concern for development of ARDS. The patient was initially treated broadly with vancomycin, cefepime, flagyl, cipro, and oseltamavir. He was treated with IV soludemedrol and albuterol MDI. He was ventialted according to ARDS-Net protocol. On admission, he had two chest tubes placed for pneumothoraces. They were removed on hospital day 1. In his first several days, his respiratory status was comprimised by lobar collapse, first of the RUL and then of the RML. His extubation was initially limited both by agitation requiring sedation and by requirements for high PEEP to maintain oxygenation. His oxygenation was improved with diuresis and agitation was better controlled with seroquel. He was extubated on [**3-1**] and respiratory status was stable. His Asthma was treated with standing and PRN albuterol and ipratriopium and a slow prednisone taper which he l completed on [**2115-3-18**] and he was restarted on Advair -patient may require additional nebs on top of his standing advair though his respiratory status has been very stable, without wheezing for the last week. - would like benefit from outpatient PFTs and is scheduled to see a pulmonologist in follow up. . # Ventilator associated pneumonia: Patient developed a fever on [**2-27**] with new infiltrates on chest xray while intubated. He was initially covered with vanc/cefepime and cipro. Cipro was eventually discontinued. He did not grow any organisms other than yeast in his sputum. He completed an 8 day course of Vanco/Cefepime. . # Myoclonus: when mental status improved, was noted to have myoclonic jerks. per neurology, likely [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Syndrome which is anoxic injury to the purkinje cells. These jerks continued for about one week and then became rare. . # dilated [**Last Name (LF) 89982**], [**First Name3 (LF) **] 30%. s/p ICD. Patient was diuresed with IV lasix in the ED and then transitioned to PO lasix, home dose, on the floor. His respiratory status remained stable. Also continued on home dose of carvedilol and Lisinopril but ACE downtitrated from 40 to 20 when had elevated Cr 1.9 on [**3-18**] and slightly low BPs high 90s/60s. BP improved to 100s/60s. . #Hypertension: Patient's home regimen was continued on the floor, but his SBP dipped into the high 80s and low 90s so lisinopril was decreased to 20mg po daily and his SBP remained 100-130. . # L1 compression fracture: After the patient fell, he was complaining of low back pain so a L-spine Xray was performed and showed L1 compressin fracture with No cord impingement on imaging. The patient had no localizing deficits on serial neuro exam. He was treated with pain medication including low dose ultram, standing tylenol and a lidocaine patch. Calcitonin was tried for pain with compression fracture but this did not seem to help with symptoms so was discontinued. . # Leukocytosis: WBC >20 persistently in the MICU even after being treated for infection. Since no new infection was found this was presumed [**12-26**] steroids and the leukocytosis improved with prednisone taper. WBC 12 on day of discharge . # Hyperglycemia: Patient is not known to be a diabetic and was felt [**12-26**] steroids, his sugars were controlled on sliding scale insulin in the hospital but he no longer had insulin requirements as his prednisone was tapered. . #. [**Last Name (un) **]: Cr 1.9 on [**3-18**] from 1.2 which improved to 1.4 on [**3-19**] with decreasing ACE and 500cc bolus. He should have repeat creatinine and labs on [**3-22**] to ensure stability. # Guardianship: Guardianship paperwork was started in the hospital. Medications on Admission: Carvedilol 25 [**Hospital1 **] Lasix 80 mg po bid Xanax 0.25 mg 1-2 tabs prn albuterol MDI Ibuprofen prn Benadryl prn Advair diskus Lsinopril 40 daily Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 4. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**11-25**] Tablet, Rapid Dissolves PO QHS (once a day (at bedtime)) as needed for sleep. 9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain/fever. 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on and 12 hours off every 24 hour period. 13. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours. 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for SOB. 16. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days: 1 [**Hospital1 **] until [**3-22**] PM then increase to 2 tablets [**Hospital1 **] for 7 days then 3 tablets [**Hospital1 **] ongoing. 17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for back pain. 18. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) inh Inhalation [**Hospital1 **] (2 times a day). 19. lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection twice a day as needed for seizure that last longer than 5 minutes. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Anoxic Brain Injury s/p PEA arrest x2 Status Asthmaticus Ventilator Associated Pneumonia Chronic Systolic Heart Failure L1 compression fracture Seizures after hypoxic brain injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane) because he has poor motor planning Discharge Instructions: You came to the hospital after having a cardiac arrest and an asthma exacerbation. You had another cardiac arrest in our hospital and were admitted to the MICU. You required intubation but were able to wean off the machine and breathe on your own. We treated you for pneumonia and asthma. Your mental status slowly improved, though you did have 2 seizures, last on [**3-18**]. You were started ons eizure medications for this. . Please take your medications as prescribed and follow up with your doctors [**Name5 (PTitle) 7928**]. Followup Instructions: Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2115-4-3**] at 1:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2115-4-3**] at 1:30 PM With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [**2115-4-11**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

Admission Date: [**2187-7-13**] Discharge Date: [**2187-7-23**] Date of Birth: [**2104-8-30**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillin V / Methyldopa Attending:[**First Name3 (LF) 165**] Chief Complaint: general malaise Major Surgical or Invasive Procedure: dental extractions [**2187-7-15**] redo sternotomy/AVR (#19 CE Magna)-[**2187-7-17**] History of Present Illness: 82 yo F s/p CABG [**2177**] now with severe AS and recent NSTEMI, preop for [**Hospital 1291**] transferred from [**Hospital3 **] with SOB, recurrent pulmonary edema. Past Medical History: Right carotid endarterectomy CABG at [**Hospital6 **] in [**2181**] (LIMA to LAD, SVG to RCA, SVG to first diagonal, SVG to OM2) NSTEMI in [**2187-5-1**] Renal insufficiency (baseline creatinine 1.5) Hypertension Severe Aortic stenosis Dementia Peripheral Vascular Disease Anemia (baseline hematocrit 32-34) Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: Her mother died of a heart attack at age 61. Her dad died of a CVA at age 47. Her sister has diabetes. She has a son who passed away. She had six miscarriages. Physical Exam: HR 64 RR 20 BP 129/44 NAD Lungs with scattered rales Heart RRR 3/6 SEM radiating to neck Extrem warm 62" 72 kg Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Resting bradycardia for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. A left atrial appendage thrombus cannot be excluded. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area 0.5 cm2). No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. There is a small left pleural effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the OR. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and was AV paced. 1. A well-seated bioprosthetic valve is seen in the mitral position with normal leaflet motion and gradients (mean gradient = 11 mmHg and cardiac output of 2.6 L/min). Trivial central aortic regurgitation is seen. 2. Regional and global left ventricular systolic function are normal. 3. Right ventricular systolic function post-bypass is moderately hypokinetic. 4. The intra-atrial septum is dynamic. 5. Aortic contours are intact post-decannulation. [**Known lastname **],[**Known firstname 24357**] L [**Medical Record Number 41597**] F 82 [**2104-8-30**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-7-19**] 2:14 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2187-7-19**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 41598**] Reason: ? ptx s/p ct removal [**Hospital 93**] MEDICAL CONDITION: 82 year old woman with s/p cabg REASON FOR THIS EXAMINATION: ? ptx s/p ct removal Final Report STUDY: Single portable AP chest radiograph. INDICATION: 82-year-old female status post CABG and chest tube removal. COMPARISON: [**2187-7-18**]. FINDINGS: Patient has been extubated with removal of right basilar chest tube and Swan-Ganz catheter/NG tube. Atelectasis at the left lower lobe has improved. Small left pleural effusion remains. The upper lungs remain clear. Bilateral subclavian artery calcifications are again noted. Median sternotomy wires remain in stable condition. IMPRESSION: 1. Interval removal of multiple lines and tubes without pneumothorax. 2. Improvement of left lower lobe atelectasis. 3. Residual small left pleural effusion. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 4391**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: [**Doctor First Name **] [**2187-7-19**] 4:49 PM Imaging Lab Brief Hospital Course: She was admitted to cardiac surgery. Dental consult was called and tooth extractions were recommended. On [**7-15**] she had 5 teeth extracted. On [**7-17**] she was taken to the operating room on [**7-17**] where she underwent a redo sternotomy and AVR. She was transferred to the ICU in stable condition. She as extubated on POD #1. Chest tubes removed and she was transferred to the floor on POD #2 to begin increasing her activity level. She was gently diuresed toward her preop weight. Beta blockade was titrated. Pacing wires removed on POD #3.She had several episodes of A fib and coumadin was started. Target INR 2.0-2.5. She continued to make good progress and was cleared for discharge to rehab on POD #6. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: ASA 325, lopressor 25", lipitor 10, lovenox 40, norvasc 5, diovan 160,acidophilus [**Hospital1 **] Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) units SC Subcutaneous once a day. 10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: 3 mg today only [**7-23**]; all further dosing per rehab provider;target INR 2.0-2.5. 11. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO BID (2 times a day): hold for K >4.8.[**Month (only) 116**] DC when lasix is stopped. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: AS s/p AVR R CEA, CABG at [**Hospital6 **] in [**2181**] (LIMA to LAD, SVG to RCA, SVG to first diagonal, SVG to OM2), NSTEMI in [**Month (only) 547**] [**2187**], Renal insufficiency (baseline creatinine 1.5), Hypertension, Severe AS, dementia, PVD, Anemia (baseline hematocrit 32-34) ;postop A Fib Discharge Condition: Stable. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds. No driving until follow up with surgeon or at least one month. Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] 2 weeks Dr. [**First Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2187-7-23**]

Admission Date: [**2183-3-23**] Discharge Date: [**2183-5-9**] Date of Birth: [**2124-10-29**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 7591**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Bone marrow biopsy History of Present Illness: 58 y/o M presented to [**Hospital1 **] [**Location (un) 620**] after a syncopal episode today where he sustained a facial hematoma. Pt remembers going to the bathroom in the early morning and then awoke on the floor approx 2hrs laterwith left sided facial bruising and incontinence. Pt reports severe nosebleeds that began 2 days prior to admission. On saturday, he was feeling lightheaded and developped severe right thigh pain. On Sunday, he noticed decreased appetite, left thigh pain and fevers/chills. On further review of symptoms, pt has been noticing increased bruising and general lethargy for the last week. Per report, his wife has been trying to get him to see [**Name8 (MD) **] MD for months as she has been concerned about his generalized weakness. . Pt initially presented to [**Hospital1 **] [**Location (un) **] and was febrile to 101.2 and received Vanc and Ceftazidime for neutropenic fever. He underwent head CT that revealed small foci of petechial hemorrhage within the left frontal lobe and small subarachnoid hemorrhage. Initial VS on arrival to the [**Hospital1 18**] ED: T 100.4 P 76 BP 110/55 R 18 O2 sat 99% RA. Pt was given Acyclovir for possible Zoster. He underwent CTA that was negative for PE and received 2L of NS IVF. Pt was being transfused with a second bag of plts prior to arrival to ICU. . On arrival, pt was complaining of right & left proximal thigh pain approx [**8-22**]. Otherwise, denying CP, SOB, HA, abd pain, nausea, visual changes. He was feeling exhausted and still mildly lightheaded. Past Medical History: Osteoarthritis (knees) Social History: Pt works as a headmaster in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1573**] school. He lives with his wife and has two healthy children, three grandchildren. He used to be a marathon runner. Denies smoking and illicit drug use. He reports consuming approx 1 drink per day. Family History: Father died of metastatic prostate cancer in his 80s, mother alive with HTN and insulin resistance. Physical Exam: Vitals: T: 98.6 BP: 137/73 P: 83 R: 20 O2: 975 on RA General: alert, oriented, large ecchymosis over left orbit, eye swollen shut HEENT: sclera anicteric, dry MM, oropharynx with dried blood Neck: supple, JVP not elevated, precervical lymphadenopathy Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1/S2, no m/r/g Abdomen: soft, NT, ND, NABS, no rebound tenderness or guarding, no appreciable hepatosplenomegaly Inguinal: no inguinal lymphadenopathy Ext: Warm, well perfused, 2+ pulses Neuro: CN 2-12 intact (except unable to assess left eye due to swelling & eccyhmoses). Strength 5/5 all four extremities distally. Unable to assess proximal muscle strength in lower extremities [**3-17**] pain. Sensation intact distally. Gait not assessed. No saddle anesthesia, no focal spinal tenderness. Pertinent Results: [**2183-3-23**] 08:46PM GLUCOSE-116* UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 [**2183-3-23**] 08:46PM ALT(SGPT)-21 AST(SGOT)-20 LD(LDH)-286* CK(CPK)-126 ALK PHOS-65 TOT BILI-0.8 [**2183-3-23**] 08:46PM ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.0 URIC ACID-5.1 [**2183-3-23**] 08:46PM WBC-0.7* RBC-2.21* HGB-7.6* HCT-20.3* MCV-92 MCH-34.5* MCHC-37.5* RDW-17.5* [**2183-3-23**] 08:46PM I-HOS-AVAILABLE [**2183-3-23**] 08:46PM PLT COUNT-43* [**2183-3-23**] 08:46PM PT-17.0* PTT-29.8 INR(PT)-1.5* [**2183-3-23**] 08:46PM FDP-160-320* [**2183-3-23**] 08:46PM FIBRINOGE-303 [**2183-3-23**] 08:46PM GRAN CT-230* [**2183-3-23**] 06:55PM PLT COUNT-53*# [**2183-3-23**] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050 [**2183-3-23**] 03:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2183-3-23**] 03:40PM URINE RBC-[**4-17**]* WBC-[**4-17**] BACTERIA-RARE YEAST-NONE EPI-0-2 [**2183-3-23**] 03:40PM URINE MUCOUS-OCC [**2183-3-23**] 03:16PM LACTATE-2.0 [**2183-3-23**] 03:10PM GLUCOSE-123* UREA N-16 CREAT-0.9 SODIUM-137 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15 [**2183-3-23**] 03:10PM estGFR-Using this [**2183-3-23**] 03:10PM CK(CPK)-147 [**2183-3-23**] 03:10PM CK-MB-1 cTropnT-<0.01 [**2183-3-23**] 03:10PM WBC-0.7* RBC-2.63* HGB-8.9* HCT-24.2* MCV-92 MCH-34.0* MCHC-37.0* RDW-17.8* [**2183-3-23**] 03:10PM NEUTS-8* BANDS-4 LYMPHS-76* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-2* NUC RBCS-2* OTHER-6* [**2183-3-23**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2183-3-23**] 03:10PM PLT SMR-VERY LOW PLT COUNT-29* [**2183-3-23**] 03:10PM PT-15.9* PTT-28.2 INR(PT)-1.4* [**2183-3-23**] 03:10PM GRAN CT-290* [**2183-3-24**] CT HEAD IMPRESSION: 1. Increased size of left frontal and right posterior cingulate gyrus intraparenchymal hemorrhages. 2. Increased size of right frontal, right temporal, and interhemispheric subarachnoid hemorrhage. 3. No midline shift. No evidence of acute infarction. [**2183-3-24**] MRI L/T-SPINE No evidence of acute spine injury within the cervical, thoracic or lumbar spine. Note is made of a fluid level within the lower lumbar spine, most consistent with layering subarachnoid blood. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 40120**],[**Known firstname **] [**2124-10-29**] 58 Male [**Numeric Identifier 40121**] [**Numeric Identifier 40122**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. MARIAPPAN SPECIMEN SUBMITTED: Immunophenotyping, Bone Marrow Procedure date Tissue received Report Date Diagnosed by [**2183-3-24**] [**2183-3-24**] [**2183-3-25**] DR. [**Last Name (STitle) **]. MARIAPPAN/ttl Previous biopsies: [**Numeric Identifier 40123**] BONE MARROW BIOPSY (1 JAR). INTERPRETATION Immunophenotypic findings consistent with involvement by: an immature population of cells consistent with acute myelogenous leukemia. Lack of CD34 and HLA-DR [**Last Name (STitle) 40124**] to be consistent with a diagnosis of acute promyelocytic leukemia. Correlation with morphologic and cytogenetic findings is recommended. Brief Hospital Course: 58 y/o M presenting after syncopal episode found to have multiple small ICH and new pancytopenia. Had complicated course of AMPL treatment # Leukemia: Patient found to have AMPL via bone marrow biopsy the day of admission to the MICU. He was started on ATRA and monitored closely for symptoms of DIC, TLS and ATRA syndrome. He was transfused as needed with PRBC, platlets and FFP. He did not develop overt signs of DIC. He was induced with Ara-c and daunurubicin. His counts responded appropriatly. A repeat BM biopsy showed remission and he will continue the ATRA for now and follow up with Dr. [**Last Name (STitle) 410**] for plans of stage two of his treatment. . # Fevers: He initially was on Vancomycin and cefepime when first starting treatment due to a hx of fevers at home, but as his culture data was negative and he remained afebrile his antibiotics were discontinued. He remained afebrile until [**4-14**] when he spiked a fever. He was cultured and his blood grew strep viridans. He was started on vanco/cefepime at that time. He also had a headache the day he spiked and a CT was done showing what appeared to be brain abscesses. His antibiotics were eventually broadened to vanco, meropenem, fluconzaole and flagyl for the brain abscesses. He continued to spike, though for approximately a week. He complained of some thigh pain and we did an ultrasound showing bilateral fluid collections. They were drained in IR and grew MSSA. He then developed a pneumonia during his febrile period and was transferred to the ICU for several days. He required O2 for a while after being discharged from the ICU. While in the ICU, his neutrophil count started to drop, and it was worried that he might be having a drug effect. His vanco was discontinued and his counts began to recover. Eventually he was on meropenem, voriconazole and acyclovir and stopped having fevers. A repeat CT scan showed resolution of his PNA. Serial repeat head CTs showed slow decrease in size of his abscesses. And an MRI of his thigh showed retained small fluid collections bilaterally. The plan is to complete 6 week course of the above antibiotics for his brain abscesses. We will reimage his thighs with an MRI as an outpatient and depending on those results, he will either need surgical drainage or still prolonged course of abx. He will follow up with ID. . # ICH: Pt with multiple small ICH sustained from fall with acute left sided head injury in the setting of profound thrombocytopenia. CT head revealed small foci of intraparenchymal hemorrhage and subarachnoid hemorrhage. (no hydrocephalus or shift). On [**3-24**] follow-up Head CT revealed interval increase in hemorrhage but without appreciable midline shift or infarction. The pt's neurologic exam remained stable. Neurosurgery followed closely. Platlet goal was > 75K. A repeat head CT one month after a fall showed the brain abscesses that were discussed above. Neuro onc was consulted and followed along. It was decided not to do a biopsy. He also required heparin and then lovenox for DVTs, and repeat head CTs while on these anticoaulants remained stable and without new bleeds. . # Thigh pain/weakness: Etiology unclear and unable to get good exam as limited by pain. This may be bone marrow pain. No evidence of hematoma or cellulitis. No bowel or bladder dysfunction, no saddle anesthesia, no focal spinal tenderness to indicate acute cord compression. MRI or the T/L-spine revealed no evidence of acute cord compression. There was evidence of layering fluid likely from the SAH. Although unlikely to be causing the pt's leg pain (nerve irritation secondary to blood) Neurosurgery recommended starting Decadron on [**2182-3-24**]. He was not kept on decadron because chemotherapy was initiated. Eventually he was found to have abscesses in his thighs, as discussed above. . # Afib - pt went into afib while in the ICU. His blood pressures remained stable and he was started on metoprolol. His high rates were 130s-140s; he contined to have afib on and off for about a week and then remained in NSR the week prior to discharge. His metoprolol was titrated to 25 mg tid for good rate control. . # [**Name (NI) 6059**] - pt had one episode of 16 b [**Name (NI) 6059**] v. afib with aberrancy. Cards was consulted and we did agressive electrolyte repletion and continued the metoprolol. He did not have any more occurrences. . # Vasovagal bradycardia - the day prior to admission, while the patient was having a bowel movement, he was noted on telemetry to brady to the 30s, he felt light headed and it resolved in 5 minutes. Appeared to be vaso-vagal and he did not have any more occurrences. Again, cards was consulted and they recommended leaving the metoprolol dose the same at 25 mg tid, as bb actually helps prevent vagal episodes. . # DVTs - while patient was in the ICU, he developed bilaterally pedal edema, thought initially to be due to large amount of IVFs. Because of his new afib, though, we did ultrasounds and found him to have DVTs in R leg, R arm (because he was edematous and had pain around a new PICC line). Heparin was started overnight, but because of his hx of ICHs, it was decided to stop the heparin and place an IVC filter. It was put in place without complications. Evenutally he was found to have bilaterally leg DVTs and then bilateral upper extremity DVTs. At that point, it was decided that he should be anticoagulated. Heparin was initially. Repeat head CT showed no bleed. And then he was converted to lovenox for outpatient treatment of the DVTs. He also had a VQ scan during these findings of DVT that showed low prob of PE. . # Access - pt initially had a subclavian line, then it was pulled while the patient was febrile in early [**Month (only) 958**]. He had PIVs until transfer to the ICU when a PICC line was placed. The PICC line was removed after a DVT was found in the arm. He again had PIVs for a while until a IR guided subclavian line was placed. For outpatient continuation of his 6 week course of antibiotics, a hickman was placed as PICCs could not be placed due to bilateraly UE DVTs. . # Pt was discharged walking around, passing PT and going up stairs. He respiratory status was much improved and he was not on O2 and had no SOB. He was advised not to start work yet and take it easy, although, he was ready to get back to work as soon as possible. Medications on Admission: None Discharge Medications: 1. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous 6x/day. Disp:*180 flushes* Refills:*2* 2. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection 10x/day. Disp:*300 flushes* Refills:*2* 3. Meropenem 1 gram Recon Soln Sig: One (1) recon soln Intravenous every eight (8) hours for 22 days: This will make end date on [**5-30**]; will be total of 6 week course. Disp:*66 recon soln* Refills:*0* 4. Vesanoid 10 mg Capsule Sig: Five (5) Capsule PO twice a day for 14 days: No substitutions please. Disp:*140 Capsule(s)* Refills:*0* 5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours). Disp:*90 Tablet(s)* Refills:*2* 8. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: APML Intracranial hemorrhage Syncope Discharge Condition: vital signs stable, walking around, on lovenox, normal neurological exam, afebrile Discharge Instructions: You were admitted to the hospital because you fell. You were found to have low blood counts and a bone marrow biospy showed that you have leukemia. You also had some small areas of bleeding in your head that were stable based on repeat CT scans. You received chemotherapy for your leukemia. . While you were here, you developed an infection both in your brain around the areas where the inital bleeds were found, as well as in your thighs. We treated you with antibiotics which you will need to continue after going home. . You also developed blood clots in your arms and legs. We place a filter in your inferior vena cave (a large vein in your abdomen) so the clots would not go to your lungs. We also anticoagulated you with heparin. You can go home on lovenox to stay anticoagulated. . Lastly, you developed a heart arrhythmia called atrial fibrillation. For that, you should continue taking the medicine metoprolol. . You will have a home nurse help you and your wife do antibiotics and the lovenox shots. You should make sure to start returning to work very slowly. It is probably best to not work or work from home the first week and see how you are feeling before starting to think about going back to the school. You can discuss your progress with Dr. [**Last Name (STitle) 410**] at your follow up appointments. . You should return to the hospital for any fainting, headaches, dizziness, chest pain, shortness of breath, swelling in your extremities, palpitiations or any other concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 410**] on [**Hospital Ward Name 23**] 7 on Tuesday [**2183-5-13**] at 1:30 pm. Phone number [**Telephone/Fax (1) 3241**]. Please follow up with infectious disease and Dr. [**Last Name (STitle) **] on [**2183-5-19**] at 3:00 pm. Phone number ([**Telephone/Fax (1) 4170**]. You will need a repeat MRI prior to seeing Dr. [**Last Name (STitle) **]. We will give you the date and time at your next appointment. Completed by:[**2183-5-15**]

Admission Date: [**2127-7-11**] Discharge Date: [**2127-7-13**] Date of Birth: [**2070-1-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: dizziness,nausea,vomiting Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 57 y/o Spanish speaking female with h/o HTN, DM 2, hyperlipidemia, CAD s/p 4V CABG [**4-12**], and asthma who presented to her PCP for regularly scheduled visit, complained of dizziness, nausea, vomiting for one week, and with chest pain, and was found to be hypotensive. She was sent to the ED by her PCP. [**Name10 (NameIs) **] the ED she got atropine x 3 for bradycardia, lasix, and glucagon for blood sugar in the 30s, and was started on dopamine drip for hypotension, which was weaned off once in the CCU without futher hypotension. Ruled out for MI. AST/ALT and amylase/lipase were normal. RUQ US done last month in [**State 108**] was reportedly normal. . She decribes that she had been vomiting for one week before going to her doctor's visit. She was vomiting almost daily for one week. She was dizzy for most of that week, getting worse when going from sitting to standing. Described as the room spinning and lightheadedness. She did not have any syncope or falls. Her chest pain lasted only one minute and occured after vomiting. She had a mild cough for a week, no sputum and mild fevers. . . Past Medical History: HTN Hyperlipidemia DM 2 CAD s/p 4V CABG ([**4-12**]) LIMA to LAD, SVGs to anterior obtuse marginal, posterior obtuse marginal, and to RCA. Obesity Asthma s/p CCY s/p C-section s/p Left foot surgery Social History: Married. Formerly from [**Male First Name (un) 1056**], Spanish-speaking only. No history of tobacco use, EtOH, or IVDU. Family History: Mother had CAD, CVA, DM2. Father died of complications from renal failure. Extensive DM in family. Physical Exam: Vitals: T 98.6 BP 120/70 HR 69 RR 18 SAT 96% RA General: NAD HEENT: NC, AT, amicteric, no injections, PERRLA, EOMI, OP clear. Neck: no JVP elevation. wound over right neck tender to palpation, no purulent drainage, no erythema. CV: Normal S1, S2 with no m/r/g. Pulm: Minimal bibasilar crackles. No wheezes. Abd: Soft, NT, ND, + BS. Ext: No c/c/e. DP 2+ B/L. Evidence of venous stasis changes. Healing left thigh wound packed with dressing and covered with gauze. No drainage or erythema. Pertinent Results: Labs on discharge: BUN 35 Cr 1.3 CK 69 trop <0.01 WBC 10.1 HCT 31.8 . EKG: NSR at 60, normal axis, no acute ST changes . Last CXR lungs clear . [**2127-7-11**] 03:07PM BLOOD WBC-9.7 RBC-3.03* Hgb-8.8* Hct-25.7* MCV-85 MCH-29.0 MCHC-34.1 RDW-15.3 Plt Ct-445* [**2127-7-13**] 06:45AM BLOOD WBC-10.1 RBC-3.77* Hgb-10.9* Hct-31.8* MCV-84 MCH-28.8 MCHC-34.2 RDW-15.4 Plt Ct-385 [**2127-7-11**] 03:07PM BLOOD Neuts-56.2 Lymphs-36.5 Monos-4.4 Eos-2.6 Baso-0.2 [**2127-7-11**] 06:19PM BLOOD Neuts-78.2* Lymphs-17.2* Monos-3.2 Eos-1.3 Baso-0.2 [**2127-7-11**] 03:07PM BLOOD Plt Ct-445* [**2127-7-13**] 06:45AM BLOOD Glucose-119* UreaN-35* Creat-1.3* Na-140 K-5.1 Cl-104 HCO3-24 AnGap-17 [**2127-7-11**] 08:25PM BLOOD ALT-18 AST-16 CK(CPK)-49 AlkPhos-89 Amylase-79 TotBili-0.1 [**2127-7-11**] 08:25PM BLOOD Lipase-61* [**2127-7-11**] 03:07PM BLOOD cTropnT-<0.01 [**2127-7-11**] 08:25PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2127-7-12**] 06:22AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2127-7-11**] 08:25PM BLOOD calTIBC-324 Ferritn-265* TRF-249 [**2127-7-11**] 06:29PM BLOOD Lactate-0.8 [**2127-7-11**] 03:07PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2127-7-11**] 03:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . bcx [**7-11**]: no growth ucx [**7-11**]: genital contamination Brief Hospital Course: A/P: 57 y/o Spanish speaking female with h/o HTN, DM2, CAD s/p 4VCABG, hyperlipidemia, and asthma who presented to the ED with hypotension, now resolved, a brief episode of chest pain, ruled out, and abdominal pain, likely Gas/GERD. . 1. Hypotension: the patient had nausea and vomiting prior to admission and was found to be hypotensive at her PCP's office. She was actually given lasix initially and started on dopamine gtt. It is unclear from the note if she got fluid. The hypotension was probably due to dehydration from vomiting the week prior to admission. Dopamine gtt was weaned off and the patient had no further issues with hypotension. She was discharged on lisinopril and atenolol. Lasix dose was decreased to 20 mg QD and her KCl was d/c'd because we halved her lasix and her K on discharge was 5.1. . 2. Renal Failure: Patient came in with a creatinine of 1.6 and her baseline is unknown. Could be chronic renal failure from DM that is giving her chronic renal insufficiency and perhaps she was also prerenal from the vomiting prior to admission. Creatinine steadily improved and is now 1.3 on discharge. . 3. Anemia: Crit on admission was 25. Likely ACD from DM. s/p transfusion of 2 units in the CCU. HCT improving. Crit now 31.8. . 4. DM2:bedtime sugar was 152, fasting this am 73 and at noon 118. We continued actos and avandia as well as a RISS and patient was advised to take her home doses of lantus and regular insulin at home. . 5. HTN: Blood pressure was stable after dopamine gtt was titrated off in the CCU. No issues of hypertension or hypotension. Discharged patient on atenolol and lisinopril. . 6. CAD: Patient denies chest pain. Lipid profile showed LDL 84, HDL 54. We continued ASA, atenolol, lisinopril. No acute issues. . 7. Asthma: no wheezing, stable sats. We gave the patient albuterol PRN. . Medications on Admission: Lisinopril 20 mg PO daily Lasix 40 mg PO daily Trazodone Avandia 2 mg PO daily Lantus 100 QD Regular insulin 20 in am, 30 in pm Protonix 40 mg PO daily Zoloft Albuterol KCl 10 meq PO daily Atenolol 25 mg PO daily ASA 81 mg PO daily Lipitor 10 mg PO daily Actos 45 mg PO daily Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Trazodone 50 mg Tablet Sig: .5 Tablet PO at bedtime as needed for insomnia. Disp:*15 Tablet(s)* Refills:*0* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Hypotension [**1-9**] volume depletion from vomiting Discharge Condition: Patient is afebrile, hemodynamically stable and tolerating her BP meds. Discharge Instructions: Please take all of your medications as directed. Please follow-up with all of your outpatient appointments. Please return to the ED if you develop dizziness, loss of consciousness, chest pain, trouble breathing, vomiting, difficulty urinating or any other concerning symptoms. Followup Instructions: Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 23903**] this week. Her number is [**Telephone/Fax (1) 17826**]. At that time, they should check right upper quadrant ultrasound. Patient also needs chem-7 checked as she is on lasix, lisinopril. We put patient on reduced dose of lasix (20 mg QD) because of hypotension and took her off KCl. Should see PCP this week to see if she really needs to be on lasix 40 mg QD and KCl.

Admission Date: [**2174-4-18**] Discharge Date: [**2174-5-17**] Date of Birth: [**2135-11-15**] Sex: F Service: MEDICINE Allergies: Prochlorperazine / Heparin Agents Attending:[**First Name3 (LF) 3918**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Upper GI series with small bowel follow through Right heart catheterization IR guided paracentesis History of Present Illness: 38 yo F w/ h/o ALL in remission s/p cord transplant in [**1-13**], anthracycline-induced cardiomyopathy (EF 15-20% [**1-14**]) and recurrent nausea and vomiting who presents with abdominal pain, N/V x1 week Of note, the pt was admitted here from [**Date range (1) **] with nausea and vomitting of unclear etiology. When discharged, she was tolerating good PO and had planned f/u with neuro for ? abdominal migraine and GI for possible other contributing factors including food sensitivities and gastroparesis. In the ED, VS: 98.8 94 138/100 16 100% and [**10-15**] pain. CT A/P showed a small umbilical hernia; interval increase in size and mild fat stranding and interval increase in ascites compared to recent prior imaging. WBC 12.4 with no left shift, bili 2.1 up from 1.1, Cr 2.7 up from 2.3. Surgery was consulted give CT finding and did not feel there was an indication for surgery. She received iv zofran and morphine 4mg iv and 1L IVF. On arrival to the floor, patient reports [**11-14**] total body pain and nausea. She has had ice chips today but threw them up in the ED. Review of Systems: (+) Per HPI (-) Review of Systems: Denies fevers, chest pain, SOB, diarrhea, constipation, dysuria, HA, change in vision or dizziness. Past Medical History: ONCOLOGIC HISTORY: ALL: - initially presented in [**2172-8-5**] right chest and right upper extremity pain and paresthesias and visual blurriness. WBC 149,000; received leukapheresis, started on hydroxyurea. Dx'ed with precursor B-cell ALL. - underwent phase I induction with daunorubicin, vincristine, dexamethasone, L-asparaginase, MTX; phase II with cyclophosphamide, cytarabine, mercaptopurine, MTX - Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic evidence of residual leukemia - underwent allo double cord blood SCT [**2173-1-11**], course complicated by neutropenic fever and acute skin GVHD OTHER MEDICAL HISTORY: - Embolic stroke in [**3-/2174**] on coumadin - Cardiomyopathy due to early anthracycline-related cardiotoxicity [**10/2172**] - Chronic kidney disease stage III/IV, baseline creatinine ~2.0-2.2 - Asthma - HTN - Cervical Intraepithelial neoplasia - C-section in [**2165**] Social History: Smoke: never EtOH: Occasional in past, none currently Drugs: Never Lives/works: Single, has two children (ages 7 and 18). Lives in [**Location 686**]. Was previously employed at [**Company 59330**], hasn't been working since being diagnosed with ALL in [**2172-8-5**]. Family History: Mother with gastric cancer, passed at the age of 40 Father with HTN. Physical Exam: VS: 98 145/76 87 15 100% RA GEN: well appearing F in NAD HEENT: slight dry MM, sclera anicteric, PERRL Cards: RR S1/S2 normal. prominent S3 Pulm: CTAB Abd: Hyperactive BS. Initially soft when palpating with stethoscope over all 4 quadrants then suddenly exquisitely tender on right. No guarding initially. Unable to assess for HSM. Extremities: wwp, no edema. PTs 2+. Neuro: CNs II-XII grossly intact. normal gait Psych: overly dramatic affect Pertinent Results: On admission: [**2174-4-18**] 02:00PM BLOOD WBC-12.4* RBC-3.78* Hgb-11.4* Hct-36.3 MCV-96 MCH-30.2 MCHC-31.4 RDW-16.5* Plt Ct-212 [**2174-4-18**] 02:00PM BLOOD Neuts-67.3 Lymphs-23.8 Monos-7.7 Eos-0.5 Baso-0.7 [**2174-4-18**] 04:30PM BLOOD PT-30.1* PTT-29.4 INR(PT)-3.0* [**2174-4-18**] 02:00PM BLOOD UreaN-30* Creat-2.7* Na-142 K-4.8 Cl-99 HCO3-31 AnGap-17 [**2174-4-18**] 02:00PM BLOOD ALT-15 AST-18 AlkPhos-127* TotBili-2.1* [**2174-4-18**] 02:00PM BLOOD Lipase-63* [**2174-4-18**] 02:00PM BLOOD cTropnT-<0.01 [**2174-4-18**] 02:00PM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.8* Mg-2.0 On discharge: [**2174-5-17**] 12:00AM BLOOD WBC-19.1* RBC-3.86* Hgb-11.3* Hct-37.7 MCV-98 MCH-29.3 MCHC-30.0* RDW-17.8* Plt Ct-419 [**2174-5-17**] 12:00AM BLOOD Neuts-81.3* Lymphs-11.4* Monos-6.9 Eos-0.1 Baso-0.3 [**2174-5-17**] 12:00AM BLOOD PT-31.2* PTT-28.6 INR(PT)-3.1* [**2174-5-17**] 12:00AM BLOOD Fibrino-162 [**2174-5-17**] 12:00AM BLOOD Glucose-152* UreaN-78* Creat-2.9* Na-137 K-4.7 Cl-95* HCO3-31 AnGap-16 [**2174-5-17**] 12:00AM BLOOD ALT-51* AST-41* LD(LDH)-327* AlkPhos-107* TotBili-0.7 [**2174-5-13**] 12:11PM BLOOD cTropnT-<0.01 [**2174-5-17**] 12:00AM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.1* Mg-2.7* UricAcd-8.7* [**2174-4-27**] 02:51AM BLOOD calTIBC-246* Ferritn-107 TRF-189* [**2174-5-2**] 05:55AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2174-4-28**] HHV-8 DNA, QL PCR Not Detected [**2174-4-27**] QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE [**2174-4-29**] ACE, SERUM 30 [**10/2130**] U/L Micro: [**2174-4-25**] 1:07 pm PERITONEAL FLUID GRAM STAIN (Final [**2174-4-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2174-4-28**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2174-5-1**]): NO GROWTH. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [**2174-4-30**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Final [**2174-5-13**]): NO FUNGUS ISOLATED. [**2174-4-29**] 10:15 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. CMV Viral Load (Final [**2174-5-6**]): CMV DNA not detected. ECG [**2174-4-18**]: Sinus rhythm. Possible left atrial abnormality. Lateral ST-T wave abnormality. Cannot rule out myocardial ischemia. Poor R wave progression. Cannot rule out anterior wall myocardial infarction of indeterminate age. Compared to the previous tracing of [**2174-4-2**] multiple described abnormalities persist. CT abdomen/pelvis without contrast [**2174-4-18**]: FINDINGS: There is a small-to-moderate right pleural effusion, smaller in size compared to last CT torso. There is a small pericardial effusion. Study is suboptimal for evaluation of solid organs due to lack of IV contrast. With this limitation in mind, there is no extra- or intra-hepatic biliary duct dilatation. Previously described presumably focal nodular hyperplasia in segment VI of the liver is not clearly visualized on a non-contrast CT. There is a presumably gallbladder wall edema from third spacing with moderate amount of ascites. There is likely gallbladder sludge. Pancreas and bilateral adrenal glands are within normal limits considering the limitation of no contrast administration. There is interval increase in size of a fat-containing umbilical hernia measuring 2 cm in transverse dimension with mild fat stranding(2:50), correlate with point tenderness/physical exam. The appendix is not dilated (2:49), contains air and there is a likely small appendicolith (2:53). There is no bowel obstruction. There is no evidence of colonic wall thickening, although evaluation is suboptimal given lack of IV or PO contrast and adjacent ascites.. The kidneys are normal in size. There is no evidence of hydronephrosis. Due to lack of oral contrast, evaluation for mesenteric lymph nodes is suboptimal. There are scattered lymph nodes in the retroperitoneum, however, do not meet the CT criteria for pathologic enlargement. CT PELVIS: There is free fluid in the pelvis - ascites. The uterus and urinary bladder appear normal. The rectum and sigmoid have scattered diverticula; however, no evidence of diverticulitis. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion. There is soft tissue stranding suggesting anasarca. IMPRESSION: 1. Mild-to-moderate right pleural effusion; however, interval decrease in size compared to prior. 2. Moderate ascites with interval increase. 3. No drainable fluid collection, however, evaluation is suboptimal due to lack of IV and oral contrast. 4. Diverticulosis. 5. Interval increase in size of a small fat-containing umbilical hernia with mild fat stranding, correlate with point tenderness. 6. No bowel obstruction. No definite bowel wall thickening, although the examination is suboptimal for such. 7. Pericardial effusion, similar to prior. RUQ ultrasound [**2174-4-18**]: FINDINGS: The liver is of normal echogenicity. Previously described presumably focal nodular hyperplasia in segment VI of the liver is not clearly visualized. There is no intra- or extra-hepatic biliary duct dilatation. The common bile duct measures 2 mm. There is ascites. There is gallbladder wall edema/thickening presumably from third spacing; the gallbadder is not distended. No convincing evidence of sludge on ultrasound. The main portal vein is patent. Pancreas is suboptimally evaluated due to overlapping bowel gas. There is a small-to-moderate right pleural effusion as seen on recent CT. IMPRESSION: 1. Ascites. 2. Gallbladder wall edema presumably from third spacing. 3. Small-to-moderate right pleural effusion. 4. No biliary duct dilatation. 5. Previously described presummed focal nodular hyperplasia in segment VI of the liver is not clearly visualized. Small bowel follow through [**2174-4-20**]: IMPRESSION: 1. Small, anterior cervical web that does not hinder the passage of a 13mm barium tablet. 2. Filling defect in the mid esophagus just below the carina appears to be either extrinsic compression versus a submucosal lesion. In correlation with the comparison CT torso, mediastinal lesion is less likely. Submucosal esophageal lesion remains within the differential, and direct visualization with EGD is recommended. Other possibility includes an aberrant vessel in this vicinity. 3. Mobile cecum which does not appear to be obstructive in any manner on today's examination. Renal ultrasound [**2174-4-20**]: FINDINGS: The right kidney measures 10.5 cm. The left kidney measures 9.7 cm. There is no evidence of hydronephrosis, stone or mass bilaterally. The bladder is unremarkable. Moderate amount of ascites is incidentally noted. IMPRESSION: No hydronephrosis, stone or mass within the kidneys. Peritoneal Fluid [**2174-4-25**]: ATYPICAL. Scattered atypical lymphoid cells in a background of reactive mesothelial cells IR guided paracentesis [**2174-4-25**]: IMPRESSION: Ultrasound-guided diagnostic paracentesis, with a total of 200 mL of ascites removed. TTE [**2174-5-2**]: The left atrium is mildly elongated. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 20 %). Systolic function of apical segments is relatively preserved. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is mildly increased with moderate global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Severe biventricular global hypokinesis. Severe tricuspid regurgitation. Pulmonary artery systolic hypertension. Small circumferential pericardial effusion without evidence of tamponade physiology. Compared with the prior study (images reviewed) of [**2174-4-1**], the findings are similar. TTE [**2174-5-10**]: The left atrium is dilated. A left-to-right shunt across the interatrial septum is seen at rest consistent with a stretched patent foramen ovale (or small atrial septal defect). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal with mildly impaired global left ventricular systolic function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is moderate (2+) tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of [**2174-5-6**], ther pericardial effusion is now smaller. Biventricular sysotolic function appears slightly less vigorous compared to the prior study (on a lower dose of milrinone now than during the prior study). Cardiac cath [**2174-5-5**]: COMMENTS: 1. Hemodynamics measurements in this patient demonstrate low cardiac output. Following administration of milrinone, cardiac index increased to the low-normal range with 2.5 L/min/m2. 2. Moderate pulmonary hypertension with right atrial v-waves consistent with severe TR noted. Pulmonary vascular resistance is elevated at 280 dyne-cm-sec5. FINAL DIAGNOSIS: 1. Severe systolic ventricular dysfunction. 2. Moderate diastolic ventricular dysfunction. 3. Pulmonary hypertension LE ultrasound [**2174-5-13**]: IMPRESSION: 1. No evidence for deep venous thrombosis in either lower extremity. 2. 3.6 cm [**Hospital Ward Name 4675**] cyst in the right popliteal fossa as previous. Superficial soft tissue edema in the right mid thigh, may be related to partial rupture of [**Hospital Ward Name 4675**] cyst. TTE [**2174-5-16**]: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of [**2174-5-10**], biventricular systolic function is slightly worse. The size of the pericardial effusion is slightly smaller. Brief Hospital Course: 38 yo F w/ h/o ALL in remission s/p cord transplant in [**1-13**], anthracycline-induced cardiomyopathy (EF 15-20% [**1-14**]) and recurrent nausea and vomiting who presents with 1 week abd pain, acute on chronic renal failure and new hyperbilirubinemia. Unclear unifying diagnosis. # Acute on Chronic Abdominal Pain: Pt noted to have significant abdominal pain as well as increased [**Month/Year (2) 4394**] on admission. Of note, she had an extensive work up of her chronic abdominal pain in the past with no clear cause. Abdominal CT was unrevealing for any obvious source of her pain. GI was consulted who recommended a SBFT which did not reveal any significant pathology. GI recommended bentyl for antispasmodic effect. She was also continued on her home MS contin and IV morphine for breakthrough. Her pain persisted as did her [**Last Name (LF) 4394**], [**First Name3 (LF) **] the decision was made to perform a diagnositc paracentesis under ultrasound guidance. 200ml peritoneal fluid was removed. This revealed 775 WBCs, but a lymphocytic/monocytic predominance with only 1% polys making SBP unlikely. Fluid was sent for culture which showed no growth and flow cytometry which showed no evidence of ALL recurrence. Despite lack of evidence for SBP, she was started on zosyn empirically which was stopped on [**5-2**]. She continued to have mild-moderate abdominal pain but was able to eat full meals and had BMs. She was continued on her home mscontin and morphine IR. . # Anthracycline-induced/ GVHD cardiomyopathy: EF <20% on echo from 2/[**2174**]. Pt was maintained on diuresis as above, which was subsequently held in the setting of rising creatinine with improvement in creatinine. Torsemide was slowly reintroduced and uptitrated to 40mg [**Hospital1 **] which caused another bump in creatinine to 3.0, so renal and cardiology were consulted. Renal ultrasound was unrevealing. She was then taken to the Cath lab and placed on a milrinone/lasix gtt and transfered to the CCU. Her volume overload slowly improved and her peripheral edema/ascites slowly improved as well. A repeat echo showed improved EF to 40-45% on the milrinone gtt. She was then started on solumedrol 30mg IV due to a concern for GVHD directed towards myocardium. After further discussion between cardiology and her oncology team she was also started on cellcept for further management of her GVHD. She did well on milrinone and lasix drip, but the drip was stopped when her creatinine bumped to 3.0 and it was felt her volume status was near maximization. Her milrinone was then discontiued and she was then transferred back to [**Hospital1 3242**] for further management of her abdominal pain and GVHD. She was continued on torsemide for diuresis with close follow-up with her outpatient cardiologist. Of note, she had frequent alarms on telemetry for tachycardia that cardiologist felt was mostly due to artifact; her beta blocker was uptitrated. Repeat TTE prior to discharge showed an EF of 35-40%. She was discharged home on cellcept and prednisone for possible GVHD. # Acute Renal Failure: On admission Cr was 2.7 (recent baseline was 2), but at last discharge Cr was 2.3. Renal saw the patient who thought this was likely from overdiuresis (home torsemide regimen of 20mg [**Hospital1 **]) in conjunction with her [**Last Name (LF) **], [**First Name3 (LF) **] recommended holding diuresis. Her Cr subsequently improved, but in the setting of her worsening [**First Name3 (LF) 4394**] and her cardiomyopathy, decision was made to slowly add back diuresis, and eventually she was up titrated to toresemide 40mg [**Hospital1 **] and her [**Last Name (un) **] was restarted. With this, however, her Cr began to climb again to 3.0. Given the delicate balance between her renal failure cardiomyopathy, cardiology/renal were consulted. Given her depressed EF, her rising Cr was thought to be [**3-9**] volume overload. She was sent to the cath lab and started on a milrinone/lasix gtt and transfered to the CCU with a goal diuresis of 1L per day. She was actively diuresed on her milrinone and lasix drip with a total net negative of close to 9L. Her Cr then returned to baseline by time of discharge and she was discharged home on torsemide. # Hyperbilirubinemia: Unclear cause, could have been related to a viral infection but no transaminitis to support this. RUQ u/s without cause for pain. This trended down to normal values and remained stable by time of discharge # Leukocytosis: patient had uptrending WBC in setting of starting solumedrol, clutures were sent which revealed no growth. . # H/O Embolic Stroke: Has new opening of PFO based on most recent echo which likely contributed to her recent stroke. She was maintained on coumadin 4mg daily, but anticoagulation was held on day of paracentesis and remained subtherapeutic for several days, so she was maintained on a heparin drip to bridge her to a therapeutic INR [**3-10**]. She was maintained on a decreased dose of coumadin throughout hospital admission with INR within goal between 2 and 3. She was arranged with follow-up at outpatient [**Hospital3 **]. Medications on Admission: Carvedilol 25 mg [**Hospital1 **] Fluticasone-salmeterol [**Hospital1 **] Morphine 15 mg q6h prn pain Valsartan 40 mg qd Torsemide 20 mg [**Hospital1 **] Multivitamin qd Albuterol prn Lorazepam 0.5 mg q6h prn nausea Warfarin 4 mg qd Ondansetron 8 mg tid prn Pentamidine 300 mg inhalation qmonth Colace 100 mg qd prn Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob or wheeze. 5. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 8. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). Disp:*60 Tablet Extended Release(s)* Refills:*0* 9. dicyclomine 20 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*0* 10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 13. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 14. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal pain or gas. Disp:*120 Tablet, Chewable(s)* Refills:*0* 15. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 16. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:*500 ML(s)* Refills:*0* 18. morphine 15 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for pain. 19. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: -Abdominal Pain -Acute on chronic renal failure -Systolic Heart failure Secondary: -ALL -History of embolic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], You were admitted to the hospital for abdominal pain. Your pain was treated with pain medications, and a new medication called Bentyl. You were also switched to a longer acting form of your morphine. We did a test to look at your small bowel which was negative. At this point we are not sure what is causing your pain, but you had increased swelling of your abdomen which likely contributed to your pain. You underwent a right heart catheterization and [**Known lastname 461**] to assess your heart function because worsening heart failure can cause fluid in your belly and worsening kidney disease. You were at the cardiac intensive care unit and placed on a medication that improved your heart function. A repeat [**Known lastname 461**] prior to your discharge showed that your heart function has improved somewhat and is stable. You will follow up closely with your cardiologist as several of your heart medications have changed. You were started on steroids and mycophenolate mofetil because it was felt that you heart problems may be due to your leukemia. You also had some worsening of your renal failure. You were followed by our kidney consult team while you were in the hospital. Your kidney function was stable prior to discharge. We made the following changes to your medications: -Mycophenolate Mofetil 1000mg twice a day was started -Prednisone 60mg daily was started -Coumadin was decreased to 2mg daily -Torsemide was increased to 40mg daily -Please hold your valsartan until you see your cardiologist -Metoprolol succinate 100mg daily was started; please stop carvedilol -Bentyl (dicyclomine) was started for your abdominal pain -Simethicone was started for abdominal discomfort/gas -Your morphine was switched to long-acting Morphine 15mg twice a day -Bactrim single strength, 1 tablet daily, was started to help prevent infection -Acyclovir 400mg twice a day was started to help prevent infection -Allopurinol 100mg daily was started because your uric acid levels were high Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: You have the following appointments [**Name8 (MD) 1988**] for you. You will need to follow up at [**Hospital3 **] on Thursday, [**2174-5-19**], for an INR (coumadin level) check. Please come to the [**Hospital Ward Name 23**] Center [**Location (un) 895**] for this lab test between 9am and 5pm. Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2174-5-20**] at 3:30 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2174-5-20**] at 3:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10565**], NP [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] MD, Cardiology [**Last Name (LF) 766**], [**2174-5-30**] at 11:00AM SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] Department: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2174-6-9**] at 10:00 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**] Completed by:[**2174-5-26**]

Admission Date: [**2193-6-27**] Discharge Date: [**2193-6-30**] Date of Birth: [**2162-12-8**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: chest, lower back and hip pain, s/p crush injury Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 88968**] is a 30 year old man with untreated hypertension who suffered a crush injury to his chest (tractor loaded with weight rolled onto his chest) requiring extraction with a fork lift. He denied any LOC; VS were stable during [**Location (un) **]. Upon ED presentation, he c/o hip and low back pain, yet denied chest pain, dyspnea, abdominal pain, headache or neck pain. Cardiology was consulted given concern for contusion, cardiac injury. He was noted to have a new RBBB on ECG with TWI. The patient has a CPK of 1464 and TnT<0.01. MB 5. Pt's chest pain improved with narcotics. He also denied dyspnea, although it hurts to take a deep breath. He stopped taking anti-hypertensives because lack of insurance. He had atypical chest pains in the past and was evaluated at [**Hospital1 **] with an ECG. Denies any exertional chest symptoms. No orthopnea or PND. Remaining ROS positive for back pain and pain in the hips. All other ROS are negative. Past Medical History: HTN (not currently treated) Social History: Married (wife, [**Name (NI) **] [**Name (NI) 88969**], [**Telephone/Fax (1) 88970**] is emergency contact). Non-smoker, no alcohol. No illicits. Family History: No premature CAD. Physical Exam: HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Neuro: Speech fluent Pertinent Results: [**2193-6-27**] 02:03PM BLOOD WBC-5.0 RBC-5.25 Hgb-15.0 Hct-42.7 MCV-81* MCH-28.6 MCHC-35.2* RDW-14.0 Plt Ct-225 [**2193-6-27**] 02:10PM BLOOD PT-12.4 PTT-22.9 INR(PT)-1.0 [**2193-6-27**] 02:03PM BLOOD Plt Ct-225 [**2193-6-27**] 09:36PM BLOOD Glucose-111* UreaN-7 Creat-1.0 Na-140 K-3.2* Cl-108 HCO3-23 AnGap-12 [**2193-6-27**] 09:36PM BLOOD Glucose-674* UreaN-7 Creat-1.0 Na-136 K-2.6* Cl-102 HCO3-28 AnGap-9 [**2193-6-27**] 02:03PM BLOOD UreaN-10 Creat-1.3* [**2193-6-27**] 09:36PM BLOOD CK(CPK)-909* [**2193-6-27**] 02:03PM BLOOD ALT-40 AST-42* CK(CPK)-1464* AlkPhos-64 TotBili-0.6 [**2193-6-27**] 02:03PM BLOOD Lipase-48 [**2193-6-27**] 09:36PM BLOOD CK-MB-5 cTropnT-<0.01 [**2193-6-27**] 02:03PM BLOOD cTropnT-<0.01 [**2193-6-27**] 09:36PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.9 [**2193-6-27**] 09:36PM BLOOD Calcium-6.8* Phos-1.8* Mg-1.6 [**2193-6-27**] 02:03PM BLOOD Calcium-9.1 [**2193-6-27**] 02:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2193-6-27**] 02:10PM BLOOD Glucose-105 Lactate-1.5 Na-145 K-3.5 Cl-107 [**2193-6-27**] 02:10PM BLOOD Hgb-14.8 calcHCT-44 . [**2193-6-27**] 09:36PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013 [**2193-6-27**] 02:24PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2193-6-27**] 09:36PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2193-6-27**] 02:24PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG [**2193-6-27**] 09:36PM URINE RBC-12* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [**2193-6-27**] 02:24PM URINE RBC-3* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [**2193-6-27**] 02:24PM URINE Mucous-RARE [**2193-6-27**] 02:24PM URINE Hours-RANDOM . [**2193-6-27**] 9:36 pm MRSA SCREEN; Source: Nasal swab. (Final [**2193-6-30**]): No MRSA isolated. . [**2193-6-28**] 11:25AM BLOOD WBC-4.3 RBC-5.24 Hgb-15.1 Hct-44.0 MCV-84 MCH-28.8 MCHC-34.2 RDW-14.4 Plt Ct-228 [**2193-6-28**] 11:25AM BLOOD Plt Ct-228 [**2193-6-28**] 11:25AM BLOOD Glucose-133* UreaN-5* Creat-1.0 Na-142 K-3.6 Cl-109* HCO3-25 AnGap-12 [**2193-6-28**] 11:25AM BLOOD CK(CPK)-718* [**2193-6-28**] 04:47AM BLOOD CK(CPK)-827* [**2193-6-28**] 11:25AM BLOOD CK-MB-5 cTropnT-<0.01 [**2193-6-28**] 04:47AM BLOOD CK-MB-5 cTropnT-<0.01 [**2193-6-28**] 11:25AM BLOOD Calcium-8.3* Phos-2.0* Mg-2.2 [**2193-6-28**] 04:50AM BLOOD Type-[**Last Name (un) **] pH-7.32* [**2193-6-28**] 04:50AM BLOOD freeCa-1.11* . [**2193-6-28**] 09:57AM URINE Hours-RANDOM [**2193-6-28**] 09:57AM URINE Myoglob-PRESUMPTIVE . [**2193-6-29**] 05:55AM BLOOD WBC-5.9 RBC-5.40 Hgb-15.2 Hct-44.6 MCV-83 MCH-28.2 MCHC-34.2 RDW-14.2 Plt Ct-220 [**2193-6-29**] 05:55AM BLOOD Plt Ct-220 [**2193-6-29**] 05:55AM BLOOD [**2193-6-29**] 05:55AM BLOOD Glucose-87 UreaN-15 Creat-1.2 Na-141 K-3.6 Cl-107 HCO3-25 AnGap-13 [**2193-6-29**] 05:55AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1 . [**2193-6-27**] Cardiology ECG Sinus rhythm. Right bundle-branch block with left anterior fascicular block. Probable left ventricular hypertrophy. No previous tracing available for comparison. Rate 67, PR 192, QRS 170, QT/QTc 424/436, P 65, QRS -72, T -26 . [**2193-6-27**] 1:45 PM, TRAUMA #2 (AP CXR & PELVIS PORT) IMPRESSION: No acute intrathoracic or pelvic injury. . [**2193-6-27**] 1:59 PM, CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial injury or skull fracture. . [**2193-6-27**] 2:00 PM, CT ABD & PELVIS WITH CONTRAST, CT CHEST W/CONTRAST IMPRESSION: No acute injury in the chest, abdomen or pelvis. No acute fracture. . [**2193-6-27**] 2:00 PM, CT C-SPINE W/O CONTRAST IMPRESSION: No acute fracture or malalignment. . [**2193-6-27**] 5:01 PM, MR CERVICAL SPINE W/O CONTRAST [**2193-6-27**] 5:01 PM, MR L SPINE W/O CONTRAST [**2193-6-27**] 5:01 PM, MR THORACIC SPINE W/O CONTRAST IMPRESSION: 1. No evidence of fracture or ligamentus injury. 2. Mild degenerative changes of the spine. . [**2193-6-28**] at 10:02:43 AM, ECHO, Portable TTE (Complete) IMPRESSION: No RV systolic dysfunction or pericardial effusion to suggest significant cardiac contusion. Symmetric left ventricular hypertrophy with mild global systolic dysfunction. Dilated thoracic aorta with mild functional aortic regurgitation. Mild mitral regurgitation. These findings are most consistent with hypertensive heart disease. . [**2193-6-28**] Cardiology ECG Sinus rhythm. Right bundle-branch block with left anterior fascicular block. Compared to the previous tracing no change. Brief Hospital Course: Mr. [**Known lastname 88968**] is a 30 year old man with untreated hypertension who suffered a crush injury to his chest (tractor loaded with weight rolled onto his chest) requiring extraction with a fork lift. He denied any LOC; VS were stable during [**Location (un) **]. Upon ED presentation, he c/o hip and low back pain, yet denied chest pain, dyspnea, abdominal pain, headache or neck pain. Cardiology was consulted, given concern for cardiac contusion, injury. Assesment: chronic RBBB from HTN versus RV contusion with conduction delay in the RV. LV function appeared normal. Hx not c/w acute coronary syndrome. He was noted to have a new RBBB on ECG with TWI. CPK of 1464 and TnT<0.01, MB 5, AST 42, Ca 9.1, 3 RBC in the urine, Cr 1.3, Hct 42.7. The patient was initially managed in the TICU for close fluid status monitoring. The patient was hemodynamically stable. He received agressive hydration with a goal Uop of >100cc/hr. The patient's pain was controlled and on HD2, patient was doing better. His CKs were cycled and trending down. His Creatinine normalized, so IVF rate was cut back. The patient's diet was advanced and he was transitioned to po pain meds and transferred to the floor. On the floor, he tolerated a regular diet, was ambulating with physical therapy. He continued to have intermittent muscular pain in his chest, lower back, and hips, unchanged from previous days. His pain was controlled on oral narcotic pain medications. CT imaging and MRI of spine showed no fracture or ligamentous injury, CT did not show any acute injury or fracture in chest, abdomen, or pelvis. He was ready for discharge on [**2193-6-30**] to home. Medications on Admission: none Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for muscle spasm. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: rhabdomyolysis muscular 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 ACS service. You did not have any fractures or organ injuries seen on imaging. You may feel a lot of muscular aches in the next couple of weeks as your body heals. Please resume all home medications. You can take the prescribed narcotic for pain, but do not drive or operate heavy machinery while taking the medication. You can also take tylenol or ibuprofen for pain, but do not exceed 4g of tylenol per day. Followup Instructions: Follow-up at the acute care surgery clinic as needed: [**Telephone/Fax (1) 600**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2193-6-30**]

Admission Date: [**2140-12-8**] Discharge Date: [**2140-12-12**] Date of Birth: [**2076-5-24**] Sex: M Service: CT SURGERY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 24524**] is a 64-year-old male who had a history of progressive exertional dyspnea after quitting smoking approximately six months ago. Workup for this exertional dyspnea included an exercise treadmill test that was ultimately positive for ischemic changes as well as an echocardiogram and subsequently an elective cardiac catheterization. Cardiac catheterization completed on [**2140-12-5**] showed left main coronary artery disease with modest calcification and distal 50% taper. The left anterior descending also had moderate calcification with a proximal 70% lesion after D1 and R1. The D2 moderate vessel was 90% proximal tubular lesions, D1 and R1 had ectatic proximal vessel and a large distal vessel. The left circumflex artery was nondominant vessel with a proximal 90% lesion with moderate calcification as well. The right coronary artery was the dominant vessel, with a total proximal occlusion and bridging with left-right collaterals. The posterior descending artery was known to be a good target. Additional findings on the catheterization were abdominal aorta with a large infrarenal aneurysm beginning 13 mm below the renals, bilaterally single without disease. The largest extent of the aneurysm was 4.8 cm with a length of over 11.7 cm. Proximal runoffs reveals moderate ostial left iliac lesion. The common femoral artery and the superficial femoral artery are bilaterally normal. Given the patient's significant three vessel coronary artery disease and symptoms of occasional angina and dyspnea on exertion, it was determined that he would be an appropriate candidate for coronary artery bypass grafting. The Cardiothoracic Surgery service was consulted after the catheterization procedure, and the following history was obtained. PAST MEDICAL HISTORY: History of inferior myocardial infarction by electrocardiogram, mild chronic obstructive pulmonary disease, hypertension, hypercholesterolemia, 6 cm infrarenal abdominal aortic aneurysm as noted previously that was picked up incidentally on examination by his cardiologist several months ago, benign prostatic hypertrophy, gout, greater than 75 pack year smoking history but he recently quit in the last six months. He is hypothyroid. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Aspirin 325 mg by mouth once daily, Lipitor 10 mg by mouth once daily, atenolol 50 mg by mouth once daily, allopurinol 100 mg by mouth once daily, Flomax .4 mg by mouth once daily, Tapazole 20 mg by mouth once daily, and Mavik 1 mg by mouth once daily. LABORATORY DATA: Preoperative hematocrit was 36. BUN and creatinine were 17 and 1.1. Catheterization data as stated. Chest x-ray showed no acute cardiopulmonary process. His electrocardiogram was significant for sinus bradycardia at 54, with Q waves in II, III and AVF. He had no abnormal ST/T wave changes. He had early J-point elevation. He did have early R wave progression as well. PHYSICAL EXAMINATION: Heart rate 54, blood pressure 134/70, no acute distress, no chest pain, no carotid bruits auscultated. The heart was regular, with a prominent S2, no murmur. The lungs were clear to auscultation except decreased breath sounds throughout. His abdominal examination was soft, nontender, nondistended. There was a pulsatile mass palpated between the xiphoid and umbilicus, approximately 5 cm by examination. There was no hepatosplenomegaly, there was no renal bruit. Flank examination was negative. His lower extremities had palpable dorsalis pedis and posterior tibial pulses distally bilaterally. HOSPITAL COURSE: Given this presentation, it was elected to bring him to the operating room on [**2140-12-8**]. He was first discharged after his elective catheterization on [**2140-12-5**] and ultimately readmitted on [**2140-12-8**], where he underwent an elective coronary artery bypass graft x 4 with Dr. [**Last Name (STitle) **], including a left internal mammary artery to the left anterior descending, a right saphenous vein graft to the diagonal, as well as a saphenous vein graft to the obtuse marginal and saphenous vein graft to the right posterior descending artery. The patient tolerated the procedure well. Intraoperative findings of transesophageal echocardiogram were an ejection fraction of 45 to 50%, calcified aorta, good distal targets. His pericardium was left open. He had a right radial A-line. He had a right internal jugular cordis in place, CVP, right atrial catheter. He had two ventricular wires and two atrial wires, and two mediastinal tubes and one pleural tube. His mean arterial pressure was 77, with a right atrial pressure of 9. He was found to be in normal sinus rhythm at a rate of 74. He was on a propofol drip of 20 mcg/kg/minute for sedation. He was transferred to the Cardiac Surgical Recovery Unit, where in the first 24 hours after surgery, all of his drips were weaned off and he was rapidly extubated. He remained in sinus rhythm at 88, with blood pressures in the 120s to 130s. His hematocrit was 25 postoperatively, with a BUN and creatinine of 18 and 1. Neurologically, he remained intact. He was started on his lasix, Lopressor, aspirin. Chest tubes were removed, as well as diet advanced. He was subsequently transferred to the floor by postoperative day number one. He was up and ambulating on postoperative day number one, feeling well. He worked with Physical Therapy aggressively, and continued pulmonary toilet with incentive spirometry, coughing and deep breathing. His electrolytes were repleted as needed. By postoperative day number two, he continued to feel well. He had a low-grade temperature of 100.9, but otherwise the remainder of his vitals were normal, with a heart rate of 94 and sinus, blood pressure of 114/60. His Lopressor was titrated accordingly. He had BUN and creatinine of 23 and 1.0, and a hematocrit of 24. By postoperative day number four, the patient was ambulating. His wires, chest tubes and Foley had been removed at this point. He was in sinus tachycardia to sinus rhythm, between 90 and 103. His blood pressure was ranging 106 to 110 over 50s to 60s. Oxygen saturation was 95% on room air. He had a stable sternum, with no evidence of drainage. His abdominal examination was unchanged from admission. His extremities were warm and well perfused, with palpable pulses at dorsalis pedis and posterior tibial bilaterally. Subsequently the patient was deemed stable and appropriate for discharge. DISCHARGE MEDICATIONS: Lopressor 75 mg by mouth twice a day, Lipitor 10 mg by mouth once daily, lasix 20 mg by mouth once daily for seven days, K-Dur 20 mEq by mouth once daily for seven days, Protonix 40 mg by mouth once daily, aspirin 325 mg by mouth once daily, allopurinol 100 mg by mouth once daily, Tapazole 20 mg by mouth once daily, Flomax .4 mg by mouth once daily, percocet 5/325 one to two tablets by mouth every four to six hours as needed, and Colace 100 mg by mouth twice a day. DISCHARGE STATUS: To home with VNA. CONDITION ON DISCHARGE: Stable, afebrile, in normal sinus rhythm, no evidence of sternal drainage. DISPOSITION: To home with VNA with instructions not to undergo any heavy lifting greater than ten pounds for 30 days, no driving for 30 days. Wound may get wet with shower. He will have follow up with Dr. [**Last Name (STitle) **] in four weeks, follow up with his cardiologist or primary care physician in three weeks from the time of discharge. VNA will assist the patient. If they happen to dismiss him after day seven through ten, he can return to the Wound Care Clinic, where he will receive a wound checkup. DISCHARGE DIAGNOSIS: 1. Significant three vessel coronary artery disease status post coronary artery bypass graft x 4, with left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, obtuse marginal and also right posterior descending artery. 2. Hypertension 3. Hyperlipidemia 4. 6 cm abdominal aortic aneurysm 5. Benign prostatic hypertrophy 6. Mild chronic obstructive pulmonary disease 7. 50 pack year smoker 8. History of inferior myocardial infarction and coronary artery disease 9. Hypothyroidism 10. Questionable history of osteoarthritis [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2140-12-11**] 22:42 T: [**2140-12-12**] 00:35 JOB#: [**Job Number 24525**]

Admission Date: [**2195-8-12**] Discharge Date: [**2195-9-14**] Date of Birth: [**2195-8-12**] Sex: M Service: Neonatology HISTORY: Baby [**Known lastname 2470**] is a baby boy who was born at 35-3/7 weeks to a 24 year old G2, P1 mother with estimated date of confinement of [**2195-9-13**]. Prenatal laboratories included blood type to be O+, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune and GBS status unknown. MATERNAL HISTORY AND DELIVERY: The maternal history was notable for previous primary C-section with postpartum hemorrhage requiring uterine artery ligation. This pregnancy was reportedly unremarkable until the day prior to delivery when the mother developed contractions. She came to the hospital in preterm labor, was noted with cervical dilation and was taken for repeat C-section. No sepsis risk factors were identified, and mother did not receive intrapartum antibiotic prophylaxis. At delivery the infant emerged vigorous with Apgars of 8 and 9, requiring only brief blow-by O2. Increased work of breathing was noted that persisted. Infant was brought to the NICU. In the NICU moderate grunting, flaring and retractions were apparent with room air saturations in the low 80s. Infant was then placed on CPAP. PHYSICAL EXAMINATION AT THE TIME OF ADMISSION: Weight: 2760 grams, 75th percentile. Head circumference: 33.5 cm, 75th percentile. Length: 46 cm, 50th percentile. Vital signs: Temperature 98.4, heart rate 150s, respiratory rate 40s-50s, blood pressure 37/29 with a MAP of 34 and O2 saturations 95%- 98% on 40% FIO2. In general, this is a well developed, pre- term infant, active and vigorous, with moderate grunting, flaring and retractions at rest. Skin is warm, mildly pale. Sluggish capillary refill. No rash. HEENT exam reveals fontanels soft and flat. Positive for red reflex bilaterally. Palate intact. Neck is supple. No lesions. Chest is coarse, moderately aerated. Positive for grunting, flaring and retractions. Cardiac is regular rate and rhythm. Soft systolic murmur. Abdomen is soft. No hepatosplenomegaly. No mass. Three-vessel cord. Quiet bowel sounds. GU: Normal male. Testes palpable bilaterally. Anus patent. Extremities: Warm. No lesions. Hips/Back: Stable. Neurologic: Appropriate tone and activity. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The patient was initially placed on CPAP and quickly, on day of life 1 due to persist increased work of breathing and increased O2 requirement, was intubated and placed on the conventional ventilator. Patient also received Survanta x2, and on day of life #4 was weaned to CPAP. On day of life #5 was weaned to nasal cannula and by day of life #6, [**2195-8-18**], patient was on room air and has remained on room air until discharge. Two days prior to discharge, the infant experienced a brief period of duskiness associated with crying. He was not apneic at this time. The infant was monitored for an additional two days without recurrence. This had not been previously observed, and the infant remained well. This was thought to be a breath holding event. Fluids, electrolytes, nutrition: Patient was made NPO for the 1st 5 days of life and supplemented with parenteral nutrition during this period. On day of life #6 started on p.o./p.g. feeds of breast milk/Enfamil 20. Patient continued to advance on p.o. feedings, and on day of life #30 achieved full p.o. feeds of breast milk 24/Enfamil powder. Weight at the time of discharge is 3535 g. Cardiovascular: Patient was noted to have a soft murmur at the time of birth. EKG was performed and revealed normal sinus rhythm. Murmur has since resolved GI: Patient was noted with hyperbilirubinemia on day of life #4. Bilirubin was noted at 12.7/0.5. Phototherapy was discontinued on day of life #6 with a rebound bilirubin of 7.7/0.3. Phototherapy was never restarted. Hematology: This patient was not a known setup, and no transfusion was ever given throughout his hospital course. Infectious disease: CBC and blood culture were done at birth. Patient was then started on ampicillin and gentamicin for 48- hour rule out. The length of course of antibiotics was increased to a 7-day course of antibiotics due to the persistent O2 requirement and respiratory needs of the patient despite no additional signs or symptoms of infection. Blood cultures negative, final as of [**2195-8-18**]. An LP was performed on [**2195-8-15**], with results unremarkable, and then a CSF culture was negative, final on [**2195-8-18**]. Patient currently continues on Nystatin for treatment of oral thrush. Neurologic: Patient has a normal physical exam as noted with normal suck, normal grasp, normal tone and is alert. Head ultrasound was not indicated. Sensory: Audiology: Hearing screen was performed with automated auditory brainstem responses. Patient passed his hearing screen on [**2195-8-23**]. Ophthalmology: Eye exam was not indicated for this ex-35- weeker weighing more than 1500 g, who did not require prolonged O2 throughout his hospital course. Psychosocial: The [**Hospital1 18**] social work is involved with this family. The contact social worker is [**Name (NI) 36130**] [**Name (NI) 6861**], who can be reached at [**Telephone/Fax (1) **]. CONDITION AT DISCHARGE: Patient is currently in stable condition. DISCHARGE DISPOSITION: To home with mother. PRIMARY CARE PEDIATRICIAN: [**Hospital 17566**] Pediatrics located in [**Location (un) 5871**], MA; phone number is [**Telephone/Fax (1) 37911**]; fax [**Telephone/Fax (1) 37912**]. The primary care pediatrician will be Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) **]. CARE/RECOMMENDATIONS: At the time of discharge patient is to be maintained on full p.o. feeds of breast milk 24 ad lib. MEDICATIONS: Currently include Nystatin as needed for treatment of oral thrush. CAR SEAT POSITIONING SCREENING: Car seat positioning screening was passed on [**2195-9-11**]. IMMUNIZATIONS RECEIVED: Patient did receive his hepatitis B vaccine on [**2195-8-11**]. IMMUNIZATIONS RECOMMENDED: Synergist RSV prophylaxis should be considered for [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with 2 of the following: 1) daycare during RSV season, 2) a smoker in the household, 3) neuromuscular disease, airway abnormalities or school-age siblings, or infants who have chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the 1st 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS RECOMMENDED FOR THIS PATIENT: Patient is recommended to follow up with PMD, Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) **], at [**Hospital 17566**] Pediatrics on [**Last Name (LF) 766**], [**2195-9-14**]. Time of appointment to be scheduled by mother. DISCHARGE DIAGNOSES: Prematurity, Respiratory Distress Syndrome, Presumed Pneumonia, Hyperbilirubinemia, Monilial Infection [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Last Name (NamePattern1) 62404**] MEDQUIST36 D: [**2195-9-11**] 15:05:27 T: [**2195-9-11**] 16:00:25 Job#: [**Job Number 63522**]

Admission Date: [**2176-2-5**] Discharge Date: [**2176-2-15**] Date of Birth: [**2106-8-2**] Sex: F Service: MEDICINE Allergies: Aspirin / Heparin Agents Attending:[**First Name3 (LF) 2181**] Chief Complaint: Mental status changes Major Surgical or Invasive Procedure: Intubation History of Present Illness: 69 yo F with history of ESRD on HD, DM, recently admitted to [**Hospital1 18**] for ORIF for left distal femur fracture (uncomplicated hospital course) referred to ED today after she developed acute change in mental status associated with decreased responsiveness during a dialysis treatment today. History per daughter stated that she last spoke to her mother night PTA and she was "fine" (asking her daughter about her finances, etc.). She denies that her mother has ever had a seizure, stroke in the past. Denies any baseline weakness or numbness. States the patient was living on her own prior to her recent hip fracture. . Per sparse history on dialysis notes, patient was given percocet at approximately 9:55AM and at approximately 10:30AM developed acute mental status changes, including confusion. Patient continued through dialysis with stable vital signs (BP 130's-140's/60's, HR 40's-50's). After completion of dialysis, EMS was called for transfer to the hospital. . EMS notes were significant for noting "rapid deterioration in mental status", right gaze, dry blood on lips, no response to pain, aphasia. EMS noted decreased HR to 30's x 2 on transfer, FSBS = 185. . On presentation to ED at [**Hospital1 18**], exam was notable for minimal responsiveness, GCS 13, withdrawl of all extremities to pain, following occasional commands, non-verbal (groans). VSS with T 98.8, HR 58, BP 132/102, O2 sat 98%. Labs were notable for WBC 9.5 with 86 N and 2 B, Cr 5.1 (hx ESRD on HD), AST 59, LDH 450, AP 218, T bili 3.9, lactate 2.8. Blood cxs x 2 were sent in ED. Head CT demonstrated no evidence of intracranial bleed or edema. CXR was wnl. MRI/A scan was performed (read pending). Evaluation by neuro yielded diagnosis of possible seizure activity. Pt was given narcan 0.4mg IV x 1, Ativan total of 2mg IV, dilantin load (total of 2gm IV). She was intubated for airway protection (given FFP prior to intubation as INR 1.9, on coumadin as outpt as s/p hip surgery) and transferred to the ICU for further managment. Past Medical History: 1. Diabetes type 2 2. ESRD on HD Q M,W,F 3. s/p infection in left knee 4. h/o MRSA/C.diff 5. NASH [**3-7**] to tylenol 6. s/p ORIF for left distal femur fracture on [**2176-1-23**] Social History: SOH: lives at home with daughters. [**Name (NI) **] ETOH/TOB/illicts. Family History: FH: non-contributory Physical Exam: Gen- intubated and sedated HEENT- Pinpoint pupils, reactive b/l. 2 cm healed scar of R upper forehead. c/d/i Neck- Supple, unable to assess JVP Chest- CLA anteriorly, b/l CV- Regular, bradycardic. no m/r/g Abd- +bs. soft. nd. no hepatosplenomegaly. no masses [**Name (NI) **]- 1+ le edema. 2+ dp pulses. . On transfer to the floor: Physical Exam: VS: BP 131-143/41-57, HR 74-85 RR 20 O2 92-96% RA Gen - lying in bed, slurred speech, intermittently opens eyes, intermittently answers questions HEENT - PERRLA. 2 cm healed scar of R upper forehead. anicteric sclerae Neck - Supple, unable to assess JVP, patient with left subclavian line Chest - decreased breath sounds in left base CV - RRR, S1S2 normal, systolic murmur [**4-8**] radiating into the axillae Abd - +bs. soft. nd. no hepatosplenomegaly. no masses, mild tenderness in RUQ on deep palpation. Ext - trace LE edema. 2+ dp pulses. Pertinent Results: [**2176-2-5**] 02:10PM PT-16.8* PTT-36.5* INR(PT)-1.9 [**2176-2-5**] 02:10PM PLT SMR-LOW PLT COUNT-149*# [**2176-2-5**] 02:10PM NEUTS-86* BANDS-2 LYMPHS-5* MONOS-6 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2176-2-5**] 02:10PM WBC-9.5# RBC-3.92* HGB-13.2# HCT-37.7# MCV-96 MCH-33.6* MCHC-35.0 RDW-20.1* [**2176-2-5**] 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2176-2-5**] 02:10PM T4-19.8* [**2176-2-5**] 02:10PM TSH-3.6 [**2176-2-5**] 02:10PM CALCIUM-9.4 PHOSPHATE-4.0# MAGNESIUM-1.8 [**2176-2-5**] 02:10PM LIPASE-524* [**2176-2-5**] 02:10PM ALT(SGPT)-15 AST(SGOT)-59* LD(LDH)-450* ALK PHOS-218* TOT BILI-3.9* [**2176-2-5**] 02:10PM GLUCOSE-186* UREA N-29* CREAT-5.1* SODIUM-131* POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-22 ANION GAP-20 . Imaging: [**2176-2-5**] CT head w/out contrast: No evidence of intracranial hemorrhage or edema. [**2176-2-5**] CXR: Unremarkable chest radiograph. [**2176-2-5**] MRI brain w/out contrast [**2176-2-5**]: No evidence of acute brain ischemia. Small arachnoid cyst in the right cerebellopontine angle cistern. Limited MR angiography study- the distal vasculature is poorly visualized, which could be secondary to low cardiac output. [**2176-2-6**] Liver U/S - Limited examination. Patent hepatic arteries and veins and portal veins with flow in the appropriate direction. [**2176-2-7**] EEG - Markedly abnormal portable EEG due to the slow and disorganized background and very frequent generalized sharp wave discharges. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. The sharp waves were prominent and frequent and suggest an increased risk of seizures. Nevertheless, they were not particularly rhythmic or of higher frequency during this recording so as to suggest ongoing seizures at the time of the recording. There were no prominent focal findings although encephalopathies can obscure such findings. If concern for seizures persist clinically, a repeat tracing could be of assistance. [**2176-2-8**] MR [**Name13 (STitle) 430**] - Severely limited study. No large gross changes identified compared to [**2176-2-5**], but more subtle acute changes will not be discernable on today's study. If indeed there is high clinical suspicion of an acute change from [**2-5**], repeat imaging may be necessary. [**2175-2-9**] Abdominal U/S - There is no ascites. Marked splenomegaly Brief Hospital Course: # Mental status change: Initial exam was notable for minimal responsiveness, withdrawal of all extremities to pain, following occasional commands, non-verbal (groans). VSS with T 98.8, HR 58, BP 132/102, O2 sat 98%. Head CT demonstrated no evidence of intracranial bleed or edema. CXR was wnl. MRI/A scan was performed and did not show any evidence of ischemia. Evaluation by neuro yielded diagnosis of possible seizure activity. Pt was given narcan 0.4mg IV x 1, Ativan total of 2mg IV, dilantin load (total of 2gm IV). She was intubated for airway protection and transferred to the ICU for further managment. She was also covered for possible encephalitis/ meningitis with Acyclovir, CTX, Vanco and Ampicillin. A LP was done but did not show any signs of meningitis or encephalitis. The pt continued to have waxing and [**Doctor Last Name 688**] mental status. She was found to have elevated LFTs and was thought to have a component of hepatic encephalopathy. First EEG supporting seizure activity. Repeat EEG showed slowed activity c/w encephalopathy. Possible hepatic encephalopathy: Ammonia elevated at 65, therefore pt has been started on lactulose to attempt to improve MS. Repeat was in 30's. Abx were discontinued. On the [**2-8**] the pt self extubated and was reintubated to be extubated on the [**2-9**]. A NG tube was placed for nutrition. Over the following two days the pt was more lucid and stable. She was called out to the floor for further management. The pt continued to improve and became more lucid and oriented x3. Dilantin was continued orally at 300mg QD. Free Dilantin levels were checked and below therapeutic levels and therefore Dilantin was increased to 150 TID. Free Dilantin level should be repeated in three days. Lactulose and Rifaximin were continued. Lactulose should be titrated to three bowel movements. . # Liver disease: Per pt's daughter the pt had tylenol induced liver damage in past. Per daughter no ETOH/drug abuse in the past. Hep A neg, B surface pos, core neg, Hep C neg. Serum IgG, IgA, IgM were elevated without any specific pattern suggestive of a disease process. [**Doctor First Name **] was negative, but Anti-SM and AMA were mildly positive (Titer 1:20). HSV PCR was negative. Possible primary biliary cirrhosis also consistent with obstructive enzyme pattern. Also possible steatosis hepatis from obesity. RUQ U/S showed splenomegaly, no ascites, no focal lesions in liver, no sign of biliary dilatiation. Flow in appropriate direction in portal vein. LFTs were followed up and were trending down. Follow up of LFT, CBC and Chem 7 should be obtained once in the following week. The pt has follow up arranged for her with Dr. [**Last Name (STitle) 497**] on the [**2-13**] at 9.40am. A liver biopsy might be considered to investigate the etiology of the problem further. The pt should be given hepatitis A vaccine once she is more stable. She was adviced to avoid hepatotoxic medications. . # Transient Leukocytosis and intermittent fever spike: Urine with WBC, and one time positive urine culture for klebsiella. Pt was initially treated for suspected meningitis with Ampicillin, Vancomycin and Ceftraixone. Antiobiotics were discontinued five days into her hospital course. The pt was afebrile after discontinuation of the antibiotics and remained with a normal WBC. The pt was found to have a new systolic murmur on exam, radiating into her axilla, most consistent with a mild mitral regurgitation. Follow up ECHO should be obtained. Given the fact that all blood cultures were negative and the pt remained afebrile and no other physical signs on examinations were found consistent with endocarditis the suspicion for endocarditis was considered low and no further workup was obtained. . # ESRD: Pt continued her outpatient dialysis schedule in house. She tolerated dialysis well. . # Hypernatremia: transient. Due to lack of free water because of to prolonged initial period without feeding as complicate NGT placement. Free water deficit was calculated as about 4L. Pt was repleted with free water boluses via NGT 250cc TID. Hypernatremia resolved. . # Anemia - pt has baseline anemia - about three points decreased from her baseline at around 29. Likely sequestration in spleen and possible low grade hemolysis due to liver disease in addition to renal anemia in ESRD. Hemolysis labs difficult to interpret in the setting of liver disease. Iron studies consistent with anemia of chronic disease, no iron deficiency. Erythropoetin was administered during dialysis. . # Thrombocytopenia & elevated INR: HIT AB POSITIVE. Also with splenomegaly and chronic liver disease, likely sequestering. All heparin containing products were avoided. Thrombocytes were consistently above 50,000. . # DM2: Endocrinology was consulted and sliding scale was adjusted per recommendations. Lantus 20 and RISS to be continued as outpatient. Pt had a one time episode of hypoglycemia to 49. ISSC was decreased by unit two days prior to discharge. Further fine adjustment should be achieved in the rehabilitation center. . # ORIF: pt was seen by orthopedics in house. Knee XR was obtained. No dislocation of the hardware was seen. The pt should remain not weight bearing on her L leg for 5 more weeks. F/u appointment with ortho was obtained in 5 weeks. Medications on Admission: 1. Colace 100 mg [**Hospital1 **] 2. Pantoprazole 40 mg QD 3. Acetaminophen 500 mg q6 4. Metoprolol Tartrate 25 mg [**Hospital1 **] 5. Warfarin 1 mg QD 6. Calcium Carbonate 500 mg TID 7. Hydromorphone 2 mg q6 8. Senna 8.6 mg [**Hospital1 **] 9. Bisacodyl 10 mg Tablet, QD 10. Sevelamer 800 mg TID Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:*qs * Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). Disp:*1350 ML(s)* Refills:*2* 6. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) Subcutaneous As directed. Disp:*qs * Refills:*2* 7. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID (3 times a day). Disp:*270 Tablet, Chewable(s)* Refills:*2* 8. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous at bedtime. Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Mental status changes EEG with seizure like activity Liver failure Hepatic encephalopathy ................... Diabetes type 2 ESRD on HD Q M,W,F s/p ORIF for left distal femur fracture on [**2176-1-23**] Discharge Condition: Good, Pt [**Name (NI) 9830**]3, mental status changes resolved Discharge Instructions: Please come back to the hospital or see your primary care doctor if you experience any worsening mental status, confusion, headaches, jaundice or any other concerns. . Please take all medications as instructed. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 497**] on the [**2-13**] at 9.40am for your liver disease. . Please follow up with Neurology, Dr. [**Last Name (STitle) **] on the [**3-22**] at 11.00am, [**Location (un) **] of [**Hospital Ward Name 23**] building. . Please also follow up with your primary care doctor. . And follow up with orthopedics for your fracture: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2176-3-19**] 9:00

Admission Date: [**2183-10-23**] Discharge Date: [**2183-10-28**] Date of Birth: [**2117-8-8**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman, with a past medical history significant for chronic alcohol abuse, and a history of alcoholic ketoacidosis, also depression, COPD, and multiple ED visits and admissions for intoxication, who was admitted to the ICU for severe hypophosphatemia in the setting of a recurrence of her alcoholic ketoacidosis. The patient's alcohol level was 370 on admission. She had an anion gap of 37 with a bicarbonate of 11. Her phosphate level was 0.3. PAST MEDICAL HISTORY: 1. Chronic alcohol abuse with a history of alcoholic ketoacidosis. 2. Depression. 3. COPD. 4. Recently treated for herpes zoster. 5. Benign essential tremor. 6. History of adrenal mass. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Combivent 1-2 puffs [**Hospital1 **]. 2. Naltrexone 50 mg po qd. 3. Neurontin 40 mg po tid. 4. Desipramine 10 mg po qd. 5. Zoloft 50 mg po qd. SOCIAL HISTORY: A 60-pack year tobacco history. History of alcohol abuse. No history of IV drug abuse. The patient is a former nurse. PHYSICAL EXAM: Vital signs - blood pressure 138/64, heart rate 104, respiratory rate 24, oxygen saturation 96% on 4 liters face mask. GENERAL: Chronically ill-appearing woman with a visible tremor and the odor of alcohol upon her. HEENT: Sclerae anicteric. Mucous membranes moist. PERRLA. NECK: No JVD. CHEST: Clear to auscultation. No rhonchi, rales or wheezing. CARDIOVASCULAR: Regular rate and rhythm. S1, S2 normal. No murmurs, rubs or gallops. ABDOMEN: Obese, soft, nontender with bowel sounds. EXTREMITIES: Good distal pulses. No clubbing, cyanosis or edema. NEURO: Nonfocal with the exception of not responding to name call. PERTINENT LABS AND DIAGNOSTICS: CBC revealed a white count of 5.5, with 11% bands, a hematocrit of 42.8, and a platelet count of 239. Chem-7 was significant for a sodium of 140, potassium 3.8, chloride 93, bicarbonate 11, BUN 24, creatinine 1.2, glucose 186. Anion gap was 36. ETOH level was 370. Acetone level was positive. ABG on room air was pH 7.40, PCO2 26, PO2 85. ASSESSMENT: This is a 65-year-old woman, with a history of alcohol abuse, who presents with hypophosphatemia and alcoholic ketoacidosis. In the ED, she also had coffee ground emesis, although her hematocrit remained stable. HOSPITAL COURSE - The following is a summary of the [**Hospital 228**] hospital course by systems: 1) HYPOPHOSPHATEMIA: The patient received ample phosphate repletion while she was in-house, and on her day of discharge was no longer hypophosphatemic. 2) ALCOHOLIC KETOACIDOSIS: The patient was aggressively treated with Insulin and glucose, fluids, and electrolyte repletion in the Medical Intensive Care Unit to the extent that her anion gap and acidosis resolved. 3) COFFEE GROUND EMESIS: The patient was seen by the gastrointestinal team while she was in-house. Her hematocrit was followed in the hospital and did not drop significantly. She was started on PPI. She was made NPO at first, but then slowly advanced in her diet. She underwent an EGD prior to discharge which revealed no [**Doctor First Name **]-[**Doctor Last Name **] tear, erythema, and erosion in the antrum compatible with gastritis, no esophageal varices, and an otherwise normal EGD. She was continued on her PPI and will be continued for 4 weeks. Biopsy results at the time of this dictation were pending. The gastrointestinal team recommended follow-up appointment as an outpatient, as well as a screening colonoscopy. 4) ALCOHOL INTOXICATION: The patient was maintained on a CIWA scale to monitor her for withdrawal. She received valium accordingly. The patient was visited by the substance abuse team, and the patient requested transfer to an inpatient psych facility for treatment of her alcohol dependence. 5) ESSENTIAL TREMOR: The patient was treated with nadolol with subsequent improvement of her essential tremor. She continued to have one, however, at baseline. 6) DEPRESSION: The patient was continued on her Zoloft. 7) FEN: The patient underwent aggressive electrolyte repletion, as mentioned above. She was made NPO at first, but as her hematocrit remained stable and she had no abdominal complaints, she was advanced as tolerated to a full diet. 8) PROPHYLAXIS: The patient was treated with Protonix, as mentioned above, as well as Pneumoboots and a bowel regimen. DISCHARGE STATUS: To [**Hospital1 **] for inpatient substance abuse treatment. DISCHARGE CONDITION: Fair. DISCHARGE DIAGNOSES: 1. Alcoholic ketoacidosis with hypophosphatemia. 2. Essential tremor. 3. Depression. 4. Chronic obstructive pulmonary disease. 5. Gastritis. 6. Alcohol abuse. FOLLOW-UP PLANS: The patient will follow-up with GI for a colonoscopy, as well as follow-up of her coffee ground emesis. The patient will follow-up with her primary care physician as needed. The patient will receive inpatient psych care at [**Hospital1 **]. DISCHARGE MEDICATIONS: 1. Diazepam 10 mg po q 6 h prn CIWA scale greater than 10. 2. Calcium carbonate 500 mg po tid with meals. 3. Montelukast sodium 10 mg po qd. 4. Protonix 40 mg po q 12 h. 5. Nadolol 20 mg po qd. 6. Multivitamin 1 tablet po qd. 7. Folate 1 mg po qd. 8. Thiamine 100 mg po qd. 9. Albuterol and ipratropium nebs q 6 h prn. 10.Sertraline 50 mg po qd. 11.Tylenol 325-650 mg po q 6 h prn. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12*ADF Dictated By:[**Last Name (NamePattern1) 1595**] MEDQUIST36 D: [**2183-10-27**] 13:25 T: [**2183-10-27**] 13:33 JOB#: [**Job Number 47678**]

Admission Date: [**2179-9-19**] Discharge Date: [**2179-9-25**] Date of Birth: [**2109-10-29**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2180-9-18**] Aortic Valve Replacement (23mm CE pericardial), Coronary Artery Bypass Graft x 1 (LIMA to LAD) History of Present Illness: 69 y/o male with h/o atrial fibrillation, aortic stenosis, and coronary artery disease who is now having increased symptoms of dyspnea on exertion. Along with fatigue and dizziness. He was referred for surgical intervention. Past Medical History: Aortic Stenosis, Coronary Artery Disease, Gastroesophageal Reflux Disease, Atrial Fibrillatoin s/p Ablation, s/p PPM [**2174**], Erectile Dysfunction s/p Hernia repair, s/p Bilat knee arthroscopy Social History: Denies tobacco or ETOH use. Family History: NC Physical Exam: VS: 72 18 154/98 6' 195# Gen: WDWN male in NAD Skin: Unremarkable HEENT: EOMI, PERRL NCAT Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB Cardiac: Irreg rhythm with 3/6 SEM radiating to carotids Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema, -varicosities Neuro: grossly intact, A&O x 3 Pertinent Results: [**2179-9-20**] Echo: PREBYPASS: 1. The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. 3. The ascending and transverse thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the descending thoracic aorta. 4. There are three aortic valve leaflets, which are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). 5. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. 6. There is no pericardial effusion. 7. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2179-9-20**] at 1209. POSTBYPASS: 1. Pt is currently on a phenylephrine infusion 2. The pt has thickened LV walls with an underfilled ventricle. Wall motion is unchanged from prebypass, with EF 50% 3. The aortic annular ring can be seen well seated with no perivalvular leak. There is +1 Aortic insufficiency 4. The contours of the aortic root are smooth after aortic cannular was removed. [**2179-9-21**] CXR: As compared to the previous radiograph, there is no relevant change. The monitoring and support devices are in unchanged position. There is no evidence of pneumothorax and no evidence of major pleural effusion. Subtle retrocardiac atelectasis. No focal parenchymal opacities suggestive of pneumonia. Mild overinflation of the stomach. [**2179-9-19**] 05:25PM BLOOD WBC-6.3 RBC-5.04 Hgb-15.7 Hct-44.2 MCV-88 MCH-31.2 MCHC-35.6* RDW-13.5 Plt Ct-210 [**2179-9-22**] 05:35AM BLOOD WBC-21.5*# RBC-4.63 Hgb-14.0 Hct-41.6 MCV-90 MCH-30.3 MCHC-33.7 RDW-13.9 Plt Ct-142* [**2179-9-19**] 05:25PM BLOOD PT-15.1* PTT-30.8 INR(PT)-1.3* [**2179-9-20**] 09:11PM BLOOD PT-15.9* PTT-39.0* INR(PT)-1.4* [**2179-9-19**] 05:25PM BLOOD Glucose-92 UreaN-19 Creat-1.2 Na-142 K-3.9 Cl-108 HCO3-26 AnGap-12 [**2179-9-22**] 05:35AM BLOOD Glucose-153* UreaN-20 Creat-1.2 Na-133 K-4.5 Cl-100 HCO3-19* AnGap-19 [**2179-9-19**] 05:25PM BLOOD ALT-23 AST-23 LD(LDH)-203 AlkPhos-56 TotBili-0.9 [**2179-9-25**] 08:16AM BLOOD WBC-7.6 RBC-4.02* Hgb-12.1* Hct-35.8* MCV-89 MCH-30.2 MCHC-33.9 RDW-14.1 Plt Ct-174# [**2179-9-22**] 12:27PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG Brief Hospital Course: Mr. [**Known lastname 1274**] was admitted a day before surgery d/t being on Coumadin for h/o Atrial Fibrillation. He discontinued it 5 days before surgery. Upon admission he was started on Heparin and appropriately worked up for surgery. On [**9-20**] he was brought to the operating room where he underwent a aortic valve replacement and coronary artery bypass graft x 1. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one EP was consulted to interrogate his pacemaker. Later on this day Mr. [**Known lastname 1274**] appeared to be doing well and was transferred to the telemetry floor for further care. Mr [**Known lastname 1274**] was in chronic afib that was difficult to control and his metoprolol was advanced. He was re-started on coumadin on POD 2. A rub was noticed and he was started on Ibuprofen.The remainder of his postoperative course was essentially unremarkable. [**9-22**] due to an elevated WBC ct. blood and urine cultures were sent and empiric antibiotics were started. Urine Cx originally positive and sensitive to ABX but repeat finalized negative. The WBC ct improved to normal and his temp.remained afebrile, at time of discharge blood cultures were pending, it was decided to continue a full week of antibiotic coverage. He was restared on his preoperative dose of Digoxin, along with his preoperative Coumadin regiment of 5 mg alt. with 2.5 mg daily, with VNA. He was advised on all follow up appointments. Medications on Admission: Atenolol 100mg [**Hospital1 **], Prilosec 20mg qd, Tricor 146mg qd, Digoxin 0.25mg qd, Vit C, D and E, Zetia 10mg qd, Coumadin (stopped [**9-14**]) Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*1* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 7. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: resume 5mg alternating with 2.5 mg daily or [**Name8 (MD) **] MD . Disp:*90 Tablet(s)* Refills:*0* 8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*0* 10. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days. Disp:*28 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 4 days. Disp:*32 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1 PMH: Gastroesophageal Reflux Disease, Atrial Fibrillatoin s/p Ablation, s/p PPM [**2174**], Erectile Dysfunction s/p Hernia repair, s/p Bilat knee arthroscopy Discharge Condition: good Discharge Instructions: Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. Report any fever greater then 100.5. Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. No lotions, creams or powders to incision until it has healed. Shower daily. No baths or swimming.Gently pat the wound dry. o lifting greater then 10 pounds for 10 weeks. No driving for 1 month Take all medications as directed Followup Instructions: wound clinic in 2 weeks Dr [**Last Name (STitle) **] in 4 weeks Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] in [**2-14**] weeks Completed by:[**2179-9-25**]

Admission Date: [**2124-7-14**] Discharge Date: [**2124-7-19**] Date of Birth: [**2067-12-2**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 56 year old with alcoholic cirrhosis and end-stage liver disease who has been "in and out" of the [**Location 24355**] over the past few months for repeated episodes of LE cellulitis including ? nec fascitis on one occasion. He had been in a rehab hospital today (was sent there from the VA) and was feeling well per his report, wanting to be D/C'd when they got labs that were concerning (hct, cr) and sent him to [**Hospital 6451**] Hospital. There he was found to have a Hct of 27, SBP in the 60's, Melena. He was started on levophed and NS "wide open" through one 20 Ga IV. He was transferred here. On arrival in the ED here, he was afebrile, HR 91, BP 72/36 RR 20 Sat 96% on 2L. He was given 2 18 Ga PIV, a Rt. femoral TLC, Vitamin K, a litre of NS, FFP (3 U), 1 U PRBC and IV protonix. GI and renal were consulted. His Cr. was 3.6, his K was 5.8, but he was not noted to have any ECG changes on 12-lead; he was given kayexelate. . MICU admission requested. Past Medical History: Alcoholic cirrhosis with end-stage liver disease - not on transplant list anywhere per pt. (was to be evaluated for this). CRI (? baseline Cr.) Mult. recent episodes cellulitis DM2 Social History: etoh, last drink per pt. over 10 yy ago; no IVDU, was in Army, also worked as a delivery man Family History: DM - mother, denies hx. CHD in family Physical Exam: VS: BP 60's over 40's HR 115, AF, R 25, 96% NC HEENT EOMI, sclerae are icteric COR: Tachy, regular, [**12-27**] hsm PULM: CTA ant ABD: Distended and tense ascites EXT: 4+ LE edema NEURO: Alert, oriented to place, time, event Brief Hospital Course: Patient was admitted to the MICU. His condition continued to deteriorate despite all measures and he was made DNR/DNI in consensus with his family on [**2124-7-18**]. He continued to decline and in the morning of [**2124-7-19**], after verbal discussion with his three children, patient was made COMFORT MEASURES ONLY. He was treated with morphine for respiratory distress and pressors were withdrawn. Patient passed away shortly thereafter and was pronounced deceased on [**7-19**] at 00:20 by [**First Name8 (NamePattern2) 11556**] [**Last Name (NamePattern1) 18721**] MD and [**First Name8 (NamePattern2) 2894**] [**Last Name (NamePattern1) **] MD. . . . IMP:56 y/o with ETOH cirrosis and end-stage liver disease who presented to OSH from rehab with hypotension, melena . #Hypotension: Likely cause is GIB/hypovolemia. Place A line, cont. to bolus for Map less than 65. Add vasopressin if not responding to levophed and IVF. Monitor UOP. Serial Hct. Transfuse for hct less than 25. FFP to correct coagulopathy. Discuss with GI. . #Melena - as above, call GI. [**Month (only) 116**] need NGL. Serial Hct. PPI IV BID. Octreotide gtt. . #Cirrhosis/liver disease: obstructive picture. Patient had pericentesis x 2 in order to relieve his abdominal ascites. The first removed 4.5 liters of clear yellow ascites fluid and the second removed about 2 liters. Consult liver. Continue lactulose. Follow INR. Check albumin. Hold diuretics while hypotense. . #Renal failure: ? baseline Cr. Possible HRS vs. pre-renal from volume depletion [**12-23**] GIB. Consult liver and renal, continue volume repletion, maintain SBP as above. Consider albumin post tap, Consider adding midodrine. Patient was started on CVVH. . #Hyperkalemia: Resolved. . # FEN: IVF as above, lytes prn, NPO given GIB. . # PPX: PPI [**Hospital1 **], coagulopathic. . # Access: 2 PIV, TLC lt. groin. . # Code: COMFORT MEASURES ONLY . # Communication: Daughter - [**Name (NI) **], [**First Name3 (LF) **], and daughter [**Name (NI) **] . # Disposition: MICU Medications on Admission: Aldactone Calcium Lasix Insulin Lactulose Nepro Ocycodone Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

Admission Date: [**2139-9-8**] Discharge Date: [**2139-9-26**] Date of Birth: [**2082-11-16**] Sex: F Service: Newurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 57 year old female with no past medical history who had sudden onset of midback pain and severe headache. She said it felt like a bomb while giving a speech in [**Country 2784**]. She finished her speech and vomited once. This was on [**2139-9-4**]. The headache persisted. She returned to the United States the following day with increased fatigue, headache and backache. She went to [**Hospital3 **] Emergency Department on [**2139-9-7**], where a CTA revealed a large bilobed 1.2 to 2.0 centimeter ACA aneurysm, was transferred to [**Hospital 4415**] on [**2139-9-7**], for further workup. CTA was repeated confirming the previously mentioned aneurysm. She was transferred to [**Hospital1 69**] for embolization of the aneurysm. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: None. SOCIAL HISTORY: ETOH and was a thirty pack year smoker. PHYSICAL EXAMINATION: Neurologically she was completely intact. Speech was clear. The pupils were reactive to light and accommodation, 3.0 millimeters and brisk. No facial asymmetry. No drift. Speech was clear and fluent, awake, alert and oriented times three. Vital signs revealed blood pressure 92 to 106 over 60 to 70s, respiratory rate 14 to 18. HOSPITAL COURSE: The patient was admitted and went directly to the angiography suite where she had her bilobed ACA aneurysm coiled. The coiling was only partially done at that time. During the actual angiogram and coiling, the patient did complain of chest pain. She was seen by cardiology in the angiography suite and the chest pain resolved on its own. It was felt to be anxiety produced. Postoperatively, vital signs are temperature 96.0, blood pressure 103/60, pulse 69, respiratory rate 18, oxygen saturation 99%. The patient was awake, alert and oriented times three. She was unsure of which hospital but was recently transferred. She did know the month and not the day. Negative drift, symmetric smile. The pupils were equal and reactive times light and accommodation, 2.5 to 2.0. She did have some left conjunctival hematoma. Positive pedal pulse. Groin was intact with sheath. Her upper and lower extremities revealed motor strength was [**3-23**]. She followed commands. She had no headache. Her white blood cell count was 9.4, hematocrit 32.9. Her preoperative hematocrit was 37.7. Her prothrombin time was 15.4, partial thromboplastin time 150. INR was 1.6. On the first postoperative day, the patient's vital signs were in the 99 to 100 range. She was awake and alert and oriented times three. She complained of seven out of ten headache, no diplopia. Extraocular movements were full. Visual fields were intact. Negative drift. Grip was [**3-23**]. Positive femoral right pulse. She remained in the neurologic Intensive Care Unit where she received Nimodipine 30 mg q2hours, normal saline at 150 per hour. Central line was placed. Her blood pressure was kept less than 140. Heparin was continued at 600 per hour. On [**2139-9-9**], the patient was brought back to complete her coiling. Postoperatively, she was awake, alert and oriented times three. Her speech was fluent. Naming was intact. She followed commands. Her right groin sheath remained intact. Her blood pressure was kept in the 100 to 130 range. She needed to remain on Heparin as the apparent vessel was possibly thrombosed and we did not want to wean her off. Heparin was kept at 600 per hour. We did not want the area to thrombose quickly. Her coiling went well and was successful. She remained on Heparin postoperatively. The patient remained in the Intensive Care Unit on Heparin and her partial thromboplastin time was kept between 60 to 80. The sheaths remained in place. On [**2139-9-14**], the patient was awake, alert and oriented with no complaints and grips were [**3-23**], no drift. The patient's Heparin drip was reduced on [**2139-9-14**], and she was started on Aspirin 325 mg once daily. However, the patient did start to complain of blurry vision with peripheral type tunneling of the left eye lasting thirty to forty-five minutes. A retinal fellow was consulted where she was found not to have any evidence of vascular occlusion. She did have some decreased vision in the left eye, however, the patient claimed it was lasting greater than 1.5 years. It was felt to be an ocular migraine in her left eye. The patient did continue to stay on Heparin. On [**2139-9-15**], her partial thromboplastin time was at 50. She was seen by the retinal specialist who still felt that it was an ocular migraine and they did sign off and wanted to follow-up as an outpatient. Heparin was stopped on [**2139-9-16**]. Aspirin 81 mg was continued. Her sodium was 136, and had dropped to 134. Those were monitored twice a day. On [**2139-9-16**], the patient underwent a cerebral angiogram to check the progressive thrombus of the coiled left internal carotid artery. Stable appearance of the coils were noted on that day. She was to start on Plavix at 75 mg once daily and Aspirin 325 mg once daily. She no longer needed Heparin. Postoperative check, she was awake, alert. Extraocular movements were full, no drift. On [**2139-9-18**], she remained awake and alert with no headaches at this time. Extraocular movements were full. Her face was symmetric. Her sodium was 134. Again, her angiogram the previous day showed no spasm. Intravenous fluids were kept at 150 per hour. She did continue on the Nimodipine. On [**2139-9-18**], we did ask the retinal specialist to reexamine the patient as she complained of decreased vision in her left eye for the last one to two days. Her ophthalmic examination was within normal limits. Her decreased acuity to her left eye was unclear. Possibilities included mass effect, compression of the aneurysm. They recommended considering intravenous steroids, also recommended getting an ESR, CRP and then a neurologic ophthalmology consultation. Neurophthalmology did seen the patient and felt that there was some compression of optic neuropathy but they felt that it was related to her ACA aneurysm and mass effect. They did request some steroids. The patient was started on Decadron 4 mg p.o. q6hours. On [**2139-9-19**], her vision was improved. On [**2139-9-21**], the patient underwent status post neuroform stent mediated coiling of her right internal carotid artery aneurysm. Postoperatively, she did well with no intraoperative complications. Postoperatively, she was to stay on Plavix and Aspirin. Her sheaths remained in place overnight and she remained on Heparin overnight. Postoperatively, she was alert without complaints, denied headaches or double vision. Her left groin was oozing around the sheath. Dressing was replaced. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements were full. Visual fields were full to confrontation. They recommended one unit of packed red blood cells. Her blood pressure was kept in the 120 range and continued on Aspirin and Plavix. Postoperatively, her hematocrit was 28.5 and on [**2139-9-22**], she did receive one unit of packed red blood cells. Sheath was removed. On [**2139-9-23**], her vital signs were temperature 98.2, blood pressure 97/49. White blood cell count was 10.0, hematocrit was now 32.1, platelet count 364,000. The patient was neurologically intact. There was no sign of hematomas. On [**2139-9-24**], the patient was transferred out of the Neurologic Intensive Care Unit. She was given a physical therapy consultation. Her intravenous fluids were decreased to 100 per hour. Her diet was increased as tolerated. She was given intravenous boluses for her systolic blood pressure less than 100. She remained on the surgical floor. The patient was discharged on [**2139-9-26**]. DISCHARGE INSTRUCTIONS: 1. No strenuous exercise, no driving until cleared by Dr. [**Last Name (STitle) 1132**]. 2. She is to follow-up with Dr. [**Last Name (STitle) 1132**] in one week and neurophthalmology, she was given the telephone number to call. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg p.o. once daily. 2. Percocet 5/325 one to two tablets p.o. q3-4hours as needed. 3. Plavix 75 mg p.o. once daily. 4. Aspirin 325 mg p.o. once daily. 5. Decadron wean over a week. CONDITION ON DISCHARGE: The patient was discharged neurologically stable on [**2139-9-26**]. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern4) 26792**] MEDQUIST36 D: [**2139-10-28**] 13:00 T: [**2139-10-31**] 10:17 JOB#: [**Job Number 50244**]

Admission Date: [**2198-2-1**] Discharge Date: [**2198-2-19**] Date of Birth: [**2129-10-28**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 68 year old white male had an abnormal stress test in 02/[**2194**]. He underwent cardiac cath which revealed 100 percent RCA lesion. He had angina again in [**2196**] and had an abnormal stress test and was re- cathed, and that showed 100 percent RCA lesion, a 50 percent left main stenosis, and a left circumflex stenosis. He had no symptoms and surgery was deferred. He now has had a month of angina again and had an abnormal treadmill with an EF down to 27 percent. An angio on [**2198-1-31**] revealed a 95 percent ostia left main, a 70 percent diagonal 2 lesion, 80 percent OM and 100 percent RCA lesion with a normal LV. So he was transferred to [**Hospital1 18**] for further treatment. PAST MEDICAL HISTORY: His past medical history is significant for a history of non-insulin dependent diabetes, hypercholesterolemia, hypertension, prostate CA, and status post removal of a basal cell carcinoma from his back two weeks prior to admission. He is also status post cataract surgery. MEDICATIONS: His medications on admission were nitroglycerin drip, Metformin, Lipitor, aspirin, multivitamin, Metamucil, Atenolol. ALLERGIES: He has no known allergies. FAMILY HISTORY: Family history is significant for coronary artery disease. SOCIAL HISTORY: He does not smoke cigarettes and drinks alcohol occasionally. REVIEW OF SYSTEMS: His review of systems is as above. PHYSICAL EXAMINATION: He is a well developed, well nourished white male in no apparent distress. Vital signs stable. Afebrile. HEENT exam normocephalic and atraumatic. Extraocular movements are intact. Oropharynx benign. Neck was supple. Full range of motion. No lymphadenopathy or thyromegaly. Carotids 2 plus and equal bilaterally without bruits. Lungs were clear to auscultation and percussion. Cardiovascular exam regular rate and rhythm. Normal S1 and S2 with no rubs, murmurs or gallops. Abdomen was soft and nontender with positive bowel sounds. No masses or hepatosplenomegaly. Extremities without cyanosis, clubbing or edema. Pulses were 2 plus and equal bilaterally throughout. Neuro exam was nonfocal. HOSPITAL COURSE: Dr. [**Last Name (STitle) **] was consulted and on [**2198-2-2**] the patient underwent a CABG times five with a free LIMA to the LAD and reverse saphenous vein graft to the diagonal, OM1, OM2 and PVA. Cross clamp time was 89 minutes. Total bypass time was 125 minutes. He was transferred to the CSRU on Neo in stable condition. He had a stable postop night. He was extubated. On postoperative day one he was started on a beta blocker and his nitro was weaned. Postop day two he was transferred to the floor in stable condition and his chest tubes were discontinued. Postop day three his epicardial pacing wires were discontinued. Postop day number four he began having sternal drainage. He was started on Kefzol and had his wounds painted with Betadine tid. He did have some more drainage and his lower two sternal wires seemed to have pulled through on his x-ray, so on postop day number five he underwent sternal re-wiring. He tolerated the procedure well and was transferred back to the floor. He continued to improve and had his chest tubes discontinued on postop day number one from re-wiring. He was also changed to Levofloxacin and Vanco. He continued to improve but continued to have intermittent sternal drainage. He had cultures which were negative. He had a PICC line placed and was continued on Vanco. Eventually his drainage stopped completely and he had two days of no drainage and his Vanco was discontinued and he was discharged to home on a week of Levofloxacin. So on postop day number 17 he was discharged to home in stable condition. LABORATORY DATA: His labs on discharge were white count 10,000, hematocrit 28.1, platelets 767,000, sodium 139, potassium 5.2, chloride 104, CO2 28, BUN 17, creatinine 0.9, blood sugar 116. DISCHARGE MEDICATIONS: 1. Glucophage, 500 mg po bid. 2. Colace, 100 mg po bid. 3. Aspirin, 81 mg po q day. 4. Percocet, 1 to 2 po q4-6h prn pain. 5. Lipitor, 10 mg po q day. 6. Plavix, 75 mg po q day. 7. Lopressor, 100 mg po tid. 8. Lisinopril, 10 mg po q day. 9. Levofloxacin, 500 mg po q day for 7 days. He will be seen by Dr. [**Last Name (STitle) **] in four weeks and by Dr. [**Last Name (STitle) 37063**] in one to two weeks. DISCHARGE DIAGNOSES: His discharge diagnoses include: 1. Coronary artery disease. 2. Hypertension. 3. Hyperlipidemia. 4. Non-insulin dependent diabetes. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2198-2-19**] 15:54:20 T: [**2198-2-19**] 16:33:56 Job#: [**Job Number 58744**]

Admission Date: [**2111-5-25**] Discharge Date: [**2111-5-29**] Date of Birth: [**2063-5-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending:[**First Name3 (LF) 30**] Chief Complaint: Overdose Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 47 yo female with chronic pain in low back and torticollis who has been hospitalized for 7 previous medication overdoses(always denies SI)(most recently 2 days ago) who now presents s/p OD on some combination of meds (baclofen, vicodin, soma, fentanyl patches, methadone). Unclear if suicide attempt, but she has denied this with each of her past ODs. Most recent hospitalization indicates o/d on diazepam, methadone, baclofen. Today found by halfway house staff "nodding off" and minimally responsive (to sternal rub only). No other reports available. Unable to contact halfway house o/n. Past Medical History: PMH: 1. Polysubstance overdose -- Pt had 5 suicide attempts within a five month period in [**2109**]. Also recently admitted here [**Date range (1) 76337**] for overdose of vicodin/soma/baclofen which she states was not suicide attempt, but rather attempt to control pain. 2. Substance abuse-EtOH. 3. Depression- Seen at [**Hospital1 1680**] HRI and the Mind Body Institute 4. ? Bipolar disorder 5. Chronic buttock/back pain: trigger point injections to the lower back region. 6. Cervical torticollis: receives botox injections, severe left-sided head tilt together with what may be a compensatory tilt in the opposite direction of her thoracic spine. Pain is in region of right sternomastoid and right posterior cervical muscles. 7. Gastroesophageal reflux disease. 8. h/o MRSA in sputum [**2108**], not treated 9. h/o assault requiring ICU admit last year. 10. h/o multiple miscarriages, 1 late in pregnancy, and h/o 2 yo daughter drowning. 11. Recently started on methadone for pain control on [**2-17**] . Providers: PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5781**] at [**Company 191**], [**Telephone/Fax (1) 250**] Neuro: Dr. [**Last Name (STitle) **] at [**Hospital1 18**], [**Telephone/Fax (1) 1942**] Ortho: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], [**Telephone/Fax (1) 7807**] Spinal surgeon: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28003**] [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Management Service: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 49911**] . PSYCHIATRIC HISTORY: Diagnoses: depressed [**Telephone/Fax (1) **], question of bipolar disorder h/o alcohol abuse, narcotic abuse; sexual assault Hospitalizations: At HRI, [**Doctor Last Name 16471**], [**Hospital3 44097**]. Suicide Attempts: patient denies Current [**Hospital3 2447**]: Dr. [**Last Name (STitle) 105809**] and therapist: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 105810**] at [**Location (un) 86**] [**Hospital1 1680**] Trauma Center in [**Location (un) 577**] [**Telephone/Fax (1) 7353**] (L/M with after hours line) Counselor: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 105817**] Social History: Lives in [**Location 3952**] House. Smokes [**11-16**] ppd for 10 yrs. documented h/o EtOH abuse in past, + abuse of prescription meds Family History: NC Physical Exam: VS 95.0 117/59 78 14 98% 2L NC Gen: disheveled woman sleeping, responds to painful/noxious stimuli HEENT: anicteric, PERRL --> 4mm B, OP clear w/ MMM CV: reg s1/s2, no s3/s4/m/r Pulm: CTA B (poor effort), no wheezes or crackles Abd: +BS, soft, NT, ND Ext: warm, 2+ DP B, no edema Neuro: responds to noxious stimuli, + gag reflex, moves all 4 extr. Pertinent Results: Pertinent Admission Labs: wbc 7.7, hct 33.5, INR 1.0. Serum ASA 9, Ammonia 26, Utox + benzo and methadone (neg for cocaine, opiates) LFTs: ALT 14, AST 19, A/P 98, Tbili 0.1 . EKG: NSR at 80, nl axis, nl intervals, no ST/T changes CXR: R LL atelectasis Brief Hospital Course: 47 y/o female with chronic pain in low back and torticollis who has been hospitalized for 7 previous medication overdoses who presents s/p likely OD with minimal responsiveness. A brief [**Hospital 11822**] hospital course is outlined below. 1. mental status changes/respiratory depression: Likely secondary to medication effects from substance abuse/overdose. Of note initial tox screen positive for benzos and methadone. Remainder of tox screen was negative. She was given narcan initially at max dose of 1mg/hr without increased responsiveness. Therefore this was discontinued. Her mental status gradually improved over the next 24 hours. Of note, she did not need intubation for respiratory support and she had no evidence for withdrawl signs or symptoms. She was kept on diazepam 5mg q4prn for CIWA scale > 12, however did not require any valium. CIWA scale was subsequently discontinued. All further benzos or opioid analgesics were stopped. 2. Psych: Initially held all meds on admission. Neurontin, lamictal, seroquel restarted upon improvement of MS. Pt with extensive psychiatric history including history of polysubstance abuse and OD. Psych consulted day after admission - recommended 1:1 sitter, which was obtained. Also recommended holding off on giving any benzos, other addictive substances - per psych, unlikely for patient to withdraw because of long half life, although kept on CIWA in case. Now off CIWA. Discontinued lamictal per psych recs. Increased seroquel dose for symptoms of anxiety. Plan for section 35 for patient to mandatorily receive drug rehab. 3. Torticollis: Recieved botox injection by Dr. [**Last Name (STitle) **] on this hospital stay. Medications on Admission: 1. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO three times a day. 4. Lamictal 25 mg Tablet Sig: One (1) Tablet PO once a day. 7 TABLETS ONLY 5. ASA prn Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed. 9. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Discharge Disposition: Extended Care Discharge Diagnosis: primary diagnosis: 1. respiratory depression 2. altered mental status 3. substance abuse/overdose Secondary diagnosis: 1. torticollis 2. h/o suicide attempts 3. h/o substance abuse 4. depression 5. MRSA in sputum [**2108**] Discharge Condition: section 35 for involuntary detox Discharge Instructions: Report nausea, vomiting, fever, chills, shortness of breath or pain not controlled by current regimen or other medical issues to your primary physician. Followup Instructions: follow-up with your primary physician for any medical issues

Admission Date: [**2178-12-25**] Discharge Date: [**2178-12-27**] Date of Birth: [**2116-2-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7055**] Chief Complaint: Transfer from [**Hospital3 **] where she was admitted for atypical chest pain and SOB Major Surgical or Invasive Procedure: -Central venous line insertion into R IJ -Multiple attempts at securing arterial access History of Present Illness: 62F with hx of severe of pulm HTN, CAD s/p DES to Lcx/LAD in [**10/2177**], prior CVA s/p b/l CEA's, PVD, and COPD who was admitted to OSH [**12-23**] for atypical chest pain and SOB. She ruled out for ACS with by enzymes (MB 8 -> 7 -> 5; Trop 0.06 -> 0.07 -> 0.06) and EKG without acute ischemic changes but was found to have a BNP of 11K on admission. She was assessed as having severe decompensated R-sided CHF and was diuresed with 40mg IV lasix in the ED but later that day experienced [**9-9**] back pain with desat to the 50's and was transferred to the CCU for close monitoring with HR in the 60's and BP's in the 90's. She had ECHO on [**12-24**] which showed severe pulmonary hypertension, RV pressure overload, modestly depressed RV function, and LVEF of 55-65%. . Here in the CCU she describes feeling gradually more short of breath over the past 2 months which has become acutely worse in the past 1-2 weeks. Interestingly, about 1 month ago she was started on sildenafil for treatment of her pulm htn but felt she became more short of breath when taking that medication and stopped taking it about 2 weeks ago when she started feeling acutely more short of breath. She states that she has only gained about 2-3lbs in the past two weeks but noticed increased ankle swelling, increasing need for oxygen (she is usually at 88-92 on 3LNC at home but prior to these past 2 weeks she has only used oxygen at night). She has 2 pillow orthopnea, but denies PND. She denies dietary indiscretion, recent illnesses, fevers, chills, cough, sputum production, or other symptoms. According to her family she has never had low back pain as a problem before but the patient states her back pain gets better with positional changes and rubbing. Also, her baseline daily function has decreased as she is normally able to move around the rooms of house but has not been able to walk more than 10 feet due to shortness of breath in addition to her basleine vascular claudication. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: CAD s/p LAD cypher stenting - CABG: n/a - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: n/a 3. OTHER PAST MEDICAL HISTORY: -Occult SBE with aortic valve vegetation -Severe pHTN -Severe PVD s/p multiple vascular surgeries -Rt Fem-[**Doctor Last Name **] bypass -Rt CEA following CVA prior to [**2173**] -Lt CEA following TIA [**2173**] -Stenting of LCx DPromus [**Name Prefix (Prefixes) **] -[**Last Name (Prefixes) **] of Prox/Mid LAD with Promus Stent Social History: Pt livers with two daughters at home. Tob: 0.5ppd x40years (since age 17) EtOH: social - 2 beers every 2 weeks Illicit drug use: denies Family History: Father had MI in his 50's and stroke in his 60's. Siblings with DM. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=96.7 BP=103/66 HR=72 RR=10 O2 sat= 93% non-rebreather GENERAL: 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 to the earlobes CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, loud S2. No m/r/g. S3 at apex. No thrills, lifts. LUNGS: Rales halfway up bases ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pitting to mid shin, several old scars from prior vascular surgery procedures. No femoral bruits. SKIN: Mild stasis dermatitis changes. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP dopplerable, PT dopplerable . DISCHARGE PHYSICAL EXAM: Patient expired. Pertinent Results: ADMISSION LABS: . [**2178-12-25**] 06:24PM BLOOD WBC-12.5* RBC-4.46 Hgb-11.4* Hct-35.8* MCV-80* MCH-25.5* MCHC-31.7 RDW-17.5* Plt Ct-348 [**2178-12-25**] 06:24PM BLOOD Neuts-77* Bands-0 Lymphs-18 Monos-4 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1* [**2178-12-25**] 06:24PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-OCCASIONAL Target-OCCASIONAL Burr-2+ [**2178-12-25**] 06:24PM BLOOD PT-17.0* PTT-34.3 INR(PT)-1.5* [**2178-12-25**] 06:24PM BLOOD Glucose-40* UreaN-45* Creat-1.8* Na-131* K-3.6 Cl-93* HCO3-22 AnGap-20 [**2178-12-25**] 06:24PM BLOOD CK(CPK)-180 [**2178-12-26**] 05:17AM BLOOD ALT-81* AST-65* LD(LDH)-365* CK(CPK)-149 AlkPhos-88 TotBili-1.2 [**2178-12-25**] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37* [**2178-12-25**] 06:24PM BLOOD Calcium-8.7 Phos-5.6* Mg-1.4* . PERTINENT LABS: . [**2178-12-25**] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37* [**2178-12-26**] 05:17AM BLOOD CK-MB-11* MB Indx-7.4* cTropnT-0.31* [**2178-12-26**] 08:54PM BLOOD CK-MB-9 cTropnT-0.35* [**2178-12-27**] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00* [**2178-12-27**] 04:23AM BLOOD Cortsol-32.8* [**2178-12-27**] 04:23AM BLOOD TSH-2.1 [**2178-12-26**] 05:41AM BLOOD Lactate-1.7 [**2178-12-26**] 03:52PM BLOOD Lactate-2.5* [**2178-12-26**] 11:26PM BLOOD Lactate-7.5* [**2178-12-27**] 01:50AM BLOOD Lactate-8.7* [**2178-12-27**] 04:24AM BLOOD Lactate-11.1* [**2178-12-27**] 05:05AM BLOOD Lactate-10.3* [**2178-12-27**] 11:38AM BLOOD Lactate-5.1* [**2178-12-26**] 03:52PM BLOOD Type-ART pO2-52* pCO2-35 pH-7.42 calTCO2-23 Base XS [**2178-12-27**] 01:50AM BLOOD Type-[**Last Name (un) **] pO2-40* pCO2-69* pH-7.02* calTCO2-19* Base XS--15 [**2178-12-27**] 04:24AM BLOOD Type-CENTRAL VE pO2-53* pCO2-60* pH-7.10* calTCO2-20* Base XS--11 [**2178-12-27**] 05:05AM BLOOD Type-CENTRAL VE pO2-52* pCO2-58* pH-7.16* calTCO2-22 Base XS--8 [**2178-12-27**] 11:38AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-73* pH-7.20* calTCO2-30 Base XS--1 . DISCHARGE LABS: . [**2178-12-27**] 11:16AM BLOOD WBC-26.6*# RBC-4.37 Hgb-11.3* Hct-36.8 MCV-84 MCH-25.8* MCHC-30.6* RDW-16.9* Plt Ct-335 [**2178-12-27**] 04:23AM BLOOD Glucose-506* UreaN-41* Creat-1.8* Na-131* K-4.2 Cl-89* HCO3-19* AnGap-27* [**2178-12-27**] 04:23AM BLOOD ALT-226* AST-262* LD(LDH)-905* CK(CPK)-288* AlkPhos-89 TotBili-1.7* [**2178-12-27**] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00* [**2178-12-27**] 04:23AM BLOOD Albumin-3.4* Calcium-8.1* Phos-7.3*# Mg-2.5 [**2178-12-27**] 11:38AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-73* pH-7.20* calTCO2-30 Base XS--1 [**2178-12-27**] 11:38AM BLOOD Lactate-5.1* . MICRO/PATH: . Blood Cultures x 2: Pending MRSA Screen: Pending . IMAGING/STUDIES: . CXR Portable [**12-25**]: IMPRESSION: Mild interstitial pulmonary edema is present, along with a very small right pleural effusion, decreased since [**9-5**]. Heart size is top normal, and the main pulmonary artery is substantially dilated, as before indicating persistent pulmonary arterial hypertension. Previous mediastinal adenopathy documented on the chest CT in [**Month (only) 216**] is difficult to assess but probably has not worsened. No pneumothorax. . Aorta/Branches U/S [**12-25**]: IMPRESSION: No evidence of abdominal aortic aneurysm. Atherosclerosis. . CXR Portable [**12-25**]: Tip of the new right internal jugular line ends in the region of the superior cavoatrial junction. No pneumothorax or increase in small right pleural effusion. Interval increase in mediastinal caliber due to vascular engorgement, and due to elevated central venous pressure, probably a function of biventricular heart failure, reflected mild increase in the heart size, moderate increase in pulmonary edema. Severe pulmonary atrial enlargement, an indication of marked pulmonary arterial hypertension, aortic valvular calcification, which could be hemodynamically significant (particularly in setting of decreased LV filling), and severe, global coronary calcification were shown on a Chest CT in [**Month (only) 216**] [**2178**], discussed with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30814**] at the time of dictation. . R LENI [**12-26**]: IMPRESSION: Limited assessment of the right lower extremity due to early termination of the examination. No DVT seen in the examined veins. . CXR Portable [**12-27**]: FINDINGS: In comparison with the study of [**12-25**], there has been placement of an endotracheal tube with its tip at the upper clavicular level, approximately 6.5 cm above the carina. Nasogastric tube extends into the upper stomach, though the side hole is within the lower portion of the esophagus. Continued enlargement of the cardiac silhouette with substantial pulmonary arterial enlargement consistent with pulmonary artery hypertension. There is moderate pulmonary edema as well. . TTE [**12-27**]:The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis. The basal inferolateral wall contracts best (LVEF = 25%). The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. [Intrinisic right ventricular systolic function is more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with extensive systolic dysfunction c/w diffuse process (multivessel CAD, toxin, metabolic, etc.). Marked right ventricular cavity dilation with free wall hypokinesis and abnormal septal motion c/w marked pulmonary artery hypertension (not quantified). Moderate to severe tricuspid regurgitation. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2178-10-16**], biventricular systolic function has deteriorated and the heart rate is much higher. Biventricular cavity size is similar. Brief Hospital Course: 62F with hx of severe of pulm HTN, CAD s/p DES to Lcx/LAD in [**10/2177**], prior CVA s/p b/l CEA's, PVD, and [**Hospital 2182**] transferred from OSH for evaluation and management of right-sided diastolic CHF exacerbation with background of severe pulmonary hypertension who rapidly decompensated and passed away despite maximal medical therapy. . ACTIVE DIAGNOSES: . # Right-sided Diastolic CHF Exacerbation: Pt with clinical evidence of rales halfway up lung fields, JVD, and peripheral edema on admission with CXR evidence of pulmonary edema and BNP 11,000 at OSH, and ECHO demonstrating fluid overloaded RV with S3 gallop on exam. She was ruled out for ACS at OSH with negative enzymes and non-ischemic EKG's and was transferred on dopamine drip for pressure support with max O2 on venturi mask in moderate respiratory distress satting in the low 90's. On arrival to the CCU, R IJ was placed without complications and she was started on sildenafil 20mg QID with the hope that pressor support and vasodilatation of the pulmonary vasculature would increase cardiac output and allow for gentle diuresis. Unfortunately she was found to be anuric despite these measures with a Cr of 1.8 on transfer up from 0.8-0.9 the days prior at OSH. In the late morning the day following transfer, dobutamine was added in an attempt to improve ionotropy but after this medication was started her BP began to drop and over the next few hours norepinephrine had to be added to maintain MAPs >65. These medications were up and down titrated to try to achieve a stable blood pressure but this kept ranging from 70/40-140/50. No stability could be reached. At the same time her HR was between 100-130's. The CCU team (including the CCU attending) attempted to place an arterial line for better BP monitoring given very severe peripheral vascular disease but this was unsuccesful via the radial aproach. Anesthesia was contact[**Name (NI) **] to attempt an axial arterial line but this was not deemed feasible. The anesthesia attending attempted to obtain a L femoral arterial line without success. The right side was not attempted given her previous Fem-[**Doctor Last Name **] bypass. Through all of this her oxygenation was worsening and she had to be switched to 100% non-rebreather. At around 1600 dobutamine was stopped as this was felt to be contributing to her persistently low BP's. She remained stable until around 2100 when her BP again began to decrease. A 250 mL NS bolus was given without response and phenylephrine was started at this point. Also at around this time her oxygen saturation began to drop and BiPAP was started. At this point the patient was on dopamine, norepinephrine and phenylephrine for BP support and BiPAP for respiratory support with BP in the 79/55-101/57 and O2 sat of 90%. At 2300 (after ~3 hrs on BiPAP) given her tenious state with persistently low BP, persistnently low O2 sat and tachypnea a discussion was held with the patient and the family regarding endotracheal intubation. Given her worseining cardiopulmonary status the CCU team recommended intubation to try to achieve better oxygenation, prevent respiratory colapse and to allow us to manage her worsening heart failure while maintaing a patent airway with adequate oxygenation. Anesthesia was called at 0000 for non-emergent intubation. This was performed succesfully and the patient tolerated it well. At ~0030, milrinone was added in an attempt to improve ionotropy. At this point the anesthesia attending was asked for assistance in placing an arterial line given the need for better blood pressure and oxygenation parameters. Right radial was attempted as well as left femoral without success. At around 0100-0130 her BP began to drop, milrinone was stopped and vasopressin added. Despite these 4 pressors her BP continued to drop. At this point she was given 4 amps of bicarb, 1 mg epinephrine and 1 amp of calcium carbonate. Her family was updated of her condition. Despite all of these additions her BP continued to drop and at this point a bicarb drip and an epinephrine drip were started. After this she stabilized at around 0200 and remained with HR 120-130's and SBP 80-100's for the next several hours. At around 0500 the ventilator began alarming due to high peak/plateau pressures. This was thought to be due to pulmonary edema as repeated succitioning brought up frothy fluid. She was continued on max doses of 5 pressors throughout the day with maximal respiratory settings for the sake of oxygenation. Her condition continued to deteriorate despite maximal medical support. Her family was made aware of her grave circumstances and started to carefully consider her code status. She coded in the later morning 2 days following transfer for pulseless electrical activity and was coded briefly until resuscitative efforts were halted per family request. The cause of her rapid decline was unclear but hypothesis of the team included possibly a PE (with suboptimal LENI which was negative). She has an abdominal ultrasound to look for possible ruptured AAA given report of acute onset low back pain at OSH but this was negative. . # Anuric Acute Kidney Injury: Cr 1.8 on admission with oliguria/near anuria, 0.6-0.7 at baseline. Was 0.9 yesterday at OSH and making urine. Thought to be due to her brief hypotensive episode after receiving bolus of 40mg IV lasix at OSH. # Severe Chronic Pulmonary Hypertension/Cor Pulmonale: Unclear etiology. Perhaps related to her mild-moderate COPD on CT (although re-assuring spirometry in records) or possibly recurrent embolic phenomena. She was treated aggressively as above but unfortunately had a poor outcome. . CHRONIC DIAGNOSES: . # COPD/Hypoxia: PT with mild-moderate COPD changes on most recent CT chest but with essentially normal PFT's. She requires 3LNC at home often worn during sleep but more recently during the day and even when at rest. Has a 20-40 pack-year smoking history. Not on any home COPD medications. She ended up ventilated for respiratory support as above. . # CAD: Pt with severe 3VD with prior [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LCx and LAD in 8/[**2177**]. Non-ischemic EKG here on admission and at OSH. Enzymes unimpressive x 3. No chest pain or discomfort. She was continued on aspirin, plavix, and a statin. . # HLD: Stable. Continued on her statin. . # Severe PVD: Stable. Continued on her statin. . # NIDDM Complicated by Neuropathy: Stable. Managed on HISS while in-house as well as lyrica and gabapentin prior to her hemodynamic compromise. . TRANSITIONAL ISSUES: -To the deep regret of the CCU team, Mrs. [**Known lastname **] did very poorly over her hospital course. Her team took solace in the fact that she was surrounded by her large, loving family and hopefully felt little pain or suffering in her final hours. Medications on Admission: - Plavix 75mg PO daily - Gabapentin 200mg PO QHS - Aspirin 81mg PO daily - Metoprolol succinate 100mg PO daily - Ativan 1mg PO TID PRN - Metformin 100mg PO BID - Glyburide 2.5mg PO daily - Lisinopril 2.5mg PO daily - Torsemide 40mg PO daily - Lyrica 100mg PO BID - Tylenol PM 1 tab QHS - Simvastatin 40mg PO daily - Prilosec 20mg PO daily - Niacin 500mg PO BID Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: -Severe Pulmonary Hypertension/Cor Pulmonale -Biventricular diastolic congestive heart failure -Severe peripheral vascular disease -Chronic obstructive pulmonary disease Discharge Condition: Deceased Discharge Instructions: Patient was transferred from OSH for acute decompensated biventricular heart failure complicated by severe pulmonary hypertension. She was managed aggressively with pressors (5 at max doses) with the goal to optimize her cardiac function with the hope of inducing diuresis. Unfortunately her hemodynamics declined rapidly. Code was called for PEA with initiation of chest compressions and epi x 1 at which time code was called off per family preference. Followup Instructions: N/A Completed by:[**2178-12-28**]

Admission Date: [**2169-8-3**] Discharge Date: [**2169-8-10**] Date of Birth: [**2169-8-3**] Sex: F Service: NB IDENTIFICATION: [**Known lastname 63410**] [**Known lastname 63411**] is a 7 day old former 40 [**5-4**] wk infant with meconium aspiration syndrome and neonatal depression who is being discharged from the [**Hospital1 18**] NICU. HISTORY OF PRESENT ILLNESS: [**Known lastname 63410**] [**Known lastname 63411**] was born on [**2169-8-3**] as the 2.74 kg product of a 40 and [**5-4**] week gestation pregnancy to a 37 year-old, G4, P1 now 2 woman. Prenatal screens: Blood type B positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative, HIV negative, group Beta strep status negative. The pregnancy was notable for normal fetal survey and amniocentesis with karyotype 46XX. On the day of delivery, the mother presented with decreased fetal movements. Fetal heart rate monitoring showed a non-reassuring pattern with decreased variability and late decelerations, and the mother was taken for urgent Cesarean section delivery. At delivery, meconium stained amniotic fluid and nuchal cord were noted. The infant emerged limp with poor tone and absent respiratory effort. She was intubated with meconium suctioned from below the cords. Subsequent resuscitation included vigorous stimulation and positive pressure ventilation for approximately 1 minute, with gradual improvement in color, tone and onset of respiratory effort. Apgars were 3 at 1 minute, 7 at 5 minutes and 8 at 10 minutes. Cord blood pH was 6.95. Due to persistent work of breathing and oxygen requirement, the infant was admitted to the Neonatal Intensive Care Unit. PHYSICAL EXAMINATION AT ADMISSION: Wt 2740 gm (10-25%) HC 34.5 cm (50-75%). BP 59/38 (51). O2sats in 70s-80s on 100% blow-by oxygen. Well developed infant in moderate respiratory distress, stunned appearing with decreased responsiveness and open eyes. Fontanelles soft and flat. Palate intact. Red reflex present bilaterally. Neck supple. Chest coarse, poorly aerated, with moderate grunting, flaring, and retractions. Cardiac regular rate and rhythm without audible murmur. Abdomen soft, no hepatomegaly, 3-vessel cord that is thin and meconium stained. Normal female genitalia, anus patent. Tone grossly normal, activity decreased, no clonus. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: System #1, Respiratory: Secondary to significant hypoxia, [**Known lastname 63410**] was placed on continuous positive airway pressure shortly after admission to the NICU with 100% oxygen. Initial oxygen saturations revealed pre-ductal saturations in mid-80s with post-ductal saturations in mid-70s, consistent with persistent pulmonary hypertension. CXR revealed diffuse increased interstitial markings consistent with aspiration, as well as a small right pneumothorax. Initial blood gas had a pH of 7.06 witha PC02 of 52, and pO2 of 55. Oxygen saturations gradually improved to mid- to high-90s, and subsequent blood gas revealed pH 7.22, pCO2 41, and pO2 68. She initially received normal saline boluses in presence of pulmonary hypertension and metabolic acidosis, and subsequently received sodium bicarbonate. Her respiratory status steadily improved. The pneumothorax resolved over the first 24 hours of life. She was able to transition to nasal cannula 02 on the second day of life and by day of life 3, had weaned to room air. At the time of discharge, she is breathing comfortably in room air with a respiratory rate of 30 to 60 breaths per minute. System #2, Cardiovascular: As described above, [**Known lastname 63410**]'s initial course was consistent with pulmonary hypertension. She received two normal saline boluses, and remained hemodynamically stable throughout. No murmurs have been noted. Baseline heart rate is 120 to 160 beats per minute with a recent blood pressure of 65/54 with a mean of 57. System #3, Fluids, electrolytes and nutrition: [**Known lastname 63410**] was initially n.p.o. and treated with intravenous fluids. She had umbilical, arterial and venous catheters placed. Initial blood glucose was 13. She required multiple boluses of dextrose and eventual continuous infusion of 15% dextrose with normalization of her blood glucose level. Enteral feeds were started on day of life 3 and gradually advanced. She was able to wean off the glucose infusions by day of life number 5. Serum electrolytes were within normal limits throughout. At the time of discharge, she is breast feeding ad lib. Discharge weight is 2.895 kg with a corresponding head circumference of 34 cm and a length of 47.5 cm. System #4, Infectious disease: [**Known lastname 63410**] was evaluated for sepsis upon admission to the Neonatal Intensive Care Unit. White blood cell count was 33,800 with a differential of 39% polymorphonuclear cells, 2% band neutrophils. A blood culture was obtained prior to starting intravenous Ampicillin and Gentamycin. Blood culture was no growth at 48 hours. [**Known lastname 63410**] did receive a 7 day course of antibiotics for presumed sepsis and possible meconium pneumonitis. Gentamycin levels were within normal limits. A lumbar puncture was performed and was reassuring without evidence of meningitis. System #5, Hematologic: Hematocrit at birth was 57%. Initial platelet count was 72,000. This was followed daily through day of life 3 when her platelet count fell to 36,000. She received a platelet transfusion with a post transfusion count of 176,000. Subsequent platelet counts initially decreased but then remained stable, with values of 111, 96, 105, and 96. Most recent platelet count on the day of discharge is 96,000. Coagulation studies revealed normal PT, PTT, and fibrinogen, with mildly elevated D-dimers. Maternal blood was sent for platelet antibody screen; HLA-antibodies were present, but no platelet-specific antibodies were detected. The HLA-antibodies are not thought to contribute to alloimmune thromobocytopenia. Overall the thrombocytopenia is most likely secondary to mild neonatal depression. [**Known lastname 63410**] is blood type B+ and is Coombs negative. System #6, Gastrointestinal: Liver function tests were sent on day of life number 1 and were mildly elevated. The repeated values on day of life 4 showed a gradual decline. Peak serum bilirubin occurred on day of life 4, total of 12.4 over 0.6 mg/dl. She was not treated with phototherapy. System #7, Neurology: Perinatal course was consistent with mild neoantal depression. A head computed tomography scan was performed on [**2169-8-6**] with results within normal limits, without evidence of hemorrhage. She was evaluated by the neurology service from [**Hospital3 1810**], and was thought to have an improving exam with mild hypertonia. Follow-up with the neonatal neurology program 1 month after discharge was arranged. At the time of discharge, her neurological examination is reassuring with normal tone and reflexes. System #8, Sensory/Audiology: Hearing screening was performed with automated auditory brain stem responses. [**Known lastname 63410**] passed in both ears. System #9, Psychosocial: This family is from [**Country 63412**] with plans to return there at the end of [**Month (only) 216**]. Parents have been very involved with [**Known lastname 63410**] and her care during admission. The [**Hospital1 69**] social work department was involved with this family. The contact social worker is [**Name (NI) 36130**] [**Doctor Last Name 56162**] and she can be reached at [**Telephone/Fax (1) 8717**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 2270**] [**Last Name (NamePattern1) 63413**], [**Hospital1 2921**], [**Country **]., [**Hospital1 3494**], MA, phone number [**Telephone/Fax (1) 51263**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: ad lib breast feeding. 2. Medications: Tri-Vi-[**Male First Name (un) **] 1 ml p.o. once daily. 3. State newborn screens were sent on [**8-7**] and [**2169-8-10**] with no notification of abnormal results to date. The initial screen sent on [**2169-8-7**] was obtained prior to the initiation of feeding. 4. Immunization administered: Hepatitis B vaccine was given on [**2169-8-10**]. 5. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks; (2) Born between 32 and 35 weeks with two of the following: Daycare during RSV season , a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or (3) with chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach six months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for house hold contacts and out of home caregivers. FOLLOW-UP: Infant will be seen one day after discharge by pediatrician, including a repeat platelet count. Appointment has been scheduled with Dr. [**Last Name (STitle) **] of the Neonatal Neurology Program at [**Hospital3 1810**] for [**2169-9-6**], at 1pm. DISCHARGE DIAGNOSES: 1. Meconium aspiration syndrome. 2. Persistent pulmonary hypertension. 3. Right pneumothorax. 4. Presumed pneumonia. 5. Hypoglycemia. 6. Thrombocytopenia. 7. Neonatal depression. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2169-8-10**] 03:15:26 T: [**2169-8-10**] 06:13:18 Job#: [**Job Number 63414**]

Admission Date: [**2181-4-20**] Discharge Date: [**2181-4-22**] Date of Birth: [**2135-4-5**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 23197**] Chief Complaint: intoxication / seizure Major Surgical or Invasive Procedure: Intubation History of Present Illness: 46 y/o M with hx of etoh abuse (per ED signout) and possible depression presented to the emergency room at around 6pm this evening. He was obviously intoxicated. Was found by EMS in front of a liquor store and brought in for eval. Initial vitals were t 98.1, p 100, bp 112/94, r 20, 95% on RA. While in the ED, he climbed over his side rails on his bed and fell. He was transferred to the Red Zone after his fall and was found to be mostly non-responsive despite noxious stimuli. He had a CT scan of his head and C-spine at that time that were negative. He had an EJ and femoral line place. He was almost intubated but then became arousable. . Over the next few hours, he was alert and interactive. His speech was slurred and he appeared drunk. On interview and exam, the patient was complaining of abdominal pain, bloody vomit and stool (was guiac negative), and suicidal ideation. He had a fight with his brother-in-law and was feeling very depressed because of that. He also claimed that he wanted to hurt his brother-in-law, too. Psych was consulted for the SI/HI but were waiting to interview him until he was sober. . While in the yellow zone waiting for evaluation, he had an abrupt onset fall where he went to the ground and was unresponsive for about a minute or two. He then had a witnessed tonic-clonic seizure. He received 2 mg ativan at that time. Several minutes later he had another tonic-clonic seizure, and he was again given 2 mg ativan. He was intubated at that time for airway protection. He was initially started on a midazolam gtt but was aggitated. He was switched to a propofol gtt. He had another CT head and C-spine that were preliminarily read as normal. . On arrival to the floor, he was intubated and sedated. He was moving all 4 extremities but would not follow commands appropriately. . Past Medical History: ETOH abuse Hx of pancreatitis Depression Social History: smokes occasionally, drinks heavily on a daily basis, also history of ?heroin v. cocaine use in [**Male First Name (un) 1056**] (moved here 2 months ago), unmarried Family History: per brother-in-law, HTN Physical Exam: Vitals - afebrile, 141/96, 81, 18, 100% on cmv 18 x 550, 100% x5 Gen - thin man, intubated, sedated, intermittently aggitated and trying to pull at his restraints HEENT - PERRLA, ET tube in place CV - RRR, no m,r,g Lungs - CTA B, referred vent sounds Abd - soft, NT, ND, no hsm or masses Ext - warm, well perfused, palp pulses, track marks; LE scarring Neuro - could not obtain secondary to infection Pertinent Results: [**2181-4-20**] 07:30PM ASA-NEG ETHANOL-295* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2181-4-20**] 07:30PM LIPASE-78* [**2181-4-20**] 07:30PM cTropnT-<0.01 [**2181-4-20**] 07:30PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-182 ALK PHOS-64 TOT BILI-0.1 [**2181-4-20**] 07:30PM WBC-6.3 RBC-5.35 HGB-15.1 HCT-46.1 MCV-86 MCH-28.1 MCHC-32.7 RDW-14.4 CT C-SPINE W/O CONTRAST Study Date of [**2181-4-21**] 1:05 AM IMPRESSION: No evidence of acute injury to the cervical spine. Head CT NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, or [**Doctor Last Name 352**]-white matter differentiation, abnormality. The ventricles and extra-axial spaces are within normal limits. There is no evidence of fracture. Mucosal thickening within bilateral maxillary sinuses and ethmoid sinus air cells and sphenoid sinuses are mild. There are aerosolized secretions in the nasopharynx. IMPRESSION: No acute intracranial abnormality. Brief Hospital Course: 46 y/o M with hx of etoh abuse (per ED reports), coming in intoxicated and then complaining of abdominal pain, n/v/diarrhea, and suicidal ideation. Had a seizure and was intubated for airway protection. . # Seizure: No further seizure activity after initial one in ED. [**Month (only) 116**] have been due to EtOH intoxication. CT head, labs were unremarkable. . # Abdominal Pain: Resolved once pt was extubated. . # Respiratory Failure: The pt had to be intubated for altered mental status and airway protection in the setting of a seizure. Was successfully extubated the morning following admission, with no further respiratory problems. . # EtOH/SI: The pt was seen by psychiatry and was found to have capacity to make medical decisions. He declined rehab/detox and reported that he had psychiatric follow up at [**Hospital1 **] CHC on Tuesday. The pt was discharged in the care of his girlfriend who planned to take him to her church to stay overnight. Medications on Admission: 1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Medications: 1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Intoxication Discharge Condition: Mental Status: Clear and coherent, fluent Spanish Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted with intoxication. You were intubated (a breathing tube was placed) to protect your airway. You were evaluated by psychiatry, and they felt that you were safe to return home with your family, with close psychiatric follow up. . Please continue to take your seroquel and wellbutrin. We have added folate and thiamine for your nutritional status. Followup Instructions: Please follow up with your psychiatrist at [**Hospital1 **] St. Community Health Center as planned on Tuesday.

Admission Date: [**2147-6-8**] Discharge Date: [**2147-6-12**] Date of Birth: [**2088-3-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: polyuria, polydipsia Major Surgical or Invasive Procedure: None History of Present Illness: This is a 59M with HTN, glaucoma who presents with polyuria and polydipia. He was at his regular health status until about 3 weeks prior to admission, when he started to note polyuria, polydipsia, and altered taste while he was eating. The dryness of mouth got worsen while he was chewing the food and eventually he tasted the food like a "cardboard". He could not swallow the food and "it stayed in the mouth". He stated that he could sense and recognize the sweetness, salt taste, bitter taste and sour taste of the food. He denies f/c/n/v, dysuria, cough, or diarrhea. . In the ED, vitals showed T 96.0 HR 90, reg BP 177-193/96 RR 23 SO2 96% r/a. He was noted to have ARF with creatinine 1.8 and hyperglycemia with a sugar 360, AG 22, with positive urine ketones. He was started on insulin gtt, given 3L NS, and admitted to MICU for further care. Past Medical History: 1. Hypertension 2. Glaucoma Social History: Married, lives with wife, has a daughter. [**Name (NI) 1403**] at Pharmaceutical company for drug development. Occasional ETOH, Smoke [**12-20**] cigarette/day now, used to smoke 10-15years, Denied drug. Family History: Mother had diabetes and stroke. Father died when the patient was 20 years, he is not sure of the cause. Physical Exam: vitals: T 97.9 78 174/70 17 97 RA gen: awake, alert, NAD heent: perrl, eomi, mmm cv: RRR, no m/r/g pulm: CTAB abd: soft, NT/ND ext: 1+ DP pulses, no edema neuro: a+ox4. CN ii-xii intact, moves all extremities well. Pertinent Results: [**2147-6-8**] - Admission labs WBC-5.5 RBC-5.39 Hgb-17.0 Hct-50.8 MCV-94 MCH-31.5 MCHC-33.4 RDW-13.5 Plt Ct-186 Glucose-360* UreaN-12 Creat-1.8* Na-129* K-6.6* Cl-95* HCO3-11* AnGap-30* Albumin-4.7 Calcium-9.4 Phos-2.9 Mg-2.6 %HbA1c-13.7* tox screen: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG. . [**2147-6-9**] Triglyc-176* HDL-34 CHOL/HD-7.3 LDLcalc-179* Homocys-7.1 . [**2147-6-12**] WBC-4.2 RBC-4.10* Hgb-13.3* Hct-37.2* MCV-91 MCH-32.4* MCHC-35.7* RDW-14.0 Plt Ct-118* Glucose-219* UreaN-4* Creat-1.2 Na-136 K-3.4 Cl-102 HCO3-21* AnGap-16 Phos-2.4* Mg-2.3 . [**2147-6-8**] CT OF THE HEAD WITHOUT CONTRAST: No intracranial mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct is apparent. Density values of the brain parenchyma are within normal limits. The surrounding osseous and soft tissue structures are unremarkable. Falx calcifications are noted. The visualized paranasal sinuses are unremarkable. IMPRESSION: No acute intracranial pathology, including no sign of intracranial hemorrhage. . [**2147-6-8**] PA AND LATERAL VIEWS OF THE CHEST: The cardiac silhouette, mediastinal and hilar contours are normal. There is an 8-mm nodule in the right lung base. Otherwise, the lungs are clear. No evidence of pleural effusions. No evidence of pneumothorax. The pulmonary vasculature is normal. IMPRESSION: 8-mm lung nodule in the right lung base. Comparison with prior outside studies, if feasible, or follow-up study is recommended to assess stability. . [**2147-6-9**] CT CHEST W/O CONTRAST FINDINGS: Linear scarring or atelectasis is present within the right lower lobe, but there is no evidence of a suspicious lung nodule or mass in this region. No suspicious endobronchial lesions are identified. Small bulla is present in the right upper lobe, and there are very minimal areas of emphysema at the extreme lung apices. No suspicious lytic or blastic skeletal lesions are identified. Degenerative changes are present in the spine. Left lobe of thyroid gland is enlarged measuring about 3.7 cm. No enlarged mediastinal or hilar lymph nodes are present. Heart size is normal. There is no pericardial or pleural effusion. In the imaged portion of the upper abdomen, there is probable mild fatty infiltration of the liver, with relative sparing around the gallbladder. Imaged portions of the adrenal glands and remaining portion of upper abdomen are unremarkable, but please note the examination was not specifically tailored for evaluating the abdominal structures. IMPRESSION: 1. Linear scar versus atelectasis in the right lower lobe but no evidence of discrete lung nodule or mass. 2. Probable fatty infiltration of the liver. 3. Enlarged left lobe of thyroid gland, probably representing asymmetric goiter, but thyroid ultrasound may be considered for more complete assessment if warranted clinically. Brief Hospital Course: 59 AA M with HTN, glaucoma who presents in DKA and with ARF, without prior diagnosis of diabetes. This presentation is consistent with "flatbush" or type 1B diabetes. . 1. Acute renal failure: Cr 1.8 on admission. By discharge, had decreased to 1.2 with IVF. Unclear baseline. Likely prerenal in setting of DKA. . 2. DKA: Newly diagnosed DM2; given age and race may represent Flatbush Phenomenon given his mild DKA on presentation. There was no evidence of any other cause of an anion gap acidosis, as patient had a negative tox screen and lactate was not significantly elevated. Was initially admitted to ICU on Insulin gtt; transitioned to glargine 25 units daily with Humalog SS. Received diabetes education from [**Last Name (un) **] consultants and nurse educators, trained to administer home insulin until outpatient follup with [**Last Name (un) **]. His BS were well controlled on this regimen and his AG closed to normal. A HgA1c level sent was 13.9%. ASA was started during this admission given that he now had multiple cardiac risk factors and a CAD equivalent. . 3. HTN: Given his new onset DMII, started an ACE. BPs have been in normal range. Can titrate up as needed as outpatient. Patient has evidence of LVH on ekg, likely hypertensive in etiology. Will need pcp f/u. . 4. Lung nodule: Incidental lung nodule was noted on CXR which on follow up Chest CT revealed Linear scar versus atelectasis in the right lower lobe but no evidence of discrete lung nodule or mass. . 5. High Cholesterol A cholesterol panel showed elevated levels (TC 248, LDL 179). He was started on simvastatin 20mg daily. . 6. Glaucoma continued pilocarpine 0.5% 1 gtt to both eyes q6h . 7. Incidental L Thyroid Lobe enlargement probably represents asymmetric goiter, but thyroid ultrasound may be considered for more complete outpatient assessment if warranted clinically. . 8. Altered Taste Neurology consulted, felt that this is not necessary for inpatient assessment at this time. Suggest Diamox as cause, as it is known to have appetite loss and can alter the sensation of taste. Can follow up as outpatient. . FEN: diabetic diet . Proph: heparin SC . Access: PIVs . full code Medications on Admission: 1. Pilocarpine 2. Diamox 3. Kossup Discharge Medications: 1. Pilocarpine HCl 0.5 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*0* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Insulin Glargine 100 unit/mL Solution Sig: One (1) 25 Subcutaneous every morning before breakfast. Disp:*1 vial* Refills:*2* 6. Humalog 100 unit/mL Solution Sig: One (1) see sliding scale Subcutaneous qAC and HS. Disp:*1 vial* Refills:*2* 7. Syringe with Needle, Safety 1 mL 28 X [**12-20**] Syringe Sig: Four (4) Miscellaneous once a day. Disp:*120 syringes* Refills:*2* 8. sharps box Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetes Mellitus II with ketoacidosis . Secondary: Hypertension Glaucoma Discharge Condition: Improved, stable Discharge Instructions: Please take all medications, including insulin, as prescribed. Please check your blood sugar at home as instructed. If you experience any symptoms that are concerning to you, including dizziness/lightheadedness, fatigue/lethargy, or excessive urination/thirst, please call your PCP or go to the nearest Emergency Room. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**12-20**] weeks. Also, please call the [**Last Name (un) **] Center to make an appointment for your diabetes care and management.

Admission Date: [**2129-3-4**] Discharge Date: [**2129-3-6**] Date of Birth: [**2053-6-30**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Ace Inhibitors Attending:[**First Name3 (LF) 443**] Chief Complaint: RCA dissection Major Surgical or Invasive Procedure: Cardiac Catheterization with placement of 4 bare metal stents Intra-operative (catheterization) trans-esophageal echocardiogram History of Present Illness: 75 y/oF with hypertension, HL and exertional angina who initially presented for elective cardiac catheterization c/b RCA dissection, being transferred to the CCU for further management. . Briefly, patient complained of exertional angina for several weeks. She described chest discomfort radiating to jaw while walking on treadmill or riding exercise bike vigorously. Also experianced dyspnea and chest discomfort while walking up 1 flight of stairs. Symptoms always resolved with rest. Exercise stress test on [**2129-2-14**] was concerning for ischemia: after 8 minutes on [**Doctor First Name **] protocol, peak HR of 116 (80% predicted for age), patient developed recurrent angina and EKG showing 0.5mm ST depressions in infero-lateral leads. Given positive stress test, patient was referred for elective coronary catheterization. . This morning, he underwent coronary catheterization which showed calcification in coronary arteries with diffuse disease in RCA with proximal 90% stenosis and distal 60-80% stenosis. The catheterization was complicated by an RCA dissection with retrograde extention to the right sinus of valsalva. She received four bare metal stent to the RCA: 2 overlapping distal, 1 non-overlapping proximal, and 1 ostial integrity stents. Following ostial stent depolyment, contrast was no longer seen flowing into the sinus. Post-catheterization TEE showed unchanged AI, functioning leaflets and no pericadial effusion. She was transfered to the CCU in stable condition. . On arrival to the CCU, she endorsed mild left sided chest and jaw pain that had significantly improved compared to what she had experienced in the cath lab. She endorsed comfortably breathing and denied other complaints. . 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 chest pain as per HPI; she denied paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - moderate AI, moderate MR 3. OTHER PAST MEDICAL HISTORY: - Left Breast Cancer s/p Mastectomy in [**2103**] - GERD - Hemorrhoids - Pneumonia x2 (in [**2097**]'s) - Hiatial Hernia - S/p Hysterectomy - Osteopenia - s/p Tonsillectomy - s/p Adenoidectomy - s/p Appendectomy Social History: Retired, lives with husband. [**Name (NI) **] very active lifestyle, going to gym daily - Tobacco history: - ETOH: drinks approx 4oz red wine daily - Illicit drugs: denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: died at age 83 of CHF - Father: died in 80s of CVA Physical Exam: Admission Exam: VS: T=98.4 BP=127/80 HR=93 RR=14 O2 sat=100% on 2L GENERAL: 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 8cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, systolic murmur loudest at apex. No thrills, lifts. LUNGS: left mastectomy scar noted. 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: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge Exam: Tc 98.0, Tm 98.4, BP 128-146/49-68, HR 58-88, RR 16-18, Sats 95-99% on RA GENERAL: 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 8cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, systolic murmur loudest at apex. No thrills, lifts. LUNGS: CTAB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. 2+ pulses in radial/DP Pertinent Results: Admission Labs ([**2129-3-4**]): Hct-32.2* Glucose-218* UreaN-17 Creat-0.6 Na-134 K-3.8 Cl-99 HCO3-23 AnGap-16 Calcium-9.5 Phos-3.7 Mg-2.1 [**2129-3-4**] 04:09PM BLOOD CK(CPK)-69 [**2129-3-5**] 06:00AM BLOOD CK(CPK)-98 [**2129-3-4**] 04:09PM BLOOD CK-MB-4 cTropnT-<0.01 [**2129-3-5**] 06:00AM BLOOD CK-MB-5 cTropnT-LESS THAN . Imaging: Intra-operative TEE ([**2129-3-4**]): Conclusions No atrial septal defect is seen by 2D or color Doppler. The left ventricle is not well seen but overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the aortic arch. A mobile density is seen in the aortic sinus at the right coronary cusp consistent with an intimal flap/aortic dissection.the flap extends minimally above the sinus of Valsalva.The aortic valve leaflets (3) are mildly thickened. Mild to moderate ([**12-12**]+) aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Dissection flap at the right coronary sinus, largely contained within the sinus of Valsalva. Preserved global LV systolic function with mild to moderate aortic regurgitation and moderate mitral regurgitation. . CTA of chest ([**2129-3-4**]): FINDINGS: Trace pericardial sluid is noted. There is multivessel coronary arterial calcification and mitral annular calcifications. Density in the right coronary artery is compatible with known stent. The proximal RCA appears low attenuation centrally, but assessment is limited by overlying stent and non-gated study. Close to the origin of the RCA, a minimal linear mural irregularity at the proximal aorta is seen (4,58), which likely represents a small focal dissection as noted at time of coronary angiogram. No distal propagation is seen. Some calcification at the left anterolateral papillary muscles is noted (6,61). This is likely due to prior ischemia. The pulmonary arterial tree is opacified without evidence of pulmonary embolism. There is no mediastinal, hilar, or axillary lymphadenopathy by CT size criteria. With the exception of trace bibasilar dependent atelectases , the lungs are clear. Central airways remain patent. Limited subdiaphragmatic evaluation demonstrates hyperdense material within the gallbladder, compatible with vicarious excretion of contrast status post recent cardiac catheterization. A tiny hiatal hernia may be present. The left adrenal gland is mildly prominent, without focal nodularity. A small non-specific 7mm hypodensity is seen at the dome of the right hepatic lobe (4,68), too small to characterize. BONE WINDOW: No focal concerning lesion. Mild multilevel thoracic spondylosis is present. Mild levoconvex thoracic curvature is noted. IMPRESSION: 1. Tiny linear irregularity at the aortic root adjacent to the RCA origin compatible with known tiny dissection. No propagation seen. 2. Apparent opacification of the RCA proximally may be artifactual related to stent and non-gated study, but clinical correlation is advised. 3. Coronary calcification and small area of calcification at the tip of anterolateral papillary muscle. . Cardiac Cath ([**2129-3-4**]): Report not yet finalized . Discharge Labs: [**2129-3-6**] 08:35AM BLOOD WBC-7.2 RBC-3.77* Hgb-11.8* Hct-32.7* MCV-87 MCH-31.2 MCHC-36.0* RDW-12.6 Plt Ct-299 [**2129-3-6**] 08:35AM BLOOD Glucose-119* UreaN-17 Creat-0.6 Na-137 K-4.0 Cl-102 HCO3-24 AnGap-15 [**2129-3-6**] 08:35AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.0 Brief Hospital Course: ASSESSMENT AND PLAN Mrs. [**Known lastname **] is a 75 year-old woman with HTN, HLD and exertional angina s/p elective cardiac catheterization c/b RCA dissection with placement of 4 BMS in the RCA. # Coronaries: Patient has known CAD identified on cardiac cath [**3-4**] now s/p RCA dissection during cardiac catheterization and placement of 4 BMS to RCA. Patient received integrillin during procedure. Chest pain has significantly improved. Discussed with patient importance of avoiding valsalva or manuvers that increase intra-thoracic pressure. CTA report not finalized but per radiology wet read no significant dissection still noted post-proceedure although contrast timing sub-optimal for evaluation. Before CTA pt received premedication with benadryl, prednisone, and mucomyst/IV hydration. Nitro gtt was weaned off and cardiac enzymes were stable. Pt will be continued on ASA indefinitely and will need to take plavix 75 mg daily for at least 1 month. Plan will be for repeat CTA 2-3 weeks after discharge to re-evaluate RCA dissection. Pt will follow-up with Dr. [**Last Name (STitle) **] in outpatient setting. # Pump: Patient has no know CHF symptoms. LVEF was not obtained durring TEE performed in cath lab. Patient has remained hemodynamically stable during hospitalization. # RHYTHM: Patient was in sinus rhythm. She has no known dysrhythmia. Was monitored on Tele in the CCU and then on the floor but no signficiant arrhythmias noted. # HTN: Patient with Hx of HTN on only metoprolol as home BP med. Day after cath pt was started on 25mg daily of losartan for better BP control and metoprolol increased from 50 mg po tid to 200 mg po daily. # HLD: Patient takes rosuvastatin 20mg daily at home and was on atorvastatin 80mg while admitted. She was discharged on her home regimen of rosuvastatin 20 mg po daily. #Code: Full (confirmed with patient) Medications on Admission: - ciprofloxacin 250 mg [**Hospital1 **] prn UTI - hydrocortisone acetate - 25 mg Suppository - 1 rectally up to tid prn irritation and pressure - metoprolol tartrate 50mg [**Hospital1 **] - omeprazole 20 mg Capsule, Delayed Release(E.C.) daily - rosuvostatin 20 mg daily - vitamin C 500 mg daily - ASA 81 mg daily - calcium carbonate- vitamin D3 500 mg (1,250 mg)-400 U Tablet daily - geriatric MVI w/iron 1tab daily - magnesium 250mg 4 tabs daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 8. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 9. geriatric multivit w/iron-min Tablet Sig: One (1) Tablet PO once a day. 10. magnesium 250 mg Tablet Sig: Four (4) Tablet PO once a day. 11. hydrocortisone acetate 25 mg Suppository Sig: One (1) Rectal once a day as needed for irritation and pressure . Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Coronary artery disease Coronary artery dissection Secondary: Hypertension 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 a small tear in one of your coronary arteries occurred during your cardiac catheterization. To help stabilize the artery and to open up your coronaries which were found to have some narrowings, 4 bare metal stents were placed in your coronary arteries. Your chest pain improved significantly the next day and a CT scan of your chest showed no worsening of the tear in your artery. You were started on plavix 75 mg daily and Aspirin 325 mg daily. You must take the plavix every day for at least the next month and take the aspirin daily indefinitely in order to help keep your stents from clotting. It is very important that you take these medications every day otherwise you are at risk for clots forming in your stents. We also increased your metoprolol dose and started a new blood pressure medication called losartan to help keep your blood pressure in a good range. You will follow-up with Dr. [**Last Name (STitle) **] and will likely get a repeat CT scan or your heart in [**1-13**] weeks. The following changes were made to your medications: - Metoprolol dose increased to metoprolol XL 200 mg by mouth once daily - Added Losartan 25 mg by mouth once daily for blood pressure - Added clopidogrel (Plavix) 75mg by mouth daily for at least the next month - it is very important that you do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s of this medication. Please talk with Dr. [**Last Name (STitle) **] about when it is ok to stop taking this medication. - Increased Aspirin dose from 81 mg daily to 325mg by mouth daily - Continue your other home medications You should refrain from lifting weights greater than 20 pounds for 1 month after your hospital discharge. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in [**12-12**] weeks. Please call her office to make sure that you have an appointment. The number to call is [**Telephone/Fax (1) 4105**]. You will likely have a repeat CT scan of your heart in [**1-13**] weeks. You should refrain from lifting weights greater than 20 pounds for 1 month after your hospital discharge.

Admission Date: [**2192-1-5**] Discharge Date: [**2192-1-20**] Date of Birth: [**2117-9-11**] Sex: F Service: CARDIOTHORACIC Allergies: Hydralazine / Opioid Analgesics / Compazine Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain / epigastric pain Major Surgical or Invasive Procedure: Coronary artery bypass grafts x 4 (LIMA-LAD,SV-DG,SV-OM,SV-PDA) [**1-13**] left heart catheterization, coronary angiography History of Present Illness: The patient is a 74 year-old female who has a significant PMH for recent NSTEMI ([**2191-11-5**]), CAD, hyperlipidemia, hypertension, DM-2, and ESRD on hemodialysis who presented after several hours of epigastric pain which evolved into predominant complaint of [**2193-8-13**] chest pressure. She had a similar presentation on [**2191-11-22**] and was diagnosed with an NSTEMI after positive cardiac enzymes noted with new LBBB on EKG. She underwent cardiac catheterization at that time which showed LAD lesion of 90% and totally occluded mid LAD lesion, RCA lesion of 90%, and circumflex showed minimal disease. Unfortunately, she had unsuccessful PCI, and CT Surgery consulted to arrange for future CABG plan. Past Medical History: -Hypothyroidism (thyroidectomy in [**2173**] for benign growth) -Diabetes type II for >10yrs -End-Stage Renal Disease: on hemodialysis left forearm AV graft in [**2187**], now using Tunelled HD Line -CVA [**2186**]: left caudate infarct; several mini-strokes before that -Gait disorder/shaky and unsteady when she walks -Splenectomy in [**2145**] (trauma related) -SVC stenosis -Cataract surgery (bilateral) -Hypertension -Hyperlipidemia -Coronary Artery Disease (recent cath [**11/2191**] showing 90% proximal LAD totally occluded mid LAD and 90% RCA and minimal disease of the circumflex) Social History: Patient lives alone at home but daughter [**Name (NI) **]([**Telephone/Fax (1) 108910**]) is extensively involved in her care. She has 7 other children. She uses a walker at baseline, but has been wheelchair bound for about 1 year per daughter because patient is afraid of falling. She denies current or past tobacco, alcohol or illicit drug use. Family History: Mother: died 5 year ago (cause unknown to pt) Father: died when pt was 17 (cause unknown to pt) Children have no major medical problems Physical Exam: Admission VS -T 98.6F, BP 153/100, HR 80s, RR 20, 96% 3L oxygen Gen: appears fatigued, middle aged female in NAD, Oriented x3. Affect somewhat flattened. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 7-8cm. Left EJ in place (clean/intact) and left IJ HD catheter in place with non-erythematous surrounding skin. CV: S1/S2 appreciated, RRR, II-III/VI systolic murmur noted @ LUSB, No murmurs, rubs, gallops. No thrills, lifts. No S3/S4. Chest: No chest wall deformities or scoliosis, but + Mild kyphosis. Respirations unlabored, no accessory muscle use. Decreased aeration at bases bilaterally (R>L). No wheezes or rhonchi. Abd: Soft, mild upper epigastric tenderness, moderate distension. No HSM or tenderness at RUQ. Due to distension, unable to ausculate well for abdominial bruits -but all 4 quadrants with +normoactive BS. Ext: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] cool, 1+ DP and PT pulses on left and 2+ DP and 1+ PT pulse on right. No femoral bruits/femoral pulses 2+ bilaterally. Skin: LE calves with scaling of skin, no sores/lesions/rashes. Pulses:Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ . Discharge VS T 98.4 BP 144/71 HR 80 SR RR 20 O2sat 97%-2LNP Gen NAD, sitting in chair Neuro A&O x3, nonfocal exam Pulm CTA bilat CV RRR, sternum stable, incision CDI Abdm soft, NT/+BS Ext Warm, trace pedal edema bilat. Skin staples L groin down thigh. Left subclav HD catheter Pertinent Results: ADMISSION LABS: [**2192-1-5**] 03:57PM PT-41.6* PTT-37.8* INR(PT)-4.6* [**2192-1-5**] 03:03PM GLUCOSE-381* NA+-138 K+-4.4 CL--91* TCO2-27 [**2192-1-5**] 03:03PM HGB-14.3 calcHCT-43 [**2192-1-5**] 02:45PM GLUCOSE-385* UREA N-33* CREAT-4.2* SODIUM-137 POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-27 ANION GAP-23* [**2192-1-5**] 02:45PM ALT(SGPT)-150* AST(SGOT)-104* CK(CPK)-46 ALK PHOS-205* TOT BILI-0.3 [**2192-1-5**] 02:45PM LIPASE-50 [**2192-1-5**] 02:45PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.2 [**2192-1-5**] 02:45PM WBC-14.1* RBC-4.46 HGB-13.8 HCT-44.2 MCV-99* MCH-31.0 MCHC-31.3 RDW-17.4* [**2192-1-5**] 02:45PM BLOOD cTropnT-0.21* [**2192-1-6**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.29* [**2192-1-6**] 12:19AM BLOOD CK(CPK)-77 [**2192-1-5**] 02:45PM BLOOD CK(CPK)-46 [**2192-1-19**] 09:30AM BLOOD WBC-17.8* RBC-3.11* Hgb-9.6* Hct-30.0* MCV-97 MCH-30.8 MCHC-32.0 RDW-17.8* Plt Ct-280 [**2192-1-19**] 09:30AM BLOOD Plt Ct-280 [**2192-1-17**] 04:00AM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3* [**2192-1-19**] 09:30AM BLOOD Glucose-233* UreaN-43* Creat-5.2*# Na-137 K-5.1 Cl-99 HCO3-28 AnGap-15 [**2192-1-12**] 09:00AM BLOOD %HbA1c-7.0* [**2192-1-6**] 01:10PM BLOOD TSH-2.9 . ADDITIONAL STUDIES: [**2192-1-10**] Cardiac MD/Thallium Viability study: IMPRESSION: 1. Moderate Anterior wall/apical defect that is completely reversible by 24 h. 2. Moderate septal defect that is partially reversible by 24 h. . [**2192-1-8**] CTA Chest/Pelvis/Abdomen : IMPRESSION: 1. There is opacification of the SMA, without evidence of ischemic bowel. 2. Extensive atherosclerotic disease, without aortic aneurysm or dissection seen. 3. Extensive colonic diverticulosis, with minimal stranding surrounding the descending colon, suggesting mild uncomplicated diverticulitis. 4. Incompletely characterized hypodense lesions in the kidneys again noted. 5. Soft tissue nodule arising from the medial limb of the left adrenal gland again incompletely characterized. 6. Increased number of mediastinal and retroperitoneal lymph nodes, without size enlargement. =============================================================== [**Known lastname **],[**Known firstname 108974**] [**Medical Record Number 108975**] F 74 [**2117-9-11**] Radiology Report CHEST (PA & LAT) Study Date of [**2192-1-19**] 4:15 PM [**Hospital 93**] MEDICAL CONDITION: 74 year old woman s/p CABG x4 REASON FOR THIS EXAMINATION: atelectasis Final Report HISTORY: Status post CABG with atelectasis. FINDINGS: In comparison with study of [**1-17**], there is little overall change. Extensive opacification at the left base persists, possibly increasing with further pleural fluid. Central catheter remains in place. The right axillary catheter again remains outside of the hemithorax. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: [**First Name8 (NamePattern2) **] [**2192-1-19**] 6:21 PM = = = = = = = = ================================================================ [**Known lastname **],[**Known firstname 108974**] [**Medical Record Number 108975**] F 74 [**2117-9-11**] Radiology Report [**Numeric Identifier **] PICC W/O PORT Study Date of [**2192-1-17**] 12:30 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2192-1-17**] SCHED PICC LINE PLACMENT SCH Clip # [**Clip Number (Radiology) 108976**] Reason: ESRD on HD. LT scv Permacath, s/p mult RIJ caths. Unable to [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with s/p cabg REASON FOR THIS EXAMINATION: ESRD on HD. LT scv Permacath, s/p mult RIJ caths. Unable to pass wire into IJs at time of recent CABG. Has RT femoral Cordis. IV unable to thread wire for PICC at bedside. please place as midline only ***** Final Report INDICATION: 74 year old woman requiring IV access. Request right mid-line due to presence of left HD catheter in SVC. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Dr. [**Last Name (STitle) 3012**] and Dr. [**First Name (STitle) **] performed the procedure. Dr. [**Last Name (STitle) 2492**], the attending radiologist, was present and supervised the procedure. TECHNIQUE: Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Ultrasound images were obtained before and immediately after establishing intravenous access. A guidewire was advanced into the right subclavian vein under fluoroscopic guidance. A peel- away sheath was then placed over the guidewire and a double-lumen PICC measuring 20 cm in length was placed through the peel- away sheath with its tip positioned in the axillary vein under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC placement via right brachial venous approach. Final internal length is 20 cm, with the tip positioned in the right axillary vein. The line is ready to use. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 2671**] [**Doctor Last Name **] DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Approved: WED [**2192-1-18**] 9:17 AM = = = = = ================================================================ [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 108974**] [**Hospital1 18**] [**Numeric Identifier 108977**] (Complete) Done [**2192-1-13**] at 6:17:28 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2117-9-11**] Age (years): 74 F Hgt (in): 60 BP (mm Hg): / Wgt (lb): 140 HR (bpm): BSA (m2): 1.61 m2 Indication: Intraop CABG evaluate LV function, Valvular function, Aortic contours ICD-9 Codes: 410.92, 440.0, 424.0 Test Information Date/Time: [**2192-1-13**] at 18:17 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: [**Doctor Last Name **] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 25% to 30% >= 55% Aorta - Ascending: *3.5 cm <= 3.4 cm Findings LEFT ATRIUM: Marked LA enlargement. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity size. Severe regional LV systolic dysfunction. RIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal RV systolic function. AORTA: Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Moderate to severe (3+) MR. [**First Name (Titles) **] vena contracta is >=0.7cm TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. Dilated main PA. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Pre Bypass: The left atrium is markedly dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. There is severe regional left ventricular systolic dysfunction with septal hypokinesis at the base and akinesis at mid and apical levels, and hypokinesis of anteroseptal and anterior walls.. The right ventricular cavity is moderately dilated with borderline normal free wall function. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) central mitral regurgitation is seen. The mitral regurgitation vena contracta is >=0.7cm. There is a small pericardial effusion. TEE used for hemodynamic monitoring throughout. Estimated PASP 43 pre bypass. Frequent cardiac output measurements obtained. CO 2.0 to start case, increased to 2.7, then later 3.9 just prior to bypass. Post Bypass: Patient is on epinepherine infusion (.08) and phenylepherine (2), AV paced. Biventricular function is slightly improved on ionotropes. LVEF 30-35%. The anterior wall motion has improved. The septum is paced with paradoxical movement and cannot be fully evaluated. Mitral reguritation is now [**1-6**]+. Aortic contours intact. Remaing exam is unchanged. Cardiac output post bypass initally [**2-7**], improved by end of case to 4.1 with ionotropes and volume. All finidings discussed with surgeons at the time of the exam. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2192-1-16**] 14:34 Brief Hospital Course: Ms. [**Known lastname 108904**] is a 74 year old female with a past medical history of a recent NSTEMI ([**11/2191**]), extensive coronary artery disease, hyperatension, diabetes mellitis type II, end stage renal disease on hemodialysis, who presented to the emergency department with several hours of epigastric pain and chest pressure. She ruled out for acute coronary syndrome/myocardial infarction. A workup for mesenteric ischemia was negative and she was scheduled for a coronary artey bypass. On [**2192-1-13**] she underwent a coronary artery bypass grafting times four. This procedure was performed by Dr. [**Last Name (STitle) 914**]. She tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. On post-operative day one she was dialyzed, extubated, and weaned from her pressors. Dialysis resumed on the following day. Her chest tubes and epicardial wires were removed. She was seen in consultation by the physical therapy service. Over the next several days her hospital course was uneventful, she progressed very slowly with physical activity and on POD7 it was decided she was ready for discharge to rehabilitation at [**Hospital1 **]. Medications on Admission: -Vitamin B Complex/Vitamin C -Folic Acid 1 mg daily -Renagel 800 mg tablet three times a day. -Levothyroxine 100 mcg tablet daily -Atorvastatin 80 mg Tablet PO daily -Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 4,000-11,000 unit dwell Injection PRN (as needed) as needed for line flush: **for use by dialysis ONLY. -Prevacid 30 mg Capsule, (E.C.)daily. -Lorazepam 0.5 mg tablet PO Q6H as needed for Anxiety. -Acetaminophen 325 mg, 1-2 Tablets PO Q6H PRN -Warfarin 7.5 mg tablet PO daily at 4 PM. -Aspirin 81 mg tablet once a day. -Lisinopril 40 mg tablet daily. -Toprol XL 100mg daily. . Discharge Medications: 1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-6**] Drops Ophthalmic PRN (as needed). 6. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000) units Injection TID (3 times a day). 7. Sevelamer Carbonate 800 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 11. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 13. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day) as needed. 15. Ibuprofen 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [**Last Name (STitle) **]: One (1) Appl Rectal QID (4 times a day) as needed. 17. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3 times a day). 18. Glipizide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 19. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: sliding scale Subcutaneous Q AC&HS. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: unsatble angina s/p coronary artery bypass grafts end stage renal disease hypertension cerebrovascular disease noninsulin dependent diabetes mellitus hypothyroidism s/p thyroidectomy s/p hysterectomy s/p splenectomy Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any fever greater than 100.5 report any redness of, or drainage from incisions report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-6**] weeks ([**Telephone/Fax (1) 250**]) Completed by:[**2192-1-20**]

Admission Date: [**2160-3-26**] Discharge Date: [**2160-3-30**] Date of Birth: [**2103-6-21**] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Egg / Fish Product Derivatives / Milk Attending:[**First Name3 (LF) 1974**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: 56 yo F with severe asthma presents with difficutly breathing and a prominent wheeze. Patient had recently seen her outpatient pulmonologist Dr. [**Last Name (STitle) **] [**3-3**] and was placed on a steroid taper. She had been feeling much better until about a week ago when her apartment was flooded. As a result she reported than mold grew which is a trigger for her asthma. Also her neighbors have been smoking which is also a trigger. 2 days prior to admission the patients nebulizer broke and since then her symptoms have been quite severe. She has been unable to eat secondary to coughing. . In the ED the patient was given nebs, azithromycin, solumedrol, magnesium with some effect. However still required continuous nebs. . On arrival to the unit the patient was still extremely wheezy and short of breath. Denied other symptoms. Denies HA, neck stiffness, CP, abd pain, dysuria, hematuria, N/V, diarrhea. . Past Medical History: - Asthma ([**3-3**] PFT FVC 1.7(56%); FEV1 1.1(50%) which is decreased from prior. Mult admissions including ICU, however never intubated. Peak flow generally 200-250 when feeling well. - GERD - chronic R hemiparesis - Blind in R eye from cataracts . Social History: Lives at home by herself, on disability. Divorced. Has many family members dispersed throughout the country - 4 children, 5 grandchildren. Denies any tobacco, EtOH, or illicits. Not sexually active for many years. No prior h/o STDs or HIV. Family History: h/o asthma, degenerative eye disease, CAD, CVA. No h/o any cancers, HTN, NIDDM, or any bleeding/clotting disorders. Physical Exam: VS 98.6 134 148/60 25 95 on nebs Gen - A+Ox3, dyspnic HEENT - OP clear Neck - supple, no LAD Cor - RRR tachy Chest - diffuse and severe wheeze, prolonged expiration Abd - s/nt/nd +BS Ext - no edema . Pertinent Results: ADmit: [**2160-3-26**] 11:25PM GLUCOSE-305* UREA N-13 CREAT-0.9 SODIUM-143 POTASSIUM-3.1* CHLORIDE-105 TOTAL CO2-21* ANION GAP-20 [**2160-3-26**] 11:25PM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.8* [**2160-3-26**] 06:45PM GLUCOSE-116* UREA N-11 CREAT-0.8 SODIUM-145 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-18 . [**2160-3-26**] 06:45PM WBC-12.8* RBC-4.34 HGB-13.6 HCT-38.8 MCV-89 MCH-31.3 MCHC-35.0 RDW-14.5 [**2160-3-26**] 06:45PM NEUTS-72.8* LYMPHS-13.4* MONOS-3.3 EOS-10.3* BASOS-0.2 [**2160-3-26**] 06:45PM PLT COUNT-253 . Transfer from MICU: [**2160-3-28**] 03:49AM BLOOD WBC-30.8*# RBC-3.91* Hgb-11.9* Hct-34.9* MCV-89 MCH-30.4 MCHC-34.2 RDW-14.5 Plt Ct-254 [**2160-3-28**] 03:49AM BLOOD Plt Ct-254 [**2160-3-28**] 03:49AM BLOOD Glucose-207* UreaN-19 Creat-0.8 Na-138 K-4.4 Cl-105 HCO3-21* AnGap-16 [**2160-3-28**] 03:49AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.3 . Reports: CXR:[**3-7**]: No acute pulmonary process [**3-28**]: No acute pulmonary process . EKG - sinus tach, poor baseline, no sig change from prior . PFT [**3-3**]: FVC 1.68; 56% FEV1 1.11; 50% Brief Hospital Course: 1) ASTHMA FLARE: On HD#2, patient was taken off continuous nebs, and was increased to q4 hour intervals and was switched to PO steroids. She then developed anion gap acidosis/elevated lactate that was thought to be attributable to respiratory muscle breakdown. On HD#3, patient was transferred to the floor, after neb treatments were decreased to q4 hours. On transfer to the floor she reported feeling much improved. She was continued on PO prednisone at 60mg. She was also continued on Z-pak which had been started in ICU due to productive cough depsite clear CXR. Her nebs were spaced out to 6hours. Her dyspnea resolved almost completely though she still was wheezing on exam. She will complete a 2 week steroid taper, Z-pak. 2) Eosinophilia: [**Month (only) 116**] be related to asthma and allergy. There was also thought of ABPA which can be worked up as an outpt. Medications on Admission: Meds: Flonase Advair 500/50 nebs claritin 10 protonix 40 singulair 10 finished prednisone tape [**3-7**] . Discharge Medications: 1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 2. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 3 days. Disp:*3 Capsule(s)* Refills:*0* 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prednisone 10 mg Tablet Sig: taper as directed Tablet PO once a day for 2 weeks: 4 tablets [**Date range (1) 9236**] 3 tablets [**Date range (1) 9237**] 2 tabs [**Date range (1) 9238**] 1 tabs [**Date range (1) 9239**] half tab [**4-11**]. Disp:*15 Tablet(s)* Refills:*0* 5. Nebulizers Device Sig: One (1) device Miscellaneous AS DIRECTED. Disp:*1 device* Refills:*0* 6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. Claritin Oral 10. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-5**] puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 aersol* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation Discharge Condition: Good. Discharge Instructions: Please take medications as prescribed. Please call Dr. [**Last Name (STitle) **] if you have fevers, increasing shortness of breath or wheezing, worsening cough, chest pain, or any other symptoms that concern you. Followup Instructions: Please make an appointment to see Dr. [**Last Name (STitle) 2185**]/[**Doctor Last Name **] or Dr. [**Last Name (STitle) **] in the next 7-10 days to follow up. You also have the following appointments already scheduled: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2160-6-11**] 3:20 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2160-6-11**] 3:40

Admission Date: [**2176-4-9**] Discharge Date: [**2176-4-12**] Date of Birth: [**2121-4-8**] Sex: F Service: SURGERY Allergies: Ovral-21 / Codeine / Sulfonamides Attending:[**Doctor First Name 5188**] Chief Complaint: bruising and some mild abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy, debridement of abdominal wall, small and large bowel resection, and closure over a [**Location (un) 5701**] bag. Exploratory laparotomy. History of Present Illness: INDICATIONS FOR SURGERY: This is a 55-year-old woman who noted some bruising and some mild abdominal pain over a large incisional hernia site. She came to the emergency room where she developed profound sepsis and a CT scan which showed intraperitoneal air. She also was found to have crepitance and expanding hematoma or bruising over her incisional hernia. The patient was taken emergently to the operating room. Past Medical History: s/p MVC ('[**61**]), s/p R AKA, ventral hernia repair w/ component seperation ('[**66**]), anxiety Social History: Mother and son are the patient's support system Family History: noncontributory Physical Exam: gen: Intubated, secated CV: +s1s2 Pulm: coarse BS diffusely Abd: large [**Location (un) 5701**] bag in place Ext: + edema Pertinent Results: [**4-9**] CT: 1. Large ventral abdominal wall hernia with two discrete defects. The more inferior hernia defect (smaller defect) contains several loops of necrotic- appearing bowel with evidence of pneumatosis and possible perforation, suggesting strangulated ventral hernia. Large amount of subcutaneous free air within the ventral hernia sac inferiorly which tracks retroperitoneally and into the mesentery, for which necrotizing fascitis should be considered. 2. Likely aspiration at the lung bases, worse on the right side. [**4-10**] Pathology: I) Ventral hernial sac (A-B): Hernial sac with acute inflammation and serositis. II) Abdominal wall (C-D): Skin and subcutaneous tissue with extensive necrosis and abscess formation. III: Distal ileum and ascending colon, resection (E-L): Extensive hemorrhagic necrosis and transmural infarction of the small and large intestine: a. Transmural necrosis is present at the proximal (ileal) resection margin. b. Viable distal (colonic) resection margin with serositis; acute inflammation focally extends into the subserosa and muscularis. [**2176-4-9**] 06:00PM BLOOD WBC-19.2* RBC-3.46* Hgb-11.0*# Hct-33.3* MCV-96 MCH-31.6 MCHC-32.9 RDW-13.5 Plt Ct-163 [**2176-4-11**] 02:39AM BLOOD WBC-63.3*# RBC-2.66* Hgb-8.0* Hct-25.5* MCV-96 MCH-30.2 MCHC-31.4 RDW-17.1* Plt Ct-47*# [**2176-4-11**] 08:09PM BLOOD WBC-50.3* RBC-3.14* Hgb-9.5* Hct-27.5* MCV-88 MCH-30.1 MCHC-34.4 RDW-18.5* Plt Ct-25* [**2176-4-9**] 06:00PM BLOOD Neuts-65 Bands-12* Lymphs-6* Monos-10 Eos-1 Baso-1 Atyps-0 Metas-2* Myelos-3* [**2176-4-10**] 01:40AM BLOOD Neuts-79* Bands-3 Lymphs-11* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-1* [**2176-4-9**] 06:00PM BLOOD ALT-62* AST-212* LD(LDH)-359* AlkPhos-139* Amylase-17 TotBili-3.8* [**2176-4-10**] 09:50AM BLOOD ALT-33 AST-98* LD(LDH)-245 AlkPhos-94 Amylase-42 TotBili-6.4* [**2176-4-11**] 08:12AM BLOOD ALT-88* AST-406* AlkPhos-158* Amylase-27 TotBili-7.4* [**2176-4-12**] 03:09AM BLOOD ALT-160* AST-576* AlkPhos-297* TotBili-8.1* [**2176-4-9**] 06:00PM BLOOD Lipase-22 [**2176-4-10**] 09:50AM BLOOD Lipase-63* [**2176-4-11**] 08:12AM BLOOD Lipase-17 [**2176-4-11**] 03:54PM BLOOD Cortsol-30.6* [**2176-4-11**] 03:54PM BLOOD Cortsol-34.2* [**2176-4-9**] 06:06PM BLOOD Lactate-3.2* K-3.6 [**2176-4-10**] 10:03AM BLOOD Glucose-78 Lactate-4.3* Na-126* K-3.9 Cl-102 [**2176-4-11**] 02:51AM BLOOD Glucose-93 Lactate-5.9* Na-124* K-4.3 Cl-109 [**2176-4-11**] 11:46AM BLOOD Lactate-7.7* [**2176-4-12**] 06:11AM BLOOD Glucose-146* Lactate-5.1* K-3.7 Brief Hospital Course: The patient was admitted, and underwent the aforementioned surgical procedures; for details, please see operative notes. The patient returned to the SICU intubated and sedated for further care. On [**4-12**], her family decided to make the patient CMO after two exploratory laparotomies. Neuro: The patient was sedated and received paralytics at times to keep her comfortable while ventilated. She received pain medications IV when appropriate. CV: The patient's vital signs were routinely monitored, and was put on vasopressin, norepinephrine and epinephrine during her stay to maintain appropriate hemodynamics. Pulmonary: Vital signs were routinely monitored. She was intubated and sedated throughout her admission, and her ventilation settings were adjusted based on ABG values. Serial chest x-rays were performed. A bronchoscopy was performed on [**4-10**], with aspiration of feculant material from the right bronchus intermedius, blood clot adherent to left main bronchus. GI/GU/FEN: Post operatively, the patient was made NPO with IVF. She was unable to be extubated and did not receive any nutrition. On [**4-12**], the patient was made CMO. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Her white blood count continued to rise throughout her admission; for trends, please see results section. The patient was in septic shock with multiorgan failure. She was on vancomycin, fluconazole and Zosyn during her stay, and culture data was routinely monitored. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly, and she was put on a drip when necessary. She received cosyntropin for a cortisol stimulation test. Hematology: The patient's complete blood count was examined routinely; multiple (over 6 units) transfusions were required during this stay. Prophylaxis: The patient received subcutaneous heparin during this stay. The patient was made CMO on [**4-12**], after which she passed away. Medications on Admission: serax 15''', amitryptiline Discharge Disposition: Expired Discharge Diagnosis: Perforated viscus, dead bowel, and deep tissue infection. Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]

Admission Date: [**2186-2-1**] Discharge Date: [**2186-2-10**] Date of Birth: [**2163-2-7**] Sex: M Service: NEUROLOGY Allergies: Codeine / Depakote Attending:[**First Name3 (LF) 7567**] Chief Complaint: Elective admission for depth electrode placement and invasive EEG monitoring for possible temporal lobectomy Major Surgical or Invasive Procedure: Craniotomy for depth electrode placement History of Present Illness: The patient is a 22 year old right handed man with a history of refractory complex partial epilepsy who has been admitted for invasive electroencephalographic monitoring. He is being transferred from the Neurosurgery service after placement of depth electrodes and strips. His history of seizures began at age 16. He had no history of febrile seizures, meningo-encephalitic infection in early childhood, or head trauma. Preceding his first witnessed seizure by a few months, he was noted to have intermittent stairing spells of unknown duration and significance that were noted in retrospect. He had an unwitnessed event while driving a car, leading to a motor vehicle accident and possibly a head concussion. While hospitalized for this injury, he had witnessed generalized convulsions at the hospital one day later. He was initially started on Phenytoin after left temporal slowing was found on routine EEG. His medication compliance was poor, resulting in generalized convulsions approximately every six months. His seizures have multiple semiologies. The generalized convulsions (secondary generalized tonic-clonic) were usually nocturnal, included loss of consciousness and tongue biting, and were not preceded by auras. During some of these he sometimes showed the appearance of experiencing ictal fear. He had a different type of episode (complex partial) where he would have pupillary dilation, staring, and behavioral arrest. These are sometimes preceded by feelings of [**Last Name (un) 5083**] vu. These events typically last seconds to minutes (per OMR 5 seconds to 3.5 minutes). He also has a third type of episode (simple partial) which only includes the feeling of [**Last Name (un) 5083**] vu. He reports having some feelings of jamais vu as well along with the [**Last Name (un) 5083**] vu prior to the staring spells. With these auras, he sometimes feels that things appear unreal or strange, almost as though he were out of his own body. He denies any micropsia/macropsia, tableau visual distortion, strange tastes or smells, or epigastric rising sensation. He has had approximately three work-reated minor head injuries after the initial onset of seizures. He has been tried on Dilantin/phenytoin (ineffective vs noncompliance), Depakote/valproic acid (weight gain, tremor), and Trileptal/oxcarbazepine (headaches). He was subsequently switched to Keppra/levetiracetam and Lamictal/lamotrigine by our Epilepsy service with some diminishment in seizure frequency per the patient and his mother. Past Medical History: 1. Epilepsy including generalized tonic-clonic and "absence seizures" which are more likely complex partial seizures 2. Headache d/o related to (pre/post) seizures 3. h/o right hand fracture after punching a wall 4. h/o right UE trauma-related thrombosis after MVC [**11/2179**] for which he was placed on Lovenox for two months (unrevealing hypercoagulable workup). Social History: +Tobacco (occasional cigar, no cigarettes). +ETOH (weekend, social). No illicit drug use. Born full-term without perinatal complications. Reportedly achieved developmental milestones early. Completed some college level education, but did not complete due to concentration difficulties. Currently unemployed. Not currently driving. Family History: Seizures (maternal aunt, possibly from drug use). No other seizure history. Mother - hypothyroidism. Father - died of PE (@bed rest for sciatic pain). Physical Exam: ADMISSION EXAM: General: NAD, lying in bed comfortably. / Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions / Neck: Supple, no nuchal rigidity / Cardiovascular: RRR, no M/R/G / Pulmonary: Equal air entry bilaterally, no crackles or wheezes / Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses / Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Recalls a coherent history. Registration [**3-18**] and recall [**3-18**]. Concentration maintained when recalling months backwards. Follows two step commands, midline and appendicular. Language fluent with intact repetition and verbal comprehension. Normal prosody. No paraphasic errors. High and low frequency naming intact. No dysarthria. No apraxia or neglect. - Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number counting. Funduscopy shows crisp disc margins, no papilledema. [III, IV, VI] EOMI, no nystagmus, slightly droopy eyelids with left slightly lower than right but notably very tired/exhausted, can hold up both eyelids volitionally. [V] V1-V3 without deficits to light touch bilaterally. [VII] No facial asymmetry. [VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5 bilaterally. [XII] Tongue midline. - Motor - Normal bulk and tone. No pronation, no drift. No tremor or asterixis. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [[**Last Name (un) 938**]] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 - Sensory - No deficits to light touch bilaterally. - Reflexes =[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc] L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. - Coordination - No dysmetria with finger to nose testing. Slight change in cadence with right hand [**Doctor First Name **], less impaired on left hand [**Doctor First Name **]. - Gait - Unable to assess at the time of examination, in restraints s/p electrode placement. ---- Pertinent Results: WBC 14.7, Hgb 14.1, Plt 297, Na 145, Cr 1, Glu 158 NCHCT [**2-1**] - no hemorhage, depth electrodes in place, pneumocephalus MRI Head [**2-2**] FINDINGS: There is interval placement of electrodes, through the posterior parietal and approach, one on each side. The right-sided electrode, courses through the parietal and temporal lobes, and through the hippocampus, with the tip extending slightly beyond the margins of the hippocampus antral medially and inferiorly in the right temporal lobe. The left-sided lead has the tip within the left hippocampus. There is no focus of slow diffusion to suggest acute infarction. The ventricles and extra-axial CSF spaces are normal. No focal areas of altered signal intensity are noted in the brain parenchyma on the non-contrast images. The major intracranial arterial flow voids are noted. The imaged portions of the paranasal sinuses and the mastoid air cells are clear. Post-procedural changes are noted in the soft tissues of the scalp and the bone and adjacent soft tissues in the posterior temporal regions. NCHCT `[**2-9**] FINDINGS: Previously visualized bitemporal depth electrodes as well as bilateral temporal grids have since been removed. Five burr holes are again noted in both temporal lobes, posterior aspect of both parietal lobes, and right lateral aspect of the frontal bone. Mild right frontal and bitemporal pneumocephalus is noted, as well as a focus of gas in the subgaleal tissues overlying the right temporal bone. There is, however, no evidence of hemorrhage, edema, large vessel territorial infarction, or shift of normally midline structures. The ventricles and sulci remain normal in size and configuration. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: Interval removal of previously placed depth electrodes and grids. No evidence of post-procedural complications. EEG [**2-2**] IMPRESSION: This is an abnormal video intracranial EEG monitoring session because of a left temporal clinical focal seizure, as described above. This arose regionally from the antero-mesial temporal region (subdural strip anterior temporal strip hippocampus), but the exact ictal onset zone is not recorded. The only clinical manifestation was brief eye opening. This ictal activity briefly spread to the right subtemporal strip, with repetitive spikes and spike-wave activity for about 20 seconds, but did not spread to other right temporal electrodes. There were abundant bilateral hippocampal depth electrode spikes, as described above. Spikes are most frequent in the right anterior hippocampus but are also seen frequently in the left anterior hippocampus. EEG [**2-3**] IMPRESSION: This is an abnormal video intracranial EEG monitoring session because of two left temporal complex partial seizures as described above. These appear to arise regionally from the antero-mesial temporal region (subdural strip anterior temporal strip hippocampus), but the exact ictal onset zone is not recorded. The ictal activity spread briefly to right subdural strip electrodes, with repetitive spikes in RST2-3 and RST3-4, but did not involve other right temporal electrodes. There were abundant bilateral hippocampal depth electrode spikes, as described above. Spikes are most frequent in the right anterior hippocampus but are also seen frequently in the left anterior hippocampus. Compared to the prior day's recording, there is no significant change interictal activity, but two complex partial seizures are recorded. EEG [**2-4**] IMPRESSION: This is an abnormal video intracranial EEG monitoring session because of abundant bilateral hippocampal depth electrode spikes as described above. Spikes are most frequent in the right anterior hippocampus but are also seen frequently in the left anterior hippocampus. No electrographic seizures are present. Compared to the prior day's recording, there is no significant change interictal activity, but no seizures are recorded. EEG [**2-5**] IMPRESSION: This is an abnormal video intracranial EEG monitoring session because of abundant bilateral hippocampal depth electrode spikes as described above. Spikes are most frequent in the right anterior hippocampus but are also seen frequently in the left anterior hippocampus. No electrographic seizures are present. Compared to the prior day's recording, there is no significant change in interictal activity, but no seizures are recorded. Brief Hospital Course: 22yoW h/o epilepsy, depression electively admitted for depth electrode placement, continuous EEG, and further localization of temporal lobe seizure focus in anticipation of surgical resection. [] Depth Electrodes Placement for Invasive EEG Monitoring - The depth electrodes were placed by Dr. [**Last Name (STitle) **]/Neurosurgery without major perioperative complications, and they were removed similarly without major complications. He had no persistent new neurologic deficits after either procedure. He was covered with antibiotics including 7 days of cephalexin after his discharge (vancomycin and gentamicin while in-house). [] Epilepsy - The patient was monitored with invasive EEG monitoring with his medications downtitrated which revealed bilateral temporal lobe seizures. His medications were restarted with lamotrigine being uptitrated to 200 qAM and 300 qPM. [] Depression - His Sertraline was increased to 100 mg daily. He did not display any signs of worsening depression, but the new findings of his bilateral temporal seizures and inability to get temporal lobectomy could be a major trigger for worsening depression. PENDING STUDIES: EEG final reports TRANSITIONAL CARE ISSUES: [ ] Please assess his seizure frequency on his new dose of lamotrigine. [ ] Please follow his emotional state/depression on the higher dose of Sertraline. Medications on Admission: Keppra 1500mg [**Hospital1 **], Lamictal 200mg [**Hospital1 **], Sertraline 50mg Daily Discharge Medications: 1. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO QAM. Disp:*30 Tablet(s)* Refills:*2* 2. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO twice a day. 3. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO PRN as needed for headache. 4. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days: for prevention of infection after your operation. Disp:*28 Capsule(s)* Refills:*0* 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain for 3 days: Do not take more than prescribed amount. Do not drive or operate heavy machinery as this can make you drowsy. Disp:*18 Tablet(s)* Refills:*0* 6. lamotrigine 200 mg Tablet Sig: 1.5 Tablets PO QPM. Disp:*45 Tablet(s)* Refills:*2* 7. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Epilepsy/Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neurologic: No deficits. Discharge Instructions: [ NEUROLOGY DISCHARGE INSTRUCTIONS ] Mr. [**Known lastname 88790**], You were admitted to the hospital for invasive electroencephalographic monitoring for your seizure disorder (temporal lobe epilepsy). The depth electrodes and strips were placed by our Neurosurgical team without any major complications. We monitored you in the Epilepsy Monitoring Unit and were able to record several seizures. The electrodes were subsequently removed. Dr. [**First Name (STitle) **] will be using this data to continue guiding you through the management of your epilepsy. At this time, we are not making any changes to your medication regimen. Please take your anticonvulsants as previously prescribed. We are changingthe following medications: 1. Please increased your evening dose of LAMICTAL/lamotrigine to 300 MG per night. You will take LAMICTAL 200 MG in the morning and 300 MG in the evening. 2. Please take KEFLEX/cephalexin 500 MG four times per day (every 6 hours) for 7 days for prevention of infection after your surgery. 3. Your Sertraline has now been increased to 100 MG per day. I am prescribing you a new tablet. 4. Please take Docusate Sodium and Senna as prescribed to prevent constipation whiel taking Oxycodone for pain. 5. You can take Oxycodone 5 mg every 8 hours as needed for pain over the next few days. Do not operate heavy machinery while using this medication as it can make you drowsy. You can also take Acetaminophen 650 MG three or four times daily as needed for your headache for a few days (do not take as frequently in the long term). Please continue to take your own scheduled medications. We would like you to followup with Dr. [**First Name (STitle) **] as listed below. If you have any of the following symptoms, please seek medical attention. It was a pleasure providing you with medical care during this hospitalization. [ NEUROSURGERY 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. ?????? Dressing may be removed on Day 2 after surgery. ?????? If you have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? If your wound was closed with staples or non-dissolvable sutures then you must wait until after they are removed to wash your hair. 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. 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: NEUROLOGY Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone: [**Telephone/Fax (1) 3294**] Date/Time: [**2186-3-3**] 1:00 NEUROSURGERY: Please call [**Telephone/Fax (1) 1669**] to set up a time to have your staples removed. This should occur in about 1 week. (The Neurosurgeons have provided you with this information and these instructions.)

Admission Date: [**2140-2-29**] Discharge Date: [**2140-3-4**] Date of Birth: [**2069-7-18**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: C2 type II dens fracture s/p HALO placement Major Surgical or Invasive Procedure: [**2140-2-29**]: Open reduction and internal fixation of type II C2 dens fracture. History of Present Illness: Pt is a 79 year old woman with a known C2 fracture sustained after a fall in [**2139-10-22**]. She was placed in a halo at that time, then discharged to [**Hospital 100**] Rehab, and is here today for follow up. She has not yet been discharged from rehabilitation. She complains of pain related to the halo at times, and feels that she has had a decrease in mobility especially when getting out of bed or a chair. No additional complaints. No HA, numbness/tingling. Past Medical History: CAD Hiatal hernia SVD Vaginal hysterectomy Post colporrhaphy and bladder neck suspension, R breast lumpectomy L mastectomy for Breast Ca C2 type II dens fracture. Social History: widowed Family History: Father - CAD, [**Name (NI) **] Ca. Mother - PE Physical Exam: GENERAL: She is alert and oriented x 3, pleasant, and in no acute distress. NEUROLOGIC: She has a halo on and it is intact. She is able to rise from her seat, but is tentative, uses her arms for additional strength. Full strength throughout, [**3-25**]. Deep tendon reflexes 2+ throughout. Sensation is intact. Halo pin sites, no erythema, edema, or drainage. C-spine CT from [**2-2**] - Again seen is an oblique fracture involving the base of the odontoid process (type 2). Fracture fragments appear in unchanged alignment. Multiple small osseous fragments, also unchanged in appearance, are noted. There is slight cortication of the still-evident fracture line margins. However, the lack of change in alignment suggests development of fibrous [**Hospital1 **]. Pertinent Results: [**2140-3-3**] 06:45AM BLOOD WBC-8.9 RBC-4.32 Hgb-12.9 Hct-38.4 MCV-89 MCH-29.9 MCHC-33.6 RDW-14.0 Plt Ct-99* [**2140-3-3**] 06:45AM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-145 K-4.3 Cl-105 HCO3-32 AnGap-12 [**2140-3-3**] 06:45AM BLOOD Calcium-8.5 Phos-2.8# Mg-1.8 RADIOLOGY Final Report CT C-SPINE W/O CONTRAST [**2140-3-1**] 12:03 PM CT C-SPINE W/O CONTRAST Reason: please evaluate post op at 0800 on [**2140-3-1**]. thank you. [**Hospital 93**] MEDICAL CONDITION: 70 year old woman s/p ORIF of C2 type II dens fx. REASON FOR THIS EXAMINATION: please evaluate post op at 0800 on [**2140-3-1**]. thank you. CONTRAINDICATIONS for IV CONTRAST: None. CT scan of the cervical spine with multiplanar reformatted images. Exam compared to previous examination of [**2140-2-2**]. FINDINGS: There has been intramedullary fixation of the fracture of C2 and the odontoid with a metallic device extending from the body of C2 into the odontoid process. There is no evidence of abnormal calcification within the spinal canal. The retropharyngeal mass is again demonstrated and is unchanged from prior studies. There is no alteration in alignment. IMPRESSION: Status post internal fixation of odontoid fracture. Stable appearance of retropharyngeal mass. DR. [**First Name (STitle) 23303**] [**Doctor Last Name **] Approved: TUE [**2140-3-1**] 3:57 PM Brief Hospital Course: Pt admitted to the neurosurgery service s/p ORIF type II C2 dens fracture. Pt keep in the PACU overnight for q1 hr neurochecks. Post operatively she was awake, alert and orientated X3 moving upper extremeties with good strength. She had a post op CT scan: FINDINGS: There has been intramedullary fixation of the fracture of C2 and the odontoid with a metallic device extending from the body of C2 into the odontoid process. There is no evidence of abnormal calcification within the spinal canal. The retropharyngeal mass is again demonstrated and is unchanged from prior studies. There is no alteration in alignment. She was seen by PT and found to be hypotensive so she was observed additional day. Social work was also involved with her discharge planning and Ms [**Known lastname 98305**] agreed to return to rehab. Medications on Admission: protonix 40mg qd triethanolamine/water (shampoo) Th@10 to scalp. neosporin triple antibiotic ointment to pin sites tylenol 650 q4h prn tylenol 650 [**Hospital1 **] fosamax 70mg qSat lipitor 80mg qPM dulcolax 10mg PR prn calcium/vit D 500 tid celexa 40 qhs colace 250 qAM [**Doctor First Name 130**] 30 qd prn robitussin syrup 5ml q6prn MOM 30ml qd prn MVI oxycodone hcl 5 q4 prn senna 2 tabs qHS trazodone 25 daily prn lasix 40 qod Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Use while on Percocet. Disp:*30 Tablet(s)* Refills:*1* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: Use while on Percocet. Disp:*60 Capsule(s)* Refills:*2* 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 8 days. Disp:*32 Capsule(s)* Refills:*0* 12. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): to pin sites. Disp:*1 500unit/g* Refills:*2* 13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: C2 type II dens fracture. Discharge Condition: neurologically stable. Discharge Instructions: Restart you home medications as usual. Please take newly prescribed medications as instructed. Must wear collar at all times except when bathing No heavy lifting Diet low in cholesterol and high in fiber. Do not get steristrips wet until tomorrow, may shower starting tomorrow. Watch incision for redness, drainage, bleeding, swelling, or if you develop a fever greater than 101.5 call Dr [**Last Name (STitle) 17511**] office You may shower but please keep incision covered with tegaderms during shower. Please keep incision clean, dry, intact till you see Dr. [**Last Name (STitle) **] clinic. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Reddness/swelling/discharge from wounds * Anything that concerns you. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 8 weeks. Please call [**Telephone/Fax (1) 1669**] to make an appointment. Please keep the following appointments: Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2140-3-4**] 1:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 98306**], [**Name12 (NameIs) 16569**] RNC Date/Time:[**2140-4-4**] 1:20 Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. Date/Time:[**2140-4-11**] 3:30

Admission Date: [**2126-2-27**] Discharge Date: [**2126-3-5**] Date of Birth: [**2050-6-17**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: This is a 75 year-old woman with a past medical history of hypertension, hypercholesterolemia who was transferred from [**Hospital6 33**] for emergent cardiac catheterization since she presented to that hospital earlier this evening of admission with complaints of 6 out of 10 abdominal indigestion. The patient noted back pain, but denies nausea or vomiting. Electrocardiogram showed ST segment elevations about 6 mm in leads V2, V3 and 5 mm changes in V5, 3 mm in V6 and 3 mm changes in leads 2 and AVL. The patient with old right bundle branch block and with reciprocal changes in the inferior leads. The patient was given Lopressor, nitroglycerin and Integrilin at the outside hospital with chest pain that decreased to 1.5 out of 10. Of note patient with similar complaints on Sunday. At that time those complaints were associated with nausea and vomiting as well. In the catheterization laboratory the patient underwent stenting of the mid left anterior descending coronary artery lesion due to 50% proximal and 50% first septal and 100% mid occlusion. The patient also underwent percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery just beyond flow stent. The patient had multiple infusions of intracoronary nitroglycerin and Diltiazem to improve flow. Hemodynamically the patient's right atrium was a pressure of 10, PA of 42/21, wedge pressure of 26, cardiac output 3.24, cardiac index 1.95, FVR 2100. The patient was given 10 mg of intravenous Lasix and transferred to the Coronary Care Unit. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Status post appendectomy. ALLERGIES: Penicillin causes a rash. MEDICATIONS: 1. Atenolol 50 once a day. 2. Lipitor 10 once a day. FAMILY HISTORY: Negative for coronary artery disease. Father with an aortic aneurysm. Mother with a stroke. SOCIAL HISTORY: Former tobacco smoker about half a pack per day for five yeas. Alcohol before dinner occasionally. No drugs. She lives at home with her older sister. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 150/80. Pulse 78. O2 sat 96% on 2 liters. In general, she is a pleasant elderly woman in no acute distress. HEENT normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are moist. Clear oropharynx. Cardiovascular regular rate and rhythm. Normal S1 and S2. 1 out 6 systolic ejection murmur. JVP at about 8 cm. Lungs clear to auscultation anteriorly. Abdomen is soft, nontender, nondistended. Positive bowel sounds. Extremities no clubbing, cyanosis or edema. Good dorsalis pedis pulses and posterior tibial pulses 2+ bilaterally. Right groin arterial sheath and Swan in place. Skin no rashes or lesions. LABORATORY DATA: White blood cell count 11.4, hematocrit 38.9, platelets 319, sodium 138, K 4.2, chloride 103, bicarb 26, BUN 23, creatinine 1.0, albumin 4.1, troponin 0.79. Electrocardiogram as described previously. HOSPITAL COURSE: This is a 75 year-old woman with a history of hypertension, hypercholesterolemia status post large anterior myocardial infarction with placement of stent in the mid left anterior descending coronary artery. At catheterization the patient was noted to have an elevated wedge pressure and residual lesion of the left circumflex, which was not intervened on. 1. Coronary artery disease: The patient has a large anterior myocardial infarction and catheterization results as noted above. The patient was continued on aspirin, Plavix, Integrilin for 18 hours and then discontinued. Also continued on heparin and beta-blocker was continued as tolerated. The patient was continued on her Lipitor 80 mg and weaned off her nitro drip. Otherwise the patient remained mostly chest pain free throughout the course of her stay. She was started on a beta-blocker and titrated up as tolerated and the patient was evaluated by the EP team for possible risk stratification in the future secondary to her anterior myocardial infarction and decreased ejection fraction. She did continue to have some episodes on telemetry of tachycardia with exertion and plans were made to have an outpatient Holter monitor and an outpatient stress in six weeks time with T wave alternans at which time she will follow up with Dr. [**Last Name (STitle) **] following those studies and to reassess her obtuse marginal and right coronary artery lesions for a possible reintervention. The patient was also started on low level Coumadin for three to four months of anticoagulation for her anterior myocardial infarction and hypokinesis of her anterior wall and decreased ejection fraction. For this she was also started on Lovenox as a bridge waiting for Coumadin to become therapeutic and can have this followed as an outpatient. Goal INR of 1.5 at which time she can discontinued her Lovenox. The patient was given teaching of her Lovenox during her stay and understood injections. Otherwise the patient was also started on ace inhibitor to improve cardiac function and for her decreased ejection fraction. 2. Congestive heart failure: The patient with an ejection fraction of 35% after her anterior myocardial infarction. She had akinesis of her mid distal and anterior septum, distal anterior wall and apical akinesis and the patient was continued on her ace inhibitor for after load reduction and we started her on low dose Coumadin. The patient's Is and Os were monitored and she did receive some Lasix on a prn basis. She was transfused one unit of blood for a hematocrit less then 30 and was followed by a dose of Lasix as she had some bibasilar crackles following the blood. 3. Hematuria: The patient had some hematuria, which was likely secondary to a traumatic Foley placement during admission, however, the patient was recommended to have outpatient cystoscopy and urology follow up as she will get this further evaluated once acute process is resolved. 4. Nutrition: The patient was continued on a cardiac diet and her electrolytes were followed closely. The patient was seen and evaluated by physical therapy with no acute needs for rehab or physical therapy. The patient was ambulating without difficulty or without desaturation or orthostasis. DISCHARGE CONDITION: Good. Discharged with services for Lovenox teaching. The patient ambulating without difficulty and not requiring oxygen. DISCHARGE DIAGNOSES: 1. Anterior wall myocardial infarction. 2. Congestive heart failure. 3. Hypertension. 4. Hypercholesterolemia. 5. Hematuria. DISCHARGE MEDICATIONS: 1. Lovenox 100 mg subq q day until INR greater then 1.5. 2. Coumadin 5 mg po q day for three to four months with goal INR of 1.5. 3. Toprol XL 100 mg one po q day. 4. Lisinopril 10 mg one po q day. 5. Sublingual nitroglycerin prn. 6. Atorvastatin 80 mg po q day. 7. Plavix 75 mg one po q day. 8. Aspirin 325 mg one po q day. DISCHARGE FOLLOW UP: The patient is to follow up with her primary care physician on [**Name9 (PRE) 2974**]. The patient is to have her INR checked at that time and adjusted accordingly. The patient is to follow up with an outpatient neurologist and establish herself with a local cardiologist once she sees her local primary care physician. [**Name10 (NameIs) **] she will follow up with Dr. [**Last Name (STitle) **] on [**2126-4-17**]. The patient will have a Holter monitor placed on [**4-8**] and then will return for a stress test with T wave alternans on [**4-9**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**] Dictated By:[**Name8 (MD) 264**] MEDQUIST36 D: [**2126-3-5**] 04:24 T: [**2126-3-6**] 08:50 JOB#: [**Job Number 54527**]

Admission Date: [**2156-11-17**] Discharge Date: [**2156-11-19**] Date of Birth: [**2156-11-17**] Sex: F Service: NB HISTORY: Baby Girl [**First Name4 (NamePattern1) 47506**] [**Known lastname **], twin #1, delivered at 35- 4/7 weeks gestation, was admitted to the newborn intensive care nursery for management of prematurity. Birth weight 2215 gm (25th to 50th percentile), length 47 cm (50th percentile), head circumference 32 cm (50th percentile). Mother is a 38-year-old gravida 1 mother with estimated date of delivery [**2156-12-18**]. Her prenatal screens included blood type A positive, antibody screen negative, hepatitis B surface antigen negative, rubella immune, RPR nonreactive, and group B strep unknown. This pregnancy was conceived by in [**Last Name (un) 5153**] fertilization resulting in dichorionic diamnionic twin gestation. The pregnancy was complicated by advanced maternal age, twin gestation, and gestational hypertension treated with Aldomet. She presented on day of delivery with pre-term premature rupture of membrane and pre-term labor. She was delivered by cesarean section under spinal anesthesia secondary to multiple gestation. The amniotic fluid was clear. No maternal fever. No interpartem antibiotics. This twin emerged with a cry, was dried, bulb suctioned. Apgar scores were 9 at one minute and 9 at five minutes. PHYSICAL EXAMINATION AT DISCHARGE: Weight 2205 gm. Awake and alert infant. Anterior fontanelle open, soft, flat. No clefts. Red reflex deferred. Breath sounds clear and equal bilaterally with easy work of breathing. No murmur. Normal pulses and perfusion. Abdomen soft, nondistended, positive bowel sounds, cord dry. Spine intact. Hips stable. Normal pre- term female genitalia. Active with normal tone and activity for gestational age. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory - has been in room air since admission with comfortable work of breathing, respiratory rate remains in the 30s to 40s, no apnea. Cardiovascular - no murmur, heart rates range 130s to 140s; blood pressure 62/29 with a mean of 41. Fluids, electrolytes, nutrition - the baby initially had an IV on admission and was started on ad lib feeds. IV fluid was discontinued on [**2156-11-18**]; is taking Enfamil 20 ad lib, taking around 18-35 cc every 3-4 hours, is voiding and stooling appropriately. Gastrointestinal - very mild facial jaundice, bili has not been drawn yet, plan to draw on day of life 3. Hematology - hematocrit on admission 51%. Infectious disease - a CBC and blood culture were drawn on admission and was started on ampicillin and gentamicin for rule out for infection on [**2156-11-19**]. CBC showed a white count of 8.9 with 21 polys, no bands, platelets 331,000, hematocrit 51%. Blood culture has no growth to date. Sensory - hearing screening has not been performed yet, will need prior to discharge. CONDITION AT DISCHARGE: Stable pre-term infant. DISCHARGE DISPOSITION: Transferred to newborn nursery. NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) 74887**], M.D., [**Location (un) 74888**], [**Apartment Address(1) 50442**], [**Location (un) **], [**Numeric Identifier 1415**], telephone #[**Telephone/Fax (1) 43701**]. CARE RECOMMENDATIONS: Feeds - Enfamil 20 with iron ad lib, monitor weight, may need 24 calories per ounce. Medications - currently on no medications, iron and vitamin D supplementation, iron is recommended for pre-term and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units, may be provided as a multivitamin preparation, daily until 12 months corrected age. Car seat position screening test has not been performed, will need prior to discharge. State newborn screen has not been drawn, plan to draw it on [**2156-11-20**], when draw bilirubin. IMMUNIZATIONS RECEIVED: Has not received hepatitis B immunization yet. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 4 criteria - 1) born at less than 32 weeks, 2) born between 32 and 35 weeks with 2 of the following - day care during RSV season, smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, 3) chronic lung disease, 4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers. This infant has not received rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of pre- term infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. FOLLOW-UP APPOINTMENTS: Recommended followup per pediatrician. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age, pre-term female at 35- 4/7 weeks. 2. Twin #1. 3. Rule out sepsis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2156-11-19**] 02:26:25 T: [**2156-11-19**] 03:52:12 Job#: [**Job Number 74889**]

Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**] Date of Birth: [**2054-2-16**] Sex: F Service: CARDIOTHORACIC Allergies: Relafen Attending:[**First Name3 (LF) 4679**] Chief Complaint: Recurrence of lung cancer Major Surgical or Invasive Procedure: [**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and decortication of lung, Wedge resection of right lower lobe lung cancer. History of Present Illness: Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a right thoracotomy, right lower lobe superior segmentectomy on [**2125-7-27**]. The pathology revealed a 2.5cm, moderately differentiated, adenocarcinoma with negative margins. The lymph nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic [**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET showed an FDG-avid subpleural nodule in the right lower lobe, compatible with recurrence as well as in the chest wall in the region of the right 5th and 6th ribs is new from [**2125-7-3**] and also concerning for recurrence. She underwent a core biopsy [**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies any symptoms at this time. Past Medical History: Hypertension Hyperlipidemia breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant chemorads Renal angiomyolipoma Emphysema PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring partial resection via thoracotomy Social History: She quit smoking in [**2109**] and smoked 40 years 2 packs a day. Denies alcohol use. Unfortunately, husband has terminal gastric cancer, is hospitalized at the VA which greatly upsets patient. Family History: She has two daughters who are healthy. There is a history of allergies and emphysema in her family. Physical Exam: Gen: NAD, anxious Neck: no [**Doctor First Name **] Chest: clear ausc, incisions c,d,i Cor: RRR no murmur Ext: no CCE Pertinent Results: ADMISSION LABS [**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9* MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333 [**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140 K-4.1 Cl-106 HCO3-22 AnGap-16 [**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5* DISCHARGE LABS [**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2* MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455* [**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136 K-3.9 Cl-96 HCO3-30 AnGap-14 [**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8 [**8-30**] CXR post op Right pneumothorax post surgery with three chest tubes in place [**9-7**] CXR Interval removal of the right basilar chest tube. There continues to be some subcutaneous emphysema within the right lateral chest wall soft tissues. Post-surgical changes of the right hemithorax and lung are stable. Stable right lateral pleural thickening and right basilar pleural thickening could be post-operative or represent some pleural fluid. However, the appearance is stable. No pneumothorax is seen. The left lung remains well inflated and clear. Cardiac and mediastinal contours are stable. Clips in the right upper quadrant are consistent with cholecystectomy. No pulmonary edema. Brief Hospital Course: Patient was admitted on [**2126-8-30**] to the thoracic surgery service for a planned right thoracotomy, right lower lobe wedge resection with decortication. She tolerated the procedure well, was extubated and recovered in the PACU prior to being transferred to the ICU in stable condition. For full details please see the operative report. Three chest tubes were placed during the procedure and a postoperative chest x-ray showed expected right pneumothorax post surgery with three chest tubes in place. Pathology revealed a 1.8 cm poorly differentiated adenocarcinoma with negative margins and no positive nodes. She was started on a clear liquid diet, her pain was controlled with an epidural and she was started on her home medications. On POD 1 her diet was advanced to regular and she was transferred to the surgical floor from the ICU. On POD 2 she was noted to have increased somnolence which was thought to be related to her pain medications so her epidural was turned down and narcotics for breakthrough pain were discontinued. She was given a unit of PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and improved somnolence. On POD 3 metoprolol was started because of elevated systolic blood pressures. She continued to have an air leak from all three chest tubes. Her epidural was discontinued and her foley catheter was removed. She was started on oxycodone and tramadol for pain. By POD 4 the air leak had stopped in the anterior chest tube so it was removed. The posterior chest tube was removed on POD 6. On POD 7 she noted that she felt dizzy when she was getting out of bed and was found to be in atrial fibrillation with RVR. She was given metoprolol once without effect and was then given IV diltiazem once with return to sinus rhythm. Cardiac enzymes were negative and she was monitored with telemetry without recurrence. On POD 8 the air leak had resolved in the basilar chest tube so it was removed. A post pull chest xray showed no PTX. Because her pain was well controlled, she was tolerating her diet and was ambulating without assistance, she was discharged to home on POD 9 with instructions to follow up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray. Medications on Admission: 1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] twice a day Rinse mouth after use 2. Nortriptyline 30 mg PO HS 3. Pravastatin 40 mg PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] twice a day Rinse mouth after use 4. Nortriptyline 30 mg PO HS 5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills:*0 6. Pravastatin 40 mg PO DAILY 7. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*30 Tablet Refills:*0 8. Tiotropium Bromide 1 CAP IH DAILY 9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY 10. Metoprolol Tartrate 12.5 mg PO BID HTN Hold for SBP < 100 or HR < 60 RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a day Disp #*15 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Recurrent lung cancer 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 surgery on your lung. You have done well after the procedure and may return home to continue your recovery. There is a dressing over the site of your chest tube- this may be removed in 24 hours. You can leave the incision open to air after that. You may shower with the dressing in place. Please take the prescribed pain medication as needed. Constipation can be a problem with narcotic use, therefore drink plenty of fluid to stay well hydrated and use a stool softener while taking narcotics. Do NOT drive while taking narcotic pain medications. While in the hospital, you were noticed to have a heart rhythm called atrial fibrillation. We were able to convert the rhythm back to normal using medication; please ask your primary care doctor if you need further tests or treatment. We also started you on a new medication called Metoprolol for your high blood pressure and new dysrhythmia, please ask your primary care doctor if you need to continue it. If you develop any chest pain, shortness of breath or any other symptoms that concern you, please call your surgeon or go to the nearest Emergency Room. Thank you for allowing us to participate in your care. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call [**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with a chest x ray. Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min prior to your appointment for a chest x-ray. Please follow up with your primary care doctor within a week from discharge.

Admission Date: [**2126-11-1**] Discharge Date: [**2126-11-6**] Date of Birth: [**2069-11-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: s/p PEA arrest Major Surgical or Invasive Procedure: None History of Present Illness: 58 year old male with history of atrial fibrillation, DM2, prior MI presents s/p PEA arrest at an OSH after VATS. . Patient is intubated and unresponsive on arrival, history is obtained from outside records. . In early [**Month (only) 359**], he had a sore throat and felt poorly. He went to his PCP and was treated with 10 days of ammoxicillin. he then was treated with penicillin for a dental extraction. Shortly after this, he became progressively short of breath. He saw his PCP who referred him to Cardiology (Dr. [**Last Name (STitle) 77919**]. At that time a CXR was performed that showed opacification of the right lower [**12-9**] to [**12-8**] hemithorax, interpreted as infiltrate + pleural effusion. He also had a stress echocardiogram and a cardiac catheterization was planned. A chest X-ray was repeated on [**2126-10-28**], which was unchanged. His cath was deferred and he was scheduled to undergo VATS with possible pleural decortication. . He was admitted to [**Hospital3 26615**] on [**2126-10-30**] for VATS and bronchoscopy. 2600 cc of straw colored pleural fluid was removed, and pleural biopsy was taken. At the end of the procedure, prior to extubation, patient had a drop in blood pressure and suffered a PEA arrest. Patient received defibrillation, epinephrine, and chest compresions for 17 minutes. He returned to [**Location 213**] sinus rhythm, and was transferred to the ICU. He was put on a lasix drip. There an echo demonstrated no pericardial effusion, and and CT PA demonstrated no PE. His labs were significant for a WBC of 12. Cardiac enzymes were flat. He was treated with levaquin and unasyn for presumed PNA. He was weaned off of sedation and only responded to noxious stimuli. He was evaluated by neurology who recommended MRI and EEG. He is transferred to [**Hospital1 18**] for further cardiology and neurology evaluation. On transfer, he was on a heparin drip, midazolam/fentanyl for sedation and mechanical ventilation (AC). Past Medical History: - Atrial Fibrillation - Diabetes Type II - H/O MI Social History: -Tobacco history: Quit smoking three years ago, 1 ppd x 20 years previously -ETOH: 12 pack on weekends -Illicit drugs: Family History: NC Physical Exam: VS: T= 99.7 BP= 126/81 HR= 78 RR= 16 O2 sat= 100/ AC FiO2 100, Tv 550, RR 16, PEEP 5 GENERAL: Intubated, sedated, not responsive to commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ NEURO: Unresponsive to commands. Pupils reactive to light, corneal relfex intact. Babinski up going. no spontaneous movement observed. . At time of death: extubated Pertinent Results: [**2126-11-1**] 06:22PM BLOOD WBC-9.1 RBC-4.64 Hgb-14.7 Hct-41.6 MCV-90 MCH-31.8 MCHC-35.4* RDW-13.5 Plt Ct-222 [**2126-11-1**] 06:22PM BLOOD Neuts-74.9* Lymphs-17.0* Monos-5.7 Eos-0.7 Baso-1.8 [**2126-11-1**] 06:22PM BLOOD PT-15.6* PTT-32.2 INR(PT)-1.4* [**2126-11-2**] 04:11AM BLOOD ESR-30* [**2126-11-1**] 06:22PM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-136 K-3.7 Cl-98 HCO3-29 AnGap-13 [**2126-11-1**] 06:22PM BLOOD ALT-24 AST-51* CK(CPK)-100 AlkPhos-75 TotBili-2.1* [**2126-11-2**] 04:11AM BLOOD ALT-22 AST-50* AlkPhos-69 TotBili-2.0* [**2126-11-3**] 04:26AM BLOOD ALT-22 AST-54* AlkPhos-69 TotBili-2.4* [**2126-11-1**] 06:22PM BLOOD CK-MB-1 cTropnT-<0.01 [**2126-11-1**] 06:22PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1 [**2126-11-2**] 04:11AM BLOOD CRP-41.7* [**2126-11-2**] 04:11AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2126-11-1**] 06:27PM BLOOD Type-ART pO2-386* pCO2-39 pH-7.48* calTCO2-30 Base XS-6 [**2126-11-3**] 05:12AM BLOOD Type-ART pO2-143* pCO2-39 pH-7.47* calTCO2-29 Base XS-5 [**2126-11-1**] 06:27PM BLOOD Lactate-1.6 . EEG: This is an abnormal routine EEG due to the presence of a low-voltage background that was invariant and nonreactive to external stimulation. This finding suggests a diffuse and severe encephalopathy, such as that caused by hypoxic-ischemic injury, toxic-metabolic changes, or medication effect, among other things. There were no focal abnormalities or epileptiform features noted. . PCXR: The ET tube tip is 5.2 cm above the carina. The NG tube tip passes below the diaphragm with its tip being in the stomach. Diffuse pericardial calcification is noted, circumferential. Mediastinum is minimally widened but it might be related to portable technique of the study. There is minimal vascular congestion but no overt edema. Left retrocardiac opacity might represent area of atelectasis, aspiration or infectious process and should be closely monitored. . TTE: The left atrium is elongated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. There is mild to moderate regional left ventricular systolic dysfunction with basal to mid inferior, inferolateral, and anterolateral hypokinesis. Due to suboptimal technical quality, additional focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 40%). Unable to assess left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. . MR HEAD W/ and W/O CON: 1. Extensive confluent areas of decreased diffusion in the bilateral parietal and occipital [**Month/Day/Year 3630**] and parts of the frontal lobes likely related to cortical infarction with some degree of cortical swelling. Spreading of the temporal lobes, the basal ganglia and the right cerebellar hemisphere and probably the left cerebellar hemisphere. Correlate clinically and consider followup/correlation with brain scan. 2. Area of increased signal intensity on the T2 and FLAIR sequences in the right frontal [**Last Name (LF) 3630**], [**First Name3 (LF) **] relate to changes in the parenchyma surrounding small developmental venous anomaly. However, given the lack of prior studies and the extent of FLAIR hyperintense area, which measures 2.1 x 2.6 cm, consider followup to assess stability/progression to exclude any associated low-grade neoplasm. 3. Mucosal thickening in the mastoid air cells on both sides, right more than left. . Brief Hospital Course: #. s/p PEA arrest. Post-op/peri anesthesia hypotension most likely precipitant of PEA. Possible contribution from hypoxia given lung collapse seen on CT. CT PA negative for PE, echo negative for tamponade. Labs essentially normal, cardiac enzymes negative. Neurology consulted and EEG and MRI head done, all consistent with very poor neurologic prognosis. Neurology team explained prognosis to patient's family and they agreed that it would not be within his wishes to exist without meaningful interaction. NEOB was initially contact[**Name (NI) **] but pt. was no longer a possible donor once extubated. . # Respiratory Failure/Pleural Effusion: Patient was never extubated post-thoracentesis. Continued levaquin and unasyn given concern for aspiration/oral flora given unilateral PNA, recent tooth extraction and alcohol history. Pleural fluid analysis not an empyema, but suggestive of exudate. Fluid cytology negative. Patient was overbreathing vent with excellent RSBI prior to extubation. He was made DNR/DNI prior to extubation. He was successfully extubated on [**11-4**] and morphine drip was given with scopolamine patch for comfort measures. He expired on the morning of [**11-6**]. Autopsy was requested by the family. Medications on Admission: HOME MEDICATIONS: Metformin 1000mg PO bid ASA 325mg PO daily Glyburide 5mg PO bid Imdur 30mg PO daily . MEDICATIONS ON TRANSFER: Combivent Heparin gtt 900 U/hr Unasyn 3gm IV q6 Levaquin 750 mg q24 Lasix 40mg IV q daily Discharge Disposition: Expired Discharge Diagnosis: s/p PEA arrest Death Discharge Condition: Expired

Admission Date: [**2176-5-31**] Discharge Date: [**2176-6-14**] Date of Birth: [**2101-7-5**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4111**] Chief Complaint: Constipation, fatigue, weight loss Major Surgical or Invasive Procedure: Resection of transverse colon and splenic flexure, colocolostomy, resection of small bowel (en bloc) enteroenterostomy and feeding jejunostomy. History of Present Illness: Mrs [**Known lastname 1391**] is a 74F who presents with a several month history of constipation, diarrhea, occasional nausea/vomiting, and a weight loss of approx 25lbs over the past 6 months. She first sought medical attention 3 weeks before admission, when her workup, including colonoscopy and CT scan, showed a mass in the transverse colon. Biopsy showed moderately differentiated adenocarcinoma. She denies black or bloody stools, or dysuria. Past Medical History: CAD with CABG in [**9-/2172**] Hypothyroidism Recent onset of heartburn symptoms, no formal dx of GERD Social History: 30-40py smoking history Widowed for 6 years 3 Children Family History: Mother died of pancreatic cancer, father of prostate cancer Physical Exam: Physical exam on discharge: VS: RRR CTAB Abd soft, non-tender with jejunostomy tube in place. J-tube site free of erythema or induration. Brief Hospital Course: Ms [**Known lastname 1391**] was admitted on [**2176-5-31**] to begin nutritional optimization in preparation for surgery. A pre-operative cardiology clearance was obtained with no cardiac intervention required. A central line was placed on [**6-1**] and total parenteral nutrition was initiated, although the pt continued to attempt self-support through oral intake. A CT scan on [**6-5**] for pre-operative planning was not encouraging, as it showed a metastatic lesion invading the mesentery with likely involvement of the celiac and mesenteric vessels. She underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] prep and Fleets #1 prep on [**6-5**], and was taken to the operating room on [**6-6**]. Please refer to the operative report of Dr [**Last Name (STitle) 957**] for further details on that procedure. Post-operatively she was noted to be markedly bradycardic, with heart rates as low as 29 and blood pressures that proved very difficult to measure by either machine or direct auscultation. She was thus placed in the MICU overnight at the advice of the cardiology service, who felt that in the unlikely event her HR dropped so low she was unable to support her blood pressure, it would be essential to have close monitoring. Fluid resuscitation continued, and the patient's HR gradually normalized. Electrophysiology was consulted, who recommended no pacemaker at this time, as the rhythm was Wenckebach and did not constitute an indication for a pacemaker. Although she was continued on TPN post-operatively, as her functional level improved she was returned to oral intake, with tubefeeds to supplement. On [**6-11**] she began to complain of a suprapubic burning pain, but a urinalysis was negative for UTI, and her pain was deemed post-surgical. As she improved, her TPN was stopped, her tubefeeds and oral intake were increased, and her central line was removed. She was discharged to home with services on [**6-14**]. Follow up with Heme/Onc was arranged, and pt expressed a wish to follow up with Dr [**Last Name (STitle) **] of [**Hospital3 **]. It has also been recommended that she seek care with the [**Hospital3 35292**] service at [**Hospital1 18**], as this modality may be well suited to her tumor. Medications on Admission: Atenolol 25 Fosamax 35 q week Levoxyl 88mcg 81mg ASA Ambien prn Vicodin prn, MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 7571**]Nursing Assc. Discharge Diagnosis: Colon cancer Discharge Condition: Good Discharge Instructions: Take all medications as prescribed. Do not drive while taking a narcotic pain medication such as percocet or vicodin. Please follow the VNA's instructions for your tubefeeds. If you develop fevers, chills, nausea/vomiting, cessation of bowel movements or flatus, difficulty flushing the J-tube, severe abdominal pain, or other concerning symptoms, please contact our office or a local emergency room. Please call Dr[**Name (NI) 6275**] office to schedule your follow up appoitnment. They will also be able to put you in contact with the [**Name (NI) 35292**] office, to help arrange for your chemotherapy treatments. Dr[**Name (NI) 35293**] office will be contacting you and Dr [**Last Name (STitle) **] for followup as well, if you don't hear from them within one week please call their office. Followup Instructions: Please call Dr[**Name (NI) 6275**] office to schedule your follow up appoitnment. They will also be able to put you in contact with the [**Name (NI) 35292**] office, to help arrange for your chemotherapy treatments. Dr[**Name (NI) 35293**] office will be contacting you and Dr [**Last Name (STitle) **] for followup as well, if you don't hear from them within one week please call their office.

Admission Date: [**2162-6-3**] Discharge Date: [**2162-6-9**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 1402**] Chief Complaint: lethargy, bradycardia, fever Major Surgical or Invasive Procedure: None History of Present Illness: 89M w/ COPD, Afib on coumadin, moderate dementia and urinary retention with an indwelling foley, admitted with altered mental status, admitted to MICU for fever, new complete heart block and question of sepsis. The morning of admission, patient noted to be fatigued and unable to walk. At baseline, he lives at [**Hospital1 100**] and generally is oriented to self and can answer basic questions, and walk with a walker. On exam at rehab, he had bradycardia to 40s, BP 154/64, O2 sat 94% RA, temp 99.3. EKG showed complete heart block. He was transferred to the ED for further evaluation. In the ED, initial VS were: 101.3 44 155/37 32 87% RA. Hypoxia improved with 2L nasal cannula. UA sig for UTI (>182 WBC, lrg leuks, pos nitrates, many bacteria). CXR concerning for ? infiltrate. Pressures stable with SBPs 120s-130s. Got 2L IVF, ceftriaxone and azithro. Confirmed 3rd degree heartblock on EKG. Labs showed acute renal failure (Cr 1.6, baseline 1.0), lactate 2.7, and there was concern for mild sepsis. An 18G and 20G placed. A&O&1. Patient confirmed DNR, but would consider a PPM. His foley catheter was replaced. On arrival to the MICU, patient resting comfortably. On questioning by his daughter he denies pain. She felt that he appeared better than this morning. On further discussion, they would like temporary pacing if necessary. They would like their father to be DNR/DNI, but would be okay with reversing that status during a pacemaker placement. Past Medical History: - Bacteremia in [**11/2161**] with VRE and [**Female First Name (un) **] - COPD (unclear history, always a nonsmoker) - HTN not on meds - AF on coumadin - colon cancer [**2152**] - dementia (recognizes children and oriented to place but not able to converse normally and not oriented to place or time), has significant behavioral component - History of TB, found to have 10mm PPD in [**2153**], had a negative CXR so treated in [**2153**] for 9 months for latent TB. CXR repeat in [**2156**] looked increased density at the bases - BPH with chronic indwelling foley, h/o [**Year (4 digits) 40097**] E.Coli urine infection - GERD - anemia - intermittent complete heart block. Asymptomatic, discussion with family, no PPM as no clear benefit. Social History: Lives at [**Hospital 100**] Rehab. Never a smoker. Able to walk with a walker with assist. Diet had been pureed/nectar thickened for several months, recently switched back to thin liquids. Family History: Daughter does not know of any significant family history. Physical Exam: Admission Exam: VS: 101.3 44 155/37 32 87% RA General: Alert, oriented to self, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP mildly elevated to 8-10cm, no LAD CV: Distant heart sounds, marked bradycardia, normal S1 + S2, no audible murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, moving all four extremities, unable to cooperate. Discharge Exam: Vitals: afebrile x2.5days, Tc 98.5, 150/85, 51, 18, 99%RA General: resting comfortably in bed, no acute distress, interactive, smiling HEENT: Sclera anicteric, dryMM Neck: supple, JVP not elevated, no LAD CV: bradycardiain the 50s, normal S1 + S2, no audible murmurs, rubs, gallops Lungs: + mild rales bilaterally at bases, no rhonchi/wheezes. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: indwelling foley in place Ext: room temperature, improved cap refill, 2+ pulses, no clubbing, cyanosis or edema Dementia: Not speaking sensical Russian currently, oriented to self. This is baseline. Pertinent Results: Admission Labs: [**2162-6-3**] 02:20PM BLOOD WBC-14.0*# RBC-5.66# Hgb-13.2*# Hct-44.6# MCV-79* MCH-23.3* MCHC-29.6* RDW-15.8* Plt Ct-221 [**2162-6-3**] 02:20PM BLOOD Neuts-89.0* Lymphs-6.7* Monos-3.7 Eos-0.6 Baso-0.2 [**2162-6-3**] 02:20PM BLOOD PT-32.5* PTT-39.6* INR(PT)-3.2* [**2162-6-3**] 02:20PM BLOOD Glucose-145* UreaN-27* Creat-1.6* Na-138 K-7.4* Cl-106 HCO3-21* AnGap-18 [**2162-6-3**] 02:20PM BLOOD ALT-49* AST-76* AlkPhos-81 TotBili-0.5 [**2162-6-3**] 02:20PM BLOOD Lipase-40 [**2162-6-3**] 02:20PM BLOOD cTropnT-0.06* [**2162-6-3**] 02:20PM BLOOD Albumin-3.8 Calcium-8.8 Phos-2.6* Mg-2.4 [**2162-6-3**] 02:28PM BLOOD Lactate-2.7* K-5.7* Admission UA: [**2162-6-3**] 02:30PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.020 [**2162-6-3**] 02:30PM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2162-6-3**] 02:30PM URINE RBC-9* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 Repeat UA: [**2162-6-5**] 09:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019 [**2162-6-5**] 09:00PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2162-6-5**] 09:00PM URINE RBC-7* WBC-5 Bacteri-NONE Yeast-NONE Epi-0 Lactate trend: [**2162-6-3**] 02:28PM BLOOD Lactate-2.7* K-5.7* [**2162-6-4**] 12:33AM BLOOD Lactate-1.4 [**2162-6-5**] 07:51PM BLOOD Lactate-3.4* [**2162-6-5**] 08:14PM BLOOD Lactate-1.4 Troponin Trend: [**2162-6-3**] 02:20PM BLOOD cTropnT-0.06* [**2162-6-3**] 10:10PM BLOOD CK-MB-3 cTropnT-0.06* [**2162-6-5**] 04:06AM BLOOD CK-MB-3 cTropnT-0.05* WBC trend: 14.0->11.7->10.1->9.2->7.9->8.2->7.8->6.9 Discharge Labs: [**2162-6-9**] 06:49AM BLOOD WBC-6.9 RBC-5.05 Hgb-11.9* Hct-39.7* MCV-79* MCH-23.6* MCHC-30.0* RDW-16.1* Plt Ct-257 [**2162-6-9**] 06:49AM BLOOD PT-22.8* PTT-32.0 INR(PT)-2.2* [**2162-6-9**] 06:49AM BLOOD Glucose-77 UreaN-22* Creat-0.9 Na-146* K-4.4 Cl-114* HCO3-24 AnGap-12 [**2162-6-9**] 06:49AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.2 MICRO: [**2162-6-3**] MRSA SCREEN MRSA SCREEN-negative [**2162-6-3**] URINE URINE CULTURE- Mixed Flora [**2162-6-3**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-6-3**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-6-8**] STOOL C. difficile DNA amplification assay-negative [**2162-6-5**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-6-5**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-6-5**] URINE URINE CULTURE-mixed flora IMAGING: [**2162-6-3**] EKG: Sinus rhythm with high grade A-V block. Baseline artifact obscures interpretation but it appears that complete heart block is present with a junctional escape of approximately 40 beats per minute. Compared to the previous tracing of [**2161-5-29**] heart block is now new. High grade A-V block is new. TRACING #1 [**2162-6-4**] EKG: High grade A-V dissociation with junctional escape at approximately 34 beats per minute. What appear to be conducted P waves are likely isorhythmic dissociation. There is variation in P-P interval which may be due to ventriculophasic affect. Compared to the previous tracing of [**2161-5-29**] heart block persists. TRACING #2 [**2162-6-3**] CXR: Low lung volumes. Probable bibasilar atelectasis but aspiration is difficult to exclude. Possible trace bilateral pleural effusions. [**2162-6-4**] Echo: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2161-11-18**], no clear change. [**2162-6-5**] CXR: The heart is moderately enlarged. There is a moderate-sized left effusion that is increased compared to prior. There is pulmonary vascular redistribution and alveolar infiltrate suggesting an element of fluid overload; however, in addition, there is more dense alveolar infiltrate involving the left lower lobe. It is unclear if this is due to an infectious process. Chronic right upper lobe and lower lobe lung changes are again visualized. IMPRESSION: 1. New infiltrate in the left lower lobe. 2. Increased fluid overload. Brief Hospital Course: 89M w/ COPD, Afib on coumadin, moderate dementia and urinary retention with an indwelling foley, admitted with altered mental status, new complete heart block and infection of unclear source. Acute Issues: # Complete heart block: Patient previously had PR interval of 218, suggesting progressive nodal disease. He has a narrow QRS, but slow escape rhythm. Trial atropine suggestive of infranodal disease, but telemetry also shows multiple foci of disease. During course of hospital stay, his heart block resolved intermittently and his heart rate at the time of discharge was persistently in the 50-60s. The result of a family discussion about the risks and benefits of a PPM in this elderly patient with end stage dementia and intermittent asymptomatic complete heart block on coumadin for afib, was that the potential (not guaranteed) benefits of PPM placement would not outweight potential risks. # Fever/UTI/Infection of unclear source: Patient presented with a fever to 101.3F and a grossly positive UA. Most likely source is urinary, given very positive UA. Indwelling foley was replaced in the ED. CXR very similar to prior. He has a history of resistant bacteria (VRE and [**Month/Day/Year 40097**] e.coli), so he was iniatially covered broadly with Meropenem and Linezolid and then [**Last Name (un) **] and Daptomycin. Urine culture finalized as mixed flora with no evidence of VRE or [**Last Name (LF) 40097**], [**First Name3 (LF) **] pt was narrowed to ceftriaxone. 10 hours after his last dose of meropenem, he became febrile to 102.9F, with a venous lactate of 2.4. As UTI does not cause high fevers, ddx included prostatitis, pyelonephritis, PNA. Repeat UA was without bacteria and repeat urine culture again with mixed flora. CXR showed fluid overload with possible infiltrate/PNA, but no sypmtoms. C. diff PCR negative. Blood cultures all NGTD. He was rebroadened to Meropenem (Daptomycin not restarted, as no suspicion for gram positive infection) and WBC continued to trend down without subsequent fevers. Patient lost IV access (pulling at all IVs and EKG leads) and no replacement IVs were successfully placed. Given that the source of his infection was unknown, and he failed a trial of narrowing antibiotics, he was continued on [**First Name3 (LF) **] 1gm IM daily for the remainder of his antibiotic course. He continued on the [**First Name3 (LF) 49799**] for 2 days inhouse afebrile with normal WBC, and will continue his course through [**2162-6-12**]. # Respiratory Alkalosis/Hypoxia/dCHF: On transfer from the MICU, he was noted to be tachypneic with decreased O2 saturation. ABG showed respiratory alkalosis, likely due to hyperventilation 2/2 hypoxia: pH 7.53, pCO2 23, pO2 62. Placed on O2 and repeat ABG showed pH 7.40, pCO2 40, pO2 68. CXR showed acute congestive heart failure with posible infiltrate in the LLL. Echo showed mild pulmonary hypertension (increased TR gradient) with nml EF. CHB has likely decreased CO and caused some mild CHF. Given 10mg IV lasix for gentle diuresis with good urine output and improvement in O2 sats. Patient was without symptoms of cough. WBC continued to trend down on current meropenem/[**Last Name (LF) 49799**], [**First Name3 (LF) **] pneumonia treatment was not initiated. # Hypertension (Occult Hypoperfusion): Patient carries a diagnosis of HTN, though is not noted to be on any antihypertensives as an outpatient. Since being in CHB, patient has been noted to have higher BPs (SBPs in the 150s-180s). With low HRs (30-40s), patient is dry and cool, suggesting he is vascularly constricted, likely in a effort to maintain perfusion to tissues while in CHB. Venous lactate 3.4, arterial lactate 1.4, again supporting likely occult hypoperfusion [**2-4**] CHB. Several days into his admission, his heart rates improved to the 50-60s, and he was rarely in complete heart block. His elevated blood pressure never rose above a SBP of 200, and so were tolerated in an effort to maintain perfusion to his tissues. Chronic Issues: # Dementia: Patient has end stage dementia, only oriented to self and not able to communicate sensically. Initially he was found to be fatigued and not able to walk around. Family was concerned that he was below baseline in terms of mental status at this time, however with treatment of infection he returned to baseline MS. There may be an element of decreased MS with heart rates in the 30s, however as infection improved, heart rate improved, and so this was difficult to assess. Patient was continued on home mirtazipine and zyprexa with rare doses of zydis for agitation (which family reports it his baseline). # [**Last Name (un) **]: Patient presented with [**Last Name (un) **] (Cr 1.6, baseline noted to be 1.0). Likely due to hypoperfusion from infection compounded by complete heart block. Cr trended down since admission, and on discharge was 0.9. # Afib: CHADS score 2, on coumadin with goal [**2-5**]. Presented with INR 3.2. Coumadin was initially held, but restarted and remained therapeutic on home dose of 3mg daily except on Mondays when he takes 3.5mg daily. # COPD: Written for albuterol and ipratropium nebs as needed for wheezing. # BPH: Continued finasteride and the chronic foley, which was exchanged in the ED [**2162-6-3**]. Transitional Issues: DNR/DNI Given that patient is only intermittently in complete heart block, anticoagulated with end stage dementia, and given that he appears to be at baseline mental status currently, it was decided that the risks outweight the benefits of pacemaker placement. As long as blood pressure is <200, elevated blood pressures should be tolerated when patient is bradycardic. These higher blood pressures are a natural compensation to maintain blood perfusion to the body when his cardiac output has decreased from the slower heart rate. Medications on Admission: - mirtazapine 30mg QHS - trazodone 50mg QHS PRN insomnia - Senna 17.2mg QHS - Miralax 17gm daily - Bacitracin 1 application [**Hospital1 **] - finasteride 5mg daily - tylenol 650mg Q6hrs PRN - olanzapine 2.5mg daily - warfarin 3mg daily TuWeThFrSaSu - warfarin 3.5mg daily Mo Discharge Medications: 1. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 5. bacitracin Topical 6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 8. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 3 mg Tablet Sig: One (1) Tablet PO daily except 3.5mg on Mondays. 10. warfarin 1 mg Tablet Sig: 3.5 Tablets PO 1X/WEEK (MO): 3mg daily, except 3.5mg on Mondays. 11. [**Hospital1 49799**] 1 gram Recon Soln Sig: One (1) gram Injection once a day for 4 days: Give at 2pm daily for 4 doses, last dose on [**2162-6-12**] at 2pm. Mix injection with lidocaine to lessen pain of injection. Disp:*4 gram* Refills:*0* 12. miconazole nitrate 2 % Aerosol Powder Sig: One (1) application Topical four times a day: fungal rash on buttocks. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Complete Heart Block, Urinary Tract Infection Secondary Diagnosis: Hypertension Dementia Acute Kidney Injury Atrial Fibrillation COPD BPH Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 55195**], It was a pleasure taking care fo you at [**Hospital1 827**]. You were admitted for extreme fatigue and an irregular heart beat. During this admission you were found to have a urinary tract infection, which you were treated for. Additionally, you were noted to have an irregularly slow heart rhythm called Complete Heart Block, however this improved on its own during the admission. It was decided that the risks outweight any possible benefit of placing a pacemaker for this problem. [**Name (NI) **] improved with the treatment of your infection and are now safe for discharge. Please make the following changes to your outpatient medication regimen: START [**Name (NI) **] 1mg intramuscular injection daily for 4 more days. START miconazole powder to be applied 4 times daily to fungal rash on buttocks. Keep area dry and clean. No other changes have been made to your outpatient medications. Continue all medications as previously prescribed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: You will be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab.

Admission Date: [**2109-6-6**] Discharge Date: [**2109-6-7**] Date of Birth: [**2051-9-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: afib w/ RVR Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 85533**] is a 57 year old woman with hard to control HTN and hypothyroidism, who is transferred from OSH to [**Hospital1 18**] after being found to have atrial fibrillation for TEE/DCCV. . Ms. [**Known lastname 85533**] states that over the past week she has been having mild chest pain, that last several minutes. She also has had shortness of breath in the evenings that has kept her from sleeping. On further questioning she states that her chest pain in addition to palpitations and feeling of skipped beats have been going on for two years. Throughout this time she thought it was her "nerves." She went to her PCP, [**Name10 (NameIs) **] having not been seen by a physician [**Last Name (NamePattern4) **] 2 years, and had an ECG done in office. She was found to have atrial fibrillation and sent to the ED. . At the OSH, she was given metoprolol po and iv without improvement in heart rate. Initially her labetalol was increased and then stopped and switched to toprol XL. Her heart rates ranged from 120s-130s. She was started on coumadin and lovenox. She had an echo that showed mildly decrease in EF. Her labs: d-dimer negative, hct 41.9, cr 0.8, trop <0.01. . Of note, she has poorly controlled hypertension sbp<200s and dbp>100s. She reports being compliant with medications but states that she infrequently goes to her PCP. [**Name10 (NameIs) **] last time she was seen prior to this visit was two years ago. . Currently, she denies shortness of breath or chest pain. 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. S/he 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, syncope or presyncope. . ROS is positive for back/neck pain, chronic headaches, weight gain over three weeks, chronic stable LE edema over the past 10 years. . Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - HTN poorly controlled - Afib which is new, but ? if going on for 2 years given funny feeling chest - Hypothyroidism - S/p ?thyroid or parathyroid surgery Social History: - Cigs: 3 PYs in 50s - etOH: denies - Illicits: denies - Works as a CNA - Kids in [**Country 19639**] Family History: - Father: MI age 63 - Mother: CVA age 64 Physical Exam: Vital Signs: BP 150/90 HR 90 RR 16 98%RA GEN: Sitting up in bed in NAD Cardiac: nl JVP, irregular rhythm, no murmurs Resp: Clear lungs Abd: soft, NT ND Ext: no edema noted Pertinent Results: [**2109-6-6**] 01:42PM %HbA1c-5.5 eAG-111 [**2109-6-6**] 12:20PM GLUCOSE-88 UREA N-16 CREAT-0.9 SODIUM-142 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-29 ANION GAP-13 [**2109-6-6**] 12:20PM estGFR-Using this [**2109-6-6**] 12:20PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-2.3 [**2109-6-6**] 12:20PM TSH-2.5 [**2109-6-6**] 12:20PM TSH-2.5 [**2109-6-6**] 12:20PM NEUTS-78.2* LYMPHS-15.2* MONOS-3.6 EOS-2.4 BASOS-0.6 [**2109-6-6**] 12:20PM PLT COUNT-259 [**2109-6-6**] 12:20PM PT-16.9* PTT-27.5 INR(PT)-1.5* Brief Hospital Course: 57 yo female with atrial fibrillation, severe hypertension and diastolic heart failure. Initial plan was for TEE/cardioversion. A TEE was performed which did not show any clot. She initially had an attempted DC cardioversion X 3 however these attempts did not bring her into sinus. She was initiated on sotalol with good rate control established with HRs < 100 however she remained in sinus rhythm. She was continued on coumadin for anticoagulation. She was hypertensive and hypokalemic and a work-up for hypertension was initiated; renal artery ultrasound pending. Valsartan was increased from 80 to 160 daily for improved BP control; spirinolactone was discontinued. Labetalol was discontinued given initiation of sotalol. Plasma renin/angiotensin were ordered but were pending. Given symptomatic improvement and rate control, she was transferred to the floor for further management. She was evaluated for [**Doctor Last Name **] of hearts monitor on discharge; follow up with Dr [**Last Name (STitle) 171**] is scheduled. She also has an appointment with her PCP scheduled on Wednesday [**6-12**] for follow-up along with lab check [**Month (only) 766**] [**6-10**] at [**Hospital3 **] for INR and for potassium. Medications on Admission: Benecar 40 + HCTZ 12.5 QD Labetolol 100mg PO BID Levothyroxine 100mcg PO daily Tylenol PRN Hx "water pills" Discharge Medications: 1. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM. Disp:*45 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diovan HCT 160-12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Outpatient Lab Work Please get INR, Potassium, Magnesium, calcium, and phosphate checked on [**Last Name (LF) 766**], [**6-10**]. 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: (1) Atrial fibrillation (2) Hypertension (3) Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [**Known lastname 85533**], You were admitted because your heart rate was too fast in the rhythm that we can "atrial fibrillation" and also had high blood pressure. We tried to convert you from this rhythm using electrical shock, however this did not keep you in a normal rhythm for long. For this reason, we started you on a new medication while in the hospital to help control your heart rates. We also made some other medication changes to help control your blood pressure. These changes in medication are scheduled below. You will need to follow up with your cardiologist Dr [**Last Name (STitle) 171**] as an outpatient, who may try additional therapies to try to convert you out of atrial fibrillation. . The medication changes we made during this hospitalization are: (1) Started warfarin, a blood thinning medication, which you should take every day. You need to take 3 mg daily. This is important medicine because it prevents your heart from forming blood clots while you are in atrial fibrillation. You will need to see the [**Hospital3 **] on [**Hospital3 766**] morning to get labs checked for this medicine. Instructions on attending this clinic are listed below. (2) Started Diovan HCT 160 - 12.5 mg which is a medicine to help lower blood pressure. (3) Started sotalol 120 mg twice a day. This medicine helps prevent your heart rate from going too fast. (4) Started amlodipine 10 mg daily - another medicine to help control your blood pressure. (5) Started spirinolactone 25 mg daily for your blood pressure. (6) Stop your benicar-HCTZ combination pill. (7) Stop labetolol. (8) You should go to the [**Hospital3 **] at [**Hospital1 **] [**Location (un) 620**] on [**Location (un) 766**] [**6-10**] to get your INR (coumadin level) checked. The [**Hospital3 271**] will call you on [**Hospital3 766**] morning to confirm this. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] -You need to get your blood checked on [**First Name3 (LF) 766**] at the hospital: you have a prescription to get this labwork done as an outpatient. -You have an appointment with Dr [**Last Name (STitle) 5419**] on: Wed 16th at 430 PM Phone: [**Telephone/Fax (1) 31235**] FAX [**Telephone/Fax (1) 85534**] . [**Hospital3 271**] at [**Hospital1 **] [**Location (un) 620**]: [**Telephone/Fax (1) 41860**]. Please go to the hospital registration and ask for directions on [**Telephone/Fax (1) 766**] am to have INR checked. . You have an appointment with Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2109-6-17**] 12:40

Admission Date: [**2108-9-26**] Discharge Date: [**2108-10-5**] Service: MEDICINE Allergies: Aspirin / Sulfa (Sulfonamides) / Codeine Attending:[**First Name3 (LF) 2297**] Chief Complaint: transfer from MWH for cardiac catheterization for CP with trops elevation to 0.79, likely NSTEMI (non ST elevation myocardial infarction) Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 84yo male with CAD - CABG x5 in [**2094**] (LIM to LAD, SVG to DA, SVG to [**Female First Name (un) **], SVG to PDA, SVG to lt ventr branches), MI in [**2070**], s/p AAA repair, s/p fem-[**Doctor Last Name **] bypass, CRF on HD is transferred from MWH for cath for ?dx of MI. Patient initially presented to MWH ED on [**2108-9-24**] with c/o continuous 7 out 10 shoulder to shoulder chest pain with no radiation. He denied SOB or diaphoresis. Took nitro at home x2 with no relief. In ED, he had +Trop 0.79, EKG 100% paced, received iv nitro and morphine, plavix and heparin. No aspirin given (as per GI) because of the h/o severe GI bleed on aspitrin. Pt had 2 subsequent episodes of CP overnight relieved by Morphine. [**9-26**], pt was transferred to [**Hospital1 18**] for cath. Past Medical History: CAD - MI [**2070**], CABG x5 in [**2094**] at [**Hospital1 336**] s/p AAA repair [**2082**] PPM [**2105**] Bilateral Fem-[**Doctor Last Name **] Bypass CRF-HD on T-Th-Sat (last dialysis [**9-25**], tolerated well) severe duodenal ulcer bleed [**2105**] - received 11 PRBC Chrone's Dx diverticulosis Social History: past tobacco Family History: . Physical Exam: PE: pt in bed, looks comfortable, no acute distress T 98.7 BP 130/72, HR 60, RR 18, 96% R/A HEENT: symm neck, mouth clear, no LN, flat JBP CHest: limited exam, clear, GAEB CVS: rrr, N S1S2, syst gr II-III/VI murm over precordium [**Last Name (un) **]: soft, N BS, NT Extrem: no edema, varicose veins Pulses: normal carotid, radial, doplerable pedal Neuro: alert, oriented x3, grossly N Lt Groin: no hematoma (4pm) Pertinent Results: [**2108-9-26**] 06:55PM CK-MB-30* MB INDX-13.8* cTropnT-0.89* [**2108-9-27**] 03:00AM CK-MB-129* MB Indx-20.4* [**2108-9-27**] 06:40AM CK-MB-155* MB Indx-20.9* cTropnT-2.54* [**2108-9-26**] 06:55PM WBC-7.1 RBC-3.25* HGB-11.4* HCT-33.7* MCV-104* MCH-35.0* MCHC-33.7 RDW-15.8* [**2108-9-26**] 06:55PM PLT SMR-NORMAL PLT COUNT-178 [**2108-9-26**] 06:55PM GLUCOSE-74 UREA N-52* CREAT-6.4* SODIUM-135 POTASSIUM-5.3* CHLORIDE-92* TOTAL CO2-21* ANION GAP-27* Cardiac cath:1. Coronary and grft angiography showed a previous right dominant system. The LMCA was diffusely disesed with no focal or critical lesions. The LAD tapered off in the mid segment until a large S2 where it is totally occluded. The D1 and D2 are small vessels and are diffusely diseased. The D3 which recived a SVG is not seen in the LMCA injection. The Mid and the distal LAD receives the LIMA. The Cx vessel it self has no lesions. It gives a lengthy collateral. The OM1 arises close to the LMCA and is small. The OM2 too arises close to the LMCA and is large. This has a proximal lesion of 80%. The OM3 recives the SVG and is not seen on LMCA injection. The OM4/postero latateral branch arises distally and is a small vessel. The RCA is occluded proximally. The distal RCA including the PDA and the PLV are collateralised by the left system. The PDA is poorly filled and has a mid 60% lesion. The LIMA , the LIMA-LAD anastomosis and the distal LAD are free of disease. The LIMA fills the LAD retrogradely to supply the proximal LAD and the D3. The D3 has an ostial 70% lesion with TIMI III flow. The SV grafts to the RCA and the PLB are occluded completely and are seen as stumps in the aorta. The graft to the Diagonal could not be located, but is likely to be occluded given the other angiogaphic findings. The SVG to the OM3 shows diffuse disease with a mid lengthy lesion of 99 % and the whole vessel showed TIMI II flow. There were no collaterals for this OM. 2. Left ventriculography was not performed. 3. Predilation using 1.5 X 15 Maverick balloon, stenting using 3.0 X 28 and 3.0 X 33 OTW Cypher stents and thrombus extraction using export catheter with gradual deterioration of flow of the SVG to the OM3. The flow deteriorated from TIMI I to TIMI 0. FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease with functioning LIMA to the LAD. 2. Acute occlusion of the SVG to the OM and chronically occluded SV grafts to the PDA, PLB and Diagonal. 3. Unable to restore flow in the SVG to the OM despite stenting, pharmacotherapy and thrombus aspiration. . Echo: . The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed. Basal inferior hypokinesis is present. 3. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis. 4. The mitral valve leaflets are mildly thickened. 5. There is mild pulmonary artery systolic hypertension. . ct scan: 1. No evidence of intrahepatic gas as suggested on prior ultrasound. Repeat ultrasound is suggested given this change in appearance. 2. Bibasilar dependent atelectatic changes/consolidation with associated effusions. 3. Gas distended loops of bowel with air-fluid levels but without transition suggesting ileus. Stool distended rectum. 4. Small infrarenal abdominal aortic aneurysm. Brief Hospital Course: He was admitted with unstable angina, had total occlusion of all svg grafts with a patent LIMA to LAD, and received 2 cypher stents. His catheterization was compicted by failed thrombus extractuib abd a TIMI 0. After catherization he had persistent CP and evidence of a NSTEMI. Initially he was not treated with ASA because of a past GI bleed, but with persistent ischemia, it was added to the plavix. He required a significant of morphine to controll his pain. Through discussions between the MICU team and the family pain control was determined to be the only option for him. His code status was changed to DNR/DNI/. Due to ongoing ischemia, he had persistent hypotension that required multiple pressors. His HD was changed to CVVH because of his low blood presssure. He also had intermittent NSVT. He had been transferred from the [**Hospital Unit Name 196**] team to the MICU team due to hypotension at HD after his cardiac catheterization out of concern for possible sepsis. There was a concern that he had an acute abdomen but he appeared to be impacted with stool. He was disimpacted and received an aggresive bowel regimen. His distension and pain improved. He had low grade temperatures and was initially treated for pneumonia because he was hypoxic. No source of infection was identified. It is more likely that he was in cardiogenic shock with fluid overload. A repeat bedside echo did not reveal worsening ventricular function. He required blood transfusions for persistently dropping HCT in the setting of very frequent blood draws. He also had a coagulopathy which did not appear to be from DIC. He required vitamin K supplementation. He expired at 6:45am on [**2108-10-5**] after an episode of severe chest pain. Medications on Admission: Plavix 300mg x2 [**2078-9-24**] mg [**Hospital1 **] starting [**2108-9-26**] Lopressor 12.5mg [**Hospital1 **] Foslo 667mg x4 TID Quinine 324mg daily Pentasa 250mg x4 QID MVI Mirtazapine 15mg qhs Colace 100mg [**Hospital1 **] Protonix 40mg daily Morphine prn Nitro prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: sinus tachycardia nsvt cardiogenic shock coagulopathy obstipation nstemi esrd Discharge Condition: expired Discharge Instructions: . Followup Instructions: . Completed by:[**2108-12-21**]

Admission Date: [**2156-7-21**] Discharge Date: [**2156-9-3**] Date of Birth: [**2156-7-21**] Sex: F Service: NEONATOLOG HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 1071**]-[**Known lastname 29608**] is a former 961 gram product of a 31-5/7 week gestation pregnancy born to a 28-year-old G1, P0, woman. Prenatal screens: Blood type O positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B surface antigen negative, Group beta Strep status unknown. Estimated date of confinement was [**2156-9-17**], based on last menstrual period and first trimester ultrasound. The pregnancy was uncomplicated until [**2156-7-6**], when there was intrauterine growth restriction noted on fetal ultrasound. There was extensive laboratory evaluation and workup and no etiology for the growth restriction was identified. She was followed closely with fetal biophysical profiles [**9-3**] and normal amniotic fluid volume then. On the day of delivery her amniotic fluid volume dropped and the fetus was noted to have two heart rate decelerations. She underwent elective induction but was taken to cesarean section for concern for fetal distress. The infant emerged with spontaneous cry, required blow-by oxygen, had Apgars of 8 at one minute and 8 at five minutes. She was transferred to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION ON ADMISSION TO NEONATAL INTENSIVE CARE UNIT: Weight 961 grams, less than 10th percentile. Length 38 cm, 58th percentile. Head circumference 25.5 cm, less than 10th percentile. General: Nondysmorphic, well-appearing, pre-term infant. Head, eyes, ears, nose and throat: Anterior fontanelle soft and level. Red reflex present bilaterally. Palate intact. Symmetric facial features. Chest: Breath sounds clear and equal. Minimal retractions. Cardiovascular: Regular rate and rhythm without murmur. Two plus peripheral pulses including femoral. Abdomen benign without hepatosplenomegaly. Small umbilical cord noted. Genitourinary: Normal female external genitalia consistent with gestational age. Spine normal with normal sacrum. Hips stable. Skin pink with brisk capillary refill. Neuro: Normal tone and responsiveness. Alert and in no acute distress. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: The retractions and tachypnea noted upon admission resolved within the first eight hours of life. [**Known lastname **] always remained in room air throughout her Neonatal Intensive Care Unit admission. She had infrequent episodes of apnea and bradycardia, the last occurring on [**2156-8-9**]. 2. Cardiovascular: [**Known lastname **] has maintained normal heart rates and blood pressures during admission. A soft murmur has been noted intermittently and remains audible at the time of discharge. It is felt to be consistent with peripheral pulmonic stenosis and benign in nature. 3. Fluids, Electrolytes and Nutrition: Initial glucose was 45. [**Known lastname **] required several dextrose boluses for hypoglycemia which resolved within 24 hours of birth. She was initially NPO and maintained on intravenous fluids. Parenteral feeds were started on day of life number two and gradually advanced to full volume. Her maximum caloric intake was 30 calories per ounce. She is currently taking 150/cc/kg/day of breast milk or Enfamil fortified to 26 calories per ounce. The formula is four calories by concentration and two calories by corn oil and the breast milk is four calories with Enfamil powder and two calories by corn oil. Serum electrolytes were checked in the first week of life and were within normal limits. Discharge weight is 1.875 kilograms which is 4 pounds, 2.1 ounces, a length of 47 cm and a head circumference of 30.5 cm. 4. Infectious Disease: Due to her prematurity, [**Known lastname **] was evaluated for sepsis. A white blood cell count was 7,900 with 33% polys, 0% bands. A blood culture was obtained and she was not treated with antibiotics. The blood culture was no growth at 48 hours. 5. Hematological: Initial hematocrit at birth was 66.3% and platelets were 43,000. [**Known lastname **] is blood type O positive and is Coombs negative. Platelet count fell to 24,000 on day of life one and [**Known lastname **] was transfused with platelets and also received intravenous gamma globulin. On day of life number four and again on day of life number seven she required transfusion of platelets for counts less than 60,000. On the day after her third platelet transfusion her platelet count was 104,000 and within 72 hours it was 255,000. A repeat count on day of life 17 was 694,000. The etiology of the thrombocytopenia was consistent with the intrauterine growth restriction. The platelet antibody was sent on the mother and was negative. [**Known lastname **] low hematocrit occurred on [**2156-8-25**], at 22.1%. Reticulocyte count at that time was 7.9%. A repeat hematocrit on [**2156-8-1**], was 25.7%. 6. Gastrointestinal: [**Known lastname **] required treatment for unconjugated hyperbilirubinemia with phototherapy. Her peak serum bilirubin occurred on day of life number one with a total of 5.9 mg/dl. She was treated with phototherapy for approximately five days. Her rebound bilirubin on day of life nine was 2.6 total over 0.6 mg/dl direct. 7. Endocrine: A state screen sent on [**2156-8-5**], had a thyroid stimulating hormone level of 45.7 with the reference range being less than 15 microunits per mL. An Endocrine consult from [**Hospital3 1810**] was obtained. Repeat thyroid function tests showed a definite clinical hypothyroidism and treatment with Synthroid was started on [**2156-8-13**]. A significant part of the history was that the mother was treating a wound dehiscence with Betadine packing and it was theorized that the hypothyroidism may have been induced by the infant's exposure to iodine through the mother's milk. The breast milk was held for one week and then breast feeding re-initiated. Thyroid function tests have been followed weekly and have been slowly normalizing. The most recent thyroid stimulating hormone was 9.1 down from 12 with a normal range of 0.27 to 4.2. T3 was 167 up from 140 and the free T4 was 1.8 up from 1.4 with a normal range of 0.93 to 1.7. [**Known lastname **] is being discharged home on Synthroid with Endocrine follow up in four weeks with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 51137**] at [**Hospital3 1810**], phone number [**Telephone/Fax (1) 37116**]. Thyroid function tests will be checked again at that time. 8. Neurology: Head ultrasounds were obtained on [**7-23**] and [**2156-8-18**], and both studies were within normal limits. There were no neurological concerns at the time of discharge. 9. Sensory: Audiology: Hearing screening was performed with automated auditory brainstem responses. [**Known lastname **] passed in both ears. Ophthalmology: The retinal examination was performed on [**2156-8-12**], showing mature retinas bilaterally. Recommended follow up at eight months of age. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 51138**] [**Name (STitle) 19419**], [**Location (un) 246**] Pediatric Associates, [**Location (un) 51139**], [**Last Name (NamePattern1) 51140**], [**Location (un) 246**], [**Numeric Identifier 51141**], Phone number [**Telephone/Fax (1) 37501**], fax number [**Telephone/Fax (1) 51142**]. There is an appointment scheduled for [**Last Name (LF) 766**], [**9-6**] at 1:30 p.m. RECOMMENDATIONS AT DISCHARGE: 1. Feeding: Enfamil 26 calorie per ounce at concentration two by corn oil or expressed mother's milk fortified to 26 calories with four of Enfamil powder plus two of corn oil. 2. Medications: Ferrous sulfate 25 mg per mL dilution 0.3 cc p.o. q. day; levothyroxine 12.5 mcg p.o. q. day. 3. Car seat position screening was performed. The infant was observed for 90 minutes without episodes of oxygen desaturation or bradycardia. 4. State newborn screens were sent on [**7-25**], [**8-4**] and [**2156-8-21**]. Except for the hypothyroidism as previously mentioned, the results were within normal limits. The state screen sent on [**2156-8-21**], showed a normal TSH and T4 level. 5. No immunizations have been administered to date. She did not receive hepatitis B as she does not meet weight criteria as yet. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks; (2) Born at 32 to 35 weeks and plan for day care during RSV season, with smoker in the household or with preschool sibs or (3) With chronic lung disease. 2. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age the family and other care givers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENTS: 1. Primary pediatrician, Dr. [**Last Name (STitle) 19419**], on [**2156-9-6**]. 2. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 51137**] in four weeks after discharge with thyroid function tests to be drawn at that time including T4 and thyroid binding globulin. 3. Pediatric ophthalmology at eight months of age. DISCHARGE DIAGNOSES: 1. Prematurity at 31-5/7 weeks gestation. 2. Symmetric small for gestational age. 3. Transitional respiratory distress. 4. Thrombocytopenia. 5. Anemia. 6. Suspicion for sepsis, ruled out. 7. Polycythemia. 8. Unconjugated hyperbilirubinemia. 9. Hypothyroidism. Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2156-9-2**] 23:23 T: [**2156-9-3**] 03:10 JOB#: [**Job Number 51143**]

Admission Date: [**2108-4-4**] Discharge Date: [**2108-5-8**] Date of Birth: [**2036-9-21**] Sex: F Service: SURGERY Allergies: Sulfa(Sulfonamide Antibiotics) / Heparin Agents Attending:[**First Name3 (LF) 32612**] Chief Complaint: Painless jaundice. Major Surgical or Invasive Procedure: [**2108-4-4**]: -Diagnostic laparoscopy. -Peritoneal washings and cytology -Exploratory laparotomy. -Cholecystectomy. -Harvest of pedicled omental flap for protection of anastomoses. -Pancreaticoduodenectomy with standard gastrojejunostomy, antecolic. - Right hepatic artery reconstruction using right gonadal vein interposition graft (performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]). History of Present Illness: 71F presented with painless jaundice, dark urine, bloating, and anorexia. She first noticed the onset of symptoms in [**Month (only) **] or [**Month (only) 1096**] and then was alerted by a friend to her increasing jaundice, which prompted medical evaluation. At [**Hospital3 3583**], her labs were as follows: total bilirubin 28, Alk phos 338, ALT 128 prior to arrival. She underwent an ultrasound and a CT with contrast and was found to have a 2.4 x 1.8 cm mass with a cystic structre in the head of the pancreas, distended and thickened gallbladder, intrahepatic (1.9 cm)and pancreatic duct (1.2 cm). At the time of consultation she was clinically well and denies nausea, vomiting, or changes in bowel habits. She underwent ERCP which revealed a single irregular stricture of malignant appearance that was 2 cm long at the lower third of the common bile duct. There was severe post-obstructive dilation. A limited pancreatogram revealed a stricture of the main duct at the head. Cannulation of the biliary duct was successful. Contrast medium was injected resulting in complete opacification. A sphincterotomy was performed. A 7cm by 10FR biliary stent was placed. Cytology samples were obtained for histology which returned positive for adenocarcinoma. The patient was offered a Whipple operation, with the following explained: a 1-2% risk of death, a 30-40% risk of complication. From her OSH scan report, she had no involvement of the mesenteric vessels and no evidence of metastatic disease, although there is periportal lymphadenopathy. She understood the risks/benefits of the surgery, and decided to proceed with the operation. Past Medical History: PMH: None PSH: Tonsillectomy/adenoidectomy, all teeth extracted Social History: Retired high school teacher, no children, lives with her female HCP. [**Name (NI) 4084**] [**Name2 (NI) 1818**], drank [**2-17**] glasses of wine per night until symptoms started in [**Month (only) **]/[**Month (only) **], no drug use. Family History: Sister died from leukemia at age 65, mother died of cervical cancer. No history of benign or malignant pancreatic disease. Physical Exam: Physical Exam on Admission: 97.3 91 173/94 20 100%RA Gen: Alert and oriented, pleasant Skin: Pronounced scleral and dermal jaundice CV: RRR Resp: Clear to auscultation Abd: Soft, non-tender, non-distended. Negative [**Doctor Last Name 515**] sign, no palpable masses Ext: 1+ edema, palp DP/PT pulses. Pertinent Results: [**2108-4-12**] 07:24AM BLOOD Vanco-31.4* [**2108-5-8**] 06:05AM BLOOD Vanco-12.4 [**2108-4-4**] 07:54PM BLOOD Albumin-2.1* Calcium-8.9 Phos-5.7*# Mg-1.9 [**2108-5-8**] 01:56AM BLOOD Calcium-10.9* Phos-2.1* Mg-2.7* [**2108-4-4**] 07:54PM BLOOD CK-MB-2 cTropnT-<0.01 [**2108-4-15**] 12:58PM BLOOD CK-MB-2 cTropnT-0.03* [**2108-4-5**] 03:30AM BLOOD Lipase-13 [**2108-5-7**] 01:23AM BLOOD Lipase-7 [**2108-4-4**] 07:54PM BLOOD ALT-303* AST-827* CK(CPK)-57 AlkPhos-56 TotBili-5.7* [**2108-4-18**] 01:45AM BLOOD ALT-38 AST-80* AlkPhos-59 TotBili-32.4* DirBili-23.7* IndBili-8.7 [**2108-5-2**] 01:18AM BLOOD ALT-49* AST-82* AlkPhos-65 TotBili-36.9* [**2108-5-8**] 01:56AM BLOOD ALT-59* AST-94* LD(LDH)-202 AlkPhos-77 TotBili-33.6* [**2108-4-4**] 07:54PM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-134 K-4.8 Cl-100 HCO3-15* AnGap-24* [**2108-5-8**] 01:56AM BLOOD Glucose-143* UreaN-4* Creat-0.5 Na-142 K-4.7 Cl-101 HCO3-9* AnGap-37* [**2108-4-4**] 08:12AM BLOOD Fibrino-515* [**2108-4-5**] 07:50PM BLOOD Fibrino-156*# [**2108-4-4**] 08:12AM BLOOD PT-12.3 PTT-27.8 INR(PT)-1.1 [**2108-4-6**] 03:48AM BLOOD Plt Ct-139* [**2108-4-7**] 11:55PM BLOOD Plt Smr-VERY LOW Plt Ct-62* [**2108-4-12**] 02:57AM BLOOD Plt Ct-56*# [**2108-5-7**] 08:15PM BLOOD Plt Ct-<5 [**2108-5-8**] 01:56AM BLOOD PT-49.9* PTT-122.1* INR(PT)-4.9* [**2108-4-7**] 11:55PM BLOOD Neuts-86* Bands-3 Lymphs-4* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-1* [**2108-5-6**] 02:16AM BLOOD Neuts-90* Bands-1 Lymphs-2* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 Promyel-1* [**2108-4-4**] 07:54PM BLOOD WBC-14.6*# RBC-2.58* Hgb-8.2* Hct-24.1* MCV-93# MCH-31.7# MCHC-34.0 RDW-16.5* Plt Ct-88* [**2108-4-5**] 07:50PM BLOOD WBC-26.4*# RBC-3.07* Hgb-9.7* Hct-28.4* MCV-93 MCH-31.7 MCHC-34.2 RDW-16.3* Plt Ct-102* [**2108-4-7**] 05:41AM BLOOD WBC-28.5* RBC-3.23* Hgb-9.7* Hct-29.7* MCV-92 MCH-30.0 MCHC-32.6 RDW-16.0* Plt Ct-93* [**2108-4-9**] 12:49PM BLOOD WBC-16.4* RBC-3.05* Hgb-9.5* Hct-28.8* MCV-95 MCH-31.3 MCHC-33.0 RDW-18.0* Plt Ct-43* [**2108-5-7**] 08:15PM BLOOD WBC-41.4* RBC-2.19* Hgb-7.5* Hct-23.7* MCV-108* MCH-34.3* MCHC-31.7 RDW-22.5* Plt Ct-<5 [**2108-5-7**] 10:15PM BLOOD WBC-48.1* RBC-2.26* Hgb-7.7* Hct-24.9* MCV-110* MCH-34.1* MCHC-31.0 RDW-22.8* Plt Ct-88* [**2108-5-8**] 01:56AM BLOOD WBC-47.3* RBC-2.21* Hgb-7.7* Hct-24.5* MCV-115* MCH-34.7* MCHC-30.2* RDW-23.0* Plt Ct-72* . [**2108-4-9**] 11:46 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2108-4-9**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2108-4-12**]): Commensal Respiratory Flora Absent. HAFNIA ALVEI. SPARSE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ HAFNIA ALVEI | AMPICILLIN------------ 16 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [**2108-5-1**] 5:55 am PERITONEAL FLUID DAS ACU VERIFIED BY [**First Name9 (NamePattern2) 92514**] [**Location (un) **] [**5-1**] @0950. GRAM STAIN (Final [**2108-5-1**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2108-5-5**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2108-5-2**] 2:45PM 4-3130. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. Work-up of organism(s) listed below discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. ENTEROCOCCUS SP.. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R PENICILLIN G---------- =>64 R VANCOMYCIN------------ <=0.5 S ANAEROBIC CULTURE (Final [**2108-5-5**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2108-5-2**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. . [**2108-5-6**]: [**2108-5-6**] 10:54 am URINE Source: Catheter. **FINAL REPORT [**2108-5-7**]** URINE CULTURE (Final [**2108-5-7**]): YEAST. >100,000 ORGANISMS/ML.. . [**2108-4-12**]: IMPRESSION: Non-occlusive deep vein thrombosis seen within one of the two left brachial veins . [**2108-4-16**]: IMPRESSION: 1. Status post Whipple with serpiginous hypodensity seen in the left lobe most consistent with retraction injury. No drainable collection. 2. No radiologically evident cause of leukocytosis is observed. 3. Extensive anasarca, likely secondary to volume overload. . Final Pathology Report: MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy. Tumor Site: Pancreatic head, uncinate process. Tumor Size: Greatest dimension: 2.9 cm. Additional dimensions: 2.5 cm x 2.5 cm. Other organs/Tissues Received: Gallbladder, Stomach. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G2: Moderately differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. Regional Lymph Nodes: pN1: Regional lymph node metastasis. Lymph Nodes Number examined: 11. Number involved: 1. Distant metastasis: pMX: Cannot be assessed. Margins: Margins uninvolved by invasive carcinoma: Distance from closest margin: 1 mm from peri-uncinate-process adipose tissue margin. Venous/Lymphatic vessel invasion: Absent. Perineural invasion: Present. Additional Pathologic Findings: Pancreatic intraepithelial neoplasia -- highest grade: PanIN: III; chronic pancreatitis. . Brief Hospital Course: The patient was brought to the operating room on [**2108-4-4**] for Whipple procedure, necessitating right hepatic artery reconstruction with gonadal vein for which the vascular surgery service was consulted intraoperatively. Reader referred to both operative notes for full details. She received 6 u pRBC, 2 FFP, and 500 of albumin in the OR, and was left intubated on pressors, and taken to the surgical ICU post operatively. Her course thereafter in the ICU was complicated. In brief: she required frequent blood transfusions of pRBCs, FFP, and albumin, with a persistent pressor requirement; she developed acute renal failure requiring CVVH, had persistent elevations of LFTs, had a persistent leukocytosis and in total the cardiology, infectious disease, renal, and hepatology services were consulted. Significant events by post-operative day included: On POD2 the renal service was consulted given persistent renal failure postoperatively, and she was begun on CVVH. Given down-trending platelets, HIT panel was sent and returned positive on POD5, and the patient was begun on a bivalirudin drip per hematology recommendations. On POD6 TF were initiated via NGT, her foley was removed, and sputum cultures revealed GNR for which she was begun on vancomycin/ciprofloxacin/flagyl. Antibiotics were thereafter tailored appropriately in consultation with the infectious disease service. On POD8 a left brachial vein clot was found on non-invasives and she was initiated on fondaparinux, subsequently discontinued. On POD11 the patient was noted to have QTC prolongation, for which the cardiology service was consulted, and recommendations were followed regarding medication adjustments. On [**2108-4-17**] the patient was extubated, and briefly off pressors. She was found to have SBP, and begun on meropenem in consultation with the hepatology and ID services. Lactulose was initiated given poor mental status (AOx1 initially), on which she seemed to initially improve. On POD20 the patient failed a speech and swallow evaluation, and continued on tube feedings. Her pressor requirement remained persistent, and her WBC continued to trend upwards. On [**2108-5-4**], in discussion with the patient's HCP, she was made DNR/DNI. On the evening of [**2108-5-7**] she was noted to be hypothermic to 89, was in DIC per labarotory values and she passed away on [**2108-5-8**], post-operative day 34. Discharge Disposition: Expired Discharge Diagnosis: -Pancreatic cancer -Spontaneous bacterial peritonitis -Heparin Induced Thrombocytopenia -Renal failure Discharge Condition: Expired. Discharge Instructions: N/A. Followup Instructions: N/A. Completed by:[**2108-5-9**]

Admission Date: [**2118-5-7**] Discharge Date: [**2118-5-19**] Date of Birth: [**2047-9-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2698**] Chief Complaint: Chest pain and anemia Major Surgical or Invasive Procedure: Colonoscopy and Upper Endoscopy History of Present Illness: 70 year old man with afib on coumadin, insulin dependent DM, obseity, systolic and diastolic heart failure LVEF 40-45%, CAD s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft [**2118-4-8**], presents with fatigue and dyspnea on exertion over past week. He was initially feeling well after discharge [**3-/2117**] and began exercising and losing weight. However, this past week dyspnea increased and exertional capacity decreased. He called his cardiologist who thought he might be overdiuresed, therefore his lasix and spironolactone were reduced to half prior doses. Dyspnea worsened despite this change. Then on the day of admission he had 2 bowel movements, the second of which was dark black. The bowel movement was preceeded by crampy abdominal pain. He attempted to walk from the bathroom to the kitchen but because acutely dyspneic. He sat down and then developed chest pain, took a nitro with relief. Tried to walk again but the chest pain returned, thus called EMS and was brought to an OSH. There his chest pain was relieved by repeated nitroglycerin and he was eventually started on a nitroglycerin drip. Labs at OSH were notable for HCT 25, INR 3.7, K 7. Enroute to [**Hospital1 18**], his SBP dropped with increasing nitro drip doses. Upon arrival to [**Hospital1 18**], he was chest pain free with VS 97.6 99/56, 74 16 97% 2L. ECG showed a new LBBB, trop negative. Labs notable for K 7.2 (not hemolyzed) and thus he received calcium, D50/insulin, and kayexalate. INR was 4.9. GI was called given HCT drop from 31 to 25 and made plans to scope in the morning. Rectal exam notable for brown stool guaiac positive with specks of black stool. Nitroglycerin drip was stopped and his pain was controlled with morphine PRN. He received 1L NS. Vitals prior to transfer 98.1 69 109/41 16 99% RA pain 0. On arrival to the MICU, he was initially comfortable, but then developed chest pain prompting morphine 2mg x3 without relief. SL nitro was given with improvement in pain. ECG showed narrow complex sinus rhythm with ST depressions in I, V4-V6. He later had another episode of pain relieved by SL nitroglycerin. Past Medical History: CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**] revealing a severe stenosis in the SVG to the OM s/p BMS x 3, [**2115**] at [**Hospital1 112**] (patient says stent but unknown location) IDDM morbid obesity COPD sleep apnea on BiPAP CHF, diastolic, with EF 71% per OSH reports afib HTN CVA with right sided numbness history of rheumatic fever Social History: Lives with wife and four children. Worked as a carpenter. No tob/ETOH/IVDA. Family History: Adopted, unknown Physical Exam: Admission exam: Vitals: 98F 108/44 71 9 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Discharge exam: VS - 98.0, 98.6, 96/49 (94-145/48-71), 71 (52-81), 20, 100RA GENERAL - Obese late-middle aged man in NAD. Oriented x3. HEENT - NCAT. Oropharynx clear NECK - Supple, unable to assess JVD due to habitus CARDIAC - RRR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS - CTAB, no crackles, wheezes or rhonchi. ABDOMEN - Soft, obese NTND. No HSM or tenderness. EXTREMITIES - WWP, no LE edema, no clubbing SKIN - Multiple scars across lower extremities from vein harvesting, some chronic stasis changes Pertinent Results: Admission Labs: =============== [**2118-5-6**] 11:55PM BLOOD WBC-11.2* RBC-2.82* Hgb-8.0* Hct-24.7* MCV-87 MCH-28.3 MCHC-32.3 RDW-19.2* Plt Ct-178 [**2118-5-6**] 11:55PM BLOOD Neuts-85.1* Lymphs-10.4* Monos-3.0 Eos-1.3 Baso-0.2 [**2118-5-6**] 11:55PM BLOOD PT-49.3* PTT-56.2* INR(PT)-4.9* [**2118-5-6**] 11:55PM BLOOD Glucose-187* UreaN-78* Creat-1.9* Na-131* K-7.2* Cl-99 HCO3-22 AnGap-17 [**2118-5-7**] 03:20AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.6 Pertinent Labs: =============== [**2118-5-6**] 11:55PM BLOOD cTropnT-<0.01 [**2118-5-7**] 03:20AM BLOOD CK-MB-4 cTropnT-0.02* [**2118-5-7**] 08:55AM BLOOD CK-MB-5 cTropnT-0.04* [**2118-5-7**] 10:58PM BLOOD CK-MB-4 cTropnT-0.05* [**2118-5-12**] 10:50AM BLOOD Hapto-164 [**2118-5-12**] 10:50AM BLOOD LD(LDH)-195 TotBili-2.0* DirBili-0.5* IndBili-1.5 HELICOBACTER PYLORI ANTIBODY TEST: POSITIVE BY EIA. Urine culture [**5-9**]- no growth Discharge Labs: =============== [**2118-5-19**] 06:35AM BLOOD Hct-29.5* [**2118-5-17**] 11:00AM BLOOD PT-11.9 PTT-33.3 INR(PT)-1.1 [**2118-5-18**] 11:10AM BLOOD Glucose-108* UreaN-21* Creat-1.1 Na-136 K-4.6 Cl-100 HCO3-28 AnGap-13 [**2118-5-18**] 11:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-3.2* Micro/Path: =========== URINE CULTURE (Final [**2118-5-10**]): NO GROWTH. HELICOBACTER PYLORI ANTIBODY TEST (Final [**2118-5-9**]): POSITIVE BY EIA. MRSA SCREEN (Final [**2118-5-9**]): No MRSA isolated. Imaging/Studies: ================ CXR [**5-9**]- Status post sternotomy, with mild prominence of the cardiomediastinal silhouette. There is upper zone re-distribution without overt CHF. There is minimal atelectasis at both bases. No frank consolidation or effusion. EKG [**5-9**]- LBBB -> sinus rhythm narrow complex, ST depressions V4-V6 and I, avL EGD [**5-9**]- Nodularity in the whole stomach compatible with nodular gastritis. Normal EGD to third part of the duodenum. CT abd/pelvis [**5-12**]- 1. No evidence of retroperitoneal bleed or acute intra-abdominal process. 2. Fatty infiltration of the liver. 3. Cholelithiasis. 4. Right renal cyst. Colonoscopy [**2118-5-18**]: Impression: Grade 1 internal hemorrhoids Diverticulosis of the sigmoid colon Otherwise normal colonoscopy to cecum Brief Hospital Course: 70 year old man with afib on coumadin, insulin dependent DM, obseity, systolic and diastolic heart failure LVEF 40-45%, CAD s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft [**2118-4-8**], presents with fatigue and dyspnea on exertion, found to have hematocrit drop secondary to GI bleed. ACTIVE DIAGNOSES: ================= # Chest Pain: Demand ischemia in setting of GI bleed. He has known coronary vascular disease with refractory angina that is not amenable to intervention per cardiology team. No evidence of consolidation or PTX on CXR to suggest pulmonary cause. Patient was transfused a total of 8 units pRBCs; hematocrit initially stabilized and when heparin gtt and coumadin were re-started, hematocrit dropped again and chest pain returned without EKG changes. He was continued on aspirin, plavix, and ranolazine. Imdur was started at a lower dose than home dose given concern for hypotension in setting of bleeding, but BP remained stable so imdur was titrated up to his home dose. He then had return of chest pain, with dynamic ST changes in V3-V5 and I/avL, consistent with known non-intervenable areas of disease. His imdur was increased to 240mg and metoprolol was increased to tartrate 150mg PO BID without further episodes of chest pain. # UGIB/H.Pylori + Nodular Gastritis: On EGD, patient had evidence of nodular gastritis with superficial erosions. H.pylori returned positive and patient began triple therapy with amoxicillin (not candidate for clarithromycin given interaction with ranolazine), metronidazole and pantoprazole. Coumadin was held and INR was reversed with vitamin K. Patient had ongoing hematocrit drop without obvious bleeding once heparin drip was restarted, so both coumadin and heparin were stopped. Patient will complete 2 weeks of triple therapy, then continue [**Hospital1 **] pantoprazole. He does not require GI follow-up or test of cure. He also underwent colonoscopy which did not reveal an additional or alternative source of his bleeding. If he continues to bleed, the next step would be a capsule endoscopy. He will have a [**Hospital1 **] check prior to his PCP appointment to assess his hematocrit. # Acute blood loss anemia: Source suspected to be gastritis as above. Coumadin was held on admission to the ICU and reversed with vitamin K and FFP. He was transfused a total of 8 units during admission; initially 4 units in the ICU as he had an inappropriate response to blood, then again on the floor as with initiation of coumadin and bridge with heparin drip, patient's hematocrit drifted down. Haptoglobin and LDH were normal, and indirect bilirubin was only slightly elevated (and was post transfusion) so low suspicion for hemolysis. With discontinuation of heparin drip and coumadin, hematocrit stabilized and patient did not require transfusion for >72 hours prior to discharge. # Constipation: Significantly constipated during admission. Required 2 days of prep prior to his colonoscopy. Patient discharged on senna/colace/miralax to prevent further constipation. # Acute on chronic systolic heart failure: On admission, patient had mild pulmonary edema secondary to decreased lasix and spironolactone dose over past week prior to admission. Patient was diuresed in the ICU, and was euvolemic on transfer to the floor. He was continued on home lasix 40mg daily, with extra doses with transfusions. He had a few episodes of orthostatic hypotension prompting decrease of his lasix dose to 20mg PO daily. Patient was euvolemic at the time of discharge, and weight was stable at 120 kg. # Hyperkalemia: 7.2 on admission likely secondary to ARF, spironolactone, and lisinopril. ECG improved to narrow complex once potassium normalized. Potassium remained stable for remainder of admission. Spironolactone was not restarted, and lisinopril was restarted at lower dose of 5mg PO daily. # LBBB: Suspect metabolic etiology given improved with K correction. Trop negative suggesting against acute coronary syndrome. LBBB resolved after correction of K. # Acute renal failure: Likely secondary to systolic CHF with poor forward flow with second hit of poor perfusion due to acute GIB. Patient's creatinine trended down and was 1.1 on day of discharge. # Leukocytosis: Unclear etiology, but may be due to stress of GIB. No evidence of infectious colitis, UA without evidence of infection and no consolidation seen on CXR. White count resolved and remained normal for remainder of admission. CHRONIC DIAGNOSES: ================== # HLD: continued atorvastatin # Depression: continued venlafaxine # DMII: Blood sugar well controlled during admission. Transitional issues: # Spironolactone held on discharge given hyperkalemia to 7.2 on admission. # Coumadin held on discharge -> we anticipate holding this medication for about a month while his gastritis heals with protection against stroke with aspirin 325mg and plavix 75mg in the interim. # Lisinopril decreased to 5mg daily to prevent hyperkalemia and increase pressure room to uptitrate Imdur to 240mg PO daily and metoprolol to 150mg tartrate [**Hospital1 **] # H.pylori triple therapy treatment to continue through [**2118-5-23**] # Hematocrit and electrolytes should be rechecked by PCP at [**Name9 (PRE) 702**] appointment, he has a script for this. # Insulin decreased to 70/30 mix 80 units daily given in-house hypoglycemia. We suggest setting him up with [**Last Name (un) **] for further diabetes management but wanted him to discuss this with his PCP [**Name Initial (PRE) **]. # Weight on discharge 120kg, discharged on furosemide 20mg daily. Medications on Admission: 1. aspirin 325 mg DAILY 2. nitroglycerin 0.4 mg q5min PRN 3. furosemide 40 mg PO daily 4. lisinopril 10 mg PO DAILY 5. atorvastatin 80 mg PO DAILY 6. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: One Hundred (100) units Subcutaneous twice a day. 7. metformin 500 mg PO daily 8. venlafaxine 75 mg PO DAILY 9. warfarin 5 mg PO once a day. 10. pantoprazole 40 mg PO once a day. 12. ranolazine 1,000 mg PO twice a day. 13. clopidogrel 75 mg PO daily 14. isosorbide mononitrate 60 mg PO once a day. 15. metoprolol succinate 200 mg PO once a day. 16. spironolactone 25 mg PO once a day. Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ranolazine 500 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO BID (2 times a day). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Name Initial (PRE) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 days. [**Name Initial (PRE) **]:*12 Tablet(s)* Refills:*0* 9. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 4 days. [**Name Initial (PRE) **]:*16 Tablet(s)* Refills:*0* 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0* 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Name Initial (PRE) **]:*30 Capsule(s)* Refills:*2* 12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO twice a day. [**Name Initial (PRE) **]:*180 Tablet(s)* Refills:*2* 14. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Eighty (80) units Subcutaneous twice a day. 15. Imdur 60 mg Tablet Extended Release 24 hr Sig: Four (4) Tablet Extended Release 24 hr PO once a day. 16. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day. [**Name Initial (PRE) **]:*30 packets* Refills:*2* 17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0* 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0* 19. Outpatient [**Name Initial (PRE) **] Work Please obtain CBC, Chem 7 prior to your appointment. Have the results communicated to your PCP: [**Name Initial (NameIs) 7274**]: [**Name Initial (NameIs) **],[**Name Initial (NameIs) **] Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**] Phone: [**Telephone/Fax (1) 29149**] Fax: [**Telephone/Fax (1) 29155**] Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: # Unstable Angina # H. pylori + nodular gastritis with erosions # Blood loss anemia Secondary diagnosis: # Coronary artery disease # Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (rolling walker) Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you! You were admitted to [**Hospital1 18**] for evaluation and treatment of chest pain, shortness of breath, and GI bleeding. You were found to have a low blood count likely due to a slow bleed in your GI tract related to all of your blood thinners and gastritis with erosions from H. pylori (a bacteria that pre-disposes to gastritis and ulcers). You were started on a medication to protect your GI tract, treatment for your infection, and you were given blood transfusions to improve your blood counts. You underwent an upper endoscopy which showed the inflammation of the stomach and erosions and a colonoscopy which was without source of bleeding. You also had an elevation in your potassium level, so your spironolactone was discontinued. We attempted re-starting anticoagulation but you began to bleed again. As a result, your coumadin is being held until resolution of your gastritis. We suggesting waiting a month or so until resuming coumadin and would like to re-assure you that you are recieving protection against stroke from your afib from your aspirin and plavix. The following changes were made to your medication regimen: - START Metronidazole three times day through Monday [**2118-5-23**] to treat the infection in your stomach - START Amoxicillin twice a day through Monday [**2118-5-23**] to treat the infection in your stomach - INCREASE pantoprazole to twice a day to protect your stomach lining - INCREASE Imdur to 240mg by mouth daily - CHANGE to Metoprolol Tartrate 150mg by mouth twice daily - DECREASE Lisinopril to 5mg daily - DECREASE Lasix to 20mg daily - DECREASE Insulin 70/30 to 80 units twice daily - STOP Spironolactone - STOP Coumadin -> you will have to discuss with your primary care doctor restarting this medication about a month from now once your gastritis has healed - START Senna and Colace twice a day as needed for constipation - START Miralax once daily as needed for constipation Please follow up as suggested below. Followup Instructions: Name:[**Name6 (MD) **] [**Name8 (MD) **],MD Specialty: Primary Care Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**] Phone: [**Telephone/Fax (1) 29149**] When: Tuesday, [**5-24**] at 3:15pm -Please have your labs checked prior to this appointment, on discharge your hematocrit was 29.5 Department: CARDIAC SERVICES When: THURSDAY [**2118-5-26**] at 9:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2118-5-20**]

Admission Date: [**2146-5-11**] Discharge Date: [**2146-5-14**] Date of Birth: [**2068-2-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization with Drug eluting stent to Right coronary Artery History of Present Illness: 78 year-old male patient of Dr. [**First Name (STitle) 28622**] Attar and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] who has a history that includes CAD, s/p MI X 2, s/p CABG in [**2139**], s/p prior stent to LAD and s/p prior PTCA of the diagonal who was admitted to [**Hospital6 17032**] on [**2146-5-7**] with shortness of breath. He was diagnosed with acute on chronic CHF with initial BNP 482. He was diuresed with IV Lasix and ruled out for an MI with negative cardiac enzymes. A nuclear stress was performed on [**5-9**] showed several areas with questionable reversible inferolateral and anteroapical ischemic changes but no EKG changes or chest pain. It was believed that his heart rate response was blunted [**2-14**] high dose BBlocker and deconditioning. The overall duration of his treadmill time was 5 minutes with a heart rate max of 81 bpm. He was discharged to home but returned to the [**Location (un) **] ED with continued complaints of shortness of breath. Cardiac enzymes were negative and he is now transferred for a cardiac cathterization for further evaluation of his symptoms. In cath lab, pt was unable to lie flat secondary to history of PTSD, claustrophia, and anxiety and therefore required intubation. A 90% distal lesion, just beyond the PDA was stented with a [**Location (un) **]. At the end of the procedure, an NGT was placed to dose plavix. Pt had already been started on integrelin and heparin. Subsequently, the patient developed a significant nose bleed. Heparin and integrelin were held, ENT was called, pressure was held and the patient was given intranasal afrin. Right heart cath also notable for elevated RVEDP (16 mm Hg) and PCWP (28 mm Hg mean). Past Medical History: Coronary Artery Disease s/p CABG in [**2139**] (LIMA->diag, SVG->OM1, SVG->LAD) s/p Myocardial Infarction X 2 s/p prior LAD stent and PTCA of diag Chronic systolic heart failure [**2-14**] ischemic cardiomyopathy, last known EF 20% Ischemic cardiomyopathy, s/p ICD implantation [**2141-7-14**] Type 2 Diabetes Mellitus, insulin-dependent Chronic Obstructive Pulmonary Disease, no home O2 requirement Hypertension Hyperlipidemia Diabetic Nephropathy/Chronic Renal Insufficiency Diabetic Neuropathy s/p right renal artery stent Severe Peripheral Vascular Disease, s/p left fem-[**Doctor Last Name **] bypass in [**2137**] GERD Anxiety Depression Post Traumatic Stress Disorder Paroxysmal Atrial Fibrillation Nonsustained Ventricular Tachycardia Social History: Married and lives with his wife. Retired from Army. Most recently worked as a cook at the [**Hospital **] [**Hospital6 28623**]. He used to drink alcohol heavily, but has had none in 40 years. 40+ pack year h/o smoking, quit 40 years ago. Family History: Father died of an MI at age 48. Brother died of an MI at age 64. Physical Exam: Vitals: 129/48 - 67 - 17 - 100% on room air Neuro: Alert, oriented to person, place, and time. Hard of hearing. Cardiac: Regular rate and rhythm. Normal S1,S2. No murmurs/rubs/gallops. Resp: Lungs have fine crackles at the bases bilaterally. Breathing is regular and unlabored at rest. Periph vasc: Bilateral femoral pulses are palpable. Bilateral DP and PT pulses are palpable. 1+ pedal edema bilaterally. ECG: SR 73 with PVC's Pertinent Results: Admission labs: [**2146-5-11**] 09:52PM BLOOD WBC-9.5# RBC-4.34* Hgb-13.3* Hct-39.0* MCV-90 MCH-30.7 MCHC-34.2 RDW-14.6 Plt Ct-280 [**2146-5-11**] 09:52PM BLOOD Neuts-76.0* Lymphs-13.9* Monos-6.5 Eos-3.2 Baso-0.4 [**2146-5-11**] 09:52PM BLOOD PT-13.7* PTT-24.9 INR(PT)-1.2* [**2146-5-11**] 09:52PM BLOOD Glucose-264* UreaN-29* Creat-1.6* Na-134 K-4.6 Cl-99 HCO3-27 AnGap-13 [**2146-5-11**] 09:52PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.4 . Cardiac cath ([**5-13**]): 1. Coronary angiography of this right dominant system revealed native three vessel coronary artery disease. The LMCA had a distal 50% stenosis. The LAD was occluded in the mid-vessel. The major diagonal branch had an ostial 60% stenosis. The LCx had a long 60% lesion in OM1. The RCA had a 90% stenosis just beyond the origin of the PDA. 2. Arterial conduit angiography demonstrated patent LIMA-D1 and SVG-OM grafts. The SVG-OM was occluded proximally. 3. Resting hemodynamics revealed elevated right and left sided filling pressures (RVEDP 16 mm Hg, PCWP mean 28 mm Hg). There was moderate to severe pulmonary arterial hypertension (PASP 61 mm Hg). The systemic arterial blood pressure was normal (SBP 122 mm Hg). The cardiac index was normal at 2.7 l/min/m2. The systemic vascular resistance was normal (911 dynes-sec/cm5). The pulmonary vascular resistance was normal (PVR 135 dynes-sec/cm5). 4. Successful PTCA and stenting of the distal RCA jailing the right PDA with a Xience (3x18mm) drug eluting stent postdilated with a 3.25mm balloon. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA comments). 5. Successful closure of the right femoral arteriotomy site with a Mynx closure device. FINAL DIAGNOSIS: 1. Native three vessel coronary artery disease. 2. Patent LIMA-D1 and SVG-LAD grafts. 3. Occluded SVG-OM graft. 4. Moderate biventricular diastolic dysfunction. 5. Moderate pulmonary hypertension. 6. Successful PTCA and stenting of the distal RCA with a Xience drug eluting stent. 7. Successful closure of the right femoral arteriotomy site with a Mynx closure device. . Discharge labs: [**2146-5-14**] 07:41AM BLOOD WBC-8.8 RBC-4.17* Hgb-12.7* Hct-36.9* MCV-89 MCH-30.4 MCHC-34.3 RDW-14.6 Plt Ct-275 [**2146-5-14**] 07:41AM BLOOD Glucose-206* UreaN-31* Creat-1.6* Na-137 K-4.1 Cl-99 HCO3-25 AnGap-17 [**2146-5-14**] 07:41AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.4 Brief Hospital Course: 78 year-old man who was referred from OSH for a cardiac catheterization secondary to persistent shortness of breath. # Coronary Artery Disease - Patient with known hx of CAD, prior CABG, prior stent/PTCA was referred for cardiac ctah for persistent shortness of breath. Patient did not tolerate lying flat for procedure due to significant history of claustrophobia, PTSD and anxiety and was intubated for the procedure. He was started on heparin, integrillin and plavix loaded pre-procedure however developed severe epistaxis after intubation and integrilin was stopped. Cardiac cath showed distal 90% RCA lesion and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] was placed. He was continued on aspirin, plavix and statin. After cath, he remained intubated for airway protection from epistaxis nad was admitted to CCU for closer management. He was extubated on hospital day #2 without complication. . # Chronic systolic heart failure - Ischemic cardiomyopathy, EF 20%. RHC notable for elevated RVEDP (16 mm Hg) and PCWP (28 mm Hg mean). After catheterization he was diuresed with bolus lasix and his home dose of lasix was increased to 100mg [**Hospital1 **]. He was continued on Inspra, Diovan and Toprol. At time of discharge exam was notable for lower extremity edema, but patient had no evidence of pulmonary edema with no oxygen requirement so he was instructed to continue higher dose of lasix until he could discuss lasix titration with his cardiologist as an outpatient. . # Epistaxis - Developed during cardiac catheterization and ENT was consulted. This was managed with Afrin. Estimated blood loss of 200cc which stabilized without tranfusion. This resolved within 24 hours with no recurrent events. . # Hypertension: He was continued on home [**Hospital1 4319**] of Lasix, Diovan, Norvasc, Inspra and Toprol with good control . # Hyperlipidemia: We do not have most recent lipid panel. On admission he was on tricor and statin was added to his regimen. . # Type II Diabetes, Insulin-Dependent: He was continued on home regimen of basal-bolus insulin with good control. No changed were amde to insulin regimen during admission. . # Stage 3 chronic renal failure - Baseline Cr 1.8, received pre-cath hydration and mucomyst and creatinine remained stable after contrast load during procedure. . # Depression: Mood was stable on admission . Patient not currently on pharmacological treatment for depression. Medications on Admission: Flonase 50 mcg one spray to each nostril daily Proventil inhaler two puffs four times daily prn shortness of breath or wheezing Tricor 145 mg one tab daily Lasix 80 mg twice a day (reduced at time of d/c from NVMC from prior dose of 120 mg [**Hospital1 **]) Aspirin 325 mg one tab daily Imdur 30 mg one tab daily Insulin 70/30 60 units subcutaneous injection breakfast Insulin 50/50 60 unit subcutaneous injection dinnertime Levemir 37 units subcutaneous injection at bedtime Diovan 40 mg one tab daily (recently added by Dr. [**Last Name (STitle) 11493**] Inspra 25 mg one tab daily Norvasc 2.5 mg one tab daily Toprol XL 200 mg one tab daily (added at NVMC) Plavix 75 mg one tab daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension Sig: Sixty (60) units Subcutaneous twice a day. 8. Levemir 100 unit/mL Solution Sig: Thirty Seven (37) units Subcutaneous at bedtime. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 12. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Disp:*150 Tablet(s)* Refills:*2* 14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Epistaxis Post Traumatic Stress Syndrome Discharge Condition: stable. Discharge Instructions: You had a cardiac catheterization with a drug eluting stent placed in your right coronary artery. You will need to take Plavix every day for one year. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) 11493**] tells you to. No lifting more than 10 pounds in 1 week. No baths or pools for one week. You may shower and take off the dressing on your groin. During the procedure you were intubated and on a breathing machine. You had a nose bleed that was caused by the blood thinners and needed to have Afrin sprayed in your nose to stop the bleeding. You had a fever and were on antibiotics for a short time. Your chest X-ray did not show a pneumonia and the antibiotics were discontinued. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet . Please call Dr. [**Last Name (STitle) 11493**] if you notice any increased trouble breathing, chest pain, nausea, light headedness, increased bruising or bleeding in your groin region, increasing coughs, fevers or any other concerning symptoms. Followup Instructions: Primary Care: ATTAR,[**Female First Name (un) **] Phone: [**Telephone/Fax (1) 24306**] Date/time: please call when you get home for an appt in [**1-14**] weeks. Cardiology: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:Friday [**6-10**] at 1:00pm Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2146-8-5**] 11:20 Completed by:[**2146-5-16**]

Admission Date: [**2179-12-13**] Discharge Date: [**2179-12-23**] Date of Birth: [**2107-1-5**] Sex: F Service: CARDIOTHORACIC SURGERY CHIEF COMPLAINT: Shortness of breath with exertion. HISTORY OF PRESENT ILLNESS: The patient is a 72history of woman with a history of hypertension, hyperlipidemia, congestive heart failure, rheumatic heart disease and paroxysmal atrial fibrillation, who was admitted to [**Hospital6 1760**] on [**2179-10-22**], for cardioversion from rapid atrial fibrillation. During that admission, she had transesophageal echocardiogram which showed an ejection fraction of 60% with 1+ aortic insufficiency, 2+ mitral regurgitation, 2+ tricuspid regurgitation, and small pleural cardiac effusion. The echocardiogram was unchanged from previous echocardiogram in [**2179-7-11**]. She then underwent cardiac catheterization on [**11-19**] in anticipation of future cardiac surgery. Her catheterization showed a left main of 30%, left anterior descending 70%, circumflex 30%, OM1 70%, right coronary artery 50%. Please see catheterization report full details. She was admitted on [**2179-12-13**], directly to the Operating Room for coronary artery bypass grafting and mitral valve replacement as postoperative admission. PAST MEDICAL HISTORY: Rheumatic heart disease, congestive heart failure, hypertension, hypercholesterolemia, paroxysmal atrial fibrillation. PAST SURGICAL HISTORY: Right upper lobectomy for nonsmall cell cancer in [**2179-8-10**]. Bilateral cataract surgery. SOCIAL HISTORY: She lives alone. The patient has a 30 pack-year tobacco history. She quit 15 years ago. Alcohol use is occasional. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Toprol XL 25 mg q.d., Amiodarone 200 mg b.i.d., Aspirin 325 mg q.d., Lipitor 200 mg q.d., Levothyroxine 112 mcg q.d., Coumadin 4 mg q.d., Protonix 40 mg q.d., Lisinopril 10 mg q.d. PHYSICAL EXAMINATION: General: The patient was a frail-appearing woman in no acute distress. Skin: No breaks or rashes. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx clear. Upper dentures intact. Neck: Supple. No jugular venous distention. No bruits. Lungs: Clear to auscultation bilaterally. She had a well-healed lobectomy scar on the right. Heart: Regular, rate and rhythm. There was a 2/6 systolic ejection murmur. Abdomen: Obese, soft, nontender, nondistended with no hepatosplenomegaly. Extremities: No clubbing, cyanosis, or edema. The patient had bilateral lower extremity spider veins. Neurological: The patient was alert and oriented times three. Pulses: Grossly intact pulses. Radial 2+ bilaterally, dorsalis pedis 2+ bilaterally, posterior tibial 1+ bilaterally, femoral 2+ bilaterally. Carotids not identified. HOSPITAL COURSE: As stated previously, the patient was a direct admission to the operating room. On [**12-13**], she underwent mitral valve replacement and coronary artery bypass grafting; please see operative report for full details. In summary, the patient had mitral valve replacement with a #25 Mosaic and coronary artery bypass grafting times two, with LIMA to the left anterior descending, saphenous vein graft to the obtuse marginal. She tolerated the operation well. Cardiopulmonary bypass time was 224 min, and her cross-clamp time was 181 min. She was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, she had Milrinone at 0.5 mcg/kg/min, Propofol at 20 mcg/kg/min, Neo-Synephrine at 3 mcg/kg/min. Additionally the patient had epinephrine and Nitroglycerin drips with no dose identified at this time. The patient did well in the immediate postoperative period. Her anesthesia was reversed. She was allowed to awaken initially and was then resedated after a neurological check. Her epinephrine drip was weaned to off shortly after arrival into the Cardiothoracic Intensive Care Unit. The cardioactive medications were titrated as tolerated by the patient's hemodynamics throughout the night on her operative date. On postoperative day #1, the patient's sedation was discontinued. She was weaned from the ventilator and successfully extubated. Her Milrinone was weaned to off. Her Neo-Synephrine was weaned to 0.25 mcg/kg/min. Additionally, her Nitroglycerin drip was maintained at 0.25 mcg/kg/min. The patient remained hemodynamically stable throughout postoperative day #1 and 2. On postoperative day #3, all cardioactive intravenous medications were weaned to off and transitioned to oral medications. The patient's chest tubes were discharge, and she was transferred from the Cardiothoracic Intensive Care Unit to Far Two for continued postoperative care and cardiac rehabilitation. Over the next several days, the patient had an uneventful hospital course with the exception of intermittent atrial fibrillation which was treated with Amiodarone and beta-blockade. Additionally the patient was restarted on her anticoagulation, which she had been receiving preoperatively for atrial fibrillation. With the assistance of the nursing staff and Physical Therapy staff, the patient's activity level was increased. On postoperative day 8, it was decided that the patient was stable and would be ready for discharge to home on the following day. DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature 98.2??????, heart rate 72, sinus rhythm, blood pressure 108/64, respirations 18, oxygen saturation 98% on room air. Weight preoperatively 58.5 kg, discharge 54.8 kg. General: The patient was alert and oriented times three. She moved all extremities. She followed commands. Nonfocal exam. Chest: Clear to auscultation bilaterally. Sternum is stable. Incision with Steri-Strips, open to air, clean and dry. Heart: Regular, rate and rhythm. S1 and S2. Abdomen: Soft, nontender, nondistended. Positive bowel sounds. Extremities: Warm and well perfused. The patient had 1+ edema bilaterally. Right saphenous vein graft site with Steri-Strips and large echymotic area of upper thigh. DISCHARGE LABORATORY DATA: Sodium 138, potassium 4.2, BUN 21, creatinine 1.0; PT 13, INR 1.0. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass grafting times two with LIMA to the left anterior descending, saphenous vein graft to obtuse marginal. 2. Mitral regurgitation status post mitral valve replacement with a #25 mosaic valve. 3. Rheumatic heart disease. 4. Congestive heart failure. 5. Hypertension. 6. Hypercholesterolemia. 7. Paroxysmal atrial fibrillation. 8. Gastroesophageal reflux disease. 9. Status post right upper lobectomy. 10. Status post bilateral cardiac surgery. DISCHARGE MEDICATIONS: Amiodarone 200 mg q.d., Lopressor 25 mg p.o. b.i.d., Coumadin 4 mg q.d., titrate to goal INR of 2.0-2.5, Aspirin 81 mg q.d., Lasix 20 mg q.d. x 10 days, Potassium Chloride 20 mEq q.d. x 10 days, Levoxyl 112 mcg q.d., Lipitor 20 mg q.d., Prilosec 40 mg q.d., Imdur 30 mg q.d., Colace 100 mg b.i.d., Percocet 5/325 [**2-11**] tab q.4 hours p.r.n. DISCHARGE STATUS: The patient is to be discharged to home with VNA. FO[**Last Name (STitle) **]P: She is to have follow-up with Dr. [**Last Name (STitle) **] in [**4-13**] weeks. Follow-up with Dr. [**First Name (STitle) 2031**] in [**4-13**] weeks. Follow-up with Dr. [**Last Name (Prefixes) **] in four weeks. The patient is to have a PT/INR drawn by visiting nurses on Friday, [**12-24**]. The results of that are to be called to Dr.[**Name (NI) 48166**] office, and he is to manage the patient's Coumadin dosing from that point forward. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2179-12-22**] 18:27 T: [**2179-12-22**] 18:47 JOB#: [**Job Number 48167**]

Admission Date: [**2201-6-21**] Discharge Date: [**2201-7-3**] Date of Birth: [**2171-2-21**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: Perforated diverticulitis Major Surgical or Invasive Procedure: OSH procedure: [**2201-6-20**]: Exploratory laparotomy, sigmoid colectomy and formation of Hartmann's pouch colostomy [**Hospital1 18**] operations: [**2201-6-26**]: Exploratory laparotomy with revision of sigmoid colostomy [**2201-6-28**]: Abdominal washout, liver biopsy, abdominal closure History of Present Illness: HPI: 30 yo male with hx of significant etoh abuse presenting from OSH with perforated sigmoid colon, s/p sigmoid colectomy, currently septic on Neo. Intubated the evening prior to transfer. The pt initially presented to the OSH with one week of abdominal pain, nausea and vomiting with associated diarrhea. CT scan in the ED demonstrated free air. Labs at the time were pertinent for ARF with Cr. of 2.3. Sodium 125, bicarb 22 with AG of 19 and T.bili 3.8. Pt was taken to the OR for an ex-lap and found to have perforated viscous in the sigmoid area. Fibrinous exudate in the left side was present c/w longstanding process. A Hartmann pouch and LLQ colostomy was performed. The pt was started on levaquin, flagyl and zosyn. Postop the pt had persistent acidosis with a bicarb of 15, lactate 4.8. He was started on a bicarb gtt. During the course of the OSH stay the pt has been 9 liters positive. He remains hypotensive on neo. Of note the pt drinks up to half-a-gallon a day of whiskey. His last drink was 8 days ago. Past Medical History: Alcohol abuse PSH: Hartmann's procedure Social History: History of alcohol abuse Lives with mother who works at [**Hospital6 5016**], which is where the patient was admitted previosly Family History: Non-contributory Physical Exam: On transfer to [**Hospital1 18**]: 100 115 102/55 26 93% CMV 50% 450/13 5 Neuro: Awake responsive to questions/follows commands Card: tachycardic, no m/r/g/c Pulm: Intubated clear breath sounds bilaterally GI:+Bowel sounds. Midline incision c/d/i. dusky sunken appearing colostomy. Appropriately tender to palpation Ext: peripheral edema palpable DP, radial pulses Pertinent Results: [**6-21**]: OSH CT abd/pelvis CT (OSH) free air and sigmoid stranding/diverticulitis. Labs on admission: [**2201-6-21**] 07:40PM WBC-7.4 RBC-2.62* HGB-9.5* HCT-29.2* MCV-112* MCH-36.1* MCHC-32.3 RDW-23.0* [**2201-6-21**] 07:40PM PLT COUNT-171 [**2201-6-21**] 07:40PM PT-16.4* PTT-31.7 INR(PT)-1.5* [**2201-6-21**] 07:40PM ALT(SGPT)-25 AST(SGOT)-58* ALK PHOS-52 TOT BILI-3.3* DIR BILI-2.9* INDIR BIL-0.4 [**2201-6-21**] 07:40PM GLUCOSE-141* UREA N-45* CREAT-1.8* SODIUM-138 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-20* ANION GAP-21* [**2201-6-21**] 07:40PM CALCIUM-6.5* PHOSPHATE-4.7* MAGNESIUM-2.2 [**2201-6-21**] 07:48PM freeCa-0.90* [**2201-6-21**] 07:48PM GLUCOSE-127* LACTATE-3.7* K+-3.4 [**2201-6-21**] 07:48PM TYPE-ART PO2-70* PCO2-37 PH-7.38 TOTAL CO2-23 BASE XS-- Brief Hospital Course: Mr. [**Known lastname **] was admitted to the trauma ICU on [**2201-6-21**] for further management following his Hartmann's procedure for perforated diverticulitis and septic shock. He remained on pressors which were weaned slightly overnight. He received a blood transfusion for a hematocrit of 24.1 which increased to 25.9 and was weaned off pressors. Copious secretions were noted from his ET tube. Intraoperative cultures from the OSH were obtained. They were peritoneal cultures and were polymicrobial. He was extubated and remained hemodynamically stable so was transferred to the floor on [**2201-6-24**]. At the time of transfer to the floor the pt was NPO with IV fluids and NG tube to suction. He was on IV zosyn for empiric coverage and also had a foley catheter in place for urine output monitoring. On [**6-25**] his NG tube output remained low so it was removed along with the foley catheter as he was making good amounts of urine. However, the appearance of his stoma continued to be dusky and necrotic and his WBC count increased from 9.6 on [**6-24**] to 15.2 on [**6-26**]. Therefore, he was taken back to the OR for an ostomy revision on [**2201-6-26**]. Intraoperatively, he received over 3L in crystalloid for hypotension. His abdomen was left open due to bowel edema and he was brought to the trauma ICU intubated and sedated. He was aggressively diuresed overnight and his abdomen was closed on [**2201-6-28**]. Also of note, the liver was noted to be quite yellowed in appearance suspicious of acute fatty liver and a biopsy was sent during the abdominal closure procedure (please see operative note for details). Postoperatively, his vent was weaned with continued diuresis. He was extubated on [**2201-6-29**] and transferred back to the floor hemodynamically stable. On [**6-30**] he was noted to have gas and a small amout of stool from his ostomy so his diet was advanced as tolerated. His foley catheter which had been placed upon return to the operating room was again removed and he voided without difficulty. His vital signs were routinely monitored and he remained afebrile and hemodynamically. His lung sounds were noted to have crackles and his chest x-ray appreared wet and he was diuresed with lasix as needed. His white blood cell count began trending downward to 18 from 27. His hematocrit has stabilized at 27. He was encouraged to mobilize out of bed and ambulate as tolerated throughout his postoperative course and he remained on SC heparin for DVT prophylaxis. Ostomy nursing was consulted and provided appropriate treatment and supplies for the patient to care for his colostomy. On HD #13, he was note to have mild erythema around the lower aspect of his wound and he underwent further removal of staples from the lower aspect of his wound. Remained of inferior staples were removed on POD #5 and wound was lightly packed with wet to dry dressing. The patient has been instructed in caring for his wound and dressing changes. He partipated in dressing changes and agreed to continue with them. VNA service will also provide him with assistance. His vital signs have been stable and he has been afebrile. He is preparing for discharge home with follow-up in the acute care clinic. Medications on Admission: None Discharge Medications: 1. Ostomy supplies 1 piece Coloplast Sensura ( Dist # [**Numeric Identifier 24338**] [**Doctor First Name **] # [**Numeric Identifier 20839**]) #3 boxes Refills:6 2. Ostomy Supplies [**Last Name (un) **] wafer Dist # [**Numeric Identifier 89560**], manf # [**Numeric Identifier 20840**] #3 boxes Refills: 6 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [**Hospital 16449**] Homecare and Hospice Discharge Diagnosis: Perforated diverticulitis Sepsis Acute Kidney Injury Ischemic sigmoid colostomy Open abdomen secondary to diverticulitis and sepsis Acute fatty liver Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred from [**Hospital6 5016**] after undergoing an emergent operation for perforated diverticulitis. You became septic postoperatively and were transferred here to [**Hospital1 18**] for further management. You were managed in the ICU and your condition improved so you were transferred to the surgical floor. You were then taken back to the operating for because your stoma was necrotic and had your stoma revised. Because of bowel swelling you abdomen was left open for a short period of time. Two days later it was able to be closed in the operating room. It was also noted that your liver appeared abnormal and a biopsy of it was taken during your last operation. The results of the biopsy are still pending at this time. Your infection has improved and your colostomy is now functioning well. You have resumed a regular diet and should continue to do so. You are being discharged home with the following instructions: Please follow up in the Acute Care Surgery Clinic at the appointment scheduled for you below. Your colostomy: You have received teaching from the ostomy nurses on how to care for your stoma. Empty the pouch when it becomes [**2-10**] full as instructed. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your [**Month/Day (4) 5059**] at your next visit. Don't lift more than [**11-23**] lbs for 6 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. You may start some light exercise when you feel comfortable. 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. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. HOW YOU [**Month (only) **] FEEL: You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [**Month (only) 5059**]. YOUR INCISION: Your incision may be slightly red around the staples. This is normal. Your staples will be removed at your follow up appointment in clinic. You may gently wash away dried material around your incision. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing r clothes. If the staining is severe, please call your [**Month (only) 5059**]. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next 6-12 months, your incision will fade and become less prominent. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [**Name2 (NI) 5059**]. You will receive a prescription from your [**Name2 (NI) 5059**] for pain medicine to take by mouth. It is important to take this medicine as directied. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [**Name2 (NI) 5059**] 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 [**Name2 (NI) 5059**] has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. 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 folloiwng, please contact your [**Name2 (NI) 5059**]: - 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. In some cases you will have a prescription for antibiotics or other medication. If you have any questions about what medicine to take or not to take, please call your [**Name2 (NI) 5059**]. DANGER SIGNS: Please call your [**Name2 (NI) 5059**] if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: TUESDAY [**2201-7-14**] at 2:30 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2201-7-8**]

Admission Date: [**2143-4-29**] Discharge Date: [**2143-5-12**] Date of Birth: [**2083-3-28**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 348**] Chief Complaint: abd pain, nausea/vomiting Major Surgical or Invasive Procedure: Intubation Placement of central venous catheter CVVHD Hemodialysis History of Present Illness: 60 y/o M w/alcohol abuse, HTN, who presented to [**Hospital3 **] on Saturday [**4-27**] c/o severe abd pain, n/v. Had started 2 days prior in setting of binge drinking with whiskey. Pain was epigastric radiating to his back. He was found to have a lipase of >3000. and was admitted to their medical service for acute pancreatitis. He was kept NPO and given IVF. He also was given Levaquin for "lethargy" and an infiltrate on CXR. The next day, [**4-28**], his bilirubin increased (0.8-2.6) and he continued to have severe abd pain, so he was changed from levaquin to primaxin, and he was trnasferred to their ICU. He was put on a lasix [**Hospital1 **] due to rales and cardiomegaly, and kept on NS at 100 cc/hr. He had a CT scan with po and IV contrast that showed acute pancreatitis with intrahepatic ductal dilatation; multiple hypodense irregular lesions in the right lobe of the liver, thickened GB wall with pericholecystic fluid, and a 5x4 cm hypodense collection in the RLQ adjacent to the psoas muscle. . On [**4-29**], he was supposed to go to MRCP but was claustrophobic and required ativan. After this, he felt better but required more ativan while in Radiology. [**Name8 (MD) **] RN notes, his heart rate was "sporadic" from the 40s to the 160s. He was given more ativan and then his HR dropped to the 20s (bp 145/63 at this time). He then became diaphoretic, c/o chest pain, and the MRCP was stopped. He was transferred to the stretcher and then turned [**Doctor Last Name 352**], "started to seize" and was noted to be pulseless. [**Name8 (MD) **] RN note, he was asystolic but per d/c summary and cardiology consult note, it was VT/VF. He received "several" shocks and CPR as well as one bolus dose of amiodarone. He was intubated during the code. He regained a pulse after an unknown amt of time. He became hypotensive requiring dopamine. He was then seen by Renal due to worsening renal failure (creatinine 0.8 on admission to 3.5 on d/c) who felt this was likely pre-renal failure from volume depletion plus contrast from the CT. His MRCP was read as showing small ascites, peripancreatic stranding, pericholecystic fluid, and a large gallstone. CBD did not appear dilated but the images were quite limited; no obvious intrahepatic biliary ductal dilatation or pancreatic ductal dilatation. Complex T2 hyperintesnsity along right psoas muscle as seen by CT measuring 5.2 x3.7 cm, representing a complex fluid collection. He was transferred here for further management. Past Medical History: Alcohol abuse (reportedly binge drinks regularly) HTN Hypothyroidism ? pancreatitis Social History: Per OSH notes, he "binge drinks all the time" with recurrent bouts of pancreatitis. Smokes tobacco, amt not documented. Denied illicit drug use. Family History: unknown Physical Exam: On admission: T: 99.4 BP: 87/49 P: 56 AC 500x14 FiO2 0.7 PEEP 5 O2 sat 94% CVP 13 Gen: intubated, sedated, paralyzed HEENT: icteric, ETT/OGT in place, pupils constricted Lungs: CTA anteriorly, no w/r/c CV: RRR, no m/r/g Abd: distended, hypoactive but present bowel sounds, not tense but difficult to assess peritoneal signs as paralyzed Ext: no edema, feet cold, 1+ dp bilaterally Pertinent Results: Pre-admission labs of note: [**4-29**] at 9 pm: Na 136, K 6.0, Cl 108, Bicarb 18, BUN 56, Creat 3.7 Calcium 6.5, T bili 10.0, AST 359, ALT 168, alk phos 161, CK 282, MB 6.2, MBI 2.1, Troponin T 0.02 WBC 22 with 25% bands, Hct 42, Plt 157, INR 1.3 ABG at 2:30 pm 6.88/83/68 ABG at 6:30 pm 7.14/55/260 Urine cx <1000 colonies/ml Hepatitis serologies negative Lipase on [**4-29**] 1541 Triglycerides 52 AFP 2.0 . EKG: [**2143-4-30**] Sinus rhythm. Left anterior fascicular block. Non-specific ST-T wave abnormalities. . Labs: [**2143-4-30**] 12:27AM BLOOD WBC-16.1* RBC-4.07* Hgb-12.9* Hct-38.7* MCV-95 MCH-31.6 MCHC-33.3 RDW-14.6 Plt Ct-153 [**2143-4-30**] 12:27AM BLOOD Plt Smr-NORMAL Plt Ct-153 [**2143-4-30**] 12:27AM BLOOD Neuts-69 Bands-16* Lymphs-6* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2143-4-30**] 12:27AM BLOOD PT-13.8* PTT-30.8 INR(PT)-1.2* [**2143-4-30**] 12:27AM BLOOD Glucose-339* UreaN-58* Creat-4.4* Na-139 K-5.8* Cl-108 HCO3-21* AnGap-16 [**2143-4-30**] 12:27AM BLOOD ALT-134* AST-313* LD(LDH)-1755* CK(CPK)-559* AlkPhos-142* Amylase-[**2143**]* TotBili-7.6* [**2143-4-30**] 12:27AM BLOOD Lipase-1032* [**2143-4-30**] 12:27AM BLOOD CK-MB-9 cTropnT-0.15*, 0.14, 0.13 . Micro: See OMR . Imaging: [**2143-4-30**]: Abd u/s - 1. Minimal ascites in right upper and right lower quadrants. 2. Gallstone in the neck of the gallbladder with edema of the gallbladder wall. This could reflect acute cholecystitis but also could be a manifestation of changes due to the patient's known acute pancreatitis. 3. No intrahepatic or extrahepatic biliary dilatation. 4. Patent portal vein. . [**2143-5-3**]: Head CT - Diffuse hypodensity and loss of [**Doctor Last Name 352**]-white differentiation suggesting global hypoxia and infarction. However, a similar appearance could be caused by severe acute hepatic or renal failure. Subacute left parietal infarction without hemorrhage. Possible small right parietal subacute infarction. Brief Hospital Course: In brief, the patient is a 60 year old man with history of alcohol abuse, admitted to an OSH with severe acute pancreatitis/pseudocyst, complicated by cardiac arrest, and ARDS transferred for further management. The patient was treated in the [**Hospital1 18**] ICU for approximately two weeks without recovery of neurologic function. During that time, he was treated for ARDS, severe pancreatitis, acute renal failure (with CVVHD and then HD), anemia, and altered mental status. The patient remained unresponsive after weaning sedation, and the patient's family agreed that he should be made comfort measures only given that his severely depressed mental status was due to anoxic brain injury. This conclusion was established with the aid of Neurology consultants. At that time, the patient was transferred out of ICJ to the general medicine floor. He passed away on [**5-12**], [**2142**]. Medications on Admission: 1. Amlodipine 10 mg daily 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Lisinopril 40 mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Anoxic brain injury secondary to cardiac arrest Necrotizing pancreatitis Alcohol abuse Renal failure Adult respiratory distress syndrome Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2143-5-13**]

Admission Date: [**2166-4-9**] Discharge Date: [**2166-4-18**] Date of Birth: [**2108-8-25**] Sex: M Service: Fernard Intensive Care Unit HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 405**] is a 57-year-old male who presented to [**Hospital 1474**] Hospital on [**2166-4-8**] with hematemesis. The patient was treated with transfusions and octreotide. Esophagogastroduodenoscopy was done with unsuccessful therapeutic treatment of upper gastrointestinal bleed. The patient was transferred to [**Hospital1 188**] [**2166-4-9**], with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] for transjugular intrahepatic portosystemic shunt procedure. Indications included gastric variceal bleed that was refractory to endoscopic treatment. The patient was electively intubated prior to transfer. On [**2166-4-10**], the patient had a transjugular intrahepatic portosystemic shunt procedure complicated by innominate vein perforation right internal mammary artery bleed with hemothorax. The patient was taken to the operating room for sternotomy with repair of vascular lesions. The patient was stabilized, and a chest tube placed. The patient required 12 units of packed red blood cells, and 4 units of platelets, and 4 units of fresh frozen plasma. After initial period of stability, the patient became increasingly hypotensive from [**2166-4-12**] to [**2166-4-14**] requiring pressor support. A Swan-Ganz catheter was placed and his systemic vascular resistance was decreased, and the cardiac output and index were increased. The patient was transferred to the Fernard Intensive Care Unit for further care given picture of sepsis. Of note, his packed red blood cell requirement has been 3 units per day over three days and has stopped bleeding clinically. There was no nasogastric tube output. The patient still had [**Last Name (un) **] tube in place. The patient is paralyzed due to difficulty with ventilation postoperatively. In the operating room on [**4-10**], the patient had an episode of hypotension for about one to three minutes. PAST MEDICAL HISTORY: 1. Cirrhosis. 2. Status post esophageal variceal bleed. 3. Status post transjugular intrahepatic portosystemic shunt which was unsuccessful. 4. Status post innominate vein and right internal mammary artery laceration with resultant hemothorax. 5. Status post sternotomy as described. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: Medications on transfer from Surgical Intensive Care Unit were octreotide 50 mcg q.d., insulin drip, Dilaudid drip, Ativan drip, oxacillin 2 g q.6h., levofloxacin 500 mg intravenously q.d., Flagyl 500 mg intravenously t.i.d., Protonix 40 mg intravenously b.i.d., Cisatracurium 80 mcg/kg per hour, Neo-Synephrine drip. PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure was 110/50, pulse was 80, temperature was 37. The patient was on ventilatory support on AC 550 X 12 with an FIO2 of 60%, and positive end-expiratory pressure of 20. Swan-Ganz catheter readings as follows: Central venous pressure 22, pulmonary artery pressure 44/19, cardiac output of 7.8, cardiac index was 3.95, systemic vascular resistance was 522. Ins-and-outs 2700 in and 1800 out; 1300 of that urine. In general, the patient was intubated and sedated. Pupils were small and reactive. Neck revealed left internal jugular in place; the site looks clean. The oropharynx was clear. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was in place; some purulent green discharge noted. Chest revealed fair breath sounds bilaterally, positive rhonchi throughout. Cardiovascular had a regular rate and rhythm. No murmurs, rubs or gallops. Abdomen was soft, decreased bowel sounds. Extremities were warm with fair pulses distally. Skin had no rash. Right radial and femoral lines with no purulent discharge noted from either line. PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell count was 13.4 (decreased from 19.6), hematocrit was 33.4, platelets were 146. PT was 15.4, PTT was 42.2, INR was 1.7. Chemistry-7 significant for a creatinine of 1.5 (increased from baseline of 1). Albumin was 2.7, phosphate was 4.5, magnesium was 2.1. ALT was 19, AST was 32, alkaline phosphatase was 108, total bilirubin was 13.1 (increased from admission of 6). Urine sodium was 19 on [**2166-4-11**]. Arterial blood gas revealed 7.4, PCO2 was 34, PO2 was 135, unknown FIO2, lactate was 3. Blood cultures revealed no growth to date so far. Sputum was positive for methicillin-sensitive Staphylococcus aureus. RADIOLOGY/IMAGING: A chest x-ray revealed bilateral infiltrates suggestive of congestive heart failure. HOSPITAL COURSE: In summary, this is a 57-year-old male with recent gastric variceal bleed, status post unsuccessful transjugular intrahepatic portosystemic shunt complicated by hemothorax and innominate vein injury requiring thoracotomy, now hypotensive on pressors requiring increased FIO2 and positive end-expiratory pressure to maintain oxygenation. His Swan-Ganz catheter numbers and physical with complete blood count and increased white blood cell count with left shift were suggestive of sepsis. The patient was paralyzed due to difficulty with ventilation postoperatively. The patient seemed to no longer bleeding from his varices. 1. PULMONARY: Given decreased blood pressure we tried to decrease the positive end-expiratory pressure as tolerated and tried to wean off the paralytics. The patient was also given fluid to maintain his blood pressure. Diuresis was not an option given decreased blood pressure. A Swan-Ganz catheter was placed perioperatively and was subsequently discontinued. 2. CARDIOVASCULAR: The patient was requiring Neo-Synephrine to increase his blood pressure. We tried to wean the Neo-Synephrine and add vasopressin; however, this was unsuccessful. 3. GASTROINTESTINAL: The patient had a stable hematocrit and no longer had a transfusion requirement. The patient was continued on Protonix, and the [**Last Name (un) **] tube continued to be left in. The patient had hyperbilirubinemia; most likely thought secondary to shocked liver given episode of hypotension. 4. RENAL: Creatinine had increased to 1.5 and continued to increase during the hospitalization. It was thought most likely secondary to hepatorenal syndrome. The patient continued to maintain a good urine output. On [**4-26**], the patient was started on octreotide and midodrine given the possibility of hepatorenal syndrome; however, his creatinine continued to increase. 5. ENDOCRINE: The patient was maintained on an insulin drip which was later changed to subcutaneous. 6. HEMATOLOGY: The patient's hematocrit remained stable. His coagulopathy was most likely secondary to his liver disease. 7. INFECTIOUS DISEASE: Oxacillin was changed to vancomycin given that the patient continued to be febrile. It was also thought that the patient may have a sinusitis secondary to the [**Last Name (un) **] tube; however, Gastroenterology felt that the [**Last Name (un) **] tube should be kept in given his recent episode of upper gastrointestinal bleed. The patient was continued on vancomycin, levofloxacin, and Flagyl for general sepsis to cover for sinusitis, and mediastinitis, and Staphylococcus aureus in the sputum. 8. FLUIDS/ELECTROLYTES/NUTRITION: The patient was initiated on total parenteral nutrition. The patient did not significantly improve, and given worsening renal function, it was thought that the patient's prognosis was very poor. After a family meeting, the patient was made do not resuscitate. On [**4-18**], given the poor prognosis, the family decided to make the patient comfort measures only. At 11:58, the patient expired. CONDITION AT DISCHARGE: Expired. DISCHARGE DIAGNOSES: 1. Gastric variceal bleed secondary to cirrhosis. 2. Cirrhosis; most likely secondary to ethanol use. 3. Hemothorax secondary to transjugular intrahepatic portosystemic shunt procedure; status post sternotomy and stabilization of perforations. 4. Sepsis. 5. Acute respiratory distress syndrome (ARDS). [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 218**] MEDQUIST36 D: [**2166-8-29**] 11:36 T: [**2166-9-4**] 16:33 JOB#: [**Job Number 40542**]

Admission Date: [**2139-2-17**] Discharge Date: [**2139-2-24**] Date of Birth: [**2072-4-24**] Sex: M Service: CT Surgery HISTORY OF PRESENT ILLNESS: The patient is a 66 year old male who presented with exertional angina. The patient noted two months of exertional angina and band-like chest pain radiating to the left arm, relieved with sublingual nitroglycerin. On the day of admission, the patient had a stress test and developed 1.[**Street Address(2) 1755**] elevations inferiorly and [**Street Address(2) 2051**] depressions from V4 to V6. Imaging showed severe reversible perfusion defect over the inferior and lateral walls. Cardiac catheterization was performed, demonstrating 60% to 70% stenosis of the left anterior descending artery, 90% left circumflex, and 90% right coronary artery with a left ventricular ejection fraction of approximately 50%. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2. Hypertension. 3. Hypercholesterolemia. MEDICATIONS ON ADMISSION: Lisinopril 40 mg p.o.q.d., lovastatin 20 mg p.o.q.d., hydrochlorothiazide 25 mg p.o.q.d., amlodipine 10 mg p.o.q.d., metformin 500 mg p.o.q.d., NPH insulin 36 units q.a.m. and 32 units q.p.m., terazosin 1 mg p.o.q.d., Zyrtec 10 mg p.o.q.d., and Ecotrin p.o.q.d. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On physical examination, the patient had a heart rate in the 70s, blood pressure 134/71 and oxygen saturation 98% on two liters. General: Patient was in no acute distress. Neck: No jugular venous distention. Cardiovascular: Regular rate and rhythm, I/VI systolic murmur. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: No edema. HOSPITAL COURSE: The patient was admitted to the hospital and it was decided that he would be taken to the Operating Room on [**2139-2-19**]. Coronary artery bypass grafting was performed with a left internal mammary artery to the left anterior descending artery and saphenous vein grafts to the obtuse marginal, posterior descending artery and diagonal three artery. The pericardium was left open and an arterial line was placed. Two atrial wires were placed. Two mediastinal and one left pleural tube were placed. Crossclamp time was 61 minutes. Postoperatively, the patient was transferred to the Intensive Care Unit, where he was rapidly extubated. On postoperative day number one, the Neo-Synephrine drip was appropriately weaned. The patient was A-V paced. On postoperative day number one the chest tubes were also removed. On postoperative day number two, the patient was transferred to the floor. The Foley catheter was removed on postoperative day number two. He was atrially paced for the entire day on posterior day two. On postoperative day number three, the wires were capped and the patient had a heart rate of 70 and in sinus rhythm. Wires were removed on postoperative day number five. The patient was able to ambulate at level V, was tolerating an oral diet, and his pain was controlled with oral medications. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: Lasix 20 mg p.o.b.i.d. times seven days. Potassium chloride 20 mEq p.o.q.d. times seven days. Lopressor 12.5 mg p.o.q.d. Percocet one to two tablets p.o.q.4-6h.p.r.n. Lovastatin 20 mg p.o.q.d. Amlodipine 10 mg p.o.q.d. Glucophage 500 mg p.o.q.d. NPH insulin 36 units q.a.m. and 32 units q.p.m. Terazosin 1 mg p.o.q.d. Ecotrin 325 mg p.o.q.d. Colace 100 mg p.o.b.i.d. DI[**Last Name (STitle) 408**]E FOLLOW-UP: The patient will follow up with his primary care physician or cardiologist in three weeks and with Dr. [**Last Name (Prefixes) **] in four weeks. DISCHARGE DIAGNOSIS: Status post coronary artery bypass grafting times four. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 1308**] MEDQUIST36 D: [**2139-2-24**] 11:28 T: [**2139-2-24**] 11:33 JOB#: [**Job Number 29720**]

Admission Date: [**2153-1-5**] Discharge Date: [**2153-1-11**] Date of Birth: [**2067-1-25**] Sex: M Service: MEDICINE Allergies: Codeine / Iodine Attending:[**First Name3 (LF) 2782**] Chief Complaint: malaise Major Surgical or Invasive Procedure: Percutaneous Chol. History of Present Illness: 85 yo male w/ h/o Afib, systolic CHF, and recent cholecystitis treated medically p/w fatigue, poor po intake, and malaise. Upon questioning he admits to mild ruq pain and chills but no fevers. He lost ten lbs in the last week due to poor po intake. His son brought him to the [**Name (NI) **] for evaluation after he had an appointment at his cardiologist's office. . He had been hospitalized through [**2152-12-10**] at an OSH for rx of cholecytitis afterwhich he developed lower extremity edema and dyspnea on exertion. He was started on lasix one week ago and has improved since then. He says that he gets extremely short of breath after 20 steps. No chest pain. . He has had several mechanical falls lately and for this reason, he is not anticoagulated. In the ED, initial VS were: 97.8 48 95/76 18 90%. He was given 1.5L ivf. He was treated with azithromycin 500mg iv once, ceftriaxone 1g iv once, unasyn 3g iv once. Lactate decreased from 4.6 to 2.2 with fluids. Troponin stable at .03. Surgical consultation recommends percutaneous cholecystostomy tubes. CT head . Upon transfer to the micu, 98.0, Pulse: 94, RR: 16, BP: 129/72, O2Sat: 97%, O2. On arrival to the MICU, he had no acute complaints. . Review of systems: (+) Per HPI (-) Denie night sweats, recent wt gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: S/P BILATERAL TKR *S/P ILIAL FRACTURE ATRIAL FIBRILLATION AWB DONATION- DEFFERRAL B12 DEFICIENCY ANEMIA BLADDER CANCER CERVICAL SPONDYLOSIS CHRONIC RENAL FAILURE GASTROESOPHAGEAL REFLUX HERNIATED DISC HYPERCHOLESTEROLEMIA HYPERTENSION HYPOTHYROIDISM MGUS MITRAL VALVE PROLAPSE PROCTITIS PROSTATE CANCER R SHOULDER DJD TRANSIENT ISCHEMIC ATTACK [**2141**] LVEF 25% Social History: lives alone but has daily help; no smoking or etoh Family History: Mother died of alzheimers dementia Father died of prostate cancer Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Admission Labs [**2153-1-5**] 09:45PM GLUCOSE-136* UREA N-41* CREAT-1.8* SODIUM-141 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15 [**2153-1-5**] 09:45PM CALCIUM-8.1* PHOSPHATE-4.3 MAGNESIUM-2.0 [**2153-1-5**] 12:03PM URINE HOURS-RANDOM UREA N-932 CREAT-99 SODIUM-50 POTASSIUM-68 CHLORIDE-41 [**2153-1-5**] 12:03PM URINE OSMOLAL-595 [**2153-1-5**] 12:03PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2153-1-5**] 04:49AM GLUCOSE-136* UREA N-45* CREAT-2.1* SODIUM-139 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-17 [**2153-1-5**] 04:49AM ALT(SGPT)-55* AST(SGOT)-55* LD(LDH)-255* ALK PHOS-128 TOT BILI-0.6 [**2153-1-5**] 04:49AM CALCIUM-8.2* PHOSPHATE-4.2 MAGNESIUM-2.0 IRON-38* [**2153-1-5**] 04:49AM calTIBC-179* VIT B12-740 FOLATE-GREATER TH FERRITIN-246 TRF-138* [**2153-1-5**] 04:49AM WBC-8.6 RBC-3.08* HGB-9.9* HCT-30.7* MCV-100* MCH-32.2* MCHC-32.4 RDW-17.9* [**2153-1-5**] 04:49AM PLT COUNT-239 [**2153-1-5**] 04:49AM PT-13.4* PTT-20.7* INR(PT)-1.2* [**2153-1-5**] 01:04AM LACTATE-2.2* [**2153-1-5**] 12:55AM cTropnT-0.03* [**2153-1-4**] 08:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2153-1-4**] 08:25PM URINE RBC-1 WBC-10* BACTERIA-MANY YEAST-NONE EPI-0 [**2153-1-4**] 08:25PM URINE MUCOUS-RARE [**2153-1-4**] 06:25PM LACTATE-4.6* K+-4.8 [**2153-1-4**] 06:25PM HGB-11.3* calcHCT-34 [**2153-1-4**] 06:12PM PT-14.7* PTT-24.4* INR(PT)-1.4* [**2153-1-4**] 06:12PM PLT COUNT-267# [**2153-1-4**] 06:12PM cTropnT-0.03* [**2153-1-4**] 06:12PM LIPASE-33 Brief Hospital Course: BRIEF HOSPITAL COURSE: This is an 85 year old gentleman with a history of atrial fibrillation, systolic heart failure and recent medically treated cholecystitis who presented with recurrent cholecystitis that was treated with percutaneous drainage and antibiotics. His hospital course was complicated by delirium and mild pulmonary edema. . ACTIVE ISSUES: ACUTE CHOLECYSTITIS: Mr. [**Known lastname 79**] presented with right upper quadrant pain and nausea and fatigue. Labs significant for normal LFTs. RUQ ultrasound demonstrate dacute cholecystitis. Suurgery was consulted and recommended percutaneous drainage of his gallbladder which was carried out by IR. Initial pus was drained from the gallbladder which transioned to bilious drainage on Day # 2 of admission. He was covered with Vancomycin and Zosyn initially. Culture data from the biliary drain grew ecoli sensitive to ciprofloxacin. Antibiotic therapy was changed to ciprofloxacin and metronidazole to include anaerobic coverage for a total of 14 days. His biliary drain was kept in place with plan for discontinuation by general surgery in [**5-25**] weeks. He was afebrile for the duration of his hospital course. . CONGESTIVE HEART FAILURE: On admission he was noted be dyspneic. An initial chest xray was concerning for right lower lobe pneumonia that could not be ruled out in the setting of pulmonary edema. He was initially on vancomycin and zosyn on admission to the intensive care unit. While diuresis was initially held on secondary to concern for acute kidney injury his pulmonary edema accumulated during his initial hospital days. He was given IV lasix 20mg twice and restarted on his home dose of lasix 20mg daily. This dose was uptitrated to 40mg daily which appeared to better control his volume status and improved his breathing. An echo demonstrated symmetric left ventricular hypertrophy with cavity dilation and global systolic dysfunction suggestive of a non-ischemic pattern with EF 25%. A low dose ace-inhibitor (lisinopril 5mg) was started and he was continued on an aspirin and beta blocker. He reported no cough and was afebrile for the duration of hospitalization. A repeat chest xray after diuresis revealed no evidence of pneumonia. His nighttime oxygen saturations were noted to be stably in the low 90s. . URINARY TRACT INFECTION: A urine sample from admission was concerning for infection and culture grew ecoli sensitive to ciprofloxacin. A repeat UA prior to discharge was clear of infection. . ATRIAL FIBRILLATION: Mr. [**Known lastname 79**] is rate controlled with metoprolol and anticoagulated with aspirin given fall risk. He was noted to have heart rates in the 110s with frequent episodes of non sustained ventricular tachycardia, therfore his metoprolol was incrased to 50mg three times a day with improvement in the frequency of NSVT and heart rates in the 60-70s during the day. Cardiology was consulted and agreed with management changes. There was a question of whether he was on domperidone in the past. It was taken off his medication list. . DELIRIUM: Mr. [**Known lastname 79**] was noted to have progressive delirium throughout his hospitalization which was improving prior to discharge. No pharmacologic agents were required for management. He had an attentive family at his bedside at all his times. Repeat infectious work-up including UA, chest xray and cdiff toxin were negative for infection. His electrolytes were stable. Etiology attributed to age, dementia and hospitalization including ICU stay. . SPEECH AND SWALLOW: While delirius, Mr. [**Known lastname 79**] was noted to have small aspiration events with eating and drinking. A speech and swallow evaluation recommended nectar thickened liquids with suggested re-evaluation when his delirium clears. . INACTIVE ISSUES CHRONIC KIDNEY DISEASE: His renal function ranged between 1.8 and 2.0 throughout his hospitalization which was just above his baseline. . HYPERTENSION: Well controlled. Furosemide increased to 40mg PO. Amlodipine was discontined in favor of lisinopril 5mg. Hydralazine was held on discharge given normotensive. He should discuss restarting this medication with his primary care physician after discharge. . HYPOTHYROID: He was continued on levothyroxine. . VITAMIN D: He was continued on vitamin D. . DYSLIPIDEMIA: He was continued on crestor 20mg daily. . DEPRESSION: He was continued on wellbutrin 300mg daily. . BENIGN PROSTATIC HYPERTROPHY: He was continued on flomax. . PAIN: Secondary to frequent falls. He was continued on tylenol and gabapentin. . INSOMNIA: Lunesta was held on admission and should be reconsidered on discharge. . GERD: He was continued on ranitidine and nexium. . TRANSITIONAL ISSUES: - Continue ciprofloxacin and metronidazole for 8 additional days - Primary care follow-up, Electrolytes should be checked within 1 week as she has started lasix and lisinopril. - Full Code Medications on Admission: tylenol #3 daily prn furosemide 20mg daily amlodipine 5mg daily bupropion 300mg daily calcitriol .25mcg domperidone 5mg daily gabapentin 900mg daily esmeprasole 40mg daily eszopiclone (lunesta) 2mg hs gabapentin 800mg daily hydralazine 25mg [**Hospital1 **] levothyroxine 112 mcg daily metoprolol succinate 50mg [**Hospital1 **] ranitidine 150mg daily rosuvastatin 20mg daily tamsulosin .4mg daily asa 325 vitamin d b12 1000mcg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 4. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. eszopiclone 2 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a day. 11. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days: day 1 = [**1-5**] (total course 14 days). 13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 8 days: day 1 = [**1-5**] (total 14 days). 14. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 15. gabapentin 800 mg Tablet Sig: One (1) Tablet PO once a day. 16. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. 17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 1495**] [**Hospital 122**] Rehabilitation Center Discharge Diagnosis: Acute cholecystitis Urinary tract infection Atrial fibrillation Decompensated systolic heart failure Hypertension Chronic kidney disease 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: It was a pleasure taking care of you. You came with the feeling of fatigue and fever. The reason was that you had inflammation of your galbladder and urinary tact infection. The tube was placed into your gallblader so that the bile can drain. We gave you antibiotics and you recovered. . The tube should stay in your gallbladder. Wou will see the surgeon on [**1-26**] and they will give you further instructions. . We have done the following changes to your medications: CONTINUE ciprofloxacin 500 mg tbl. twice a day for 8 more days CONTINUE metronidazole 500 mg tbl. three times a day for 8 more days CHANGE furosemide 20 mg po daily to furosemide 40 mg daily DISCONTINUE dronedorol DISCONTINUE amlodipine 5 mg daily START lisinopril 5 mg daily DISCONTINUE hydralazine 25 mg twice a day DISCONTINUE ranitidine 150 mg daily Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: FRIDAY [**2153-1-26**] at 10:15 AM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2153-2-7**] at 11:30 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2153-3-28**] at 11:30 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

Admission Date: [**2157-9-18**] Discharge Date: [**2157-10-6**] Date of Birth: [**2107-2-1**] Sex: M Service: TRAUMA SURGERY CHIEF COMPLAINT: Here for pancreas transplant. HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old status post a cadaveric renal transplant in [**2157-3-5**] complicated by delayed graft function. His baseline creatinine is 2.7. He is now here for a pancreas transplant. His CRT postoperative course has been complicated by elevated BUN and creatinine and hyperkalemia which have all resolved. He has a long-standing history of type I diabetes with nephropathy and retinopathy as well as hypertension. He denied any recent fever, chills, nausea, vomiting, diarrhea, or urinary tract symptoms. PAST MEDICAL HISTORY: 1. End-stage renal disease. 2. Type 1 diabetes. 3. Diabetic retinopathy. 4. Hypertension. PAST SURGICAL HISTORY: 1. Cadaveric renal transplant in [**2157-3-5**]. 2. Hernia repair in [**2153**]. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Prograf 2 mg b.i.d. 2. Rapamycin 5 mg q.d. 3. Valcyte 450 mg q.o.d. 4. Bactrim single-strength tablet p.o. q.d. 5. Aspirin 81 mg p.o. q.d. 6. Labetalol 200 mg b.i.d. 7. Norvasc 10 mg q.d. 8. Zantac 150 mg b.i.d. 9. NPH 15 units in the morning. 10. Humalog sliding scale. SOCIAL HISTORY: No tobacco, no ethanol, no IV drug use. FAMILY HISTORY: The patient's father had an MI. PHYSICAL EXAMINATION ON ADMISSION: General: The patient was in no apparent distress, alert and oriented times three. He was normocephalic, with no icterus. Heart: RRR. Chest: CTAB. Abdomen: Well-healed left lower quadrant scar with a transplanted kidney in the left lower quadrant. The rest of the examination was soft, nontender, nondistended with positive bowel sounds. Extremities: There was 1+ edema in the lower extremities and a right forearm AV fistula with positive thrill and bruit. neurologic: He was grossly intact. Rectal examination: Deferred. HOSPITAL COURSE: The patient was admitted to Transplant with a normal preoperative workup performed. He went for surgery for his pancreas transplant. Please refer to the previously dictated operative note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] detailing the details of this operation. Postoperatively, the patient was transferred to the Surgical Intensive Care Unit on Rapamune, tacrolimus, and antithymo globulin and Solu-Medrol for immunosuppression as well as Octreotide for reducing the secretions of the pancreas. Unfortunately, postoperatively, the ultrasound on postoperative day number one showed question of blood flow to the transplanted pancreas and it was decided that the patient would go back for evaluation of the transplant. The patient was started on heparin. Unfortunately, he became hypotensive and had a drop in his hematocrit level. He was brought urgently to the Operating Room for a washout of his abdomen. Please refer to the previously dictated operative note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from [**2157-9-19**]. Briefly, what happened is that about 1 liter of old clot was retrieved from the abdomen. This was irrigated and a source for this bleed was found in the region of the body of the pancreas which was controlled with a clip. No other bleeding was noted and the abdomen was washed out again and the patient was closed satisfactorily. Postoperatively, the patient was transferred to the Postanesthesia Care Unit and subsequently to the floor without complication. His floor course was relatively unremarkable. He was continued on immunosuppression and at the time of his discharge, his immunosuppression regimen includes Prograf 2 mg b.i.d. and Rapamune 4 mg q.d. His last Prograf level was 9.7 on this dose and his last Rapamune level was 18.5 on 5 mg q.d. The patient's pancreatic functions have been relatively normal; amylase and lipase have remained within normal limits for the majority of this operative stay and the last levels measured were 29 and 26 respectively. He does have a mild insulin requirement. He has been receiving a sliding scale and will be discharged on a dose of Lantus 5 mg q.h.s. as well as with a sliding scale. The only other postoperative complication was a fever on [**2157-9-30**], postoperative day number 12 and 11, which revealed a fever to 101.3. Workup at this time did not reveal any source for his fever. He was treated on intravenous Unasyn and subsequently p.o. Augmentin for a total course of eight days without recurrence of this fever. He is also contained on a prophylactic antibiotic regimen with Valcyte, Bactrim, and Nystatin swish and swallow which he has tolerated well. On the day of discharge, the patient is currently tolerating a p.o. diet without nausea, vomiting, or abdominal pain or diarrhea. He is in general doing very well. He is being discharged home in good condition on [**2157-10-6**]. DISCHARGE DIAGNOSIS: 1. Status post pancreas transplant. 2. Hypertension. 3. Insulin-dependent diabetes mellitus. 4. Diabetic retinopathy. 5. End-stage renal disease. 6. Status post renal transplant in [**5-7**]. 7. Status post hernia repair. 8. Anemia of chronic renal failure. 9. Hyperkalemia. 10. Chronic blood loss anemia requiring multiple blood transfusions. 11. Leukopenia. 12. Postoperative atelectasis. 13. Hypovolemia requiring fluid resuscitation. 14. Postoperative hematoma and blood loss requiring reoperation. 15. Status post exploratory laparotomy. 16. Metabolic acidosis. DISCHARGE MEDICATIONS: 1. Valcyte 450 mg p.o. q.o.d. 2. Protonix 40 mg p.o. q.d. 3. Bactrim single-strength p.o. q.d. 4. Labetalol 100 mg p.o. b.i.d. 5. Colace 100 mg p.o. b.i.d. 6. Sodium bicarbonate 650 mg p.o. q.i.d. 7. Epogen 5,000 units subcutaneously once a week. 8. Hydromorphone 2-4 mg p.o. q. four hours p.r.n pain. 9. Ambien 5 mg p.o. q.h.s. p.r.n. insomnia. 10. Aspirin 325 mg p.o. q.d. 11. Dulcolax 10 mg p.r. q.h.s. p.r.n. constipation. 12. Sirolimus 4 mg p.o. q.d. 13. Tacrolimus 2 mg p.o. b.i.d. 14. Nystatin 5 cc p.o. q.i.d. as needed for thrush. 15. Lantus 5 units subcutaneously q.h.s. as a regular insulin sliding scale. The patient is also recommended to have outpatient laboratory work every Monday and Friday starting on [**2157-10-7**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2157-10-6**] 11:39 T: [**2157-10-8**] 16:08 JOB#: [**Job Number 103031**]

Admission Date: [**2166-4-30**] Discharge Date: [**2166-5-9**] Date of Birth: [**2100-7-6**] Sex: F Service: MEDICINE Allergies: Amoxicillin / Bactrim / Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 613**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 65 y.o. female with PMHx of COPD, esophageal stricture s/p dilatation in [**Month (only) 404**] who presents with a chief complaint of falls. Patient reports a long history of falls, with 1 fall each day for the past 3 consecutive days. She reports some dizziness occasionally prior to these falls, but otherwise denies prodrome of chest pain, SOB, palpitations. She reports hitting her head with her falls, but denies LOC. She also recently fell on her right chest and has had subsequent pain. She attributes her falls to decreased vision (has a history of cataracts s/p two surgeries on the right, many years ago) and is also supposed to ambulate with a walker, but doesn't always comply. She also wears 2 liters of oxygen at baseline and has noted that she occasionally trips over her oyxgen tubing while trying to ambulate. She thus primarily comes in with a complaint of falls, but noted a cough productive of yellow/brown sputum for the past 2 months with subjective fevers (sweats) for which she was further evaluated. She reports her grandchildren as well as a gentleman in her building as potential sick contacts, but otherwise denies any recent travel or exposures. She does report getting her flu shot last year and receiving her pneumovax 2 years ago. . In the ED, patient was noted to be tachycardic to the 120s and hypoxic to 89% on RA. This improved to 96% on NRB after a failed attempt with nasal cannula. Patient was also noted to have a lactate of 3.3 and a leukocytosis to 22.8 with a bandemia of 9%. CXR showed right middle and lower lobe infiltrates, concerning for PNA and given hypoxia, lactic acidosis and leukocytosis, patient was started on Levofloxacin and Ceftriaxone. Otherwise, patient was noted to have acute renal failure from 0.6 to 1.3 and she was given 1 L of NS. Additionally, potassium of 2.4 was repleted. EKG was performed which was unremarkable, but troponin x 1 was elevated to 0.05 in the setting of ARF and ASA was given. Patient was asymptomatic otherwise. Lastly, given history of recent falls, CT neck and head were performed without evidence of fracture or bleed. Patient was subsequently admitted to the ICU for further management of probable pneumonia with significant hypoxia and bandemia. . Upon arrival in the ICU, patient was on NRB, speaking in full sentences, not in acute distress. She complained of right sided chest pain due to her fall and also endorsed dysuria and hematuria. Otherwise, she had no complaints. Past Medical History: #Esophageal stricture s/p dilatation by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] #Peptic ulcer disease s/p subtotal gastrectomy and repair of hiatal hernia with fundoplication in [**2163-8-19**] by Dr. [**Last Name (STitle) **] for a nonhealing ulcer #COPD (no PFTs in OMR) #GERD #Depression #PTSD #Anemia #Hyperlipidemia #C-section x 2 ('[**27**], '[**28**]) Social History: Lives alone in [**Hospital3 **] in [**Hospital1 3494**] on SSI and disability. Still continues to smoke an unquantified amount. She denies alcohol or illicit drugs. She has 3 children, but is estranged from them. She was the victim of domestic disputes with her ex-husband, but currently lives alone and feels safe. Family History: Asthma (children), brother with depression and PTSD Physical Exam: Vitals: T: 99.0, BP: 141/87, P: 110 R: 24 O2: 94% 4L NC. General: Awake, alert, NAD, speaking in full sentences, no accessory muscle use. HEENT: NC/AT; pale conjunctiva, PERRLA, EOMI; OP clear, nonerythematous Neck: Supple, no JVD Lungs: Decreased BS bilaterally, no wheezes, ronchi, crackles CV: RR, normal S1 + S2, [**1-24**] SM at 2RICs not radiating, no murmurs, rubs, gallops Abdomen: Soft, tender to palpation RLQ, no rebound or guarding, + BS, old midline surgical incision Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Neuro: Alert, oriented x 2, attention impaired. Pt. unable to cooperate with a full neurlogical exam. Proprioception appears to be impaired in LLE, upgoing toes b/l. DTRs 3+ at patella b/l. Impaired FTN and [**Doctor First Name **]. Pertinent Results: Labs on admission and discharge: . [**2166-4-30**] 05:10PM BLOOD WBC-23.8*# RBC-3.35* Hgb-7.9* Hct-25.8* MCV-77*# MCH-23.5*# MCHC-30.5* RDW-16.9* Plt Ct-548* [**2166-4-30**] 07:35PM BLOOD Neuts-72* Bands-19* Lymphs-4* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2166-5-7**] 07:05AM BLOOD WBC-11.6* RBC-3.00* Hgb-7.7* Hct-23.3* MCV-78* MCH-25.6* MCHC-32.9 RDW-18.3* Plt Ct-431 . [**2166-4-30**] 05:10PM BLOOD PT-15.8* PTT-33.1 INR(PT)-1.4* . [**2166-5-5**] 07:50AM BLOOD Ret Aut-0.3* . [**2166-4-30**] 05:10PM BLOOD Glucose-181* UreaN-31* Creat-1.3* Na-136 K-2.4* Cl-95* HCO3-24 AnGap-19 [**2166-5-7**] 07:05AM BLOOD Glucose-122* UreaN-3* Creat-0.5 Na-141 K-3.1* Cl-100 HCO3-33* AnGap-11 . [**2166-4-30**] 05:10PM BLOOD ALT-11 AST-25 CK(CPK)-794* AlkPhos-122* TotBili-0.5 . [**2166-4-30**] 05:10PM BLOOD cTropnT-0.05* [**2166-5-1**] 12:00AM BLOOD CK-MB-5 cTropnT-0.05* [**2166-5-1**] 06:15AM BLOOD CK-MB-6 cTropnT-0.03* . [**2166-4-30**] 05:10PM BLOOD Calcium-8.7 Phos-2.3*# Mg-2.1 Iron-7* [**2166-4-30**] 05:10PM BLOOD calTIBC-256* Ferritn-160* TRF-197* [**2166-5-1**] 06:15AM BLOOD Albumin-2.4* Calcium-7.4* Phos-2.6* Mg-2.7* . [**2166-4-30**] 05:27PM BLOOD Lactate-3.3* [**2166-5-1**] 01:12AM BLOOD Lactate-1.0 [**2166-5-3**] 04:48AM BLOOD TSH-0.33 . [**2166-4-30**] 05:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2166-4-30**] 05:55PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2166-4-30**] 05:55PM URINE RBC-0-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 [**2166-4-30**] 10:49PM URINE Eos-NEGATIVE [**2166-4-30**] 10:49PM URINE Hours-RANDOM Na-LESS THAN . [**2166-5-6**] 04:01AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2166-5-6**] 04:01AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2166-5-6**] 04:01AM URINE RBC-45* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 . Microbiology: . [**2166-5-7**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING INPATIENT [**2166-5-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING INPATIENT [**2166-5-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2166-5-6**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2166-5-6**] URINE URINE CULTURE-FINAL INPATIENT [**2166-5-6**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2166-5-5**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2166-5-5**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2166-5-4**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT . [**2166-5-2**] URINE Legionella Urinary Antigen - negative . [**2166-5-1**] BLOOD CULTURE Blood Culture, Routine-no growth [**2166-5-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-mixed flora . [**2166-4-30**] URINE URINE CULTURE-mixed flora [**2166-4-30**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2166-4-30**] BLOOD CULTURE Blood Culture, Routine-FINAL {STREPTOCOCCUS PNEUMONIAE}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2166-4-30**] BLOOD CULTURE Blood Culture, Routine-FINAL {STREPTOCOCCUS PNEUMONIAE}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] . Blood Culture, Routine (Final [**2166-5-6**]): STREPTOCOCCUS PNEUMONIAE. MEROPENEM = 0.016 MCG/ML = SENSITIVE BY E-TEST. Penicillin SENSITIVE AT 0.032 MCG/ML Sensitivity testing performed by Etest. CEFTRIAXONE SENSITIVE AT 0.023 MCG/ML Sensitivity testing performed by Etest. Note: For treatment of meningitis, penicillin G MIC breakpoints are <=0.06 ug/ml (S) and >=0.12 ug/ml (R). Note: For treatment of meningitis, ceftriaxone MIC breakpoints are <=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R). For treatment with oral penicillin, the MIC break points are <=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R). sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | ERYTHROMYCIN---------- S PENICILLIN G---------- S TETRACYCLINE---------- S TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ S . Imaging/studies: . CXR on admission: . FINDINGS: Portable upright AP chest radiograph is obtained. There is patchy consolidation in the right mid and lower lung, concerning for right middle and lower lobe pneumonia. The left lung appears essentially clear. Cardiomediastinal silhouette appears grossly unremarkable. There is no pneumothorax. Bony structures appear intact. . IMPRESSION: Findings concerning for right middle and lower lobe pneumonia. . ECG on admission: Sinus tachycardia, rate 118. Low voltage in the standard leads. Left atrial abnormality. Compared to the previous tracing of [**2165-8-28**] sinus tachycardia is new as is borderline first degree A-V block. . CT head on admission: . NON-CONTRAST HEAD CT: There is no hemorrhage, edema, mass effect, or acute large vascular territory infarction. There is extensive periventricular white matter hypodensity, consistent with sequelae of small vessel ischemic disease. There is mild prominence of sulci and ventricles, likely secondary to global parenchymal atrophy. There is no shift of normally midline structures. The basilar cisterns are preserved. Osseous structures and surrounding soft tissues, including the globes and orbits, are unremarkable. The left lens appears prosthetic. The visualized paranasal sinuses and mastoid air cells are normally pneumatized and clear. IMPRESSION: 1. Global parenchymal atrophy and sequelae of small vessel ischemic disease. 2. No hemorrhage, edema, mass effect, or acute large vascular territory infarction. . CT neck on admission: . IMPRESSION: 1. No fracture or malalignment. 2. Mild multifocal cervical spondylosis with no evidence for canal stenosis. 3. Biapical pleural scarring. . CT chest [**5-1**]: . IMPRESSION: 1. Findings most consistent with multifocal pneumonia without evidence of cavitation. Partial right middle and left lower lobe atelectasis and small bilateral pleural effusions. 2. Boarderline enlarged mediastinal lymph nodes, likely reactive in nature. 3. 2.6-cm benign-appearing left adrenal lesion. . CXR [**5-2**] - . Since yesterday, right mid and lower lung opacity increased. Left upper and mid lung opacity also increased, very worrisome for rapidly progressing multifocal pneumonia, could be Legionella. Small left pleural effusion also increased. Tiny right pleural effusion is unchanged. The cardiomediastinal silhouette and hilar contours are otherwise normal . ECHO [**2166-5-5**]: . The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus and arch levels are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No valvular pathology or pathologic flow identified. . CXR [**5-5**]: IMPRESSION: Right upper and right middle lobe pneumonia, not significantly changed. Small right pleural effusion. . CT chest [**2166-5-6**] . IMPRESSION: 1. Consolidation in the left lung has almost completely resolved. 2. Consolidations in the right middle lobe and right upper lobe with new areas of cavitation are present. 3. Unchanged left adrenal lesion. 4. Persistent slight decreased small effusions, greater on the right side. Brief Hospital Course: 65 y.o. female with PMHx significant for COPD and esophageal stricture, s/p dilatation in [**Month (only) 404**] who presents with multifocal Streptococcal PNA, sepsis. . Brief ICU course: . She was diagnosed w/ PNA via CT and w/ S. pneumococcal bacteremia ([**2-19**] BCx [**4-30**]). She was started on IV CFTX and Levaquine. Her BCx had been negative since starting CFTx and Levofloxacin, but she had a persistent WBC count and low grade fevers. She was treated w/ ABx as above, and her last fever was noted on [**5-1**] of 101F prior to transfer to the floor, but she has had low grade 100 fevers since admission. Her oxygen requirement improved to 4L NC and her RR decreased to 18-22. Pt. was also noted to have a microcytic anemia of unclear etiology, with nadir HCT of 18, transfused 2 U prbcs and has since been HD stable w/ HCT in mid 20s. Finally, patient has been tachycardic in 100s - 110s, in sinus rhythm. This was felt to be due to sepsis. She was transferred to the medical floor on for further management. . Her course was complicated by worsening WBC and fever while on the medical floor with RML consolidation developing cavitations, and multiple loose stools. Please see below for detailed discussion of each of the problems. . # PNA and S.Pneumo Sepsis. Infiltrates were felt to be due to CAP with resultant bacteremia (strep pneumo). Pt. had persistent leukocytosis. There was no aspiration noted with Video swallow, however she was noted to have penetration of thin liquids. She was continued on CFTX on the floor. However, on [**5-6**], developed Fever, and increasing O2 requirement. She was again pancultured and a CT was repeated showing improved L consolidation, slight improvement on the right but new air loculations. Due to concern for empyema (staph or strep), her ABx regimen was broadened to Vancomycin and Zosyn for treatment of HAP and Aspiration PNA. Patient remained HD stable. Due to wheezing on exam, she was started on standing ipratropium and albuterol nebulizers. With this treatment, her WBC continued to improve, and her O2 requirement resolved. She had an an episode of fever on [**5-6**] to 101.3F. CT chest was obtained and showed improved infiltrate on L and R, but newe air loculation. She was broadened to Vanco/Zosyn for one day but defervesced prior to these ABx being administered. Pulmonary team was consulted regardging bronchoscopy, and it was decided that in face of clinical improvement and likelyhood of the cavitation being [**1-20**] Strep Pneumo and/or anaerobes (too short of a course for Staph to have developed cavitation in < 24hrs if VAP). She was switched to Cefpodoxime PO and Flagyl PO for 2 weeks (day 1 = [**5-8**], pt had already received 7 days of either CFTX/Levofloxacin or Vanc/Zosyn) for a total course of 3 weeks. She will require a follow up CXR by end for 2 weeks (last day [**2166-5-22**]). PCP follow up is arranged for [**5-19**]. Please fax this summary and any rehab course notes to PCPs office prior to discharge. She will require weaning of nebulizers and restarting of home advair and starting of tiotropium for her COPD. . # Leukocytosis: Likely reactive from pulmonary infection vs. C.diff. as patient with loose stools and was on ABx > 5d prior to onset of diarrhea. Given high grade bacteremia and new murmur, TTE was obtained and did not show vegetations. Her first C.Diff was negative but she was tx empiricaly with PO Vanco given persistently loose stools and Age > 65. Her UA/UCx were negative. C.Diff retunred negative x3 and PO vanco was discontinued [**5-8**] after 2 days of tx. She was started on Flagyl as above. She remained afebrile since [**5-5**] and her WBC was 11 on day of discharge. She had persistent [**Last Name (un) 940**] stools, but of lower frequency, 5 -> 3/day. . # Anemia, microcytic. Hct at baseline, 29-30. Currently HCT 23-25, same as on admission s/p 2U PRBCs. Pt. has hx of iron deficiency anemia, confirmed on labs in [**2162**]. Previously was on iron that was stopped for unclear reasons. No colonoscopy in our system, but patient has had a history of UGI bleed, last EGD was unremarkable. Guaiac negative in the ED. There were no signs of hemolysis. Anemia was felt to be multifactorial (ACD, Fe defficiency). Per discussio w/ PCP, [**Last Name (NamePattern4) **]. [**Doctor First Name 111639**], she was reported to have had a colonoscopy that revealed 12 cm of colitis, showing acute on chronic inflammation, with ? of chronic ischemia. Her HCT upon discharge was 25 and stable. She will require a repeat outpatient colonoscopy and endoscopy. . # Elevated Troponin: In the setting of renal failure with normal EKG and asymptomatic. Troponins trended down, and there were no CK elevations. Likely due to demand. No signs of HF, EF > 60%, no WMA. She was continued on ASA 81mg. . # PTST/Depression: Contact[**Name (NI) **] patient's outpatient provider and confirmed diagnoses of PTSD and Depression. Patient has been actively obtaining treatment as OP prior to admission. She had two episodes of emotional lability and crying spells. Her attention was impaired (felt to be due to delerium in setting of infection). Patient probably had underlying dementia (global parenchymal atrophy and periventricular white matter disease on CT head), however this could not be evaluated in setting of delirium. She was continued on Celexa, Quetiapine and Duloxetine at home doses. Her ativan was temporarily held due to delerium but was restarted at 2mg [**Hospital1 **]. Her home dose is 2mg [**Hospital1 **] and 4mg QHS, which can be restarted prn as pt is remains stable. . # S/P Falls: Appears multifactorial - decreased vision, non-compliance with walker, complicated by oxygen tubing tripping and likely acutely worsened in the setting of impending infection prior to admission. CT head and c-spine without bleeding or fractures. Per PT will require acute level rehabilitation. . # Poor nutritional status. Pt. denies poor PO intake, but Albumin is 2.4. Noted to have poor PO intake by nursing staff in CCU. Has hx of esophageal stricture. Was started on Ensure supplementation TID. . # Code: FULL (confirmed with patient) . # Communication: Patient is currently at odds with her children and would prefer that communication be done with her SW - [**First Name8 (NamePattern2) 51796**] [**Last Name (NamePattern1) 111640**] at [**Street Address(2) 111641**] in [**Location 17065**]. She is in counseling with this SW and reports a history of domestic violence in the past. She currently feels safe now. She has only allowed staff to speak with her son. Finally, Pt reports she is in the process of being evicted, and states she does not want her family to know. She said case manager at Elder Services has been helping to deal with eviction problem, and consented to this SW calling her (Anjale [**First Name9 (NamePattern2) 111642**] [**Hospital1 8**] [**Hospital1 3494**] Elder Services [**Telephone/Fax (1) 16681**]). Medications on Admission: 1. Combivent 2. Citalopram 40 mg PO QD 3. Advair 250-50 mcg [**Hospital1 **] 4. Lorazepam 2 mg PO QID and 4mg QHS 5. Pantoprazole 40 mg PO BID 6. Quetiapine 300 mg PO QHS and 200 mg QPM. 7. Duloxetine 30 mg PO QHS 8. Albuterol PRN 9. Mesalamine (in OMR, but patient can't recall if still taking) 10. Ondansetron 4 mg PO Q8 PRN 11. Aspirin 325 mg Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 3. Quetiapine 300 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QPM as needed for insomnia. 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO HS (at bedtime). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Ativan 2 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia, anxiety: Hold for sedation. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 2 weeks. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. 16. Acetaminophen 500 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours) as needed for pain. 17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 18. Outpatient Lab Work CBC, Chem 10 within 1 week of discharge from the hospital 19. Imaging Patient will require a CXR after completion of ABx and results faxed to PCP's office to confirm resolution of PNA. Discharge Disposition: Extended Care Facility: [**Hospital 2251**] Nursing and Rehab Discharge Diagnosis: Primary: Streptococcal sepsis, multifocal community acquired pneumonia Secondary: COPD, PUD, Esophageal stricture, Anemia, PTSD Discharge Condition: Stable Discharge Instructions: You were admitted to [**Hospital1 18**] with severe pneumonia and bacterial in your blood. For this you were treated with intravenous antibiotics. With this treatment your breathing improved. You were transitioned to by mouth antibiotics. Your course was complicated by worsening anemia (low blood cell count) that require blood transfusions. After transfusions, your blood levels remained stable. You will require an outpatient colonoscopy and endoscopy. Several changes were made to your medications, please refer to the list below and take these medications as prescribed. You should have an outpatient colonoscopy to evaluate your anemia. Your PCP or your GI doctor can arrange this for you. Please call your doctor or return to the nearest emergency room for: recurrent nausea/vomiting, dehydration, blood in your vomit, chest pain, bloody stools, shortness of breath, chest pain, abdominal pain, fainting, fevers, chills, cough, or any other concerning symptoms. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2166-9-22**] 12:30 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2166-9-22**] 12:30 Please follow up with your psychiatrist, Dr. [**First Name (STitle) **] on [**First Name9 (NamePattern2) 111643**] [**2168-5-27**].30 am, please call to confirm your appointment, [**Telephone/Fax (1) 111644**]. Please follow up with your primary care doctor, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-[**Doctor First Name **], on [**2166-5-19**] at 11.30 am. Please call [**Telephone/Fax (1) 14315**] to confirm your appointment. Should you be in rehabilitation at time of your PCPs appointment, please change this to acommodate with your discharge from rehabilitation. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2166-5-9**]

Admission Date: [**2198-9-7**] Discharge Date: [**2198-9-11**] Date of Birth: [**2117-12-20**] Sex: F Service: MEDICINE Allergies: Codeine / Penicillins / Erythromycin Base / Morphine Attending:[**First Name3 (LF) 800**] Chief Complaint: hypotension s/p syncope Major Surgical or Invasive Procedure: none History of Present Illness: 80 year old woman with a history of COPD, HTN, CRI who presents with syncope and hypotension. She reports a recent over the past 5 days with whitish phlegm which turned green 1 day prior to admission. She denies fevers, chills or night sweats. According to the patient she awoke this morning to the sound of someone knocking on the door and the phone ringing. She went to get up and slid from her bed to the floor. She denies hitting her head or losing consciousness. She states her legs gave out on her. She report her legs given out 2 other times in the past. She denies dizziness, lightheadedness, palpitations. According to her daughter she was found by the concierge at her home on the floor with vomit and urine and her fall was not witnessed. She denies losing her urine and does not recall if she vomited. EMS was called. Initial vitals by EMS were BP 120/70 O2 sats 95% on NRB. . In the ED, initial vs were: T97.4 HR77 BP71/31 RR20 O2sats 93 on 4L NC. Patient was given 4L NS for resuscitation. A FAST scan was done showing a 3.8cm AAA. Given her AAA and hypotension, a vascular surgery consult was called. She underwent non-contrast CT torso which showed a LLL infiltrate. Vascular surgery was not concerned about the AAA. She was given 1gm CTX, 750mg Levofloxacin and 500mg Flagyl. Blood pressures improved to the mid-90s but then started to trend down. A R femoral CVL was placed and she was started on Levophed. Lactate was 2.2. She was found to be in acute renal failure with a creatinine of 2.6. Potassium was 5.6. Her WBC was 19.1 with 13% bands. INR was noted to be 4.3. Blood cultures were obtained. . On arrival to the ICU she complains of cough without significant shortness of breath. She is otherwise comfortable without pain. She denies nausea, headache, chest pain, dysuria. Pressors were weaned, and the patient was transferred to the floor after being afebrile. . Review of sytems: (+) diarrhea in the past week. she reports diarrhea on and off for her lifetime. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Pulmonary Embolism [**2-25**] on coumadin - Hypertension - Hypercholesterolemia - Monoclonal gammopathy - COPD - Arthritis - Gastrointestinal ulcers - Gastric esophageal reflux disease - Kidney stones 55 years ago in the setting of pregnancy - Elevated PTH - Chronic renal insufficiency with baseline 1.1 to 1.5 - Abdominal aortic aneurysm measuring 4.2 cm - Possible pons lacune infart noted on [**1-24**] MR [**Name13 (STitle) 2853**] - Peripheral Neuropathy of unclear etiology Social History: The patient lives alone. She is divorced and her former husband is now deceased. She has five children. She previously worked as a laboratory technician at [**Location (un) 86**] State Hospital and an office manager. She has a 50 pack year smoking history but quit greater than 25 years ago. She drinks [**2-17**] glasses of wine per day. She denies use of illicit drugs. Family History: The patient's mother died from a myocardial infarction at age 60. Her mother had hyperthyroidism. The patient's father had a myocardial infarction at age [**Age over 90 **] and a benign brain tumor. She has a sister with breast cancer. Her daughter has juvenile rheumatoid arthritis. There is no family history of gastric disorders or kidney stones. Physical Exam: Vitals: T: 98.4 BP: 118/80 P: 81 R: 18 O2: 93% on RA General: Alert, oriented, elderly female, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: decreased breath sounds on left side, otherwise clear CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic ejection murmur at the LUSB Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+ peripheral edema bilaterally, former site of femoral catheter (now withdrawn) on the right is C/D/I Neuro: A&O x 3, CNII-XII grossly intact. Pertinent Results: Labs On admission: [**2198-9-7**] 07:31PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2198-9-7**] 07:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2198-9-7**] 07:31PM URINE RBC-0-2 WBC-[**7-26**]* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2198-9-7**] 06:30PM URINE HOURS-RANDOM CREAT-96 SODIUM-27 POTASSIUM-98 CHLORIDE-62 [**2198-9-7**] 06:30PM URINE OSMOLAL-440 [**2198-9-7**] 03:51PM K+-5.6* [**2198-9-7**] 12:42PM LACTATE-2.2* [**2198-9-7**] 12:20PM GLUCOSE-144* UREA N-49* CREAT-2.6*# SODIUM-137 POTASSIUM-7.0* CHLORIDE-105 TOTAL CO2-25 ANION GAP-14 [**2198-9-7**] 12:20PM estGFR-Using this [**2198-9-7**] 12:20PM ALT(SGPT)-47* AST(SGOT)-69* ALK PHOS-65 TOT BILI-0.3 [**2198-9-7**] 12:20PM LIPASE-18 [**2198-9-7**] 12:20PM cTropnT-<0.01 [**2198-9-7**] 12:20PM ALBUMIN-3.4* [**2198-9-7**] 12:20PM WBC-19.1*# RBC-3.84* HGB-10.9* HCT-33.2* MCV-87 MCH-28.5 MCHC-32.9 RDW-14.7 [**2198-9-7**] 12:20PM NEUTS-81* BANDS-13* LYMPHS-1* MONOS-4 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2198-9-7**] 12:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2198-9-7**] 12:20PM PLT SMR-NORMAL PLT COUNT-248 [**2198-9-7**] 12:20PM PT-40.5* PTT-41.4* INR(PT)-4.3* On Discharge: [**2198-9-11**] 05:15AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.0* Hct-29.9* MCV-84 MCH-28.1 MCHC-33.5 RDW-14.3 Plt Ct-260 [**2198-9-11**] 05:15AM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-138 K-4.0 Cl-103 HCO3-29 AnGap-10 [**2198-9-11**] 05:15AM BLOOD ALT-31 AST-17 [**2198-9-11**] 05:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.4* Radiology: CHEST (PORTABLE AP) Study Date of [**2198-9-7**] 12:18 PM IMPRESSION: Mild central vascular congestion without overt failure. Bibasilar atelectasis. Increased opacity of the retrocardiac left lower lobe may reflect underlying pneumonia or aspiration. Correlate clinically. CT CHEST W/O CONTRAST Study Date of [**2198-9-7**] 12:34 PM LUNG BASES: There is consolidation and ground-glass opacification of the superior segment of the left lower lobe, as well as portions of the posterior basal segment of the right lower lobe. CT HEAD W/O CONTRAST Study Date of [**2198-9-7**] 12:33 PM IMPRESSION: No acute intracranial process. CT ABDOMEN W/O CONTRAST Study Date of [**2198-9-7**] 12:34 PM IMPRESSION: 1. No evidence of rupture of the patient's 3.8-cm abdominal aortic aneurysm. Stability in size maintained. 2. Area of density within the left breast has a lucent center, and may represent an intramammary lymph node, fat necrosis, or oil cyst. Recommend correlation with mammogram. 3. Stable appearance of adrenal nodule over 5 years, described above. 4. Status post cholecystectomy, with stable and expected dilatation of the common bile duct. 5. Diverticulosis with no evidence of diverticulitis. US ABD LIMIT, SINGLE ORGAN PORT Study Date of [**2198-9-8**] 1:54 PM IMPRESSION: Stable common bile duct at approximately 9 mm. The liver echotexture is normal and there is no underlying suggestion of cirrhosis or other parenchymal disease. No mass lesion identified. There is no intrahepatic biliary dilatation. There has been interval development of a small right pleural effusion. Known abdominal aortic aneurysm is stable in size since yesterday. BILAT UP EXT VEINS US Study Date of [**2198-9-8**] 1:54 PM IMPRESSION: No DVT in either upper extremity. Brief Hospital Course: 80 year old woman with a hx of PE on coumadin, HTN who presents with syncope, hypotension and likely PNA concerning for sepsis. . 1. Hypotension: Likely from sepsis given her chest CT findings of PNA, elevated WBC and cough. She had no fevers. She received 4L NS in the ED but continued to appear clinically dry. Volume resuscitation was continued in the MICU along with levophed which was weaned over 24 hours. PNA treatment was begun with with ceftriaxone and levofloxacin, but was later switched to cefpodoxime and levofloaxin, for a total 8 day course. Patient's blood pressure on the floor was normotensive, although we continued to hold her home medications of HCTZ, Amlodipine, and Benzepril, and discharged her with instructions to follow-up with her PCP if she should resume this medications. . 2. Acute Renal Failure: Prior kidney function 1.2. Patient made good urine throughout her hospitalization. Her creatinine peaked at 2.6 and trended down to a nadir of 1 upon discharge with volume resuscitation and holding nephrotoxic meds. 3. UTI: On [**2198-9-7**], the patient was noted to have a UTI on urine culture from E. Coli, which was sensitive to ceftriaxone. As the patient was being treated for PNA with ceftriaxone and levofloxacin, we did not change her antibiotic regimen, which should appropriately cover her for an uncomplicated UTI. . 3. Hyperkalemia: Felt to be secondary to acute renal failure in the setting of taking potassium and triamterene and benazepril. ECG without peaked T waves. Offending meds were held during the hospitalization, and were held until patient can follow-up with her primary care physician. [**Name10 (NameIs) **] patient's hyperkalemia improved with aggressive IV fluid resusitation, and her discharge K was 4.0. . 4. Syncope: Likely from hypotension, hypovolemia. It is concerning that the patient lost urine but not other signs of seizure activity during her stay in the MICU or on the floor. The patient was monitored on tele without event. An EEG was not done. . 5. Elevated INR: Likely due to infection and coumadin use. No signs of active bleeding. Would expect INR to rise with recent antibiotics. Coumadin was initially held and then restarted prior to discharge, with an INR on discharge of 2.7. . Code: Full (discussed with patient) Medications on Admission: Hydrochlorothiazide 25 mg Tab PO daily Bisoprolol Fumarate 2.5 mg Tab PO daily Omeprazole 40 mg Cap, Delayed Release 1 tab PO Daily Klor-Con 8 mEq Tab 1 tab PO BID Amlodipine 5 mg Tab 1 tab PO daily Benazepril 40 mg Tab PO daily Multivitamin Tab 1 tab PO daily Triamterene 50 mg PO daily Simvastatin 80mg PO daily Trazadone 100-150mg PO qHS PRN - has not taken this in the past few day but perhaps monday, tuesday and wednesday Coumadin alternating 1.5mg with 2mg this week Gabapentin 100mg PO TID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Sepsis secondary to Community Acquired Pneumonia Urinary Tract Infection . Secondary Diagnoses: Hx Pulmonary Embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU for low blood pressure in the setting of pneumonia. You were treated with IV fluids and antibiotics and your symptoms improved. You should complete a total of 8 days of antibiotics, and follow-up with your PCP. . We made the following changes to your home medications: -Start Cefpodoxime - continue for 6 more days to end on [**2198-9-16**] -Start Levofloxacin - continue for 6 more days to end on [**2198-9-16**] (this is an every-other-day medication). -STOP Hydrochlorothiazide, Amlodipine, Benazepril, Triamterene and Klor-Con until you see your PCP on [**Name9 (PRE) 2974**]. He will decide if you should resume this medications. -CHANGE Coumadin to 1.5 Mg daily for this week - please have your INR drawn tomorrow, Wednesday the 28th at your PCP's office. Followup Instructions: Please have your INR drawn tomorrow at your PCP's office. You have an appointment to see your PCP on [**Name9 (PRE) 2974**]: Name: [**Last Name (LF) 7726**],[**First Name3 (LF) 177**] A. When: FRIDAY, [**2198-9-14**]:30 AM Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 7728**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

Admission Date: [**2117-7-22**] Discharge Date: [**2117-7-31**] Date of Birth: [**2036-6-4**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 943**] Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: EGD Central venous line access History of Present Illness: This is a 81 year old female who presented to an outside hospital 3 weeks prior to admission with nausea, vomiting, diarrhea, and abdominal pain. She was diagnosed with cirrhosis of unknown etiology; she was negative for hepatitis, hemachromatosis, and history of alcoholism. Her symptoms improved and she was discharged. She presented to [**Hospital1 18**] with similar symptoms. CT scan of the abdomen demonstrated complete thrombosis of the SMV with partial thrombosis of the main PV and intrahepatic left and right portal veins and multiple abnormal loops of small bowel in the pelvis with wall thickening. Patient was started on heparin drip. Foley & NGT were placed. She received vancomycin & Zosyn in the ED, which was switched to Cipro and Flagyl on admission to the ICU. Past Medical History: hypertension cirrhosis osteoarthritis dyslipidemia h/o ureteral stone seborrheic keratosis thrombocytopenia appendectomy herpes zoster GERD osteopenia depression hip replacement cellulitis Social History: She denies EtOH, tobacco, and illicit drug use. She denies herbal and over-the-counter medications. Family History: aunt with ovarian ca daughter with breast ca in 50s no family history of liver disease Physical Exam: per Dr. [**Last Name (STitle) **] on initial presentation: 98.1 65 145/61 20 98% 4L gen: minimally response CV RRR pulm: CTAB abd: soft, nondistended, mildley tender on right rectal: heme pos Pertinent Results: Admission labs: 137 105 15 -------------< 117 3.7 21 0.7 Ca: 9.4 Mg: 1.7 P: 2.6 ALT: 25 AP: 271 Tbili: 2.0 Alb: 3.2 AST: 32 LDH: Dbili: TProt: [**Doctor First Name **]: 52 Lip: 54 . 12.9 9.9 >-----< 165 D 41 N:85.3 Band:0 L:9.7 M:3.7 E:0.9 Bas:0.4 . Trends and discharge labs: [**2117-7-31**] 06:45AM BLOOD WBC-5.7 RBC-3.16* Hgb-10.1* Hct-30.7* MCV-97 MCH-32.0 MCHC-32.9 RDW-16.2* Plt Ct-PND [**2117-7-26**] 05:06AM BLOOD PT-19.5* PTT-67.8* INR(PT)-1.9* [**2117-7-27**] 06:00AM BLOOD PT-21.1* PTT-62.3* INR(PT)-2.0* [**2117-7-28**] 05:21AM BLOOD PT-21.5* PTT-93.3* INR(PT)-2.1* [**2117-7-29**] 05:03AM BLOOD PT-20.7* PTT-33.5 INR(PT)-2.0* [**2117-7-30**] 06:15AM BLOOD PT-20.6* PTT-33.0 INR(PT)-2.0* [**2117-7-31**] 06:45AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-134 K-3.4 Cl-98 HCO3-33* AnGap-6* [**2117-7-22**] 06:05AM BLOOD ALT-25 AST-32 AlkPhos-271* Amylase-52 TotBili-2.0* [**2117-7-23**] 02:15AM BLOOD ALT-17 AST-26 LD(LDH)-231 AlkPhos-193* Amylase-36 TotBili-0.8 [**2117-7-24**] 01:57AM BLOOD ALT-17 AST-21 LD(LDH)-202 AlkPhos-171* Amylase-28 TotBili-0.6 [**2117-7-25**] 05:30AM BLOOD ALT-15 AST-21 LD(LDH)-191 AlkPhos-164* Amylase-27 TotBili-0.7 [**2117-7-26**] 05:06AM BLOOD ALT-15 AST-25 AlkPhos-159* Amylase-46 TotBili-0.8 [**2117-7-27**] 06:00AM BLOOD ALT-13 AST-26 LD(LDH)-213 AlkPhos-151* Amylase-45 TotBili-0.8 [**2117-7-28**] 05:21AM BLOOD ALT-16 AST-31 AlkPhos-156* TotBili-1.0 [**2117-7-29**] 05:03AM BLOOD ALT-15 AST-34 AlkPhos-179* TotBili-0.8 [**2117-7-27**] 06:00AM BLOOD Albumin-2.1* Calcium-7.9* Phos-2.8 Mg-2.1 [**2117-7-24**] 06:21AM BLOOD Lactate-1.4 . CT Abd/Pelvis ([**2117-7-22**]) IMPRESSION: 1. Complete thrombosis of the superior mesenteric vein with partial thrombosis of the main portal vein and intrahepatic left and right portal veins. 2. Multiple abnormal loops of small bowel within the pelvis with wall thickening. This likely represents venous congestion from thrombosis of the mesenteric veins. An enterocolitis (inflammatory/infectious) with secondary thrombosis of the mesenteric veins is also a possibility. The mesenteric arteries are patent; however, mesenteric ischemia from venous congestion cannot be excluded. 3. Shrunken, nodular liver, esophageal varices and ascites, all compatible with cirrhosis. . CT Abd/Pelvis ([**2117-7-27**]) IMPRESSION: 1. Stable thrombosis of the portal vasculature including partial thrombosis of the main portal vein, complete thrombosis of the left portal vein, partial thrombosis of the right portal vein, complete thrombosis of the superior mesenteric vein. 2. Improving multiple small bowel loops with decreased wall thickening and dilatation. 3. Stable cirrhotic liver. 4. Markedly increased ascites. . EGD: Impression: Grade 1 varices at the lower third of the esophagus Portal Hypertensive Gastropathy - oozing with blood and causing melena. Otherwise normal EGD to second part of the duodenum Recommendations: Requires: 1) Protonix- 40mg [**Hospital1 **] 2) Carafate - 1gram qid . Micro: c diff neg stool cx neg blood cx ngtd Brief Hospital Course: 81yo woman with cirrhosis here with SMV thrombosis. Hospital course by problem: . #Complete SMV and partial portal vein thrombosis. SMV and portal vein thromboses demonstrated on CT of [**7-22**] which was repeated on [**7-27**] showing little change. Hepatobiliary Surgery was consulted urgently in the ED for management of SMV thrombosis with ischemic bowel. Serial abdominal exams were benign. Lactate peaked at 1.5 on [**7-22**]. She had episodes of melena on [**7-17**], but remained otherwise asymptomatic. She was in the ICU for close monitoring then transferred to the floor on [**7-25**]. NGT was removed and Coumadin was started. On [**7-26**], her diet was advanced and she was transferred to Hepatology for further management of newly diagnosed cirrhosis. We continued heparin and coumadin until INR was 2.0 for two consecutive days. She received coumadin as follows: 1mg, 1mg, 1mg, 2mg, 2mg, 2mg and discharged on 2mg daily. Her HCT remained stable. She will followup with Dr. [**Last Name (STitle) **] in the liver clinic. [**Last Name (STitle) 18303**] INR is [**2-20**]. . #GI Bleeding Patient had guaiac positive stools and underwent an EGD to assess for varices which showed no active bleeding but had portal gastropathy which was thought to explain the patient's melena. Melena may also have come from venous congestion in small bowel as a result of SMV thrombosis. Repeat CT scan showed resolving venous congestion. HCT dropped 5.5 points from 41 to 34.5 from HD0 to HD1 and then to 30 by HD4, it remained stable after this, without further melena. Ms. [**Known lastname 73649**] had spotting of red blood on pads and toilet paper which was thought to be causing persistant guaiac positive stools. Exam confirmed presence of hemorrhoids but also raised the possibility of vaginal bleeding, which should be investigated as an outpatient. Colonoscopy was deferred given likely friable colon in setting of thrombosis. If BRBPR, we recommend checking hematocrit with [**Known lastname **] >28. If less than 28, discuss with patient's PCP re stopping coumadin and need for eval. In terms of the possible vaginal bleeding, we recommend outpt gynecology appt. We continued nadolol and PPI and sucralfate. . #Cirrhosis/Edema/abdominal pain Etiology of cirrhosis remains uncertain. Report of investigations at OSH ruled out common viral and autoimmune etiologies, and genetic causes would be unlikely to present at 81years of age. NASH remains a possibility, but this should be investigated further with outpatient hepatology follow up which has been arranged for Ms. [**Known lastname 73649**]. She has experienced significant fluid retention with ascites and lower extremity edema, her weight increasing approximately 4kgs. With Lasix and Aldactone, lower extremity edema has improved significantly but ascites is persistant. Ascites has caused intermittent band like upper abdominal pain which was mostly controlled with oxycodone but occassionally required 0.5mg dilaudid IV. By time of discharge, pain was controlled with oral medications alone. . # HTN: we regulated with her nadolol, spirono, and lasix. We did not continue HCTZ . # Depression: sertraline . # Activity: seen by PT. able to ambulate with assist. . # Code: Full . # Contact: daughter [**Name (NI) **]: [**Telephone/Fax (1) 100371**] Medications on Admission: lorazepam, Darvocet, Fosamax, HCTZ, MVI, Propoxyphene, ranitidine, sertraline, Zocor Discharge Medications: 1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 7. Propoxyphene 65 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for pain. 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain for 1 weeks. Disp:*20 Tablet(s)* Refills:*0* 9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): please adjust per recommendations from your PCP. [**Name10 (NameIs) 18303**] INR [**2-20**]. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 9475**] Care Center - [**Location (un) 3146**] Discharge Diagnosis: Primary: - SMV thrombosis - Cirrhosis - Portal gastropathy Secondary: - GERD - arthritis - HTN - Hyperchol - thrombocytopenia Discharge Condition: well. Able to ambulate with assist Discharge Instructions: You were admitted with abdominal pain and noted to have an SMV thrombosis. This is a clot in the vein near your liver. You also have cirrhosis and some fluid overload. We treated you in the ICU and you stabilized. We continued heparin and started coumadin to keep your blood thin. We also performed an EGD to look for any bleeding in your stomach. You remained stable. . Please take all of your medications as instructed. Please keep your followup appts. It is very important for you to have your coumadin level checked on Monday and followed closely by your PCP. . Please contact your PCP or [**Name (NI) **] if you experience worsening shortness of breath, chest pain, abdominal pain, fevers, or blood loss. . You described some possible vaginal bleeding. You should discuss this with your PCP and possibly see a gynecologist. Followup Instructions: Please followup with Dr. [**Last Name (STitle) **] on Thursday [**8-5**] at 11:30am. His office is [**Telephone/Fax (1) **] . Please followup with Dr. [**Last Name (STitle) **] on [**8-24**] @ 12:15pm. You may reach him at ([**Telephone/Fax (1) 1582**].

Admission Date: [**2165-8-2**] Discharge Date: [**2165-8-5**] Date of Birth: [**2098-2-18**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Dark blood from G-tube Major Surgical or Invasive Procedure: EGD-ulcer in the distal esophagus with active bleeding. s/p clipping of the vessel with good homostasis. History of Present Illness: 67 yo M with h/o CAD, recently admitted from [**6-21**] to [**7-25**] where he presented with severe headache, CT notable for large intracranial bleed. Found to have vertebrobasilar aneurysm, s/p coiling and stenting, ventriculostomy. Course complicated by L sided PE and was treated with heparin. Hospital course also complicated by CHF, failure to wean from vent, s/p trach, PEG placment. Patient was eventually weaned from vent at end of hospitalization. On discharge, patient was able to open eyes to stimulation, and had spontaneous movment of the R side. Patient was discharged on [**Month/Day (4) **], plavix, heparin gtt. Pt. sent to [**Hospital3 **]. Came to ED on [**7-26**] with hypotension , sbp in 80s, responded to IV boluses, cleared by N-[**Doctor First Name **] (no change). On [**8-1**], patient noted to have 50 cc dark blood in G-tube at rehab. In ED, patient was afebrile, hr-82, bp-121/64. Dark blood failed to clear with lavage. GI was subsequently consulted. In ED, hct-30, INR-2.9. Got vit K 5mg sq, IV protonix, 4 units FFP, 2 large [**Last Name (un) **] IVs placed. CXR showing CHF opacities or effusions. EKG showing NSR at 90 bpm, nl axis, IVCD in L bundle pattern, 1-[**Street Address(2) 1766**] depr in V3-6 (old) and TWI in V3-6, I L (old). Past Medical History: -CAD, s/p MI, CABG x 2 in '[**50**] and '[**62**], multiple stents -htn -s/p MV annuloplasty in '[**62**] -s/p AICD -s/p intracranial bleed [**5-28**], per HPI -mult L sided PEs ([**6-28**]) -h/o hyponatremia -VRE pos -CHF - [**6-28**] echo with EF 30%, moderate regional LV systolic dysfunction with near AK of inferior and inferolateral walls, sever HK of anterolat. wall. Physical Exam: T 97.6 BP 121/64 P82 RR30 100% 4LNC Gen: Minimally resonsive, unable to follow commands HEENT: NC/AT, PERRL 2mm bilaterally Lungs: +upper airway sounds, no crackles, no wheezing, good air movement CV: RRR, nl S1, S2, no murmurs Abd: Soft, NTND, no withdraw with deep palpation. +G-tube Ext: no edema, clubbing, cyanosis Neuro: responds minimally to verbal stimuli, withdraws to pain. Pertinent Results: [**2165-8-5**] 04:49AM BLOOD WBC-9.2 RBC-3.52* Hgb-10.6* Hct-32.2* MCV-92 MCH-30.1 MCHC-32.9 RDW-15.6* Plt Ct-400 [**2165-8-4**] 04:34PM BLOOD Hct-34.2* [**2165-8-3**] 11:41PM BLOOD Hct-32.5* [**2165-8-3**] 04:00AM BLOOD WBC-10.0 RBC-3.51* Hgb-10.6* Hct-31.5* MCV-90 MCH-30.4 MCHC-33.8 RDW-15.6* Plt Ct-379 [**2165-8-2**] 10:42PM BLOOD Hct-28.3* [**2165-8-2**] 08:13PM BLOOD Hct-29.2* [**2165-8-2**] 10:03AM BLOOD Hct-23.7*# [**2165-8-5**] 04:49AM BLOOD PT-14.7* PTT-56.5* INR(PT)-1.4 [**2165-8-4**] 08:16PM BLOOD PTT-39.1* [**2165-8-4**] 04:32AM BLOOD PT-14.7* PTT-24.2 INR(PT)-1.4 [**2165-8-3**] 04:00AM BLOOD PT-15.2* PTT-26.1 INR(PT)-1.5 [**2165-8-2**] 10:40AM BLOOD PT-16.7* PTT-30.1 INR(PT)-1.8 [**2165-8-2**] 04:15AM BLOOD PT-20.8* PTT-37.0* INR(PT)-2.9 [**2165-8-5**] 04:49AM BLOOD Glucose-117* UreaN-22* Creat-0.4* Na-143 K-3.9 Cl-108 HCO3-27 AnGap-12 [**2165-8-2**] 04:15AM BLOOD Glucose-113* UreaN-26* Creat-0.6 Na-133 K-5.3* Cl-96 HCO3-29 AnGap-13 [**2165-8-4**] 04:32AM BLOOD ALT-28 AST-30 AlkPhos-124* [**2165-8-3**] 06:45PM BLOOD CK-MB-3 cTropnT-0.07* [**2165-8-2**] 10:43PM BLOOD CK-MB-4 cTropnT-0.05* [**2165-8-2**] 04:00PM BLOOD CK-MB-3 cTropnT-<0.01 Brief Hospital Course: 1)Upper GI bleed: Patient was on coumadin for recent hx of PE and received 4 units of FFP and vit K in the EW to correct his INR. Coumadin was held intinitally for possible active bleed. GI was consulted and EGD was done on [**2165-8-2**] which showed an ulcer in the distal esophagus with active bleeding from that site. Successful clipping of the vessel was achieved using a Resolution Endoclip device and then injected with epinephrine for hemostasis. Patient received total of 3 units of PRBC. Patient was continued on PPI for prophylaxis and serial hematocrit was done which remained stable (Hct>30). 2)Neuro: Patient has a hx of intracranial bleed s/p basilar stent. Patient on Plavix and [**Date Range **] for post-stent prophylaxis. Patient remained lethargic which is his baseline. He was able to follow simple commands at times, moving his hands and feet and occasionally giving verbal response. Per family member, patient appears to be more alert than before. Neurosurgery following this patient and strongly urged to hold Coumadin for the risk of re-bleeding intracranially. After discussion with Dr. [**Last Name (STitle) 1132**] from neurosurgery, it was decided to discharge patient with Lovenox. 3)A-fib: During EGD proceduse, clipping of the bleeding vessel was done and epinephrine was injected to that site. Right after the epinephrine was injected, he went into rapid afib to 150's with ST depressions. He was given a total of 10 mg of lopressor with some decrease in his HR to the 120's-130's. After 10 mg of IV diltiazem, his HR came down to the 90's-100's and his BP dropped to the 80's briefly. MI was ruled out with serial cardiac enzymes and he was given 25 mg of lopressor. Patient remained on sinus tachycardia, and lopressor was titrated up to 50 mg tid. Patient did show good response to IV diltiazem 10 mg. 4)PE prophylaxis: Patient initially on Coumadin 12.5 mg qd and Dalteparin 7500 units [**Hospital1 **], but were held due to GI bleed with INR 2.9 and PTT 37. Neurosurgery seen the patient and strongly discouraged discontinuing Coumadin due to recent history of intracranial bleed. However, patient just had PE and is at risk for another thrombotic event. After discussion with the neurosrugery attending Dr. [**Last Name (STitle) 1132**], it was decided to discharge the patient with Lovenox. 5)ID: On [**8-4**] sputum gram stain showed gram positive cooci and rhonchi on exam. CXR intially appeared as LLL opacity so Vancomycin 1 g q12 was started. However after reviewing the film with the team on [**2165-8-5**], CXR was more consistent with fluid overload with effusion than consolidation. Since patient is afebrile with normal WBC and not showing symptom of pneumonia, Vancomycin was discontinued. Medications on Admission: protonix 40 qd, senna 2 [**Hospital1 **], epo [**2161**] units q Tu/Sat, amantidine 100 [**Hospital1 **], coumadin 12.5 [**Last Name (LF) **], [**First Name3 (LF) **] 325 qd, lopresor 25 [**Hospital1 **], dalteparin 7500 units [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Esophageal bleed Atrial fib Intracranial bleed s/p stent at vertebrobasilar aneurysm Hx of pulmonary embolism CAD CHF Discharge Condition: Hemodynamically stable, no active bleeding. Discharge Instructions: Patient needs to seek medical attention (ED, PCP), if he has bloody vomit, bloody stool, blood from G-tube, dyspnea, chest pain, new neurological deficit, fever/chills. Followup Instructions: Patient needs to be seen by his PCP as soon as possible and he has an appointment with neurosurgery on following date. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Where: LM [**Hospital Unit Name 12006**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2165-8-9**] 2:30 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2165-8-5**]

Admission Date: [**2127-5-30**] Discharge Date: [**2127-6-11**] Date of Birth: [**2127-5-30**] Sex: M Service: NB DISCHARGE DIAGNOSES: 1. Prematurity at 34 weeks gestation. 2. Feeding immaturity, resolved. HISTORY OF PRESENT ILLNESS: [**Known firstname 37958**] [**Name (NI) **] [**Known lastname **] is a 3125 gram product of a 33 and [**5-3**] week gestation (EDC [**2127-7-10**]) [**Month/Day/Year **] to a 33 year-old, Gravida I, Para 0, now I mom, with prenatal screens 0 positive, antibody negative, RPR nonreactive. Rubella immune. Hepatitis B surface antigen negative. GBS negative. Pregnancy was complicated by hypertension. The [**Known firstname **] was [**Name2 (NI) **] by an emergent Cesarean section because of non reassuring fetal heart rate tracing after a trial of induction of labor secondary to hypertension. He had Apgars scores of 4 at 1 minute and 8 at 5 minutes. Mom had been given general anesthesia. He required some positive pressure ventilation in the delivery room for the first minute and a half of life. He was brought to the Neonatal Intensive Care Unit for further evaluation. PHYSICAL EXAMINATION: The infant was large for gestational age; weight 2125 grams, greater than 90th percentile. Head circumference was 32.75 cm, 90th percentile. Length 48 cm, 90th percentile. Temperature 98. Heart rate 160. Respiratory rate 44. Saturating 98% on room air. Blood pressure 86/37, mean 53. HEENT: Normocephalic, atraumatic. Anterior fontanel open and flat. Red reflex present bilaterally. Neck supple. Lungs clear bilaterally. CV: Regular rate and rhythm, no murmur. Femoral pulses 2+ bilaterally. Abdomen soft, with active bowel sounds, no masses or distention. Extremities: Warm and well perfused. Feet smooth. Consistent with premature infant. Anus normally placed, patent. Spine midline. Hips stable. Clavicles intact. Neurologic: Good tone, moves all extremities equally. HOSPITAL COURSE: Respiratory: He remained stable in room air throughout hospitalization. He had no episodes of apnea or desaturations. Cardiovascular: He remained hemodynamically stable through his hospitalization. Fluids, electrolytes and nutrition: He was started on total fluid volume of 80 cc per kg per day and was advanced to a total fluid volume of 150 cc per kg per day by day of life five. He was started on enteral feeds on day of life two and was able to take all p.o. feeds by day of life six. He is currently on breast milk or premature Enfamil 24 calories per ounce and takes between 140 and 150 cc per kg per day volume feeds. G-sticks have been stable. Electrolytes on day of life four were sodium of 144; potassium of 4.7; chloride of 107 and bicarbonate of 21. Gastrointestinal: Peak bilirubin on day of life 3 was 10.5 with a direct component of .3. He did not require phototherapy. Infectious disease: He received Ampicillin and Gentamycin for 48 hours. These were discontinue when cultures remained negative at 48 hours. Routine health care management: Hepatitis B vaccine was given. Hearing screen was passed. Initial car seat test failed at the time of dictation and will be repeated before discharge. DISCHARGE MEDICATIONS: Fer-in-[**Male First Name (un) **]. WEIGHT AT TIME OF DISCHARGE: 3.070 kg. DISCHARGE DATE: Discharged on day of life 12, corrected to 35 and 3/7 weeks. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2127-6-10**] 16:41:37 T: [**2127-6-10**] 17:03:11 Job#: [**Job Number 94151**]

Admission Date: [**2103-7-24**] Discharge Date: [**2103-7-26**] Service: CHIEF COMPLAINT: The patient is a 78 year old female with a past medical history significant for obstructive sleep apnea, pulmonary hypertension, chronic hypercapnic and hypoxemic respiratory failure, who presented with worsening shortness of breath and decreased oxygen saturation. HISTORY OF PRESENT ILLNESS: The patient is a 78 year old woman with a history of long-standing obstructive sleep apnea and subsequent pulmonary hypertension. Two days prior to admission, the patient reported experiencing gradual worsening shortness of breath. On the morning of admission, the patient's daughter found the patient severely short of breath, cyanotic and called EMS. When EMS arrived, the patient was noted to have a room air oxygen saturation in the 60% range and she was noted to be tachypneic with a respiratory rate in the 40s. Upon arrival in the [**Hospital1 69**] Emergency Department, the patient was noted to be cyanotic and her vital signs showed a heart rate of 85, blood pressure 175/77, respiratory rate 32, and she was saturating at 97% on 100% nonrebreather face mask. She denied any chest pain at the time of Emergency Department presentation. She denied any [**Last Name (LF) **], [**First Name3 (LF) 691**] fever or chills. She denied any nausea or vomiting. There was no abdominal pain. She denied any urinary symptoms, and she denied any symptoms of paroxysmal nocturnal dyspnea. The patient was placed on full face mask BIPAP and was admitted to the Medical Intensive Care Unit for monitoring of her respiratory status. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea. This was diagnosed at least five years prior to the time of admission when sleep studies performed in [**2098-2-17**], showed 43 hypopneas and oxygen saturation in the 70s. This data was from records provided by the patient's primary pulmonologist, Dr. [**Last Name (STitle) 10132**], from [**Hospital3 **] Medical Center. At home, the patient wore CPAP for four to six hours every night and received oxygen via nasal cannula at a rate of 2 to 2.5 liters per minute during the day. 2. Chronic hypercapnic hypoxemic respiratory failure. The patient had room air oximetry studies performed in [**2102-7-21**], again at an outpatient hospital which showed that she spent approximately 63% of her time with oxygen saturation in the 90s, 24% of her time with oxygen saturation in the 80s and 5% of her time with oxygen saturation in the 70s. 3. Restrictive lung disease. 4. Pulmonary hypertension. 5. Hypertension. 6. Coronary artery disease, status post coronary artery catheterization in [**2097-10-18**], which showed clean coronary arteries. 7. Status post inferior myocardial infarction approximately fifteen years ago. 8. Inguinal hernia. 9. Chronic anemia thought to be due to Vitamin B12 deficiency. MEDICATIONS ON ADMISSION: 1. Lasix 40 mg q.d. 2. Atenolol 25 mg once a day. 3. Nitroglycerin patch 0.4 mg transdermal patch applied once a day. 4. Carvedilol 3.125 mg once a day. 5. Allopurinol. ALLERGIES: Reported allergies were to Penicillin and Streptomycin. FAMILY HISTORY: Not assessed. SOCIAL HISTORY: The patient was a Russian speaking woman who had come to the United States from [**Country 532**] eight years ago. She lives alone in the [**Location (un) 86**] area but had two daughters who lived nearby. She had no history of tobacco use and no history of exposure to asbestos or known industrial agents. PHYSICAL EXAMINATION: When we examined the patient, her vital signs revealed a heart rate of 48, blood pressure 89/48, respiratory rate 26, oxygen saturation 92% on BIPAP face mask with a pressure support of 15, PEEP of 5 and FIO2 of 40%. She was noted to be awake, alert and able to respond to questions with the help of translation. Her skin examination was notable for pallor but no cyanosis. Examination of the jugular venous distention revealed jugular venous pulse of 9.0 centimeters. Her chest examination showed diffusely decreased breath sounds, decreased more so on the left side than on the right side, however, there were no wheezes or crackles noted. Her cardiac examination revealed a bradycardic heart rate but at a regular rhythm with a harsh IV/VI systolic murmur heard across the precordium, an occasional S3 but no rubs. Her abdominal examination revealed normoactive bowel sounds, obese but soft abdomen, which was nontender. There was no costovertebral angle tenderness. Examination of her extremities showed dorsalis pedis pulses 1+ bilaterally. Her extremities were warm. There was 1+ bilateral lower extremity edema. She was also noted to have bilateral calf tenderness. LABORATORY DATA: On admission, sodium 142, initial potassium of 7.0 in a hemolyzed specimen with a repeat potassium of 4.9, chloride 96, bicarbonate 37, blood urea nitrogen 23, creatinine 0.8, and glucose of 151. Her complete blood count revealed a white blood cell count of 6.9, hematocrit 37.5, and platelet count of 357,000. The white blood cell count differential included 72% polys, 20 lymphocytes and 7 monocytes. Her coagulation panel showed a prothrombin time of 13.0, partial thromboplastin time of 29.1 and INR of 1.2. Initial CK level was 65. Electrocardiogram showed normal sinus rhythm at a rate of 78 beats per minute with some right axis deviation and right bundle branch block which was unchanged from previous electrocardiogram provided from outside hospital. A chest x-ray showed opacification at the right mediastinal border and prominent pulmonary vasculature but no focal consolidation. HOSPITAL COURSE: In the Emergency Department, an initial arterial blood gas was performed with the patient on 100% nonrebreather face mask. This blood gas revealed a pH 7.19, pCO2 122, and pO2 of 150. After the patient was placed on a face mask with 50% FIO2, a repeat blood gas showed a pH of 7.13, pCO2 of 137, and pO2 of 132. The patient was given a single dose of Levofloxacin in the Emergency Department to treat for community acquired pneumonia. She was also given intravenous Solu-Medrol to treat for any underlying bronchospastic component contributing to her pulmonary decompensation. She was given 1 mg of Morphine Sulfate and also Nitroglycerin paste in the Emergency Department. At the time of her Emergency Department presentation, the patient reported a DNR/DNI code status. Therefore, intubation was not attempted in this patient. Instead, full face mask was the preferred method of oxygen delivery and she was admitted to the Medical Intensive Care Unit for monitoring of her oxygenation and ventilatory status. On the evening of admission, ultrasound studies of the lower extremities were performed and revealed no evidence of deep vein thrombosis. The patient was also diuresed with Lasix, having received a total of 100 mg intravenous Lasix in the Emergency Department and an additional 40 mg of Lasix after admission to the Intensive Care Unit. This produced a net diuresis of negative two liters on the evening of admission. Further antibiotics were held at this time as the patient was afebrile and did not have an elevated white blood cell count and there was low clinical suspicion for pneumonia. Further steroids were also held. Overnight, the patient's oxygenation and ventilatory status improved somewhat based on repeat arterial blood gas analysis. She was placed on nasal CPAP overnight. She subsequently ruled out for myocardial infarction via cardiac enzymes. On [**2103-7-25**], hospital day two, an echocardiogram was obtained in order to assess the possible role of diastolic congestive heart failure contributing to pulmonary edema and the patient's shortness of breath. Following the echocardiogram which was performed at the bedside, the patient experienced a desaturation with oxygen saturation noted to be in the 30 to 40% range. The patient was noted to be profoundly cyanotic and also began to report left sided chest pain. An electrocardiogram was obtained and showed no changes suggestive of acute ischemia. Stat portable chest x-ray also showed no acute change from prior chest x-rays. At the time of this desaturation event, the patient was on nasal CPAP and ultimately after being placed on full face mask BIPAP, the patient's oxygen saturation returned to the 80% range. The echocardiogram ultimately showed an ejection fraction greater than 55%, mild symmetric left ventricular hypertrophy. Both the left atrium and the right atrium were noted to be dilated. There was an overall decrease in right heart function and there was severe pulmonary artery systolic hypertension. Although previously obtained lower extremity ultrasounds had revealed no deep vein thrombosis, we continued to entertain the diagnosis of pulmonary embolism. From the time of her Emergency Department presentation, the patient had been unable to lie flat without becoming profoundly short of breath. Therefore, we had been unable to send the patient for a CT angiogram study to prove the presence of pulmonary embolism. However, after this desaturation event, the decision was made to empirically anticoagulate the patient with Heparin. Her Levofloxacin was also restarted to treat for a presumptive pneumonia. This same day an initial blood culture taken in the Emergency Department returned positive for gram positive cocci in pairs and clusters in one out of two bottles and the patient was begun on Vancomycin. The patient subsequently remained stable from a respiratory standpoint but was noted to have intermittent bradycardia with heart rates in the 30 or 40s which were transient and were not associated with any hypotension. Atropine was placed at the patient's bedside. On the morning of [**2103-7-26**], the patient was restarted on Solu-Medrol to treat for any possible underlying component of bronchospastic disease and the decision was made to obtain a bedside abdominal ultrasound to evaluate the question of a pleural effusion at the right lung base seen on serial chest x-rays. However, before the ultrasound could be obtained, the patient experienced another desaturation event early in the afternoon on [**2103-7-26**]. This was accompanied by bradycardia and eventually cardiopulmonary arrest and the patient ultimately succumbed and was declared deceased on the afternoon of [**2103-7-26**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] R. 12-207 Dictated By:[**Doctor Last Name 35468**] MEDQUIST36 D: [**2103-7-27**] 14:50 T: [**2103-7-30**] 17:13 JOB#: [**Job Number 35469**]

Admission Date: [**2196-6-10**] Discharge Date: [**2196-6-14**] Date of Birth: [**2145-1-10**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: None History of Present Illness: 51M restrained driver s/p T-bone motor vehicle crash with + LOC. He was taken to an area hospital where found to have mulitple injuries and was then transported to [**Hospital1 18**] for further care. Past Medical History: HTN, kidney stones, GERD Family History: Noncontributory Physical Exam: Upon exam: Gen: WD/WN, comfortable, NAD. HEENT: NCAT Neck: In cervical collar. 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. 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, 3.5 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 voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-10**] throughout. No pronator drift Sensation: Intact to light touch throughout. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal rapid alternating movements Pertinent Results: [**2196-6-10**] 11:38PM GLUCOSE-158* UREA N-14 CREAT-0.8 SODIUM-141 POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16 [**2196-6-10**] 11:38PM WBC-17.6* RBC-4.61 HGB-14.1 HCT-40.0 MCV-87 MCH-30.6 MCHC-35.2* RDW-14.4 [**2196-6-10**] 11:38PM PLT COUNT-302 [**2196-6-10**] 11:38PM PT-13.1 PTT-21.5* INR(PT)-1.1 [**2196-6-10**] 08:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2196-6-10**] 08:54PM WBC-23.7* RBC-5.03 HGB-15.2 HCT-44.6 MCV-89 MCH-30.1 MCHC-34.0 RDW-14.0 CT Head [**2196-6-10**] IMPRESSION: 1. Longitudinal left temporal bone skull base fracture appears to spare the carotid canal. This fracture does traverse the middle ear and ossicular disruption cannot be excluded. 2. Small left posterior frontal subarachnoid hemorrhage. 3. Asymmetric left occipital hypoattenuation is suggested and acute infarct cannot be excluded. Recommend MRI/MRA versus CTA for further evaluation CT C-spine [**2196-6-10**] IMPRESSION: Non-displaced fracture of right intra-articular portion of C7, as described. No other fracture or listhesis. CT Chest/Abdomen/Pelvis [**2196-6-10**] IMPRESSION: 1. Moderately large mesenteric hematoma may represent a significant vascular injury to small bowel. 2. Left inferior pole renal infarct. While the left renal artery appears intact, a dissection cannot be excluded and CTA is recommended for further evaluation. 3. Nondisplaced right first rib fracture. 4. Bilateral transverse process fractures at L3 with left transverse process fracture at L4. 5. Bibasilar consolidations and lingular consolidation likely represent atelectasis, however a component of aspiration is not excluded. 5. Right adrenal nodule, too small to characterize. CTA Head/Neck [**2196-6-11**] IMPRESSION: 1. Left parietal subarachnoid hemorrhage is less apparent. No new hemorrhage. 2. Normal CT angiography of the neck. 3. Normal CT angiography of the head. 4. Fracture of right C7 is visualized extending to the transverse foramen, but the vertebral artery does not enter the foramen transversarium at this level but interrupts at C6 level. Right first rib fracture is identified. CT Right arm [**2196-6-11**] FINDINGS: The distal humerus is normal in appearance. There is no evidence of acute fracture. Brief Hospital Course: He was admitted to the Trauma service. Neurosurgery and Orthopedic spine consulted because of his injuries. His left parietal subarachnoid hemorrhage was managed non operatively; serial head CT scans were performed and remained stable. He will follow up with Dr. [**First Name (STitle) **] in 4 weeks for repeat head imaging. He was noted with a skull base fracture through the left temporal bone; dedicated CT of the temporal bone was done and he will require outpatient follow up with ENT for audiogram. His spine injuries were also managed non operatively with a hard cervical collar to be worn at all times and a lumbar corset to be worn when out of bed. He will follow up in 2 weeks with Dr. [**Last Name (STitle) 363**], Orthopedic Spine surgery. Orthopedics was consulted for concern of a possible right humerus fracture given that patient had increased complaints of right arm pain with movement and upon palpation. A CT of his arm was performed and no fracture was identified. It was felt that the pain he had been experiencing was likely related to the cervical spine fracture and the dermatome path that followed along the arm. He was started on Neurontin, Ultram and prn Percocet for the pain which he reported as helpful. He was evaluated by Physical therapy and was discharged to home on hospital day 5 with specific instructions for follow up. Medications on Admission: hctz, nexium, simvastatin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: DO NOT exceed 2,000mg in a day. 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: s/p Motor vehicle crash Small subarachnoid hemorrhage Basilar skull fracture Left temporal bone fracture C7 facet fracture Bilateral tranverse process fractures L3 & left L4 Mesenteric hemotoma Neuropathic pain Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: You must continue to wear the cervical collar at all times for the next 10 weeks. You will need to wear the corsett brace when out of bed for your lumbar fractures. Wear the sling for comfort on your left arm. Return to the Emergency room if you develop any fevers, chills, headache, weakness/numbness in any of your extremities, shortness of breath, chest pain, nausea, vomiting, diarrhea, loss of bowel or bladder function and/or any other symptoms that are concerning to you. Followup Instructions: Follow up next week in [**Hospital **] clinic, you will need an audiogram at this appointment as well. Call [**Telephone/Fax (1) 41**] for an appointment. Follow up in 2 weeks with Dr. [**Last Name (STitle) 363**], Orthopedics Spine Surgery for your spine fracture. call [**Telephone/Fax (1) 3573**] for an appointment. Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery for your subarachnoid hemorrhage. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2196-6-22**]

Admission Date: [**2109-7-21**] Discharge Date: [**2109-8-13**] Date of Birth: [**2053-6-5**] Sex: F Service: [**Doctor Last Name 1181**] MEDICINE HISTORY OF PRESENT ILLNESS: This is a 56-year-old white female with a history of right frontal craniotomy on [**2109-7-1**], for a dysembryoplastic angioneural epithelial lesion with features of an oligodendroglioma who was started on Dilantin postoperatively for seizure prophylaxis and was subsequently developed eye discharge and was seen by an optometrist who treated it with sulfate ophthalmic drops. The patient then developed oral sores and rash in the chest the night before admission which rapidly spread to the face, trunk, and upper extremities within the last 24 hours. The patient was unable to eat secondary to mouth pain. She had fevers, weakness, and diarrhea. There were no genital the morning of [**7-20**]. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Benign right frontal cystic tumor status post right frontal craniotomy on [**2109-7-1**]. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Lipitor, Tylenol with Codeine, Dilantin, previously on Decadron q.i.d. tapered over one week and discontinued a week ago. SOCIAL HISTORY: The patient lives with her husband, daughter, and son. [**Name (NI) **] smoking or ethanol use history. PHYSICAL EXAMINATION: Vital signs: T-max 104.3??????, currently 100.8??????, heart rate 107-110, blood pressure 110/27, respirations 15-20, oxygen saturation 98% on room air. General: The patient was an alert, ill-appearing woman with postsurgical occiput. Head and neck: Injected conjunctivae, greenish ocular discharge, ulcerative oral lesions. Cardiovascular: Regular rhythm. Rapid rate. No murmurs. Pulmonary: Clear to auscultation bilaterally. Abdomen: Normoactive bowel sounds. Soft, nontender, nondistended. Extremities: No edema. Skin: Diffuse erythema and pustules on the face. Patulous pustules on the chest, back, and proximal upper extremities. GU: No genital lesions. LABORATORY DATA: Hematocrit 34.1, WBC 10.3, platelet count 291,000, differential of 87 neutrophils, 0 bands; sodium 133, potassium 3.8, chloride 93, CO2 21, BUN 17, creatinine 0.9, glucose 121; ALT 39, AST 42, LDH 434, amylase 63, albumin 3.4, total bilirubin 0.3; urinalysis with positive ketones, negative nitrites; urine culture pending; blood cultures times two pending; conjunctival culture pending. HOSPITAL COURSE: Given the patient's severe exfoliative skin involvement with rapid progression and extensive involvement of the body, she was admitted to the Medical Intensive Care Unit for close monitoring. She was started on prophylactic Oxacillin to cover skin flora, and Dermatology was consulted along with Neurology and Ophthalmology for the ophthalmic involvement. The patient's course in the Intensive Care Unit was uneventful, and she was discharged to the floor with very close monitoring which included q.1 hour Pred Forte application to the eye and close consultation with Ophthalmology. With regard to her skin lesions, they continued exfoliate over the next couple of days, and her skin care included frequent Vaseline hydrated petroleum application to decrease insensible losses. The patient's intake and output were closely monitored and replaced appropriately; however, the intensive nursing care requirement made it difficult for the patient to receive adequate on the floor, and therefore, she was transferred to the Medical Intensive Care Unit again for frequent ophthalmic applications and skin care. While in the MICU, the patient continued to have meticulous skin care and eye care. The skin lesions continued to desquamate and exfoliate which is the natural progression of this disease. She began to have involvement of the genital area with continued desquamation of the exfoliative lesions. Her course in the Intensive Care Unit within the next 8-10 days was a slow but gradual improvement from a dermatologic and ophthalmologic standpoint. From a cardiovascular standpoint, she was in sinus tachycardia which was felt to be secondary to her [**Doctor Last Name **]-[**Location (un) **] syndrome leading to dehydration and insensible fluid losses. While in the Intensive Care Unit, she was also found to be mildly hypoxic which is likely secondary to atelectasis because of the patient's immobility. Lower extremity Dopplers were also done, and no deep venous thromboses were found. From and Infectious Disease standpoint, the patient was started on intravenous Oxacillin empirically. Blood cultures on the 5th was with no growth times two; however, one bottle from her PICC line grew out gram-positive cocci on [**7-27**]. She was started on a course of Vancomycin. Subsequently the organism was found to be CNS with Corynebacterium, and Vancomycin was discontinued prior to transfer to the floor on [**8-5**]. The patient's course on the floor was uncomplicated with continued improvement. Dermatology: The patient, as indicated, improved dramatically from her presentation to the time of discharge. Her exfoliative lesions healed over the course of this admission. Her skin care requirements decreased to Petroleum jelly twice a day at the time of discharge. She was able to take in oral foot without problems. Ophthalmology: The patient's eye care requirement improved markedly. She was able to open her eyes and use her vision without significant problems at the time of discharge. Her Pred Forte was discontinued on the day of discharge, and she is to have follow-up with Ophthalmology a couple of days after discharge. Fluid, electrolytes, and nutrition: On admission the patient was begun on TPN for nutritional support. As the patient improved from a medical perspective, her TPN was weaned, and at the time of discharge, the patient was taking adequate p.o. with supplementation of Boost. Infectious Disease: At the time of admission, she was started on empiric antibiotics and placed on contact precautions secondary to her extensive skin lesions; however, as the patient improved throughout the course of this admission, contact precautions were discontinued, and the patient was discharged home with services. Cardiology/Pulmonology: The patient was tachycardiac throughout this admission which was attributed to her fluid losses secondary to [**Doctor Last Name **]-[**Location (un) **] syndrome; however, given the patient's immobility throughout the course of this admission, a CT angiogram was performed to evaluate for possible pulmonary embolism, and none were found. Neurology: The patient has a history of cystic tumor status post resection in [**Month (only) 205**] of this year and was started on prophylactic Dilantin leading to presumed [**Doctor Last Name **]-[**Location (un) **] syndrome. At the time of this admission, the patient's Dilantin was discontinued, and no other anticonvulsants were started, given the patient's risk of seizures several weeks after her surgery was unlikely. This decision was made with the support of her neurosurgeon, Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1338**]. Five days before discharge, the patient did have a syncopal event while in the bathroom showering with the help of a nursing aide. The likely etiology of this is orthostatic hypotension from her fluid losses; however, given the patient's neurologic history, Neurology was consulted to evaluate for possible seizure. Neurology's recommendations were to obtain a repeat CT scan which was unchanged from previous showing a right frontal lobe extra-axial hypodensity which was stable. They also recommended repeat MR imaging which was again unremarkable except for a stable extra-axial lesion noted on CT scan. Neurology therefore agrees with the primary team that the syncopal event was likely secondary to a vasovagal reaction. A follow-up MR scan would be recommended with gadolinium to evaluate for the presence of residual tumor. This can be done as an outpatient with Dr. [**Last Name (STitle) 1338**]. Rehabilitation: The patient throughout this admission worked with our physical therapy people and continued to improve with regard to range of motion and strength in the upper and lower extremities, and by the time of discharge, she was ambulating throughout the [**Doctor Last Name **] and around the hospital without problems. She was therefore discharged home without need for Physical Therapy Services. At the time of discharge, the patient has markedly improved from her initial presentation and is to be discharged home with nursing assistance. DISCHARGE STATUS: Markedly improved. DISCHARGE DIAGNOSIS: 1. [**Doctor Last Name **]-[**Location (un) **] syndrome secondary to Dilantin. 2. Status post craniotomy on [**2109-7-1**], for a cystic cranial lesion, likely dysembryoplastic angioneural epithelial lesion with features consistent with an oligodendroglioma. DISCHARGE MEDICATIONS: Polysporin ophthalmology O.U. q.i.d., hydrated Petroleum as needed, Lipitor 10 mg p.o. q.d., Nystatin, Boost t.i.d. FOLLOW-UP: 1. Ophthalmology [**2109-8-20**], at 12:45 p.m. 2. Primary care physician in two weeks. 3. Dermatology as needed. DISCHARGE NOTE: PLEASE NOTE THAT THE PATIENT IS ALLERGIC TO DILANTIN AND TEGRETOL GIVEN HER [**Doctor Last Name **]-[**Location (un) **] SECONDARY TO DILANTIN. The patient is recommended to wear an alert bracelet which indicates this reaction. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern4) 40425**] MEDQUIST36 D: [**2109-9-3**] 12:59 T: [**2109-9-3**] 12:58 JOB#: [**Job Number 99931**] [**Name6 (MD) **] [**Name8 (MD) **], M.D.(cclist)

Admission Date: [**2144-3-7**] Discharge Date: [**2144-3-16**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 2145**] Chief Complaint: transfer from OSH in [**State 108**] with R hip IT fx. Major Surgical or Invasive Procedure: R hip ORIF History of Present Illness: HPI: [**Age over 90 **]F with hx dementia, CAD, CHF EF 40%, chronic afib, lives with 24 hour caretaker. Was brought into OSH for neck pain and inability to hold her head up as well as confusion, found to have transverse C2 dens fracture, which has been immobilized with [**Location (un) 5622**] collar. Pt fell 3 weeks prior to admission, but home aide stated that there were no injuries from fall. Noted to have CHF exacerbation --> resolving with diuresis and now is reportedly stable on [**3-20**] liters NC (uses no O2 at home). In-house at OSH, had a fall and unfortunately suffered right intertrochanteric fracture. Pt has family in [**Hospital1 1559**] and had pt med flighted from [**State 108**] to [**Hospital1 18**]. Family connection to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Reportedly, her C2 fracture is stable and the surgeons there only wanted to immobilize it until her hip could be addressed. . Pt had a cardiology consult in [**State 108**], she had a CHF exacerbation with a BNP of 15,000. Her Toprol XL was increased from 37.5 to 50 mg PO qd with a plan to increase to 100 mg po QD. She was started on digoixin. Her lasix was increased. . Of note, transfer paperwork notes that the pt was seen by PCP in [**Name9 (PRE) 108**] for exertional CP and SOB relieved by NTG in [**Month (only) 1096**] [**2143**]. At that time her Imdur was increased from 30 to 60 mg PO qd. . Before her hospitalization she had been increasingly agitated and had been started on Risperdal, which was recently d/c'd after she became increasingly confused. . Labs at OSH: [**3-6**]: INR 1.1, Na 146, K 3.8, Cl 106, HCO3 33, BUN 29, Cr 1.0, Ca 8.7 Dig 1.0, [**3-2**] Blood Cx: NGTD . Studies: [**3-2**] EKG: afib at 98bpm RAD, LVH, QTc 526, bad baseline [**3-4**] CT Head mod-severe atrophy, no bleed [**3-5**] R hip/pelvis, comminuted IT fx R hip [**3-5**] CT cervical spine: transverse fx through base of dens. No displacement. Transverse lucency through the spinous process at C3 (chronic) Transverse lucency through spinous process at C3 (chronic). [**3-3**] CXR: Mild CHF, patchy infiltrate base of right lung, small bilateral pleural effusions. . Past Medical History: PMH: CHF EF 40%, [**2-20**] echo: inf hypokinesis CAD, hx MI, s/p PCI of LAD, LCx and RCA with stents [**2136**] at [**Hospital1 **] afib hypercholesterolemia COPD HTN severe AS ([**2-20**] echo 59 mmHg peak gradient, valve area 0.6 cmsq) mod-severe MR mild MS [**First Name (Titles) **] [**Last Name (Titles) **] Dementia (Mild Alzheimer's vs vascular) per transfer paperwork, however pt's family states that before this hospitalization pt was living independently with live in help. Hiatal hernia s/p repair hx GIB from AVM associated with elevated INR [**4-18**] s/p ccy s/p TAH macular degeneration kyphoscoliosis DJD/OA Social History: Social Hx: widowed, with 4 children. Lived independently with 24 hour aides. No EtOH or tob. Transferring physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 24606**] [**Last Name (NamePattern1) 79**] cell [**Telephone/Fax (1) 65356**] (is on-call this weekend) [**Hospital 32303**] Medical Center in [**Hospital 65357**], [**State 108**] [**Telephone/Fax (1) 65358**]. [**Name (NI) **] son: [**Name (NI) **] [**Name (NI) 122**] [**Telephone/Fax (1) 65359**] is her HCP, he lives in [**Name (NI) 108**] and is coming to MA [**3-7**]. Pts daughter ([**Name (NI) 19948**] [**Last Name (NamePattern1) **]) lives in [**Name (NI) 1559**] and her phone number is [**Telephone/Fax (1) 65360**]. . [**Hospital1 1559**] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] ([**Hospital1 **]) [**Hospital1 1559**] Cardiologist: Dr. [**Last Name (STitle) 65361**] ([**Hospital1 **]) Physical Exam: PE: VS: T 98.6 HR 64 R 20 BP 88/54 95%2L Gen: NAD, laying in bed in Aspen collar HEENT: slight droop L eyelid, PERRL, MMM, O/P clear Neck: in Aspen collar Chest: crackles at bases, clear at apices CV: [**Last Name (un) 3526**] [**Last Name (un) 3526**] rate and rhythm, 3/6 SEM at RUSB rad to carotids, 3/6 systolic murmur at apex Abd: soft, NT, ND +BS Ext: pain with palpation R hip, lim ROM. no edema, 2+ DP pulses bilaterally Neuro: alert, oriented to person only, moves all 4. Brief Hospital Course: [**Age over 90 **] yo F with h/o dementia, CAD, diastolic CHF (EF 55%), severe AS, chronic afib, transferred from OSH with R hip fracture and possible C2 fracture for operative management of hip. She was stable on the floor on her initial arrival. Given her CHF and AS, she was a high risk surgical candidate, but the family decided to go ahead with the operation. Postoperatively she was in the MICU briefly for hypotension but was extubated without difficulty, weaned off pressors after rehydration and transferred back to the floor. Perioperatively, she developed a UTI and a LIJ clot, which were both treated. Postoperatively, she also developed delirium, and was less verbal than she was previously. She failed a speech and swallow evaluation, but the medical team was optomistic that she would improve. In the meantime, multiple attempts at NGT placement were unsuccessful. While on the floor, [**3-14**]-30, patient showed signs of inability to clear her secretions. On [**3-15**], she had an episode of hypoxia. CXR at that time revealed fluid overload, and she seemed to improve with lasix. Overnight that night, 1/2 blood culture bottles were positive for S.aureus and Vancomycin was started. [**3-16**], she continued to do poorly, and again was hypoxic. CXR this time revealed dry lungs, but likely aspiriation PNA or LUL. Despite aggressive suctioning and broadening of antibiotic coverage, Mrs. [**Known lastname 65362**] continued to deteriorate and ultimately died approx 4:25 PM on [**3-16**]. . # COde - DNR/DNI verified with son who is HCP. . # Communication: son [**Name (NI) **] [**Name (NI) 122**] [**Telephone/Fax (1) 65359**] (HCP; daughter ([**Name (NI) 19948**] [**Name (NI) **] [**Telephone/Fax (1) 65360**]). [**Hospital1 1559**] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] ([**Hospital1 **]); [**Hospital1 1559**] Cardiologist: Dr. [**Last Name (STitle) 65361**] ([**Hospital1 **]). Previously at [**Hospital 32303**] Medical Center in [**Last Name (LF) 65357**], [**First Name3 (LF) 108**] [**Telephone/Fax (1) 65358**]. . Medications on Admission: Meds on transfer: Lipitor 40 mg PO qd Digoxin 0.125 mg qD Lasix 80 mg IV BID Atrovent neb QID Imdur 30 mg PO qd Levalbuterol neb QID Losartan 12.5 mg PO BID Toprol XL 50 mg PO qd coumadin 2 mg PO alternating with 3 mg PO qd (held) Tylenol prn Discharge Disposition: Expired Discharge Diagnosis: Hip fracture s/p ORIF LIJ clot UTI Aspiration PNA Perioperative delirium Discharge Condition: Death Discharge Instructions: None. Followup Instructions: None. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

Admission Date: [**2179-3-5**] Discharge Date: [**2179-3-24**] Date of Birth: [**2105-3-13**] Sex: F Service: MEDICINE Allergies: Benzodiazepines Attending:[**First Name3 (LF) 3984**] Chief Complaint: shortness of breath, red hands and feet Major Surgical or Invasive Procedure: endotracheal intubation, mechanical ventilation, right IJ central line placed, tracheostomy tube placed in OR History of Present Illness: Ms. [**Known lastname 94714**] is a 73yo woman with h/o ALS who presents with 3 weeks of redness in her hands and feet as well as more recent difficulty breathing. The patient had not complained of dyspnea and her husband had noted tachypnea or respiratory distress but per her husband she went to her doctor today, who noted that she was "not breathing well" and sent her to the ER where she was hypoxic in the 80s, responding well to O2 by NC. She was then found to have an ABG of 7.19/126/525/51 and was started on Bipap. She did not tolerate the non-invasive mask ventilation despite sedateion (versed 2mg, and fentanyl 100mg). She experienced a reduction of blood pressure to 66/30, and was subsequently intubated. Per husband, the patient has had ALS for three years. She performs ADLs on her own but has had trouble with speech as well as with keeping her mouth closed at baseline. She has not had any respiratory complaints. She had previously lost 40 pounds but last year was given a Gtube and since then has gained back 14 pounds. [**Name (NI) 1094**] husband states that prior to the last 3 weeks she was in her USOH, and denies any new symptoms including cough, sputum, no sick contacts. She is entirely NPO and has been for about a year. CXR in the ER showed no acute CP process and UA was negative for signs of infection. Per the pt's husband they have never had any sort of conversation regarding code status. The patinet did try bipap in the past but was unable to tolerate it, but her outpatient neurologist has never mentioned intubation or tracheostomy. Mr. [**Known lastname 94714**] states that these are all new thoughts for him and he's not entirely certain what his wife would want at this point. She was transferred to the [**Hospital Unit Name 153**], and she was started on AC 450x16, 100% FiO2, PEEP 5. ABG on this setting was 7.40/57/426/37 and her FiO2 was turned down to 50%. Past Medical History: - ALS diagnosed 3y ago - has Gtube with tube feeds, has difficulty with speech - hypercholesterolemia -?depression Social History: lives at home with husband, has three children two of whom live on the west coast and one of whom lives in [**Location **]. never used tobacco, does not drink alcohol, no other drugs. Works as a writer. At baseline performs ADLs, writes, uses internet to chat with her grandchildren. Family History: father MI age 52, mother deceased at age [**Age over 90 **] Physical Exam: 96.7, 78, 112/64, 16, 100% on AC settings as above Gen: sedated, unresponsive, intubated HEENT: PERRL, NCAT Cor: s1s2, RRR, no r/g/m Pulm: CTAB Abd: soft, NT, ND, +BS, Gtube c/d/i Ext; no c/c/e, bilateral toes with skin changes c/w venous stasis, bilateral fingers with erythematous dry excoriated skin Neuro: babinski upgoing bilaterally, myoclonus BLE, hyperreflexic B patellar, biceps Pertinent Results: on arrival Na 126, CK 273-->115, MB 14-->10, trop <0.01--> <0.01, bicarb 40, UA negative [**2179-3-23**] 02:44AM BLOOD WBC-10.0 RBC-2.88* Hgb-9.4* Hct-27.6* MCV-96 MCH-32.7* MCHC-34.1 RDW-13.5 Plt Ct-316 [**2179-3-23**] 02:44AM BLOOD Neuts-78.7* Bands-0 Lymphs-15.8* Monos-3.6 Eos-1.6 Baso-0.3 [**2179-3-22**] 04:15AM BLOOD PT-11.7 PTT-22.6 INR(PT)-1.0 [**2179-3-23**] 02:44AM BLOOD Glucose-127* UreaN-24* Creat-1.3* Na-145 K-4.5 Cl-107 HCO3-31 AnGap-12 [**2179-3-19**] 05:54AM BLOOD ALT-49* AST-44* LD(LDH)-267* AlkPhos-142* Amylase-41 TotBili-0.3 [**2179-3-19**] 05:54AM BLOOD Lipase-30 [**2179-3-5**] 02:50PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-<0.01 [**2179-3-5**] 10:15PM BLOOD CK-MB-10 MB Indx-8.7* cTropnT-0.01 [**2179-3-23**] 02:44AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4 [**2179-3-19**] 05:54AM BLOOD TSH-3.0 [**2179-3-18**] 11:55AM BLOOD Cortsol-23.9* [**2179-3-18**] 12:51PM BLOOD Cortsol-43.3* [**2179-3-18**] 01:48PM BLOOD Cortsol-51.1* [**2179-3-22**] 04:11PM BLOOD Type-ART pO2-136* pCO2-50* pH-7.45 calHCO3-36* Base XS-9 [**2179-3-22**] 04:11PM BLOOD Lactate-1.2 . [**2179-3-12**] 10:57 pm BLOOD CULTURE LT PIV. **FINAL REPORT [**2179-3-18**]** AEROBIC BOTTLE (Final [**2179-3-15**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2179-3-13**] @ 2:35 PM. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S ANAEROBIC BOTTLE (Final [**2179-3-18**]): NO GROWTH. . [**2179-3-13**] 12:20 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2179-3-15**]** GRAM STAIN (Final [**2179-3-13**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2179-3-15**]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S . [**3-15**] ECHO: 1.The left atrium is normal in size. 2.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%). 3. Right ventricular chamber size is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 6.There is no pericardial effusion. . [**2179-3-5**] EKG: Sinus rhythm. Slight ST segment elevation in leads II, III and aVF which may represent active inferior ischemic process. Followup and clinical correlation are suggested. No previous tracing available for comparison . [**2179-3-12**] EKG: Atrial fibrillation with a rapid ventricular response, rate 160. Non-specific repolarization changes. Compared to the previous tracing of [**2179-3-5**] normal sinus rhythm with abbreviated P-R interval has given way to atrial fibrillation with a rapid ventricular response . [**3-21**] CXR: There continues to be dense opacification in the retrocardiac region consistent with left lower lobe collapse and a small left effusion. There are some patchy areas of increased opacity in the right lower lung and left mid lung that may represent early infiltrate or volume loss. There is no significant change compared to the film from two days ago. The right subclavian line is unchanged. . [**2179-3-22**] Renal US: Mildly echogenic but otherwise normal-appearing kidneys may be secondary to medical renal disease. 1.1 x 0.9 cm echogenic focus in the left kidney may represent a cholesterol deposit versus a nonobstructing kidney stone. Brief Hospital Course: # hypercarbic resp failure: This was felt to be likely ALS induced muscular weakness combined with possible acute PNA given LLL consolidation on CXR. She was intubated for repiratory failure, and treated for a possible pneumonia. She was not able to tolerate weaning off the ventilator, and therefore required tracheostomy for longer term ventilator support. While awaiting trach placement, Ms. [**Known lastname 94714**] also developed a ventilator associated pneumonia. She grew MRSA in her sputum and blood, and was treated with a course of vancomycin. Zosyn was added after 5 days of vancomycin as she had repeated L lung collapse with thick mucous plugging, and we wanted to cover for pneumonia as well. Subsequent surveillance cultures were clean. Zosyn was later switched to Cefepime [**1-7**] worsening renal failure attributed to Zosyn. She completed an 8 day course of antibiotics. Her tracheostomy went well, and she was started on an in/exsufflator as well to aid in clearing her secretions/mucous to prevent recurrent lung colapse. . # A fib: Ms. [**Known lastname 94714**] had several episodes of atrial fibrillation with RVR, all in the setting of L lung collapse. She was initially started on a beta blocker with good response. After having multiple episodes she was started on amiodarone and anticoagulation with heparin. In all cases she converted to sinus rhythm on her own. Shortly after starting heparin, she had an episode of guaiac positive stool, and then a small amount of melena. Her heparin was stopped, and was not restarted as she remained in sinus rhythm, and the concern was that her risk of GI bleeding is higher than her risk of stroke. Her PEG was lavaged, and was OB negative. She will also need a colonoscopy as an outpatient to further evaluate the cause of her melena. She has subtle ST changes on inital EKG, but ruled out for an MI by enzymes. . # hypotension: Ms [**Known lastname 94714**] was hypotensive on intial presentation, responding well to fluid boluses. She had a cortisol stimulation test with normal response. It became clear that she responds to sedation with benzodiazepines with prolonged hypotension (as well as increased delerium and agitation), and therefore these were stopped, and put into her allergy list. After cessation of benzodiazepines, her blood pressure was much more stable, and she did not require bolusing. She never required pressors. . # ALS: It was felt that she likely had progression of her ALS, with diaphragmatic weakness and CO2 retention. Her respiratory mechanics were repeatedly asessed, and showed that she would not be able to come off the vent. Therefore a trach was placed in the OR by thoracic surgery (IP unable to place due to her anatomy). . # hyponatremia: Mrs [**Known lastname 94714**] was hyponatremic on admission. Tis resolved with hydration, indicating that she was likely hypovolemic and total body sodium depleted. She had no further problems with this for the duration of her stay. . #Diarrhea: New on [**2179-3-24**]/ Slight increase in in WBC to 15. Afebrile. No abdominal pain. Has been on course of antibiotics for vent associated PNA. Those antibiotics stopped today. ALso on tube feeds. C. Diff is a possibility given recent abx but it may also be related to tube feeds. On C.Diff is pending. At this point it is reasonable to follow fever curve and stool output. C.Diff lab should be followed up. [**Month (only) 116**] consider empiric treatment of c. diff with flagyl if febrile or diarrhea persists. . #Hypernatremia - Likely releated to low volume. WIll increase free water with tube feeds from 100cc q4hr to 150cc q4h. A chenistry panel should be checked on [**2179-3-26**] to make sure Na remains stable. . # conjunctivitis: Ms. [**Known lastname 94714**] had bilateral conjunctivitis on admission. This resolved with a 7 day course of erythromycin eye cream. . # skin changes: Ms [**Known lastname 94715**] intitial presenting chief complaint was erythema of her hands and feet. Dermatology was consulted, and said that she likely has erythromyalgia. The treatment for this is sarna lotion and aspirin, and improvement does not occur in less than a month. She was treated with sarna and ASA throughout her stay. Additionally she had burns on the inside of both thighs from a hot tea spill at home prior to admission. Per dermatology recs, these areas were treated with antibiotic cream and xeroform dressings, and healed over cleanly without infection. . # FEN: Ms. [**Known lastname 94714**] had a PEG on admission as she has not been able to take PO intake for some time secondary to progression of her ALS. She was continued NPO, with tubefeeds per nutrition. We monitored & repleted her electrolytes lytes. She was kept euvolemic. #Renal Failure: Pt's Creatinine increased during this admission from 0.7 to 1.3. BUN remained around 20 .Urine lytes were consistent with ATN>Reanla failure was attributed to ATN d/2 Zosyn.Although it was chenged to Cefepime, there was no improvement. Renal US showed no obstruction. Pt's creatinitne remained near 1.3.Plan will be to keep pt hydrated , avoid nephrotoxins and follow creatinine as outpatient. . # PPX: Ms. [**Known lastname 94714**] was treated with SC heparin, protonix, and a bowel regimen. She did have some constipation, and her bowel regimen was increased with good results. . # access: She was maintained with PIVs throughout most of her hospitalization. Shortly before discharge a PICC line was placed as she was losing all her peripheral access. . # code status: Per discussion with Ms [**Known lastname 94714**] and her husband she was full code throughout her stay. Medications on Admission: Elavil (stopped a few weeks ago) Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: [**12-7**] PO BID (2 times a day). 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 6. Bisacodyl 10 mg Suppository Sig: [**12-7**] Suppositorys Rectal DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Amiotrophic Lateral Sclerosis Hypercarbic Respiratory Failure Atrial Fibrillation Recurrent Pneumonia-Ventilator Associated Pneumonia Renal Failure Discharge Condition: good , afebrile , no cough , no fever, tracheostomy in good condition. Discharge Instructions: Please continue using exsuflator as needed.PLease come back to ED if you have a new episode of worsening cough, fever and productive sputum. . Pleae take your medications as as prescribed. . You were noted to have diarrhea on the morning prior to discharge, please call [**Hospital1 18**] to check on the results of her c. diff stool culture on [**2179-3-25**], and consider a c. diff study if diarrhea continues. Followup Instructions: PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2936**] . Recent onset of diarrhea. Please call [**Hospital1 18**] microbiology lab at ([**Telephone/Fax (1) 94716**] to follow up results of c. diff toxin assay. . Please check cbc and chem 7 on [**2179-3-26**]. New onset of hypernatremia on [**2179-3-24**]. Free water increased in tube feeds on [**2179-3-24**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2179-3-24**]

Admission Date: [**2196-9-27**] Discharge Date: [**2196-10-17**] Date of Birth: [**2151-3-3**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESLD Major Surgical or Invasive Procedure: [**2196-9-27**] liver transplant History of Present Illness: 45M with history of EtOH cirrhosis, MELD 28 and Child class C cirrhosis recently admitted to [**Hospital1 18**] last month for fevers, anemia, ascites and ARF. In brief, during his recent hospital course, he was treated for C.perfringens bacteremia and was treated with Zosyn. Paracentesis was performed and did not reveal spontaneous peritonitis. EGD evaluation only showed Grade I varices. His renal failure issues responded to octreotide and midodrine. He was resumed on his diuretic and last Cr normalized at baseline (1.0). He is admitted in preparation for a liver transplant. Denies any change in health since previous admission. Afebrile but still rather lethargic at home. Tolerating regular diet. Normal bowel habits, described as often loose. No abdominal tenderness but tender to paracentesis site. Has not had any food since midnight. Past Medical History: EtOH cirrhosis EtOH Abuse Gout s/p appendectomy several yrs ago h/o HTN now normotensive off all meds [**2196-9-27**] liver transplant Social History: lives with wife and sons 10 and 14 yo. Works as an energy broker. Denies drug or tobacco use. Quit drinking 6 weeks ago Family History: Adopted so family hx is unknown Physical Exam: 98.9 91 128/77 18 98RA Gen: AAOX3, NAD HEENT: scleral icterus, MMM, EOMi, NCAT Skin: Jaundice Cardio: RRR Pulm: CTAB Abd: Soft, obese, umbilical hernia noted, tender to paracentesis site, distended/ascites, spider angiomas Ext: 3+ pitting edema b/l LE Neuro: no focal deficits CXR: EKG: Sinus rhythm. Non-specific anterior ST-T wave changes. Delayed precordial R wave transition Labs: 135 97 11 estGFR: >75 ---|----|----< 104 4.3 28 1.0 Ca: 9.7 Mg: 1.7 P: 3.4 ALT: 16 AST: 48 AP: 92 Tbili: 18.6 Alb: 4.0 7.7> 8.2 <149 25.1 PT: 27.2 PTT: 55.8 INR: 2.7 Fibrinogen: 59 Most recent workup: Liver/RUQ US ([**2196-8-26**]): 1) Cirrhosis with ascites. 2) New, partially occlusive main portal vein thrombosis extending into the left portal vein. Please note, the study is limited because the right portal vein, splenic vein, portal venous confluence was not well visualized. 3) Distended gallbladder without signs of acute cholecystitis. Findings may be due to a fasting state EGD ([**2196-8-26**]): Varices at the lower third of the esophagus and gastroesophageal junction, Linear non bleeding erosion at 35 cm. Erythema, abnormal vascularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy. Otherwise normal EGD to second part of the duodenum TTE [**8-30**]: EF> 60% Pertinent Results: [**2196-10-17**] 04:53AM BLOOD WBC-9.5 RBC-2.90* Hgb-8.7* Hct-27.0* MCV-93 MCH-29.9 MCHC-32.1 RDW-16.4* Plt Ct-334 [**2196-10-13**] 09:32AM BLOOD PT-11.7 PTT-23.6 INR(PT)-1.0 [**2196-9-30**] 02:52AM BLOOD Fibrino-180 [**2196-9-27**] 05:00AM BLOOD Glucose-104 UreaN-11 Creat-1.0 Na-135 K-4.3 Cl-97 HCO3-28 AnGap-14 [**2196-9-28**] 04:16PM BLOOD Glucose-114* UreaN-30* Creat-2.3* Na-142 K-4.6 Cl-104 HCO3-28 AnGap-15 [**2196-9-30**] 10:50PM BLOOD Glucose-122* UreaN-70* Creat-4.6* Na-137 K-5.8* Cl-97 HCO3-26 AnGap-20 [**2196-10-2**] 06:10AM BLOOD Glucose-137* UreaN-87* Creat-5.2* Na-135 K-5.2* Cl-93* HCO3-26 AnGap-21* [**2196-10-7**] 05:07AM BLOOD Glucose-147* UreaN-94* Creat-3.6* Na-130* K-4.2 Cl-94* HCO3-24 AnGap-16 [**2196-10-17**] 04:53AM BLOOD Glucose-93 UreaN-69* Creat-2.0* Na-132* K-5.2* Cl-100 HCO3-21* AnGap-16 [**2196-9-27**] 05:00AM BLOOD ALT-16 AST-48* AlkPhos-92 TotBili-18.6* [**2196-10-17**] 04:53AM BLOOD ALT-33 AST-31 AlkPhos-276* TotBili-1.6* [**2196-10-17**] 04:53AM BLOOD Calcium-8.7 Phos-4.7* Mg-1.5* Brief Hospital Course: On [**2196-9-27**], he underwent deceased donor liver transplant. Surgeon was Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Two 19-French [**Doctor Last Name 406**] drains were placed posterior to the liver and behind the portal structures. Please refer to operative note for complete details. Aggressive blood product resuscitation by anesthesiology staff as well as administration of protamine was performed. Induction immunosuppression was started intraop (solumedrol). Postop, he was transferred to the SICU for management where he received blood products to maintain hemodynamic stability per protocol. LFTs initially increased as expected. Hepatic duplex revealed inadequate flow demonstrated within the right posterior portal vein which could have been technical in nature versus a small amount of thrombus. Patency and appropriate direction of flow within the hepatic arteries, hepatic veins, and the left and main portal veins was seen. Splenomegaly was noted. A repeat study on [**10-1**] revealed patency and appropriate direction of flow within the hepatic and portal venous systems. High flow velocities in the main portal vein, with aliasing in the expected region of the anastomosis were noted. There was notation of fatty infiltration of the liver. LFTs trended down (ast 580, alt 530, alk phos 130, t.bili 6.6). JP outputs remained high averaging 900-1100ml per day. LFTs started to trend up on postop day 4 and 5. JP output appeared foamy. On [**10-4**], an ERCP was performed noting common bile duct with mild narrowing at the bile duct anastomosis, and minimal associated proximal ductal dilatation. There were no filling defects in the CBD or intrahepatic ducts. There was no evidence of bile leakage. A plastic biliary stent was placed. Post procedure, amylase and lipase were wnl. JP drain outputs continued to be high averaging as much as 2200ml/day. IV fluid replacements and albumin were administered per output. The lateral JP was removed on [**10-5**]. The medial JP continued to drain as much as 1800ml per day. IV lasix was given for anasarca over several days. Teds stockings were applied with improvement of edema. Weight decreased to 90.4 Kg on [**10-16**] from 117.4 on [**9-26**]. The medial JP was removed on [**9-14**]. The site remained dry after suturing. Of note, alk phos continued to rise to 518. Repeat ERCP was done on [**10-13**]. There was no obstruction of the biliary stent. The stent was exchanged. The alk phos continued to increase. On [**10-14**], a liver biopsy was performed noting no rejection. Marked bile ductular proliferation with associated neutrophilic inflammation, focal ductal dilation, marked cholestasis, bile plug formation and portal tract edema; Rare foci of mild portal mononuclear inflammation with scattered eosinophils; no endothelialitis or diagnostic involvement by acute cellular rejection identified. No steatosis or viral inclusion was seen. Rare peri-venular lipofuscin-laden macrophages, suggestive of resolving reperfusion injury. After the ERCP, LFTS trended down (ast 31, alt 33, alk phos 276, t.bili 1.6). The postop pyloric feeding tube was replaced on [**10-6**] as this was removed during the ERCP. He experienced ATN likely from intraop hemodynamics. Creatine was 1.0 on on [**9-27**]. This started to rise postop to as high as 5.2 on postop day 5. Very gradually, creatinine improved with. Creatinine decreaed to 1.8 on [**10-13**], but started to trend up again to 2.0 likely from Prograf as this trough was elevated. Levels increased to 14.1 on [**10-16**]. Prograf dose was adjusted to 0.5mg [**Hospital1 **] on [**10-16**] for 1mg [**Hospital1 **]. Immunusuppression consisted of cellcept 1gram [**Hospital1 **] which was well tolerated. Solumedrol which was tapered per transplant protocol to prednisone. Prograf was started on postop day 1 and adjusted per trough levels. Diet was slowly advanced, but poorly tolerated as the patient had no appetite. A postpyloric feeding tube was placed and tube feedings were started (novasource renal). Oral intake slowly increased, but was insufficient to support caloric needs. On [**10-10**] Dermatology biopsied his L thumb for a chronic non-healing, bleeding punctate lesion (started in [**4-21**]). Biopsy report noted many features suggestive of lichen simplex chronicus/prurigo nodularis, and the mild atypia which is present is favored to be reactive in this context. The central ulceration could be secondary to excoriation; alternatively, it may represent a channel for transepidermal elimination of a foreign body or in the setting of a perforating disorder (although the clinical history is not suggestive of the latter). An underlying pyogenic granuloma cannot be entirely excluded on the basis of this sample; if clinical suspicion persists, deeper sampling may be helpful for more definitive diagnostic evaluation. The bleeding stopped and site remained clean and dry. PT worked with him extensively during this hospital course for deconditioning. He did experience a fall onto right hip(slipped while transferring to bed). He had pain with hip flexion and pain on exam over greater trochanter. Xrays of the hip were negative. He required contact guard and a rolling walker at time of discharge, but was not ready for discharge to home. Rehab was recommended and [**Hospital1 **] accepted him. He was transferred there on [**10-17**]. Medications on Admission: Folic Acid 1, Thiamine HCl 100, Ursodiol 300''', Ranitidine HCl 150'', lactulose, Furosemide 20, Spironolactone 100, Zofran 4, Maalox, Rifaximin 200''' Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): Please fax prograf trough levels to [**Telephone/Fax (1) 697**]. Call [**Telephone/Fax (1) 673**] for dose adjustments, attn [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN coordinator. 13. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): follow taper schedule per [**Hospital1 18**] Transplant . Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: etoh cirrhosis s/p liver transplant [**2196-9-27**] bile duct narrowing, s/p stent malnutrition Left thumb bleeding s/p biopsy: pyogenic granuloma ATN, resolving Discharge Condition: good Discharge Instructions: Please call the [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take any of your medications, jaundice, abdominal distension, increased abdominal pain, edema, dizziness, incision redness/bleeding/drainage or any concerns Continue tube feedings as ordered (Novasource renal at 45cc/hr continuously via the feeding tube) Labs every Monday and Thursday by 9am for cbc, chem 10, LFTs, albumin and trough prograf level with results fax'd to [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 697**] attention [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN coordinator [**Telephone/Fax (1) 10575**] [**Month (only) 116**] shower, no heavy lifting/straining Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2196-10-20**] 3:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2196-10-27**] 11:30 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2196-10-27**] 1:20 Completed by:[**2196-10-17**]

Admission Date: [**2151-6-14**] Discharge Date: [**2151-9-18**] Date of Birth: [**2151-6-14**] Sex: F Service: Neonatology HISTORY: This is a 1320 g female, twin A, born via c-section to a 37-year-old G4, P [**1-27**] mother at 32 1/7 weeks for IUGR of twin B. She had a history of decreased Doppler flow to twin B. Maternal labs include blood type O+, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, rubella immune, and GBS unknown. The infant emerged vigorous and had Apgars of 8 and 8. She received blow-by O2 and routine stimulation and suctioning. ADMISSION PHYSICAL EXAMINATION: Vital Signs: Weight 1320 g (25th percentile); length 41.5 (25th to 50th percentile); head circumference 29.25 (25th percentile); temperature 97; heart rate 170; respiratory rate 36; blood pressure 43/34 (34); O2 saturation 89% with blow-by O2. General: Alert; pink; crying. HEENT: Anterior fontanelle open and flat; mucous membranes moist; palate intact. Lungs: Decreased air movement throughout, with prolonged expiratory phase. Cardiovascular: Regular rate and rhythm; no murmur; 2+ femoral pulses. GI: Soft; no masses. GU: Normal premature female external genitalia. Musculoskeletal: Hips and clavicles intact. Neurologic: Moved all extremities. DISCHARGE PHYSICAL EXAMINATION: Weight 3835 g; head circumference 36.0 cm; length 52 cm. SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1. Respiratory. Upon admission, the baby was started on nasal CPAP. She needed to be intubated on day of life 1 and remained intubated until day of life 3 when she transitioned back to nasal CPAP. On day of life 4, she was transitioned to room air and has been on room air since that time. She did have apnea of prematurity that was treated with caffeine. That was discontinued on day of life 14. She has had no issues since that time. 2. Cardiovascular. At birth, she had a normal blood pressure and never required pressors or fluid boluses. She does not have a murmur and has been stable. 3. Fluids, Electrolytes, and Nutrition. The baby started n.p.o. and on IV fluids. She did have a UVC in for several days and received several days of parenteral nutrition. On day of life 3, she started feeds, which were advanced as tolerated. She did have many problems with p.o. feeds. Secondary to her difficulty with p.o. feeds and not taking enough, she received a jejunostomy tube. Currently, she is on p.o. ad. lib. feeds during the day and at night, starting at 10 p.m. and going till 6 a.m., she receives J tube continuous feeds of 100 mL/kg over 8 hours. 4. GI. The baby was found to have hyperbilirubinemia on day of life 2 with a peak of 6.8/0.2. She received several days of phototherapy, and all phototherapy was stopped on day of life 5 and she has had no further bilirubin issues. On day of life 12, she was started on iron 2 mg/kg/day, which continued through today. The baby was found to have severe reflux which was worked up through GI at [**Hospital3 1810**], [**Location (un) 86**]. She was started on multiple medications, which she continues today and are Prilosec, Reglan, Zantac, and Maalox. Secondary to this, they did an endoscopy on [**2151-9-10**]. This was negative for esophagitis although pathology on the biopsies is still pending. An NJ tube was placed to see if that would improve the feeding and also improve the irritability, arching, and other reflux-related behaviors and it did. So, a jejunostomy tube was placed on [**2151-9-14**]. She will need to follow up with Dr. [**Last Name (STitle) 79**] at the [**Hospital **] clinic at [**Hospital3 1810**], [**Location (un) 86**]. 5. Hematology. At birth, a CBC was done and the baby had a hematocrit of 41.2 and 283 platelets. Her latest hematocrit was 31.1 on day of life 91. 6. Infectious Diseases. At birth, a rule-out sepsis workup was done. The baby had a white count of 7 with 51 neutrophils and 2 bands. She had 48 hours of ampicillin and gentamicin, which were discontinued. On postop day #1, [**2151-9-15**], she spiked a fever to 101.3 and a sepsis workup was done again. This was reassuring and negative. She had received 48 hours of ampicillin and gentamicin with no further issues. 7. Neurology. The baby has always had a normal neurologic exam and has had 2 normal head ultrasounds - the latest being [**2151-7-20**]. 8. Sensory. a. Audiology. A hearing screen was performed with automated auditory brain stem responses, which the baby passed. b. Ophthalmology. The baby had 2 ophthalmologic exams. The eyes were most recently examined on [**2151-7-26**], revealing mature retinal vessels. A follow-up exam in 6 months is recommended. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home. PRIMARY CARE PEDIATRICIAN: [**Last Name (un) **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] of Pediatric Associates of [**Location (un) 3786**] (phone number [**Telephone/Fax (1) 45614**]). CARE RECOMMENDATIONS: 1. Feeds at discharge - Please continue Neocate 24 feeds p.o. ad. lib. during the day and J tube feeds at 100 mL/kg over 8 hours at night. 2. Medications - Prilosec 1 mg/kg/dose b.i.d.; Reglan 0.1 mg/kg q.i.d.; Zantac 10 mg p.o. b.i.d.; Maalox 2.5 mL q p.o. feed; iron sulfate 2 mg/kg/day. 3. Iron and vitamin D supplementation. a. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. b. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 IU (may be provided as a multivitamin preparation) daily until 12 months corrected age. 4. Car seat position screening test was passed prior to discharge. 5. State newborn screening status - The baby had 3 state newborn screens - [**2151-6-17**]; [**2151-6-28**]; [**2151-7-26**] - all of which were normal. 6. Immunizations received - The baby received no immunizations prior to discharge. 7. Immunization recommendations: a. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 4 criteria: 1) born at less than 32 weeks; 2) born between 32 and 35 weeks with 2 of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, and school- age siblings; 3) chronic lung disease; 4) hemodynamically significant congenital heart disease. b. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contact and out-of-home caregivers. c. This infant has not received a rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age. FOLLOW-UP APPOINTMENT SCHEDULE RECOMMENDED: 1. The baby has a follow-up appointment with her primary care pediatrician on [**Last Name (LF) 766**], [**2151-9-20**]. 2. A follow-up appointment needs to be made with [**Hospital1 62374**] GI, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79**], for 2 weeks after discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 32 and 1/7 weeks' gestation. 2. Twin gestation. 3. Rule out sepsis. 4. Respiratory distress syndrome. 5. Severe gastroesophageal reflux. 6. Status post J tube placement. Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**] Dictated By:[**First Name3 (LF) 72788**] MEDQUIST36 D: [**2151-9-20**] 14:06:19 T: [**2151-9-20**] 15:21:09 Job#: [**Job Number 72789**]

Admission Date: [**2150-12-24**] Discharge Date: [**2150-12-26**] Date of Birth: [**2092-10-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 58f with breast cancer, HTN, CHF, PAF s/p PVI presents with shortness of breath, increasing over the past day. She notes that the symptoms became gradually, with increasing dyspnea on exertion and a productive cough but that she then developed palpitations, with increased dyspnea related to this. Her pulse was fast and irregular. She came into the emergency department and was found to be in rapid atrial fibrillation; a chest x-ray revealed a pneumonia. She recieved levofloxacin and IV diltiazem in the ED and was admitted. Past Medical History: 1. PAF s/p pulm vein isolation, w/ recurrence s/p radiation, now on amiodarone. 2. CHF diastolic EF 62% by MRI [**3-6**] 3. Breast cancer Stage II status post right mastectomy and status post six months of tamoxifen therapy, now s/p XRT 4. Hypertension. 5. Hyperlipidemia. Social History: Patient is married and lives with her husband. She denied smoking or alcohol use. Family History: NC Physical Exam: t 99.4, bp 134/86, hr 122, rr 18, spo2 96% 2L nc gen- pleasant f, looks age, mild distress, non-toxic heent- anicteric, op clear with mmm neck- no jvd/lad/thyromegaly cv- tachy, irreg irreg, no m/r/g pul- moves air well, slight bibasilar rales r>l abd- soft, nt, nd, nabs extrm- no cyanosis/edema, warm/dry nails- no clubbing, no pitting/color changes/indentations neuro- a&ox3, no focal cn/motor deficits Pertinent Results: [**2150-12-24**] 10:00PM BLOOD WBC-6.5 RBC-4.33 Hgb-13.0 Hct-36.7 MCV-85# MCH-29.9 MCHC-35.4*# RDW-14.7 Plt Ct-150 [**2150-12-26**] 06:00AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-139 K-4.3 Cl-105 HCO3-25 AnGap-13 [**2150-12-24**] 10:00PM BLOOD CK(CPK)-54 TotBili-0.6 [**2150-12-24**] 10:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2150-12-26**] 06:00AM BLOOD CK(CPK)-81 [**2150-12-26**] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2150-12-25**] 06:40AM BLOOD ALT-31 AST-18 AlkPhos-76 TotBili-0.5 [**2150-12-25**] 06:40AM BLOOD TSH-4.6* Brief Hospital Course: 58f with breast cancer, htn, chf, paf s/p pvi admitted with pneumonia and afib with rapid ventricular response . Afib -- Mrs. [**Known lastname **] is maintained on amiodarone at home in sinus rhythm. It was felt that her pneumonia was the likely culprit in this exacerbation back into fibrillation. She was seen by the EP staff who felt she would do well with a loading dose of amiodarone of 400mg twice daily for three days; she would then return to her usual dose of 200mg daily. This was begun with a good response. Sinus rhythm was quickly re-instated. Her symptoms of dyspnea and palpitations seems to improved with reversion to sinus. She was discharged with one day of loading-dose amidodarone left in sinus rhythm, with rates generally in the 70's. . Pneumonia -- Although clinically mild, it was felt sufficient to cause her loss of sinus rhythm. She had no O2 requirement and was treated with a course of levofloxacin. By the time she was discharged, she was afebrile with decreased cough and sputum production. Micro data was unrevealing. Medications on Admission: Pantoprazole 40mg daily Amiodarone 200mg daily Metoprolol 25mf twice daily Warfarin 2mg mon-fri and 1mg sat-sun ASA 325mg daily 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. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO SAT-SUN (). 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO MON-FRI (). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 days: Take 2 pills twice a day on Saturday and Sunday, then return to 200mg once a day. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Atrial fibrillation with rapid ventricular response Pneumonia Secondary: 1. PAF s/p pulm vv isolation, w/ recurrence s/p radiation, now on amiodarone. 2. CHF, one episode post cardioversion, diastolic EF 55% 2/04 3. Breast cancer Stage II status post right mastectomy and status post six months of tamoxifen therapy, now s/p XRT 4. Hypertension 5. Hyperlipidemia Discharge Condition: Good, in sinus rhythm, with improved symptoms Discharge Instructions: You were admitted for a pneumonia and a rapid heart rate; your heart rate was controlled with a temporarily increased dose of amiodarone, and you were given antibiotics for the pneumonia. . Call your PCP or return to the ED for fevers/chills, chest pain, shortness of breath, lightheadedness, loss of conciousness, or other concerning symptoms. . Take 400mg of amiodarone twice a day on Saturday and Sunday, then return to your usual dose of 200mg once a day on Monday. Followup Instructions: Please see your primary care doctor in the next 1-2 weeks; call [**Telephone/Fax (1) 2740**] to make an appointment. . Provider: [**Last Name (NamePattern4) 105871**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2151-3-4**] 8:00 . Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-3-9**] 11:00 . Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2151-3-19**] 3:15

Admission Date: [**2115-1-11**] Discharge Date: [**2115-1-19**] Date of Birth: [**2033-12-10**] Sex: M Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 7881**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 81 year old man with CAD s/p CABG in [**2103**] with a LIMA to the LAD, SVG to the PDA, SVG to the OM, HTN, IDDM, PVD s/p bilateral LE bypass, CRI, admitted to [**Hospital3 417**] Hospital [**1-7**] with shortness of breath and chest pain x one week. Initially thought to be rest angina. Ruled out for MI, no EKG changes. Transferred here for cath. In holding area pt had chest pain, no EKG changes. Underwent difficult catheterization today(received large amount of radiation)which demonstrated severe native three vessel disease. The left main was heavily calcified with an 80% distal stenosis. The left anterior descending received blood from the LIMA graft. The left circumflex demonstrated a 90% ostial lesion. RCA was diffusely diseased. The LIMA-LAD graft was patent. SVG-OM patent; SVG-RPDA patent with an 85% mid RCA lesion. No attempt at PCI today due to excessive radiation dose and dye dose. Pt scheduled for for planned PCI to the SVG-rPDA and possible LMCA intervention on Monday. Past Medical History: HTN IDDM CAD s/p CABG in [**2103**] with a LIMA to the LAD, SVG to the PDA, SVG to the OM ([**2103**]) PVD s/p bilateral LE bypass COPD carotid disease CRI BPH s/p TURP nephrolithiasis history of thrombocytopenia Social History: Social history is significant for 50 pack year smoking history; quit '[**03**], no ETOh or drug use. Lives at home with wife, independent ADLs. Family History: NC Physical Exam: GEN: elderly male, NAD HEENT: NC/AT, EOMI, PERRL, O/P clear, MMM Neck: JVP+9, supple CV: RRR, no m/r/g Lungs: CTA bilaterally Abd: Obese, soft, NT, ND Ext: WWP, no edema Neuro: A&O x3 Pertinent Results: [**2115-1-11**] 09:15PM GLUCOSE-208* UREA N-45* CREAT-1.9* SODIUM-136 POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13 [**2115-1-11**] 09:15PM CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-2.2 [**2115-1-11**] 09:15PM WBC-4.1 RBC-3.07* HGB-10.1* HCT-29.7* MCV-97 MCH-32.9*# MCHC-34.0 RDW-15.7* [**2115-1-11**] 09:15PM PLT COUNT-96* [**2115-1-11**] 06:16PM GLUCOSE-369* UREA N-45* CREAT-1.8* SODIUM-134 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-20* ANION GAP-14 [**2115-1-11**] 06:16PM estGFR-Using this C.CATH [**1-11**] COMMENTS: 1. Selective cornary angiography in this right dominant system revealed diffuse three vessel coronary artery disease. The LMCA was unable to be engaged selectively despite using a 4 french JL4, JL4.5, JL5. A five french JL5, JL4.5, AL1, AL2, and AL3 were also unsucessful. The LMCA was heavily calcified and had an ostial plaque. There was an 80% distal LMCA lesion that involved the origins of the LAD, ramus, and [**Month/Day (4) **]. The LAD had a functional ostial stenosis (extended from distal LMCA); signficiant proximal stenosis; and minimal flow into the mid LAD. Overall, the LAD was not able to be well visualized because of difficulty engaging the LMCA. The [**Month/Day (4) **] had a 90% stenosis in the origin that extended from the distal LMCA. The AV groove [**Month/Day (4) **] supplied a diffusely disease OM1 (up to 70% stenosis) and LPL. The ramus was not well seen but had an ostial 80% stenosis. There was heavily calcified plaque in the aorta at the origin of the RCA. The RCA had heavy calcification proximally with 70% and 90% stenoses. The mid vessel had a 50% stenosis. The distal RCA was a tortuous vessel that supplied a long lower acute marginal with lateral branches that supplied the inferior septum. The native AV groove RCA was heavily calcified and subtotally occluded after the take-off of the large lower AM. 2. Venous conduit angiography revealed an SVG to OM (engaged with a 5 french AL2) that was patent thoughout and touched down onto the lower pole OM that does not communicate with the native AV groove [**Name (NI) **]. The SVG-rPDA (engaged with 5 french MPA) had an ostial 30% and mid 85% stenosis; this graft retrogradely filled a severely diffusely diseased distal AV groove RCA that gave septal collaterals to the LAD. 3. Nonselective arterial conduit angiography revealed a patent LIMA with a 30% ostial stenosis that touches down on a small calibur, heavily calcifed LAD (not well imaged). 4. Left subclavian angiography revealed a heavily calcifed vessel with a proximal 50% stenosis. The left subclavian stenosis prevented advancement of a 4 french [**Female First Name (un) 899**] catheter despite use of an angled glide wire, slip catheter, and Amplatz stiff wire. A 4 french Berenstein was ultimately advance to the subclavian distal to the LIMA over the angled glide wire. 5. Left ventriculography was not perfomed secondary to renal insufficency. 6. Limited hemodynamics demonstrated systemic systolic hypertension with a central aortic pressure of 167/68 (systolic/diastolic in mmHg). There was severe diastolic dysfunction with an LVEDP of 32 mmHg. There was no gradient across the aortic valve on pullback. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. . [**1-14**] Cardiac cath: 1. Planned intervention of a 90% body of SVG-PDA lesion with direct stenting with a Vision 3.5x18mm stent. 2. Limited hemodynamics with BP 142/59 with HR 55 with significant ventricular ectopy. 3. Access via 6F long sheath in RFA. FINAL DIAGNOSIS: 1. Succesful direct stenting of SVG-PDA graft with bare metal stent. Brief Hospital Course: . #. CAD: The patient presented to an OSH on [**1-7**] with shortness of breath and chest pain. He was transferred to [**Hospital1 18**] for cardiac cathterization. This diagnostic procedure on [**2115-1-11**] was complicated requiring a signficant amount of dye and radiation, therefore, the intervention was planned for another day. It demonstrated severe native 3vd, patent LIMA-LAD, SVG-OM, 90% [**Date Range **] ostial lesion, diffusely diseased RCA with 85% lesion and patent SVG-RPDA. He received Reopro post cathterization and developed a hematoma requiring a pressure dressing. The patient developed refractory chest pain without ECG changes before the intervention could be performed, and was transferred to the CCU for monitoring and management. In the CCU, he was given Argatroban for ACS (reported concern re: HIT). He had cardiac cathterization on [**2115-1-14**] with intervention and stenting of SVG-RCA. His sheath was pulled while on Argatroban and the patient developed a significant hematoma requiring 2 units pRBC transfusion. The next day, the patient developed stuttering chest pain and plans were made to take him back to the cath lab for possible intervention on left main or RCA. He was transitioned from a nitro gtt to isosorbide for the chest pain. He was started on argatroban prior to the procedure. He underwent a third catheterization on [**1-17**] with stenting to his L. Subclavian. He subsequently remained chest pain free. He was continued on aspirin, Plavix, statin, and Toprol. No further events occured, chest pain had resolved and he was sent home on the above medications. . #. Systolic Heart Failure: An echo was performed which showed EF 60%. Patient was continued on his Lasix and his beta blocker was increased. . #. Rhythm: Patient in normal sinus rhythm during most of his hospital stay, however during the CCU he had a few episodes of bradycardia and his beta blocker was held. This was subsequently resumed prior to discharge. . #. Diabetes-Patient was placed on an insulin sliding scale and placed back on his home glyburide prior to discharge. . #CRI-Baseline 2.2 at OSH. It initially increased after the first catheterization but subsequently improved after post-cath hydration and IVF. His creatinine was monitored and remained stable throughout the rest of his hospitalization. All of the medications were renally dosed and he received pre- and post-cath hydration for each of his procedures. . #Hematuria-Pt has gross blood in foley which was thought to be related to traumatic insertion. His foley was subsequently flushed and there were no clots. There was no further evidence of hematuria and no further intervention was taken. . #BPH-Patient was continued on his home hytrin . #Thrombocytopenia-Patient has known chronic thrombocytopenia. It is unclear what his baseline is, but at the OSH his platelets were in the low 100s. HIT Ab was sent which was negative. Heparin was held throughout his stay and his platelets remained stable in the 80s to low 100s. NO further intervention taken. . #Chronic Anemia-Pt on Procrit q week (tues). He received 2 units of prbcs in the CCU for his hematoma and his HCt subsequently remained stable. He did not receive any Procrit during his hospitalization but this should be resumed per his regular schedule upon discharge. . #Sciatica-Patient was continued on his home Neurontin. Medications on Admission: ASA 325mg daily Nexium 40mg daily Toprol XL 25mg daily MVI Neurontin 300nmg daily Hytrin 2mg PO QHS Lasix 40mg daily Glyburide 5mg daily Iron 325mg daily Procrot q week (tues) Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Procrit Injection 12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes up to three times as needed for pain: Tkae every 5 minutes up to three doses; if not working call your doctor or go to the ER. Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: Primary CAD s/p 3 PCIs . Secondary HTN IDDM COPD PVD CRI BPH Thrombocytopenia Discharge Condition: Improved Discharge Instructions: You were admitted to the hospital with chest pain. You underwent 3 cardiac catheterizations and had stents placed to the blocked vessels in your heart. You had a complication after one of the procedures and had some bruising and swelling in your groin which resolved. . There were some changes made to your medications. You were started on Lipitor, and Plavix. The other medications were kept the same. . If you have any chest pain, shortness of breath, nausea,vomiting, palpitations, lightheadednes, bleeding from the groin, or any other concerning symptoms, please call your doctor or return to the ER. . Please follow up as below Followup Instructions: Please follow up with your cardiologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks. Please call and make an appt with your PCP [**Last Name (NamePattern4) **] [**4-8**] weeks.

Admission Date: [**2179-9-22**] Discharge Date: [**2179-10-14**] Date of Birth: [**2125-3-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: VF arrest Major Surgical or Invasive Procedure: [**2179-10-7**]: MV repair/MAZE/ left atrial appendage resection [**2179-10-13**]: AICD placement History of Present Illness: This 54 year old male with no known pmh presented s/p ventricular fibrillation arrest on [**2179-9-22**]. He was at the Red Sox game with his sister and they were walking to their car when he stopped to smoke a cigarette and then he collapsed. A passing physician initiated CPR within 3-5 minutes per his sister's report. He was found to be in ventricular fibrillation and was shocked 5 times, given 3mg of epinephrine, 2mg of magnesium for torsades rhythm. He eventually had spontaneous return of circulation and breathing. He was intubated in the field on route to [**Hospital1 18**]. He was transferred from the ED to the CCU and put on the arctic sun protocol. He was unresponsive and sedated and was eventually extubated on [**9-25**] and has been very agitated and uncooperative. He has a history of ETOH and is a heavy smoker. Cardiac cath [**2179-9-29**] revealed no coronary disease but he has 3+ mitral regurgitation. He is being evaluated for mitral valve repair. Past Medical History: unknown, has not gone to a doctor for at least 20 years. Social History: Lives with: sisters Occupation: works in [**Last Name (un) **] chemical pipefitting Tobacco:1.5 ppd for many years, current ETOH: a few beers per night, several on weekends Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse:108 Resp: 20 O2 sat: B/P Right: 93/81 Left: Height: 6'3" Weight: 60.7 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] NGT in place for tube feeds. Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur III/VI holo diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: A+Ox3 but unable to swallow and is still impulsive and restrained. Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2179-10-12**] 04:40AM BLOOD WBC-12.4* RBC-3.24* Hgb-10.5* Hct-31.2* MCV-96 MCH-32.5* MCHC-33.8 RDW-14.4 Plt Ct-242 [**2179-10-11**] 06:05AM BLOOD WBC-15.0* RBC-3.33* Hgb-10.6* Hct-32.4* MCV-97 MCH-32.0 MCHC-32.9 RDW-14.4 Plt Ct-213 [**2179-10-12**] 04:40AM BLOOD PT-14.0* INR(PT)-1.2* [**2179-10-11**] 06:05AM BLOOD PT-12.9 INR(PT)-1.1 [**2179-10-12**] 04:40AM BLOOD Glucose-104* UreaN-14 Creat-0.7 Na-137 K-3.6 Cl-99 HCO3-31 AnGap-11 [**2179-10-11**] 06:05AM BLOOD Glucose-91 UreaN-14 Creat-0.6 Na-134 K-3.7 Cl-96 HCO3-31 AnGap-11 [**2179-10-12**] 04:40AM BLOOD WBC-12.4* RBC-3.24* Hgb-10.5* Hct-31.2* MCV-96 MCH-32.5* MCHC-33.8 RDW-14.4 Plt Ct-242 [**2179-10-13**] 04:40AM BLOOD PT-16.6* INR(PT)-1.5* [**2179-10-13**] 04:40AM BLOOD UreaN-14 Creat-0.7 Na-133 K-4.2 Cl-100 [**2179-10-14**] 04:20AM BLOOD WBC-14.4* RBC-3.32* Hgb-10.4* Hct-31.5* MCV-95 MCH-31.4 MCHC-33.1 RDW-14.5 Plt Ct-307 [**2179-10-14**] 04:20AM BLOOD UreaN-16 Creat-0.7 Na-132* K-4.2 Cl-94* CT HEAD W/O CONTRAST Study Date of [**2179-9-22**] FINDINGS: There is no hemorrhage, edema, mass effect, or evidence for acute vascular territorial infarction. There is no shift of normally midline structures and [**Doctor Last Name 352**]-white matter differentiation is well preserved. The size and configuration of the ventricles appears normal. Osseous structures are intact. There is opacification of bilateral maxillary sinuses. Ethmoid air cells demonstrate mucosal thickening. There is trace fluid within the mastoid air cells bilaterally. There is a left occipital posterior scalp hematoma. IMPRESSION: 1. No acute intracranial process. 2. Left occipital scalp hematoma, without fracture. Intra-op TEE [**2179-10-7**] Pre-CPB: Mild spontaneous echo contrast is seen in the body of the left atrium. Overall left ventricular systolic function is mildly depressed (LVEF= 40 - 45 %). with mild global free wall hypokinesis. 1+ AI. There are simple atheroma in the descending thoracic aorta. The mitral valve shows characteristic myxomatous deformity. There is moderate/severe posterior leaflet mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is on infusons of Epi and NTG, AV-Paced. There is a mitral ring in good position with no leak and no MR. Residual area is 2.8 cm2. Biventricular systolic fxn is mildly improved. TR remains 1+, AI remains 1+. Aorta intact. Brief Hospital Course: 54 year old male with no known past medical history admitted with VF arrest while at the Red Sox game. He underwent CPR in the field along with defibrillation and transition to atrial fibrillation. He was admitted to the [**Hospital1 18**] CCU and was initiated on the Arctic Sun cooling protocol for cardiac arrest. Initial echocardiogram showed severe mitral valve prolapse and regurgitation with a flail mitral valve, which was most likely the precipitant of his VF arrest. The patient was extubated successfully approximately 48 hours after rewarming. Upon admission, he was started on empiric antibiotic therapy for possible aspiration pneumonia with cefepime, vancomycin and metronidazole. He was taken to the operating [**2179-10-7**] and underwent left sided maze procedure and Mitral Valve repair (see operative note for full details). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis, given the length of preoperative stay. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Amiodarone was started for atrial fibrillation. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Intra-operatively, the patient was found to have an osteoporotic appearing sternum. [**Month/Day/Year 6091**] was consulted and has recommended outpatient follow up following recovery from cardiac surgery. The patient continued to exhibit dysphagia, and dobhoff tube was placed for feeding purposes. Coumadin was started for atrial fibrillation. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. A dual chamber ACID was placed on [**2179-10-13**] without complication. This was interrogated [**10-14**] and follow up appointment with the device clinic was arranged. He had a repeat video swallow study and was cleared for nectar thick ground diet and tube feeds were cycled. His Dobhoff tube was removed on day of discharge and patient was instructed by the speech and swallow team for aspiration precautions. He is to follow up as an outpatient with a video swallow study (scheduled) for diet advancement. He was started on an ACE-I for EF 35% once blood pressure tolerated. His INR was 2.3 on the day of discharge and he was given 1 mg of Coumadin with plans to have INR drawn [**10-15**] with results to be called in to [**Hospital3 271**] at [**Telephone/Fax (1) 2173**] for further Coumadin dosing instructions. INR goal [**2-3**] for atrial fibrillation. By the time of discharge on POD 7 the patient was ambulating freely, the wound was healing well with staples in place and pain was controlled with oral analgesics and he was tolerating a ground diet. The patient was discharged home with services in good condition with appropriate follow up instructions and follow up appointments arranged. Medications on Admission: None Discharge Medications: 1. furosemide 20 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal [**Month/Day (3) **]: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Month/Day (3) **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. nicotine 14 mg/24 hr Patch 24 hr [**Month/Day (3) **]: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*1* 5. thiamine HCl 100 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. folic acid 1 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Month/Day (3) **]: One (1) Tablet, Chewable PO BID (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Day (3) **]: 2.5 Tablets PO DAILY (Daily). 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 10. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) for 30 days: Take x 30 days then per cardilogist instructions. Disp:*60 Tablet(s)* Refills:*0* 12. warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once) for 1 doses: Take as instructed by cardiologist for INR goal of 2.0-3.0. Disp:*60 Tablet(s)* Refills:*0* 13. clindamycin HCl 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day for 2 days. Disp:*4 Capsule(s)* Refills:*0* 14. lisinopril 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Mitral regurgitation/ Atrial fibrillation Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Provider: [**Name10 (NameIs) 6091**] [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2179-11-29**] 2:30 Provider: [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2179-10-29**] 9:10 Surgeon: Dr [**Last Name (STitle) **] [**2179-10-27**] at 1:00 PM Cardiologist: [**Last Name (LF) 171**], [**First Name3 (LF) **] [**2179-11-8**] at 1:20 PM EP Device Clinic in 1 week [**Telephone/Fax (1) 62**] [**10-19**] at 11:30 AM Primary Care Dr. [**Last Name (STitle) **] [**4-5**] weeks Video swallow follow up in 2 weeks - to be scheduled Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation Goal INR 2/0-3.0 First draw [**2179-10-15**] Results to Dr[**Name (NI) 87655**] office phone [**Telephone/Fax (1) 1989**] or NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 87656**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2179-10-14**]

Admission Date: [**2111-9-29**] Discharge Date: [**2111-10-5**] Date of Birth: [**2050-1-9**] Sex: M Service: CARDIOTHORACIC Allergies: Ampicillin / Amoxicillin / Ativan Attending:[**First Name3 (LF) 165**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: OP CABGx2(LIMA-LAD,SVG-OM)[**10-1**] History of Present Illness: 61 yo M with 2 month decline in energy and malaise who was walking at home, unable to sleep and tripped/lost balance and fell against the bath tub and developed SOB. At OSH, Was found to have R ptx and rib fx. Was also found to have pulmonary edema with elevated trops.Had known CAD, uncerwent repeat cath which showed significant CAD. Tansferred to [**Hospital1 18**] for further eval. Past Medical History: Acute on Chronic systolic heart failure DM HTN [**Hospital1 18048**] ESRD - on HD (MWF) - last dialysis [**11-8**]; [**11-11**] Thrombectomy L arm fistula [**12-22**] Hypercholesterolemia GIB [**10-20**] in prepyloric area by EGD (? [**12-19**] NSAIDS) Gastritis [**12-22**] (EGD) Anemia Hip surgery [**6-21**] - on coumadin Prostate adenocarcinoma Chronic low back pain Social History: Occasional EtOH, No tobacco, No drugs Family History: Mother: [**Name (NI) 18048**] Physical Exam: Obese M in NAD Neuro A&O, forgetful train of though, wanders, grip strenth L [**3-21**], R [**2-19**] PERRL CV RRR 2/6 SEM Resp crackles thoughout Right, Left clear GI obese, soft/NT Right groin macerated/fungal infection Pertinent Results: [**2111-10-4**] 08:20AM BLOOD WBC-8.0 RBC-2.74* Hgb-8.4* Hct-24.9* MCV-91 MCH-30.5 MCHC-33.6 RDW-16.4* Plt Ct-130* [**2111-10-3**] 08:35AM BLOOD WBC-7.9 RBC-3.03* Hgb-9.4* Hct-27.5* MCV-91 MCH-31.1 MCHC-34.2 RDW-16.9* Plt Ct-127* [**2111-10-4**] 08:20AM BLOOD Plt Ct-130* [**2111-10-3**] 08:35AM BLOOD Plt Ct-127* [**2111-10-1**] 01:33PM BLOOD PT-19.9* PTT-39.1* INR(PT)-1.9* [**2111-10-4**] 08:20AM BLOOD Glucose-155* UreaN-38* Creat-6.8*# Na-129* K-4.4 Cl-89* HCO3-30 AnGap-14 [**2111-10-3**] 08:35AM BLOOD Glucose-123* UreaN-22* Creat-5.2* Na-135 K-4.2 Cl-92* HCO3-31 AnGap-16 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 21518**] (Complete) Done [**2111-10-1**] at 10:54:10 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2050-1-9**] Age (years): 61 M Hgt (in): 70 BP (mm Hg): 137/74 Wgt (lb): 235 HR (bpm): 68 BSA (m2): 2.24 m2 Indication: Intraoperative TEE for CABG ICD-9 Codes: 410.91, 440.0 Test Information Date/Time: [**2111-10-1**] at 10:54 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% >= 55% Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm Hg Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm Aorta - Ascending: *3.6 cm <= 3.4 cm Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 7 mm Hg Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *2.0 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Moderate regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-revascularization: 1. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is moderate to severe regional left ventricular systolic dysfunction of the inferior, septal and anterior walls. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened with focal calcification of left coronary cusp causing aorto sclerosis. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. There is no pericardial effusion. Post revascularization: Pt on phenylephrine infusion in intrinsic sinus rhythm: 1. Normal Rv function. LVEF 40% 2. No new regional wall motion abnormalites, valves as listed pre-revascularization. 3. Thoracic aortic contour is intact CHEST (PORTABLE AP) [**2111-10-2**] 4:28 PM CHEST (PORTABLE AP) Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 61 year old man s/p cabg and ct removal REASON FOR THIS EXAMINATION: r/o ptx HISTORY: Status post CABG with chest tube removal; to assess for pneumothorax. FINDINGS: In comparison with the study of [**9-21**], the endotracheal tube, Swan-Ganz catheter, and nasogastric tube have all been removed. Left chest tube has also been removed and there is no evidence of pneumothorax. There is probably some residual atelectatic change at the left base as well as in the right upper zone, both of which are decreasing. Brief Hospital Course: He was admitted to cardiac surgery. He was seen by renal to continue his HD. He was taken to the operating room on [**10-1**] where he underwent an OPCABG x 2. He was transferred to the ICU in critical but stable condition. He was given vancomycin perioperative prophylaxis as he was in house preoperatively. He was extubated the morning of POD #1. He continued on HD postop. He was transferred to the floor on POD #1. He was started on renagel per renal. He did well postoperatively and was ready for discharge to rehab on POD #4. Medications on Admission: crestor 40', colace 150", zoloft 100', lisinopril 40', norvasc 10', asprin 81', thiamin 100', plavix 75', protonix 40', toprol xl 200', ambien 10', folate 1", sensipar 180', lovaza 1"" Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Cinacalcet 30 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily). 12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 38**] Rehab [**Location (un) 1110**] Discharge Diagnosis: CAD now s/p CABG Acute on Chronic systolic heart failure ESRD on HD(L AV fist), CAD s/p MI, HTN, ^lipids, DM2 , s/p L THR, prostate CA s/p cryo/lupron, h/o gastric ulcer Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions,creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 20764**] 2 weeks Dr. [**First Name (STitle) **] 4 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2111-10-5**]

Admission Date: [**2173-10-1**] Discharge Date: [**2173-10-20**] Date of Birth: [**2133-4-7**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 26411**] Chief Complaint: perineal infection Major Surgical or Invasive Procedure: [**2173-10-1**] Radical debridement of scrotum, perineum and abdomen. History of Present Illness: HPI: The pt is a 40yM with a history of diabetes who was transferred from [**Hospital 8641**] Hospital by Mediflight where he presented with scrotal pain and swelling 2 days after an incision and drainage of a small scrotal abscess and was found to have an exam c/w Fournier's Gangrene and subcutaneous gas on CT. The pt reports that he waited in the ED at [**Location (un) 8641**] for 3 hours in early afternoon where erythema of his scrotum and swelling progressed to his lower abdominal region. After his transfer to [**Hospital1 18**], he was noted to be afebrile but over the course of an hour became diaphoretic and ill appearing. The pt denies SOB< CP, neurological sx, urinary sx, or GI sx. PMH: DM, HTN, chronic back pain PSH: Vasectomy Med: Atenolol 50", oxycontin 40", ASA 81', Metformin 1000' All: NKDA Soc: Live in [**Last Name (un) 53428**], NH. Wife [**Doctor First Name 803**] can be reached at [**Telephone/Fax (1) 79837**] Labs: CH 7 129 94 25 306 AGap=18 3.3 20 1.3 CBC- 11.5 / 34.1 / 142 PT: 15.1 PTT: 26.2 INR: 1.3 OSH CT Abd: Scrotal air tracking anteriorly and posteriorly with additional gas in the buttock PE: VS: 100.4 96 100/56 21 94 Diaphoretic RRR CTAB Abdomen soft, NT, NT, erythema tracking to the right inguinal crease, within marker, crepitus palpable over left inguinal crease Phallus circumcised mild, ecchymosis at base Scrotum the size of grapefruit, ecchymotic, crepitus present, focal area of dark purple with break in skin in midline, testes non-palpable Perineum indurated without crepitus, bleeding from perineal wound Anus without crepitus, Past Medical History: DM, HTN, chronic back pain Vasectomy Social History: Live in [**Last Name (un) 53428**], NH. Wife [**Doctor First Name 803**] can be reached at [**Telephone/Fax (1) 79837**] Physical Exam: On Day of Discharge Gen: No acute distress Cards: RRR Pulm: Lungs clear to Auscultation Abdomen: soft non-tender Wound: well-approximated, healing, drains maintaining suction with clear serosanguinous drainage. Skin graft with 100% take. Mild maceration/irritation of skin on medial bilateral thighs secondary to moisture and friction. Pertinent Results: [**2173-9-30**] 10:30PM NEUTS-89.1* LYMPHS-7.5* MONOS-2.9 EOS-0.5 BASOS-0.1 [**2173-9-30**] 10:30PM WBC-11.5* RBC-5.24 HGB-11.8* HCT-34.1* MCV-65* MCH-22.5* MCHC-34.6 RDW-13.9 [**2173-10-1**] 02:30AM HGB-10.4* calcHCT-31 [**2173-10-1**] 04:25AM WBC-12.5* RBC-4.21* HGB-9.6* HCT-29.5* MCV-70* MCH-22.8* MCHC-32.5 RDW-13.5 [**2173-10-1**] 11:18AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2173-10-1**] 12:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: Pt life-flighted to [**Hospital1 18**]. Pt diagnosed with Fournier's gangrene, taken emergently by Urology to OR from ER for radical perineal debridement. Please see operative note dictated separately. Pt transferred to SICU still intubated for IV insulin, IV antibiotics (Vanc, Zosyn, Clinda), hourly wound checks, and pressor/ventilator support. POD2 Pt taken back to OR for re-debridement of wound margins by Gen [**Doctor First Name **] and Urology. In the SICU, the pt had a relatively uneventful course. see notes below. [**9-30**]: transfer from [**Hospital 8641**] Hospital, s/p incision and drainage of perineal abscess 2 days ago followed by increasing pain and redness and fever, evaluated today and found to have clinical and radiological findings c/w Fournier's gangrene. Transferred to [**Hospital1 18**] for surgical evaluation and treatment. States fevers and chills. [**10-1**]: added clindamycin for antibiotic coverage, minimally marching erythema, added propofol for sedation. A wound swab from this day was taken and was + enterococcus. All other cultures neg. [**10-2**]: back to OR for some more debridement of right thigh. weaned off of levo using fluid [**10-3**]: bronchoscopy was performed [**10-4**]:NGT placement--TF started. low grade temp. flexiseal placed [**10-5**]:started insulin gtt for refractory blood sugars in the setting of chronic wound care, lasix gtt with albumin [**10-6**]: weaned versed/fent, weaned vent, started diamox, started precedex to wean to extubation [**10-7**]: Extubated. Aggitated, responding to haldol prn [**10-9**]: no acute events, changed to po meds, po lasix, increased RISS, PCA and oral pain control, d/c'ed insulin gtt Pt transferred to Urology floor service in stable condition. Wound care, glycemic control, and continued antibiotics provided. Pt taken to OR by Plastic Surgery for local flap closure of debrided area and VAC placement to bolster skin graft over testicles. The patient did well on the floor. He was kept on bed rest POD1-5 with strict restrictions against abducting his legs. In addition, he was continued on IV antibiotics per ID recommendations. On POD 5 his VAC dressing was taken down and his skin graft had 100% take. On day of discharge POD 7, the patient was doing very well. He was Afebrile vital signs stable, his pain was well controlled with an oral regimen, he had been cleared for home by Physical therapy, and his drain outputs had decreased appropriately. Per ID recs, the patient did not require additional IV antibiotic therapy. Medications on Admission: Atenolol 50", oxycontin 40", ASA 81', Metformin 1000' Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*24 Tablet Sustained Release(s)* Refills:*0* 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp:*20 Capsule(s)* Refills:*0* 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous twice a day: take at breakfast and Bedtime. Take [**2-28**] dose if not eating. . Disp:*2 vials* Refills:*2* 14. Diabetic supplies 1/2 cc 30gauge insulin syringes prn Glucometer testing strips PRN Discharge Disposition: Home With Service Facility: ROCKINHAM VNA Discharge Diagnosis: Fournier's Gangrene Discharge Condition: hemodynamically stable, tolerating oral intake, ambulating, voiding without difficulty, pain controlled on oral regimen 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. Meds Take all medications as ordered. Drains You will have a VNA who will help you with dressing changes and wound checks as well as drain care. It will be important for you to keep good records of your drain output and bring the records with you when you return to clinic. Followup Instructions: Please call Dr.[**Name (NI) 29526**] office at ([**Telephone/Fax (1) 26412**] for a followup appointment in 1 week. Please call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for a followup appointment. F/u with your PCP regarding your insulin regimen and blood glucose control Completed by:[**2173-10-20**]

Admission Date: [**2171-8-17**] Discharge Date: [**2171-8-21**] Date of Birth: [**2134-4-7**] Sex: F Service: Transplant Surgery Service CHIEF COMPLAINT: Fever, chills, nausea, vomiting, and dysuria. HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old female postop pancreas transplant [**2171-8-7**], and living unrelated renal transplant [**2170-8-14**]. She presents with 36 hours of history of increasing fever and chills, nausea and vomiting. The patient reported shakes at home. Temperature was 101.7. The patient noted that she had foul smelling urine. Upon admission the patient was very agitated and tachycardic with a heart rate of 120. Her vital signs were normal. PAST MEDICAL HISTORY: IDDM, status post living unrelated renal transplant [**2170-8-14**]. MEDICATIONS AT HOME: 1. Prograf 3 mg PO b.i.d. 2. CellCept 1 gram b.i.d. 3. Valcyte 900 mg once a day. 4. Prednisone 4 mg once daily. 5. Bactrim single strength 1 once daily. 6. Nystatin 5 ml PO QID. 7. Protonix 40 mg PO b.i.d. 8. Os-Cal b.i.d 9. Fosamax q week. PHYSICAL EXAMINATION: Temperature 102.8, heart rate 108, blood pressure 136/80, respiratory rate 18, 98% on room air. The patient was alert and oriented, very agitated. Cranial nerves II through XII are intact. Pupils are equal, round and reactive to light. Lungs are clear bilaterally. Incision was clean dry and intact. Abdomen was tender approximately around the incision. Positive bowel sounds. Legs - no edema. HISTORY OF BRIEF HOSPITAL COURSE: The patient is a 37-year- old female presenting with severe nausea and vomiting, fever and foul smelling urine. This lady's likely diagnosis was pyelonephritis versus UTI with superimposed anxiety attacks. The patient was admitted to the transplant unit and started on IV fluid and empiric Zosyn. Chest x-ray was done and demonstrated no pleural effusions. No infiltrates. Lung fields were clear. A nasogastric tube was inserted. Correct position was noted in the stomach. The patient underwent supine film of the abdomen. Gas was noted in the loops of the colon. The patient underwent CT of the abdomen and pelvis without contrast. This demonstrated evidence of an abscess with benign appearing fluid collection along the course of the right iliac vessels, likely representing lymphocele. The patient was admitted to the SICU for monitoring. White blood cell count on admission 21.1, hematocrit 31.5, creatinine 1.2, up from day 1 of 0.9, amylase 22, lipase 14, and glucose 91. EKG revealed sinus tachycardia. No ST-T wave changes. Urine was positive for nitrates. WBC 30, large amount of blood. As previously stated the patient was started on Zosyn. Urine and blood cultures were sent. Blood cultures were subsequently negative. Urine culture demonstrated E. coli with 100,000 colonies, resistant to ampicillin and Bactrim, sensitive to the cephalosporins, imipenem, Levo, and meropenem. On hospital 2, the patient had a temperature of 104.5. She was given Tylenol and aggressive IV hydration. She continued on Zosyn and Linezolid. White blood cell count increased to 30.3. She complained of some back pain as well. Temperature defervesced. The patient was transferred to the medical- surgical unit on hospital day 3. Temperature was 99. Abdomen was soft. She was slowly advanced to house diet. IV therapy was decreased. Urine output was approximately 500 cc per day of clear yellow urine. The patient continued to feel anxious. Glucoses were normal. Foley catheter was removed. The patient was followed by nephrology throughout this hospital course. Prograf level was 7.1. Prograf was adjusted accordingly. Creatinine was 1.2, BUN 13, amylase 23, and lipase 17 with a glucose of 112. Of note, the patient complained of right hip pain on hospital day 3. She was medicated with IV Dilaudid with fair relief. The patient felt there was muscle spasm in right hip, erythematous with some swelling. Physical therapy was consulted. Localized inflammation was noted. Concern was for trochanteric bursitis. The patient was independent with mobility. She was independent with transfer, stairs, and hallway ambulation. Outpatient PCA was recommended. The patient's antibiotic was switched to ceftriaxone IV. The patient was discharged home on hospital day 5. She was given a prescription for Keflex for 1 week and Macrobid. Urine output was approximately 1.5 liters per day. Glucose has remained within normal range. She was afebrile. DISCHARGE MEDICATIONS: 1. Prednisone 4 mg PO once daily. 2. Valcyte 900 mg PO once daily. 3. Nystatin 5 mg PO QID. 4. Bactrim single strength 1 PO once daily. 5. CellCept 1 gram PO b.i.d. 6. Prograf 3 mg PO b.i.d. 7. Protonix 40 mg PO once daily. 8. Aspirin 81 mg, enteric coated, one PO once daily. 9. Hydrocodone/ acetaminophen 5/325 mg 1 tab PO p.r.n. q4 hours. 10. Keflex 500 mg PO QID x 10 days. 11. Macrodantin 100 mg cap 1 PO once daily. DISCHARGE DIAGNOSES: 1. Status post pancreas transplant on [**2171-8-7**]. 2. Status post living unrelated renal transplant [**2170-8-14**]. 3. Urinary tract infection. 4. Urosepsis. The patient was instructed to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2171-8-26**]. She was also to follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from social service as well as Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2171-9-6**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PhD [**Numeric Identifier 8353**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2171-11-12**] 16:00:13 T: [**2171-11-13**] 02:12:59 Job#: [**Job Number 41013**] cc:[**Name8 (MD) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD

Admission Date: [**2136-7-14**] Discharge Date: [**2136-7-17**] Date of Birth: [**2059-8-27**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: 76F s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 76F s/p fall; patient originally seen at outside hospital, and transferred to [**Hospital1 18**]. Past Medical History: hypertension bilateral total hip replacements Social History: EtOH use Family History: unknown Physical Exam: AXO to person, place, event CN 2-12 intact RRR CTA b/l +bs, nt, nd, soft no pelvic instability no gross abn of extremities rectal guaiac neg, no mass LE palp distal pulses Pertinent Results: [**2136-7-14**] 02:00AM BLOOD ASA-NEG Ethanol-46* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2136-7-14**] 07:50AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.1* [**2136-7-15**] 02:40AM BLOOD Calcium-7.3* Phos-2.1* Mg-3.3* [**2136-7-14**] 02:00AM BLOOD CK-MB-3 cTropnT-<0.01 [**2136-7-14**] 07:50AM BLOOD CK-MB-3 cTropnT-<0.01 [**2136-7-14**] 02:00AM BLOOD CK(CPK)-104 [**2136-7-14**] 07:50AM BLOOD CK(CPK)-106 [**2136-7-14**] 02:00AM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-142 K-3.5 Cl-102 HCO3-21* AnGap-23* [**2136-7-14**] 07:50AM BLOOD Glucose-188* UreaN-7 Creat-0.7 Na-142 K-3.2* Cl-102 HCO3-21* AnGap-22* [**2136-7-15**] 02:40AM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-142 K-4.1 Cl-111* HCO3-21* AnGap-14 [**2136-7-14**] 02:00AM BLOOD PT-12.6 PTT-21.0* INR(PT)-1.1 [**2136-7-14**] 02:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ [**2136-7-14**] 02:00AM BLOOD Neuts-90.6* Bands-0 Lymphs-5.6* Monos-3.6 Eos-0.1 Baso-0 [**2136-7-14**] 02:00AM BLOOD WBC-13.7* RBC-3.81* Hgb-14.5 Hct-42.1 MCV-110* MCH-38.1* MCHC-34.5 RDW-15.9* Plt Ct-407 [**2136-7-15**] 02:40AM BLOOD WBC-5.4 RBC-2.92* Hgb-11.2* Hct-32.3* MCV-111* MCH-38.5* MCHC-34.8 RDW-16.1* Plt Ct-284 [**2136-7-16**] 09:05AM BLOOD Hct-37.8 [**2136-7-14**] 01:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2136-7-14**] 01:20AM URINE Hours-RANDOM [**2136-7-14**] 01:20AM URINE RBC-[**2-12**]* WBC-[**2-12**] Bacteri-MOD Yeast-NONE Epi-1 [**2136-7-14**] 01:20AM URINE Blood-LGE Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2136-7-14**] 01:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005 AP CXR: 1. There are compression deformities of several lower thoracic vertebral bodies, of uncertain chronicity. 2. There is widening of the ascending aortic contour, which may represent aneurysmal dilatation. AP Pelvis: bilat THR, no Fx CT c-spine: Marked osteopenia and degenerative changes are seen, without any definite fracture or subluxation identified CT head: Bilateral areas of intraparenchymal (hemorrhagic contusions) and subarachnoid hemorrhage EKG: Sinus tachycardia. Left ventricular hypertrophy. Diffuse ST-T wave changes may be secondary to left ventricular hypertrophy. No previous tracing available for comparison Brief Hospital Course: Patient was admitted with intraparenchymal and subarachnoid hemorrhages, and with poorl controlled hypertension. Her hospital course (by system): Neuro: Patient had 2 CT of head done, without interval change, and her mental status improved during hospital course. Patient also did not develop any focal neurologic deficits. She was treated with dilantin for seizure prophylaxis for a 7-day course, and she also received valium for DT prophylaxis. CV: Patient was treated with metoprolol and lisinopril for her hypertension, and her BP was maintained under 160 SBP throughout hospital course. Patient also had an EKG which showed her to be in sinus tachycardia on [**7-14**]; her HR decreased to within normal limits on discharge. Resp: Patient was treated with incentive spirometry during her hospital course, and her respiratory status was good throughout hospital stay. GI: Patient received colace during hospital course, and she tolerated a regular diet throughout; she also received protonix for GI prophylaxis. GU: patient had a foley in place through most of hospital course; it was d/c'd without incident, and patient was able to urinate on her own. FEN: Patient received thiamine, folate and a mulivitamin on admission because of EtOH use and risk of Wernicke-Korsakoff syndrome. Heme: no issues ID: no issues Medications on Admission: norvasc zestril Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day: hold for SBP <100 or HR <55. 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 4 days. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: 1) subarachnoid hemorrhage 2) frontal intraparenchymal hemorrhage *3) hypertension (poorly controlled at admission) Discharge Condition: stable Discharge Instructions: You have suffered an intraparenchymal hemorrhage and a subarachnoid hemorrhage following a fall. You should return to headache, nausea/vomiting, difficulty breathing, chest pain, decreased sensation or motor function, or any other symptoms that are concerning to you. Followup Instructions: follow-up at Trauma Clinic in 2 weeks ([**Telephone/Fax (1) 6439**]) follow-up with neurosurgery in 2 weeks ([**Telephone/Fax (1) 1669**]) follow-up with PCP regarding BP control [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2136-7-17**]

Admission Date: [**2115-1-20**] Discharge Date: [**2115-1-31**] Service: NEUROLOGY Allergies: Percocet / Penicillins / Atropine / Keflex / Bactrim / Inderal / Levaquin / Reglan / Ciprofloxacin Hcl / Doxycycline / Azithromycin Attending:[**Doctor Last Name 15044**] Chief Complaint: prolonged R sided shaking Major Surgical or Invasive Procedure: intubation History of Present Illness: Briefly, pt is a [**Age over 90 **] year old woman with PMH notable for breast CT in [**2081**] (s/p R mastectomy), pancreatic CA [**2094**] (s/p whipple's), colon CA d/c'ed [**1-2**], s/p total colectomy, who is transferred from the ICU after presenting in partial status epilepticus. According to the daughter, after her recent colectomy she has had complications of post-operative ileus, overall decreased po's and weight loss. She was in her nursing home and was relatively stable until the day prior to admission when she was more tired and not taking in any po's. That night her nursing aid noted that she had L face, arm, and leg twitching, unclear if true LOC associated with it. The twitching began around midnight and continued through the morning and she was brought to [**Hospital1 18**] for further evaluation. IN ED she was noted to be talking coherently through the twitching, with O2 sats down to the low 90's on 2L NC. She was given a total of 4 mg ativan and then 1 gm dilantin bolus that stopped the shaking, however she became so sedated that she required intubation. She was admitted to the ICU for further management. Past Medical History: 1. pancreatic cancer status post Whipple procedure [**2094**] 2. Multiple duodenal strictures and ulcers 3. Adhesions status post lysis from radiation to pancreas. 4. Status post transverse colectomy for radiation-induced injury to colon. 5. Status post appendectomy [**2041**]. 6. Status post cholecystectomy for gangrenous cholecystitis [**2105**] 7. Status post gastrojejunostomy. 8. Macular degeneration reportedly legally blind in left eye 9. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 10. Breast cancer status post modified radical mastectomy in [**2081**] 11. Hypertension. 12. History of Methicillin resistant Staphylococcus aureus infection. 13. Multiple falls. 14. status post ileocolectomy for colon cancer [**1-2**] 15. osteoarthritis 16. reported history of hepatitis A in [**2064**] 17. status post partial hysterectomy [**2061**] 18. status post ventral incision hernia repair [**2095**] Social History: nursing home resident, formerly a lawyer, per daughter cognitively at baseline very intact, was writing her life memoir until her recent surgery, which left her quite ill. Family History: Noncontributory Physical Exam: Exam on admission to the floor (from ICU) very limited by pt's mental status. Gen: sleeping, arousable but not following commands, breathing comfortably, heart RRR with 2/6 SEM at LSB, lungs with crackles on L mid and base anteriorly, abd soft, non distended, incision site C/D/I. Peripheral pulses easily palpable Neuro: follows no commands, but does intermittently wiggle toes, unclear if to command CN: R pupil 3--2, L pupil surgical, +OC's but no purposeful EOM's, face symmetric, tongue midline, +gag M: moves all 4 extremities vigorously to mild painful stimuli, but moves LUE less than others. S: localizes to pain in all 4 R: RUE and LUE 1+ throughout, patellae 1+ bilaterally, 5 beats of ankle clonus non sustained bilaterally, toes up bilaterally, +jaw jerk, -[**Doctor Last Name **] Pertinent Results: [**2115-1-20**] 11:54AM TYPE-ART TIDAL VOL-500 O2-100 PO2-437* PCO2-33* PH-7.40 TOTAL CO2-21 BASE XS--2 AADO2-252 REQ O2-49 INTUBATED-INTUBATED [**2115-1-20**] 11:54AM O2 SAT-100 [**2115-1-20**] 09:51AM CEREBROSPINAL FLUID (CSF) PROTEIN-49* GLUCOSE-64 LD(LDH)-50 [**2115-1-20**] 09:51AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1550* POLYS-73 LYMPHS-26 MONOS-1 [**2115-1-20**] 09:51AM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-2550* POLYS-67 LYMPHS-30 MONOS-3 [**2115-1-20**] 08:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2115-1-20**] 08:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2115-1-20**] 08:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2115-1-20**] 07:38AM TYPE-ART PO2-301* PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1 INTUBATED-NOT INTUBA [**2115-1-20**] 07:38AM GLUCOSE-112* LACTATE-3.3* NA+-131* K+-4.4 CL--99* [**2115-1-20**] 07:38AM HGB-11.5* calcHCT-35 O2 SAT-99 CARBOXYHB-0.4 MET HGB-0.7 [**2115-1-20**] 07:38AM freeCa-1.10* [**2115-1-20**] 07:20AM GLUCOSE-93 UREA N-15 CREAT-1.1 SODIUM-136 POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-26 ANION GAP-19 [**2115-1-20**] 07:20AM ALT(SGPT)-9 AST(SGOT)-31 AMYLASE-141* TOT BILI-0.5 [**2115-1-20**] 07:20AM WBC-7.8 RBC-3.95*# HGB-11.8*# HCT-36.7 MCV-93 MCH-30.0 MCHC-32.3 RDW-14.1 [**2115-1-20**] 07:20AM NEUTS-82.0* LYMPHS-14.9* MONOS-2.7 EOS-0.3 BASOS-0.2 [**2115-1-20**] 07:20AM PLT COUNT-472*# Brief Hospital Course: ICU/Floor course by system: Neuro: 1. First time seizures - This episode was thought to be focal status, and once stopped she never had a recurrent of seizure-like activity. It was thought that perhaps her seizure was secondary to severe electrolyte abnormalities in the setting of poor nutrition post operatively. She was continued on dilantin, initially 100 mg IV TID, but her levels were persistently supratherapeutic and upon transfer to the floor the dilantin was held each day while levels were checked. On [**1-29**] the level was finally within low-therapeutic range (4.4, when corrected for albumin was approximately 9) and she was restarted on 100 mg qday. It was thought that has intrinsic slow clearance of dilantin, as none of her other medications are known to decrease dilantin clearance. Upon discharge her level was 3.7. Her levels should be followed 2x/week. Further neurologic workup for seizure included LP that was unremarkable and MRI that showed no enhancing lesions, one small area of DWI right thalamus without FLAIR correleate of unclear significance. Radiology reported diffuse meningeal uptake, but this was likely s/p LP effects. No EEG was performed. 2. Encephalopathy - Pt was initially very encephalopathic, thought to be due to infection as well as dilantin toxicity. As her pneumonia was treated and her dilatnin level was reduced, she became markedly awake and lucid, and by discharge was conversant and easily following commands. ID: 1. Aspiration pneumonia - She had a LLL infiltrate on CXR, leukocytosis to 13K, low grade temp (98.8 ax), she was started on levofloxacin and flagyl and completed a 10 day course. Her wbc was 6 upon discharge and her lung exam was much improved. Her blood and urine cultures were negative to date. Pulm: She was intubated on [**1-20**] for airway protection after the multiple sedating medications she received for her seizure. She was easily extubated at 6pm on [**1-21**]. On [**1-24**] she had an episode of acute respiratory distress, her CXR and lung exam were consistent with pulmonary edema and she was given IV lasix with excellent response. She was started on a maintenance dose of lasix for the remainder of her stay and this was discontinued upon discharge. Heme: On admission, hct dropped from 36->29, repeat was 32 She does not appear to be iron deficiency or anemia of chronic disease, she does however have borderline low B12 and folate. Stool guiaic's were negative. Her hct stayed around 28-29 for the remainder of her stay. Pain: Continued fentanyl patch (for OA) to prevent withdraw, prn tylenol. FEN: Pt was not PO'ing due to encephalopathy. Upon transfer, nutrition consulted and plan for PICC placement for TPN made. PICC was placed but it was only able to be placed peripherally, therefore she was started on [**Month/Year (2) 32813**]. Electrolytes were followed daily and her initial hyponatremia resolved. She also initially had hypomagnesemia, hypocalcemia, and hypokalemia, all of which were stabilized with her [**Month/Year (2) 32813**]. On [**1-28**] she passed her speech/swallow evaluation and an oral diet was started. She tolerated this well and upon discharge her [**Month/Day (4) 32813**] was discontinued with plans to augment her oral nutrition as well as possible. Her daughter met with the medial nutrition group prior to discharge. Her electrolytes should be followed weekly. She also should be restarted on pancrease once she is eating a more full diet. PPx: for stroke ppx, was initially given ASA, but due to decreasing hct and recent surgery, upon transfer the ASA was d/c'ed. As DVT prophylaxis she was receive heparin in her [**Last Name (LF) 32813**], [**First Name3 (LF) **] was not given SC heparin, but was started back on SC heparin upon discharge. For GI prophylaxis she was receiving pepcid, and was switched back to her home regimen of protonix upon discharge. Code: She was intially DNR but not DNI, after much discussion with her daughter and her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] the decision was made to make her DNR/DNI. Dispo: She was transferred back to her nursing home in much improved condition on [**2115-1-31**]. Medications on Admission: 1. Zestril 10mg daily 2. Protonix 40mg daily 3. Pancrease 3 packets per meal 4. Fentanyl patch 25mcg/hr every 72 hours. 5. Ocuvite twice daily Discharge Medications: 1. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Ocuvite Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: One (1) Injection three times a day. Disp:*qs * Refills:*2* 4. Dilantin 100 mg qday 5. Protonix 40 mg qday 6. Fentanyl patch 7. Zestril 10 mg qday 8. Multivitamin Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: Partial seizure Pneumonia Discharge Condition: improved Discharge Instructions: Please return to ED if pt develops worsening respiratory distress or seizure-like activity. Once she is taking a more complete diet she should be restarted on her pancrease Her dilantin level and electrolytes should be followed weekly. CHeck an albumin with the dilantin level. Followup Instructions: Dr. [**Name (NI) **], pt will schedule

Admission Date: [**2114-11-18**] Discharge Date: [**2114-11-19**] Date of Birth: Sex: Service: DIAGNOSIS: Right temporal intracranial mass. HISTORY OF THE PRESENT ILLNESS: This is a 53-year-old gentleman who presented with vertigo and ringing in his ears and headache since [**Month (only) 359**]. He had had a C-scan and MRI with and without gadolinium at an outside hospital, where he was diagnosed to have a 3-cm x 3-cm intracranial right temporal mass. He was referred to the [**Hospital1 188**] for further evaluation. HISTORY OF THE PRESENT ILLNESS: The patient has history of headache, ringing of ears, and vertigo since [**Month (only) **] to early [**Month (only) 359**]. There was no history of nausea, vomiting, visual disturbance, diplopia, or seizures. There was no evidence of weakness or tingling or numbness anywhere. On admission, the patient was found to have a mass with edema around it and bleeding surrounding the tumor. He was admitted to the Intensive Care Unit for blood-pressure control and anti-seizure medication therapy and for close monitoring. Further workup revealed left lung mass and adrenal mass; preliminary diagnosis of carcinoma of the lung with extensive metastasis had been made. Further workup was required. The patient expressed explicit desire to be home on [**Holiday **] Eve until [**Holiday **] and had no intentions of staying in the hospital on [**Holiday **] Day. Therefore, he was started on high-dose Decadron for anti-edema measures. He was discharged home on high-dose Decadron. He will be having further followup. He us scheduled for CT guided lung biopsy on the [**3-22**] in the [**Hospital Unit Name 1825**] at 9:30 am. He is also to continue on Decadron 8 mg p.o. q.6h. for two days and 6 mg Decadron q.6h. for two days followed by 4 mg Decadron q.6h. until he meets with Dr. [**Last Name (STitle) 724**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Brain [**Hospital 341**] Clinic on [**2114-11-26**]. Based on the tissue diagnosis, the patient will be having eyelid surgery and chemotherapy or chemotherapy or radiotherapy, which is to be decided. The patient was also given strict instruction to contact us at the earliest date if there is any change in his mental status or in the severity of his headache. ALLERGIES: The patient is allergic to LIPITOR AND SULFA. A new allergy to DILANTIN was documented. DISCHARGE MEDICATIONS: 1. Zantac 150 mg p.o.b.i.d. 2. Depakote 350 mg p.o. three times a day. 3. Decadron starting at 8 mg, tapering down to 4 mg p.o. q.6h. until further followup and further plans will be made. The patient is also noted to have a past medical history of coronary artery disease with three-vessel stenting and angioplasty; hypertension; diabetes mellitus, for which he takes Insulin. DISCHARGE CONDITION: The patient is awake, alert, oriented, but no localizing signs, no focal lesions. The patient is fully aware of the risks of him being discharged. The patient is willing to go home. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 14-120 Dictated By:[**Last Name (STitle) 22910**] MEDQUIST36 D: [**2114-11-21**] 10:43 T: [**2114-11-21**] 12:44 JOB#: [**Job Number 24026**]

Admission Date: [**2175-8-10**] Discharge Date: [**2175-8-22**] Date of Birth: [**2148-2-15**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6565**] Chief Complaint: Right flank pain, fever Major Surgical or Invasive Procedure: embolization of bleeding artery under IR History of Present Illness: 27 F here for 2 days of right flank pain, sharp, worsened by deep breaths. No similar pains on past. Associated fatigue and fevers x 2 days. No dysuria, hematuria or any other urinary symptoms. Chronic tingling in the right foot (since she was diagnosed with cord compression many months back. No headache. ER course - given Abx as below. Temp 103.9 ROS: Constitutional: Fatigued, weight loss in past 5 weeks. Fever and associated chills as above. Also anorexic. Neuro: No confusion, numbness of extremities, dizziness or light-headedness, vertigo, weakness of extremities, confusion, tremor. Parasthesias-as above Psychiatric: no depression, suicidal ideation Eyes: No blurry vision, diplopia, loss of vision, photophobia. Wears glasses. ENT: No dry mouth, oral ulcers, bleeding nose, gums, tinnitus, sinus pain, sore throat Cardiac: no chest pain, DOE, syncope, PND, orthopnea, palpitations, peripheral edema Pulmonary: No shortness of breath, hemoptysis, pleuritic pain. Has chronic coung for many weeks GI: Had some nausea and vomiting. No diarrhea, constipation, hematemesis, melena, hematochezia. Abd pain as above. Heme: no easy bleeding, bruising, lymphadenopathy GU: no dysuria, hematuria, increased frequency, urgency or incontinence Endocrine: Lost hair since starting chemo. No skin changes, heat or cold intolerance Skin: no rash or pruritis Musculoskeletal: no myalgias, arthralgias, back pain Allergy: no seasonal allergies- NKDA. . [x] All other systems negative on detailed review except as noted. Past Medical History: - Hepatocellular carcinoma - metastasis to bone, lung, abdomen -Had been receiving weekly 5-FU leucovorin after having progressed on the weekly doxorubicin. She previously was treated with gemcitabine, Cisplatin, and Avastin. - Pulmonary embolism and SVC clot - on anticoagulation. -R ovarian cyst-She affirms increasing abdominal girth [**2168**], feeling increased bloating, presented to the ED found to have a right ovarian cyst, was resected. - [**2155**] (7yrs old) hospitalized for 6 months for fever/cough, weakness, unclear source of infection, did require blood transfusions. - Gyn- no menstrual periods for the past year Social History: Social History: Lives with her sister and brother. Recently relocated from [**Country 3587**] [**12-21**] - speaks Creole and Portugese. Denies stds, denies etoh, ivdu, smoking. Family History: 1 sister age 27, with question of R leg mass resected 4 yrs ago. Brother had liver problems as a child. Father - HTN Denies other cancer history Physical Exam: VS T 99.6 P 123/min, BP 104/68 RR 16 100% RA Gen - Thin female appears chronically sick. Not in acute distress. Eyes - pale, not jaundiced ENT - moist mucosae, no thrush, ulcers or erythema Neck - supple, no LAD, JVP normal CV - S1, 2 - normal, No murmurs or rubs, or gallops. Tachycardia RS - no crackles or wheezing Abd - rt UQ abd pain, no RT or distenstion. Liver edge palpable. Rt CVA tenderness Extremeties - no edema Skin - no rash GU - no catheter Neuro - Alert and oriented x3, Cr n [**3-27**] normal. Motor - [**5-20**] UE and LE bilaterally equal, prox and distal. Sensory normal to crude touch bilaterally. Plantars flexor bilaterally. No pronator drift. Fluent speech. Psychiatric - not anxious. Calm. Not depressed Heme/lymph - no cerv LAD, thyroid normal. Pertinent Results: CXR - IMPRESSION: No acute cardiopulmonary process. Multiple pulmonary masses present at the lung base is better evaluated on the CT examination of [**2175-7-26**] CT abdomen, pelvis - IMPRESSION: 1. Significant interval worsening of metastatic disease as described above. 2. Interval increase in size of the left adnexal dermoid. 3. Unchanged appearance of osseous metastasis . . Brief Hospital Course: # acute blood loss anemia/hemoperitoneum: Likely bleeding from hepatic tumors, however, angio did not identify obviously bleeding lesions, so no embolization performed initially. Pt then had increased abdominal distension and pain; repeat CT scan did not show demonstrable change in hemoperitoneum, but could not rule out continued oozing from liver lesions. R hepatic artery was therefore embolized with Gel-foam to prevent further/future bleeding. Following procedure, patient had a stable hematocrit, and did not require additional transfusions. . # Fevers: No clinical signs that would indicate current infection, as pt w/o cough, SOB, dysuria, or diahrea. Serial blood cultures were without crowth. Fevers believed to be secondary either to diffuse cancer or blood in peritoneum. . # Pain: Pt swtiched from PCA to MS contin w/ diluadid PRNs. While patient was significantly uncomfortable on admission, pain ins well controlled at time of discharge. Pain due to carcinomatosis of abdomien. . # hepatocellular carcinoma: HepB +, widely metastatic. last chemo over 2 weeks ago. As pt has failed multiple chemotherapeutic regimens, felt that would not gain advantage from additional treatment. Pt seen by palliative care, and their assistance is most appreciated. Patient discharged with home hospice. Medications on Admission: LOVENOX 60MG subcutaneously [**Hospital1 **] Discharge Medications: 1. Roxanol Concentrate 20 mg/mL Solution Sig: [**1-17**] mL PO q 1 hour as needed for discomfort/respiratory distress. Disp:*4 syringes* Refills:*0* 2. Wheelchair Misc Sig: One (1) Miscellaneous once a day. Disp:*1 * Refills:*0* 3. hospital bed please provide pt w/ one hospital bed 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for Pain. Disp:*150 Tablet(s)* Refills:*2* 8. Morphine 30 mg Tablet Sustained Release Sig: Four (4) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*240 Tablet Sustained Release(s)* Refills:*2* 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:*250 ML(s)* Refills:*1* 10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*50 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VistaCare Discharge Diagnosis: Metastatic liver cancer hemoperitoneum Discharge Condition: Stable Discharge Instructions: You are discharged after an admission due to bleeding in your belly. This bleeding was from one of your liver tumors. You had the blood suppy to that tumor blocked so that it won't bleed. Because of these bleeding tumors, you are no longer a canidate for the serafinib treatment. Unfortuantly all the chemotherapy we normally use to treat liver cancer has not proven successful. You are now being discharged home, and arangements are being made to give you the support to remain comfortable. Followup Instructions: Call your Dr. [**Last Name (STitle) **] you develop severe abdominal pain, confusion, difficulty breathing, vomiting. [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]

Admission Date: [**2146-10-13**] Discharge Date: [**2146-10-23**] Date of Birth: [**2072-12-29**] Sex: M Service: Hepatobiliary REASON FOR ADMISSION: This is an admission for a head of the pancreas mass. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old healthy gentleman who presented to an outside hospital in [**2146-7-26**] with cholangitis and gram-negative bacteremia. After he was transferred to [**Hospital1 188**], later in his hospital course, workup with an endoscopic retrograde cholangiopancreatography revealed a smooth stricture in the distal common bile duct and a subsequent computed tomography noted no evidence of a pancreatic mass; however, later evaluations did reveal a pancreatic mass. He is currently asymptomatic without fevers, chills, nausea, vomiting, pruritus, jaundice, dark urine, or loose stools. He is here for elective resection of the pancreatic mass which was shown on the [**9-29**] computerized axial tomography. PAST MEDICAL HISTORY: 1. Hypertension. 2. Transient ischemic attacks. 3. Cholangitis. PAST SURGICAL HISTORY: None. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: (His medications included) 1. Aspirin 81 mg by mouth once per day; last took aspirin on [**2146-9-28**]. 2. Lotrel 5 mg and 10 mg respectively by mouth once per day. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Hepatobiliary Surgery Service and was taken to the operating room for a Whipple procedure. Please review the previously dictated Operative Note by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] from [**2146-10-14**] for the specifics of this procedure. In brief, an open cholecystectomy and pylorus-preserving Whipple procedure were performed. The patient tolerated the procedure well. Postoperatively, he was transferred to the Postanesthesia Care Unit and then to the floor without complications. His postoperative pain was initially controlled with a Dilaudid epidural which he tolerated until day four, at which time he started to complain of hallucinations. The epidural was stopped, and the patient was placed on Toradol until he tolerated by mouth medications. 1. CARDIOVASCULAR ISSUES: Cardiovascularly, the patient did well. However, he did have some problems with tachycardia and some atrial ectopy which presented itself on postoperative day six. These tachycardic episodes were controlled with Lopressor, and a Cardiology consultation was obtained. The Cardiology team decided that anticoagulation was not necessary as it was neither was it atrial fibrillation nor what they considered to be a chronic or continuing process. An echocardiogram was performed on postoperative day six which showed a normal left ventricle, with an ejection fraction of greater than 55%, and a moderately dilated left atrium, and mildly thickened aortic and mitral valves. 2. RESPIRATORY ISSUES: The patient did have some postoperative atelectasis which was controlled with incentive spirometry and pulmonary toilet. 3. GASTROINTESTINAL ISSUES: Gastrointestinally, after the surgery the patient was obviously nothing by mouth and given intravenous fluids. In addition, he was given octreotide and Reglan to reduce his pancreatic juice output and to increase his gastric motility. Prior to his discharge, on postoperative day six, the amylase in his [**Location (un) 1661**]-[**Location (un) 1662**] drain was checked and was 201. It was decided to keep the [**Location (un) 1661**]-[**Location (un) 1662**] drain in until his follow-up appointment with Dr. [**Last Name (STitle) 468**]. Of final note, one complication of this procedure was a wound infection. The patient was maintained on oxacillin for several days postoperatively for erythema surrounding the wound. Eventually, the erythema got a little bit worse. On [**10-22**], the wound was opened with some expulsion of purulent material. This was packed open, and the patient defervesced and any signs of fluctuance relieved themselves. At the time of discharge, the patient had been afebrile for greater than 24 hours. Finally, the patient's pathology from the surgery revealed pancreatic adenocarcinoma, a moderately differentiated ductal adenocarcinoma, with a TNM classification of T3 N1 MX. The patient had [**2-6**] lymph nodes involved. The margins of the resected mass were not involved by carcinoma, and there was no lymphatic vessel invasion. On the day of discharge, the patient was afebrile with stable vital signs. In general, he appeared well. In no apparent distress. Cardiovascular examination revealed a regular rate and rhythm. The lungs were clear to auscultation bilaterally. The abdomen was obese, soft, nontender, and nondistended with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain in the right upper quadrant. The abdominal wound from the surgery was open with a wick in it with no signs of continued infection. He still had some slight pedal edema. DISCHARGE DISPOSITION: Therefore, on [**10-23**] (which was postoperative day 10). The patient was discharged home with visiting nurse services with the following diagnoses: DISCHARGE DIAGNOSES: 1. Pancreatic adenocarcinoma (stage T3 N1). 2. Status post pylorus-sparing Whipple procedure. 3. Hemodynamic monitoring with central venous catheter. 4. Hypovolemic ............ including resuscitation. 5. Hypokalemia. 6. Hypermagnesemia. 7. Postoperative atelectasis. 8. Atrial fibrillation. 9. Cellulitis. 10. Wound infection. 11. Hyperglycemia. MEDICATIONS ON DISCHARGE: (His discharge medications included) 1. Vicodin one tablet by mouth q.4-6h. as needed (for breakthrough pain). 2. Amlodipine 5 mg by mouth once per day 3. Benazepril 10 mg by mouth once per day. 4. Reglan 10 mg by mouth four times per day. 5. Protonix 40 mg by mouth once per day. 6. Metoprolol 50 mg by mouth twice per day. 7. Levofloxacin 500 mg by mouth once per day. 8. Miconazole powder applied as needed. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. [**Hospital6 407**] was sent to assist with wound care, drain education and blood glucose monitoring. 2. He has a follow-up appointment with Dr. [**Last Name (STitle) 468**] on the 13th. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2146-10-25**] 21:32 T: [**2146-10-28**] 09:09 JOB#: [**Job Number 52004**]

Admission Date: [**2118-12-2**] Discharge Date: [**2118-12-16**] Date of Birth: [**2039-1-27**] Sex: M Service: SURGERY Allergies: Ativan / Morphine Attending:[**First Name3 (LF) 2836**] Chief Complaint: weakness, abdominal pain Major Surgical or Invasive Procedure: None Attempted IV Port placement History of Present Illness: The patient is a 79y man with end ileostomy, well-known to the surgery service and recently discharged on [**11-30**], who returns to the ED with 24h of peristomal abdominal pain and weakness. The pain began the day following his discharge, and he describes it a constant dull pain, non-radiating. He also complains of weakness. His ostomy out-put has been within normal limits for the patient. The out-put has been liquid with no visible blood. He denies dizziness, fever, chills. He had one episode of emesis the morning of presentation. His SBP on admission to the ED was 70s. PMH: 1. Gout 2. Hypertension 3. atrial fibrillation 4. h/o spontaneous pneumothorax 5. ? pulmonary fibrosis 6. h/o rheumatic fever 7. h/o of multiple small bowel obstructions 8. carotid artery stenosis 9. brain infarct asymptomatic 10. h/o recent c.diff 11. GERD 12. Chronic renal insufficiency 13. h/o Port-a-cath 14. Colonic stricture with chronic small bowel obstruction, partial. PSH: 1. Colectomy, ileostomy for "gangrene"/diverticulitis/"toxic megacolon" 2. Ileostomy reversal 2 years ago 3. Lysis of adhesions on [**2118-7-5**] 4. Appendectomy 5. Removal of cyst on his neck 6. Left hip replacement 7. Removal of 2 burs from his elbows 8. s/p talc pleurodesis ([**Hospital1 112**]) 9. s/p port removal for staph sepsis 10. Resection of ileocolic anastomosis and creation of end-ileostomy ([**11-2**]) Past Medical History: PSH: 1. Colectomy, ileostomy for "gangrene"/diverticulitis/"toxic megacolon" 2. Ileostomy reversal 2 years ago 3. Lysis of adhesions on [**2118-7-5**] 4. Appendectomy 5. Removal of cyst on his neck 6. Left hip replacement 7. Removal of 2 burs from his elbows 8. s/p talc pleurodesis ([**Hospital1 112**]) 9. s/p port removal for staph sepsis 10. Resection of ileocolic anastomosis and creation of end-ileostomy ([**11-2**]) Social History: Social History: Quit smoking 35 years ago. No ETOH. Family History: Family History: Noncontributory Physical Exam: VS: 97.5 85 122/56 17 1003L Gen: no acute distress CV: RRR S1 S2 Lungs: coarse breath sounds bilaterally, no rales or wheeze Abd: soft, non-distended, moderate tympany, tender to palpation diffusely but primarily around ileostomy site. No rebound or guarding. Ostomy is pink and healthy appearing. Brown liquid out-put in the bag. Ext: Warm, well perfused Pertinent Results: Admit Labs CBC: 26/35.9\539 Chem: 128/98/42 ---------<239 5.8\13\2.0 Lactate:7.4 Tbil:0.5 AST:26 ALT:57 AP:96 . [**2118-12-2**] 01:10PM BLOOD WBC-26.3*# RBC-3.66* Hgb-11.8* Hct-35.9* MCV-98 MCH-32.1* MCHC-32.8 RDW-15.1 Plt Ct-539* [**2118-12-3**] 04:48AM BLOOD WBC-23.5* RBC-3.47* Hgb-11.1* Hct-32.4* MCV-94 MCH-32.0 MCHC-34.2 RDW-15.5 Plt Ct-454* [**2118-12-13**] 05:45AM BLOOD WBC-12.6* RBC-2.92* Hgb-9.4* Hct-27.7* MCV-95 MCH-32.2* MCHC-34.0 RDW-16.4* Plt Ct-422 [**2118-12-11**] 04:25AM BLOOD PT-27.8* INR(PT)-2.8* [**2118-12-2**] 01:10PM BLOOD Glucose-239* UreaN-42* Creat-2.0* Na-128* K-5.8* Cl-98 HCO3-13* AnGap-23* [**2118-12-3**] 04:48AM BLOOD Glucose-132* UreaN-37* Creat-1.5* Na-132* K-5.5* Cl-102 HCO3-18* AnGap-18 [**2118-12-13**] 05:45AM BLOOD Glucose-106* UreaN-18 Creat-1.1 Na-131* K-4.8 Cl-101 HCO3-22 AnGap-13 [**2118-12-5**] 03:54AM BLOOD ALT-27 AST-18 LD(LDH)-151 AlkPhos-54 Amylase-36 TotBili-0.5 [**2118-12-13**] 05:45AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.9 [**2118-12-7**] 04:30AM BLOOD TSH-13* [**2118-12-7**] 04:30AM BLOOD Free T4-0.91* [**2118-12-6**] 06:15AM BLOOD Digoxin-0.7* [**2118-12-2**] 01:28PM BLOOD Lactate-7.4* [**2118-12-3**] 05:04AM BLOOD Lactate-3.0* [**2118-12-5**] 04:17AM BLOOD Lactate-0.6 . [**2118-12-5**] 11:08 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2118-12-6**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. . Radiology Report CT PELVIS W/CONTRAST Study Date of [**2118-12-2**] 2:10 PM IMPRESSION: 1. Significant small bowel dilation and fecalization just proximal to the right mid abdominal anastomosis concerning for massive impaction. Stricture at the stoma cannot be excluded. Small amount of free intra- abdominal air and pneumatosis of several loops of ileum deep within the pelvis are all concerning for an ischemic process. 2. Unchanged aneurysm (x2) of the infrarenal abdominal aorta. . Brief Hospital Course: The patient is a 79yM w/ end ileostomy presenting w/ abdominal pain and weakness, found to have small foci of free air and pneumatosis of the ileum proximal to the ostomy. He was admitted to surgery and started on IVF for resuscitation for dehydration, weakness and elevated Lactate. A CT scan was done which showed some fecal impaction and he was disimpacted in the emergency room. It also demonstrated a small foci of free air and possible pneuomotosis in proximal illeum. Currently he reports significant improvement in his abdominal pain since the disimpaction. Vascular was consulted due to his history of superior mesenteric artery stent for mesenteric ishemia and resection of ileocolic anastomosis and creation of end-ileostomy. He presented with increased watery ostomy output and parastomal abdominal pain. Review of the CT scan shows the stent is patent and this unlikely is mesenteric ischemia. Leukocytosis: He was started on Zosyn and a 1 week course in which his WBC defervesced. C.diffs were negative. Hyponatremia/Hyperkalemia: Improved with hydration Hypotension/Hemodynamic Instability: Dehydrated and improved with hydration. His diet was advanced and he was eating well. His ostomy output was about 1-liter/day. He was ordered for Opium Tincture and Psyllium 1.7 g Wafer. His abdomen was soft and nontender and nondistended. An IV Port was attempted, but not successful. He needs continued close monitoring of his I&O's. Medications on Admission: protonix 40', amiodarone 200'', digoxin 0.125', lopressor 12.5''', Tylenol prn, Imodium 2mg tab''', coumadin (for afib, 3mg/d), levothyroxine 50mcg PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Monitor INR. 5. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO QID (4 times a day). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Opium Tincture 10 mg/mL Tincture Sig: Three (3) Drop PO TID (3 times a day): 0.3mL. Titrate according to stool consistency. Avoid constipation. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Abdominal pain Weakness Leukocytosis Elevated Lactate to 7.4 Hyponatremia/Hyperkalemia Hypotension Hemodynamic Instability Dilated loops of small bowel with fecalization of distal ileum Acute Renal Failure Discharge Condition: Good Discharge Instructions: You were admitted with dehydration, weakness and hemodynamic instability. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Take all 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. * Continue to increase activity daily * Continue with Ostomy care Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in [**2-27**] weeks. Call [**Telephone/Fax (1) 2998**] to schedule an appointment. Completed by:[**2118-12-15**]

Admission Date: [**2120-11-9**] Discharge Date: [**2121-1-9**] Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old female with a history of rectal cancer who was admitted to [**Hospital1 69**] on [**2120-11-9**] for a low anterior resection of her rectal cancer with ileostomy and omental flap placement over the stump. Her initially course was complicated by necrosis of the omental pouch and a prolonged postoperative ileus. Multiple CT scans of her abdomen revealed no evidence of obstruction and the ileus was thought to be secondary to inflammation and irritation from the necrotic omentum. On [**12-18**], the patient was found to be less responsive with increasing respiratory effort. An arterial blood gas revealed a pH of 7.22, CO2 100 and a PA2 of 84 on 3 liters of oxygen. At this point the patient was intubated for hypercarbic respiratory failure and was transferred to the Medical Intensive Care Unit. From a respiratory standpoint, the patient was extubated on the following day, but required reintubation after three days secondary to increasing secretions and need for constant pulmonary toilet. The patient remained difficult to wean. This was attributed to volume overload secondary to diastolic dysfunction as well as a component of chronic obstructive pulmonary disease. A sputum culture from [**12-18**] subsequently grew MRSA and the patient was treated with a ten day course of Vancomycin. The patient was finally extubated on [**1-5**] after extensive diuresis. From a gastrointestinal standpoint a CT of the abdomen on [**12-16**] revealed a communication between Hartmann's pouch and the peritoneal cavity with an abdominal fluid collection. Per the Surgery Service the collection was noted to be draining into the rectal stump and they recommended no further surgical management. From an infectious disease standpoint four out of four blood culture bottles from [**12-5**] and [**12-6**] grew coag negative staphylococcus, which has been treated with Vancomycin. Surveillance cultures from [**12-28**] revealed no growth to date. As mentioned previously, the patient had a sputum on [**12-18**], which grew MRSA. Blood cultures from [**12-18**] subsequently grew [**Female First Name (un) **] [**Female First Name (un) 29361**], and the patient completed a fourteen day course of Fluconazole on [**1-4**]. Lastly, sputum from [**1-4**] grew Pseudomonas. The Infectious Disease Service was consulted and they believed the patient is colonized, particularly since she currently has no evidence of pneumonia. From a cardiac standpoint there has been concern about volume overload secondary to diastolic dysfunction. The patient had an echocardiogram on [**12-19**], which revealed a left ventricular ejection fraction of 55% and unremarkable chamber sizes and thicknesses. There was also concern about coronary artery disease. The patient reportedly had a cardiac catheterization at the outside hospital with a 30% left anterior descending coronary artery and a 50% right coronary artery. She had several episodes of atypical chest pain during her stay and was ruled out for myocardial infarction multiple times. During her MICU stay the patient had frequent episodes of paroxysmal atrial fibrillation. She has been treated with Amiodarone and Lopressor with good effects. From a nutrition standpoint the patient was initially on total parenteral nutrition, but this was discontinued after the [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**] fungemia. The patient has since been on tube feeds via nasogastric tube and is at her goal. From a psychiatric standpoint the patient has been profoundly depressed and is being followed by the Psychiatry Service. There was on episode of a self extubation attempt. At this point they do not feel that she is a suicide risk. She has been tried on Celexa and Ritalin without benefit. She is currently on Wellbutrin. PAST MEDICAL HISTORY: 1. Rectal carcinoma status post radiation therapy and chemosensitization and low anterior resection on [**2120-11-15**]. 2. Hypertension with a question diastolic dysfunction. 3. Coronary artery disease with a 30% left anterior descending coronary artery, 50% right coronary artery. 4. Status post cholecystectomy. ALLERGIES: Penicillin, Erythromycin and intravenous contrast (but she can tolerate the contrast). MEDICATIONS ON TRANSFER: Lopressor 50 mg po b.i.d., Wellbutrin 100 mg po t.i.d., Lasix 80 mg po b.i.d., Prevacid 30 mg po q.d., Amiodarone 400 mg po q.d., Atrovent, Colace 100 mg po b.i.d., Reglan 10 mg po q.i.d., heparin subQ, Tylenol prn. SOCIAL HISTORY: She lives with her husband. She has a positive tobacco history. PHYSICAL EXAMINATION: The patient had a temperature of 99.9. Her blood pressure was 129/34. Heart rate 78. Respiratory rate 30. She was sating 100% of 4 liters of oxygen by nasal cannula. In general, the patient was a sad, but conversant older female in no acute distress. Neck examination she had a jugulovenous pressure of approximately 8 cm of water. Her neck was supple without lymphadenopathy. Cardiovascular examination regular rate and rhythm. No murmurs, rubs or gallops. Respiratory examination, the patient had decreased breath sounds bilaterally as well as soft bibasilar rales. Abdomen examination the patient had positive bowel sounds. Her abdomen was soft, nontender, nondistended. Her colostomy site was clean and intact. Her extremities are warm without clubbing, cyanosis or edema. She had 2+ dorsalis pedis pulses bilaterally. LABORATORY: The patient had a white blood cell count of 11.6, hematocrit 32.2, platelet count 376, sodium 137, potassium 4.8, chloride 88, CO2 41, BUN 15, creatinine 0.4, calcium 9.1, mag 1.8, phosphate 4.3. Studies, the patient had a chest x-ray on [**1-6**], which revealed interval improvement in upper zone redistribution with a small left pleural effusion and residual left lower lobe collapse with a questionable consolidation in the retrocardiac region thought to be secondary to atelectasis. She had a CT of the abdomen on [**12-25**], which revealed a collection of fluid and air within the abdomen consistent with an abdominal abscess. She had a CT of the adomen on [**12-16**], which revealed a collection of fluid and air within the abdomen with no identifiable Hartmann's pouch. She had a TTE on [**12-19**]. She was found to have an ejection fraction of 60%. Her left atrium was mildly dilated. Her left ventricular thickness and cavity size were normal. Her right ventricular thickness and size were normal. She was found to have a moderate mitral annular calcification and 1+ mitral regurgitation. Microbiologic data, sputum culture from [**1-4**] grew Pseudomanas. On [**12-28**] MRSA, [**12-22**] MRSA and [**12-18**] MRSA. Blood cultures on [**12-28**] no growth times two sets. [**12-18**] one out of four [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**], [**12-6**] two out of two coag negative staph. [**12-5**] two out of two coag negative staph. [**11-27**] no growth times two. HOSPITAL COURSE: The patient was transferred to the General Medicine Service on [**1-6**] for further management. 1. Pulmonary: The patient had daily chest physical therapy and an aggressive pulmonary toilet. She was encouraged to use her incentive spirometer. We decided to treat the patient with a course of Ciprofloxacin for the Pseudomonas in her sputum. We discussed her treatment with the infectious disease fellow who did not think that she needed to be double covered for the pan sensitive Pseudomonas in her sputum. The patient's respiratory status continued to improve on a daily basis. Her oxygen saturations improved dramatically to the point that she required 3 to 4 liters by nasal cannula to maintain appropriate oxygen saturation. 2. Infectious disease: As was mentioned previously we treated the patient empirically for a Pseudomonas pneumonia with Ciprofloxacin. There was no clear evidence of pneumonia, but given her history and tenuous status we opted to treat her empirically with a single [**Doctor Last Name 360**]. From an infectious disease standpoint the patient did very well. She did not have any overt signs of infection. We followed her blood cultures carefully and there was no additional growth to date on her surveillance cultures. Her white blood cell count and fever curve remained within normal limits. 3. Gastrointestinal: The patient has been noted to have an abdominal collection that is draining into the rectal stump. She was followed by the Surgery Service during her stay and they did not believe that she needed any further surgical management. Her abdominal examination remained benign. 4. Cardiovascular: From a cardiovascular standpoint we did not have any evidence of acute ischemia, however, after her stay in the Medical Intensive Care Unit the patient had several episodes of paroxysmal atrial fibrillation. She was continued on the Amiodarone and Lopressor. Despite this she did have several episodes during her stay on the general medicine floor. Each time she remained hemodynamically stable with a ventricular response rate to the 150s. She responded quite well with low dose intravenous Lopressor converting to sinus rhythm almost instantaneous. We think that the atrial fibrillation is secondary to all the patient's general medical problems. Toward the end of her hospital stay the patient remained in normal sinus rhythm. Despite this we opted to continue the Amiodarone and Lopresor. During her stay in the Medical Intensive Care Unit, the patient was felt to have a diastolic dysfunction, but was noted to be very fluid sensitive and responsive to Lasix. By the time she arrived to the medical floor we felt that she was euvolemic. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 11732**] MEDQUIST36 D: [**2121-3-18**] 17:00 T: [**2121-3-19**] 05:41 JOB#: [**Job Number 36073**]

Admission Date: [**2117-7-18**] Discharge Date: [**2117-7-29**] Date of Birth: [**2047-11-12**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old male with a history of coronary artery disease status post myocardial infarction who was transferred to [**Hospital1 346**] for percutaneous angioplasty after a seven minute episode of ventricular tachycardia without intervention. The patient was found in the bed by his wife, choking and unresponsive in the mid afternoon on the day of admission. The wife called her daughter who in turn activated the Emergency Medical System. The patient was found in V fibrillation and was treated with epinephrine, atropine and Dopamine. He was then taken to [**Hospital 35774**] Hospital where he was given Lidocaine and Amiodarone. Electrocardiogram was notable for ST depressions in V4 and 5 and 6 leads with junctional rhythm. He was transferred to [**Hospital1 69**] for emergent cardiac catheterization. Cardiac catheterization was notable for mild to moderate left anterior descending coronary artery stenosis and stenting of first diagonal was performed. He was then transferred to the floor sedated and intubated. PAST MEDICAL HISTORY: Significant for hypertension, which is life long, coronary artery disease, questionable myocardial infarction in [**2108**], percutaneous transluminal coronary angioplasty [**2116-6-14**], left anterior descending coronary artery 95% stenosis, OMI 90% stenosis, obtuse marginal one stent and diabetes apparently diet controlled. ALLERGIES: No known drug allergies. FAMILY HISTORY: Significant for coronary artery disease. The patient's father died at age 57 of an acute myocardial infarction. SOCIAL HISTORY: The patient has an 80 pack year history of smoking until [**2115**]. No ethanol. He is an engineer and married with children. MEDICATIONS ON ADMISSION: Zocor 40 once a day, Plendil 5 once a day, atenolol 25 once a day and Vaseretic dose unknown. PHYSICAL EXAMINATION: Temperature 99.8. Heart rate 66. Blood pressure 124/61. The patient was intubated on AC at 600 tidal volume 14 respirations with an FIO2 of 40% PEEP 5. On physical examination intubated, sedated, spontaneous monoclonic jerks. HEENT pupils small, minimally reactive to light. No gag reflex. Cardiovascular regular rate and rhythm. No murmurs. Pulmonary clear to auscultation anteriorly. Abdomen nondistended, soft. Extremities positive pulses in all four extremities. The patient has paroxysmal monoclinic jerks. Neurological examination eyes open spontaneously. No tracking. No roving eye movements. No response to verbal or painful stimuli. Cranial nerves examination pupils 2 mm no light reaction appreciated except for possible minimal change in left pupil. No corneal reflex bilaterally. Does not blink to light bilaterally. Slide both eye movements, but no response to ________ testing. No gag obtainable. Motor increased tone throughout with normal bulk and intermittent myoclonic movements of all four extremities that increase in frequency when the patient is stimulated. No drawer, no flexor or extensor response to pain. The patient does not protect face when arm drop towards it. Reflexes has 3+ brachial radialis biceps and triceps reflexes, both left and right arms. 3+ triceps reflexes bilaterally, 2+ patella reflexes bilaterally and 4+ ankle reflexes bilaterally. No plantar movements. The patient has positive [**Doctor Last Name **] sign bilaterally in upper extremities three to four beats of clonus at both ankles. LABORATORY: White blood cell count 10.0, hematocrit 41.5, platelets 165, sodium 145, K 3.3, chloride 105, bicarb 19, BUN 20, creatinine 1.6, glucose 237. Arterial blood gas pH 7.3, PCO2 46, PO2 292, calcium 8.4, total bilirubin 0.4, CPK 44, alkaline phosphatase 83, troponin less then 0.4. HOSPITAL COURSE: Immediately upon admission a neurological consult was obtained and indicated wide spread severe anoxic brain damage. CT scan of the head was done and showed a small subcortical hemorrhage in the left frontal lobe multiple lacunar infarcts, which were chronic and reduced great white matter of visibility consistent with global ischemic change. Given the patient's history he was started on Amiodarone to prevent further arrhythmias. He was also hypertensive and was started on Lopressor, aspirin, Plavix, statin, Captopril. Since admission the patient started spiking low grade fevers and was started on Flagyl and Levofloxacin for empiric treatment of possible infection. Since the beginning of the [**Hospital 228**] hospital stay there were multiple meetings with the patient's family were undertaken by the primary care team and neurology team in attempt to explain the poor prognosis, which according to neurology given the patient's status 93% no improvement and 7% slight improvement with severe neurologic damage, 0% moderate to complete improvement of the patient's neurological status. The patient's family voiced their understanding of the current situation and decided to proceed with tracheostomy and PEG tube placement and maintain the patient full code. On [**7-23**] a tracheostomy tube was performed at the bedside by interventional pulmonology without complications. PEG tube placement was performed by GI on [**7-27**]. The patient was extubated on [**7-28**] in the early a.m. and remained stable over the next 24 hours on flow by oxygen at 35%. His cardiovascular status remained stable with high normal blood pressures and cardiac rhythm significant for intermittent atrial fibrillation with spontaneous conversion to sinus bradycardia without requiring any intervention. Infectious disease wise he remained afebrile since the initiation of antibiotic treatment. His neurological status remained unchanged. The patient was in a vegetative state at the time of discharge. The patient was discharged to [**Hospital3 **] Hospital Naddick for long term care and management with a diagnosis of acute myocardial infarction status post ventricular fibrillation and anoxic brain injury. His discharge medications were insulin sliding scale per flow sheet, calcium gluconate 500 po t.i.d., Lansoprazole oral solution 30 mg nasogastric q.d., heparin 5000 units subQ q 12, aspirin 325 mg po q day, Metoprolol 75 mg nasogastric b.i.d. being held for a systolic blood pressure less then 100 or a heart rate less then 60, Captopril 75 mg po t.i.d. to be held for systolic blood pressures less then 90. Saliva substitute 1 to 3 milliliters po q 1 to 2 hours prn, Metronidazole 500 mg intravenous q 8 last dose [**8-1**]. Acetaminophen 325/650 po q 4 to 6 hours prn for fever or pain, Levofloxacin 500 mg po q 24 hours last dose to be given on [**8-1**]. Simvastatin 40 mg po q day and Plavix 75 mg po q.d. last dose [**2117-8-18**]. Aspirin 325 mg po q day and Atropine sulfate 0.5 mg intravenous prn for symptomatic bradycardia and hypertension. He was discharged on tube feeding diet. The staff at [**Hospital3 **] Hospital at Naddick to schedule primary care physician for follow up on this patient. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-222 Dictated By:[**Doctor First Name 35775**] MEDQUIST36 D: [**2117-7-29**] 12:01 T: [**2117-7-29**] 12:08 JOB#: [**Job Number 35776**]

Admission Date: [**2153-2-3**] Discharge Date: [**2153-2-7**] Date of Birth: [**2074-10-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: hypotension, fever to 101 Major Surgical or Invasive Procedure: femoral central line History of Present Illness: 78 yo man c PMH of Chronic Liver disease, Hepatoma s/p [**First Name3 (LF) 54267**] x 2, COPD, Afib on coumadin, was in his USOH until [**2153-2-3**] AM when he began having chills, rigors and was febrile at home to 101, per pt. He went to [**Location (un) **] ED were he was found to be hypotensive BP in low 70 s. Pt denies having: cough, SOB, dysuria, urinary frequency, diarrhea, abdominal pain, n/v, night sweats, anorexia. Last BM was yesterday. At [**Location (un) **]: Levaquin, 3 L NS, dopamine 5 mcg/min. Pt arrived to [**Hospital1 18**] ED c BP in near 120/48 HR 80-90s. Dopamine drip was stopped. However pt was noticed to have refractory hypotension and started on Levophed again. In the [**Hospital1 **] ED, he received IV Vanco, Levoflox, FFP and NS IVF at 100cc/hour. . His MICU course: The pt was on vanc, levo, flagyl in the unit. Panculture negative to date. CXR without infiltrates. Abd u/s negative for cholecystitis. Abdominal CT to r/o new liver abscess considering pt's PMH was negative. Vancomycin was tapered off [**2-6**] (received 4 days). IV levoflox and flagyl were continued. Pt was also on steroids for bronchospasm, COPD in MICU, and received prednisone 60mg po qd in the unit, with bronchodilators. He is satting 99-100% on 2L NC (his baseline oxygen requirement). Initially, his INR was supratherapeutic to 4.9, so coumadin was held initially. Coumadin was restarted for goal INR [**1-12**]. His foley was d/c'd and he continues to urinate well. He is tolerating a regular diet, taking all meds orally. Past Medical History: -Afib for many years on coumadin -HTN -COPD -Hepatocellular carcinoma and cirrhosis s/p [**Month/Day (3) 54267**] surgery x 2, dx'd 2 years ago, folloed by Dr. [**First Name (STitle) **] at [**Hospital1 18**] . Pt has hx of liver abscess s/p second [**First Name9 (NamePattern2) 54267**] [**5-13**]. -Prosthetic rigtht eye s/p HSV and subsequent enucleation -Stent in pancreas for mass and h/o obstructive jaundice -Sarcoidosis s/p lung biopsy on right -h/o Right temporal infarct [**1-11**] subtherapeutic INR, Afib by MRI, [**6-13**] -h/o splenic infarct thought [**1-11**] subtherapeutic INR, Afib [**6-13**] -last echo [**2152-6-13**]: EF 55%, mod-markedly dil atria b/l. dil RV with free wall hypokinesis, RV pressure overload, 1+MR, 4+TR, severe pulm artery HTN, Cardiologist at [**Location (un) **] is Dr. [**Last Name (STitle) 3503**], dry weight 162 lbs. Social History: The patient lives at home with wife, independent in ADLs, has 2 daughters, originally from [**Name (NI) 4754**] but here since [**2103**], smoked 2ppd x 20 years quit 40 yrs ago, no etoh, no drugs. Former construction worker for [**Location (un) **] gas co. Family History: The patient is one of 11 children. 2 brothers and 1 sister with strokes, brothers at ages 38 and 50. One brother with [**Name2 (NI) 499**] cancer. No seizures run in family. Physical Exam: Physical Exam on admission: VITALS: 99.7 HR 90-110 afib, 88-96/58-70, 18, 95% 2 Lt GEN: no acute distress, pleasant elderly man SKIN: no rash , jaundiced [**Name2 (NI) 4459**]: NC/AT, anicteric sclera, mmm NECK: supple, no meningismus , + JVP CHEST: normal respiratory pattern, CTA bilat anteriorly , decreased breath sounds in both bases CV: irregular irregular rate, no murmurs ABD: soft, nontender, nondistended, +BS, liver edge not palpable , no ascites. EXTREM: no edema, 1+ dorsalis pedis pulses, 2+ radial pulses . Phys Exam on call out from MICU: Vitals: Tm: 96.8 Tc: 96.6 BP: 111/64 (99-120/49-69) P: 81 RR: 19-25 O2sat: 98-100% on 2L NC. 24 hour I/O 3090/1310 +1780. 8 hour I/O: 1250/2365 -1115. General: Well appearing CM in NAD. Pleasant and cooperative. Sitting upright in chair talking with daughter. [**Name (NI) 4459**]: right eye is prosthetic, left eye PERRL, left eye EOMI. No nasal discharge. MM slightly dry, OP clear. Poor dentition. JVD mid neck. No cervical LAD. Lungs: CTAB CV: Irregularly irregular rhythm. S1 and S2 audible. Abd: Soft, NT, ND, Positive BS, No ascites. No HSM. Ext: No peripheral edema. No cyanosis/clubbing. Ext warm and well perfused. 2+ DP pulses b/l. Pertinent Results: [**2153-2-3**] 08:00PM WBC-12.2*# RBC-2.92* HGB-10.3* HCT-29.8* MCV-102* MCH-35.1* MCHC-34.5 RDW-16.8* [**2153-2-3**] 08:00PM NEUTS-73* BANDS-11* LYMPHS-11* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2153-2-3**] 08:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2153-2-3**] 08:00PM PLT COUNT-163 [**2153-2-3**] 07:45PM LACTATE-1.3 [**2153-2-3**] 08:00PM PT-43.3* PTT-39.9* INR(PT)-4.9* . [**2153-2-3**]: CXR IMPRESSION: Cardiomegaly with congestive heart failure.Bibasilar atelectasis with small bilateral pleural effusions. . [**2153-2-4**]: Abdominal Ultrasound IMPRESSION: No evidence of acute cholecystitis or cholelithiasis. Patchy areas of increased echogenicity in the right lobe of the liver likely representing changes associated with prior RF ablation. . [**2153-2-5**] CT TORSO IMPRESSION: 1. Bilateral predominantly peripheral ground glass opacities, which are new from the prior study. The etiology is uncertain, but differential diagnosis includes includes infectious or inflammatory process, cryptogenic organizing pneumonia, eosinophilic or hypersensitivity pneumonia and pulmonary edema superimposed on severe emphysema. Clinical correlation and follow up if indicated is recommended. 2. Stable renal cysts. 3. Stable appearance of the radiofrequency ablations site. No evidence of abdominal abscess or pseudocyst. 4. Peripheral high attenuation area transiently seen ?perfusion anomaly, as described. . CULTURE DATA: [**2153-2-3**] Blood cx X 4 neg [**2153-2-4**] Blood cx X 4 neg [**2153-2-3**] Urine cx no growth [**2153-2-3**]: UA neg nitr, neg leuks, 0-2 WBC, [**2-11**] RBC, rare bact, 0-2 epi. . Brief Hospital Course: 78 yo man with Chronic Liver disease, Hepatoma s/p [**Month/Day (1) 54267**] x 2, h/o liver abscess, COPD, Atrial fibrillation on coumadin admitted for fever and hypotension, thought to be septic secondary to unclear etiology-- CXR negative for infiltrate but with bilateral pleural effusions (effusions too small for a diagnostic thoracentesis), Urinalysis negative, urine cx negative, blood cx X 4 negative. Pt covered empirically X 4 days on Vanco/Levo/Flagyl, d/c Vanco [**2153-2-6**], and continued Levo/Flagyl to complete 7 day course given history of liver abscess in past. . 1. Hypotension, Fever on admission thought to be [**1-11**] Septic-picture: with no clear source. However low BP, documented fever at OSH, and hx of chills makes infection likely. Pt started on Levofloxacin + Vanc in ED and on Levophed trough peripheral IV. On vanc, levo, flagyl in the MICU. Panculture negative to date. CXR without infiltrates. Abd u/s negative for cholecystitis. CT torso showing ground glass opacities in lungs inflamm vs. infectious, bilateral effusions too small to tap. No intraabd abscess. - Plan to continue Levo/Flagyl for 2 more days to complete 7 day course given h/o liver abscess in past. . 2. Cardiovascular: A. Coronaries: No signs of ischemia on EKG, enzymes negative. Aspirin was held and his beta blocker was continued. B. Pump: No signs of ischemia on EKG or enzymes. Getting 20mg IV lasix for diuresis, transitioned to 40mg po lasix on transfer to medical floor. Of note, he usually gets 80mg po qd of lasix at home. Last echo was [**6-13**] showing EF 55%, severe pulm a HTN, dil atria b/l, dilated right ventricle with pressure overload. On discharge, he is monitor his daily weight and call his PCP if his weight increases by 3 lbs or more, as this may indicate heart failure. C. Rhythm: Atrial fibrillation. He is to continue his beta blocker, atenolol, for rate control, and coumadin for anticoagulation. Goal INR [**1-12**]. The pt is at goal INR with 1mg coumadin po qday. . 3. COPD: Started prednisone 60mg qday for total of 5 days, which was completed during this hospitalization. He is to continue bronchodilators. Pt satting well on 2L NC, his baseline oxygen requirement. He was satting well ambulating with physical therapy. . 4. GI: Pt with hx of liver disease, hepatocellular carcinoma status post [**Month/Day (3) 54267**]. LFTs are elevated, AFP high, however stable and trending downward. No abd pain, nausea, vomiting, diarrhea, constipation. No intraabdominal abscess was seen on CT abdomen. Stable appearance of radiofrequency ablations site on CT Abdomen. . 5. HTN: Pt's blood pressure has remained stable, he has not required pressors in over 48 hours, no fluids needed for past 24 hours. Taking well po. Restarted Beta blocker and his [**Last Name (un) **] with tight hold parameters. . 6. Code: Pt is full code. Medications on Admission: 1. Aspirin 81 mg Tablet 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: 4. Atenolol 25 mg Tablet Sig 5. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. LT4 25 ug QD 8. Lasix 20 QD Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*3* 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): You will need to see Dr. [**Last Name (STitle) 8521**] for refills and to monitor your INR lab values/adjust dose. . Disp:*30 Tablet(s)* Refills:*0* 5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): You will need to follow up with Dr. [**Last Name (STitle) 8521**] for refills, and to check your electrolytes. Disp:*60 Tablet(s)* Refills:*0* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for wheezing. Disp:*1 MDI* Refills:*2* 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 MDI* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1. Hypotension 2. Atrial fibrillation 3. Hypertension 4. Chronic Obstructive Pulmonary Disease 5. Hepatocellular carcinoma 6. history of right temporal infarct 7. history of splenic infarct 8. history of sarcoidosis status post lung biopsy on the right 9. history of prosthetic right eye Discharge Condition: Stable, Good Discharge Instructions: If you experience fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, please report to the emergency room immediately. Please take all of your medications as prescribed. Please follow up with your physician. [**Name10 (NameIs) **] information below. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 31446**] [**Name (STitle) 8521**], 11:00am, [**2-14**], [**2152**]. Please call her office at [**Telephone/Fax (1) 54268**] if you need to reschedule your appointment. Completed by:[**2153-2-7**]

Admission Date: [**2146-3-28**] Discharge Date: [**2146-3-31**] Date of Birth: [**2105-8-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7202**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization [**2146-3-28**]: 2 Cypher stents to the right coronary artery History of Present Illness: The patient is a 40 year old male with a history of 2 ppd x 20 years tobacco history and a family history of heart disease who presented to [**Hospital3 **] this afternoon after having [**10-24**] substernal chest pressure around 2 pm after shoveling snow today around 12:30-1 pm. The patient returned indoors and felt [**10-24**] substernal chest pressure associated with diaphoresis, shortness of breath and left arm radiation with tightness radiating to the area between his clavicles in his back. He reports no prior history of chest pain. He was taken to [**Hospital6 3105**] where his EKG showed 1-[**Street Address(2) 1766**] elevations in II, III and avF, normal axis and [**Street Address(2) 4793**] elevation in V3 with inverted T waves in I, avL with no prior EKG for comparison. Right-sided EKG showed persistent II, III and avF ST elevations with [**Street Address(2) 4793**] V2-V6, TWI I and avL. His CK was 105. At [**Hospital3 **], he was placed on a nitro drip, heparin gtt, integrillin and given IV morphine and aspirin. His SBP was 123/90 with a pulse of 58. He was transferred to BIMC for cardiac catheterization. His cath on [**2146-3-28**] showed: Right-dominant system LMCA normal LAD mild disease without lesions LCX Non-dominant vessel with lesions RCA dominant with mid-segment 99% lesion with evident thrombus RA 19 PCW 31 PA 40 CO 7 CI 3 Cypher x 2 to RCA placed Past Medical History: 2 ppd x 20 years tobacco history h/o hernia repair herniated disc in upper spine (on disability) no [**Date Range 2320**] Social History: The patient is currently on disability. He formerly worked in a warehouse doing heavy lifting when he herniated a disc in his upper spine and is now on disability. He smokes 2 ppd x 20 years. He also drinks 6-7 beers/week. He denies any illicit drug use. Family History: Father - Deceased from MI at age 44 Paternal father - MI at age 55 Mother - [**Name (NI) 2320**], MI x 2 11 brothers and 3 sisters - no major medical problems Physical Exam: Tc = 97.3 P=74 BP=159/100 RR=16 99% O2 on 2liters NC Gen - NAD, AOX3, heavy-set male HEENT - PERLA, EOMI, no JVD, no carotid bruits bilaterally Heart - RRR, Soft holosystolic murmur Grade II/VI at RUSB Lungs - CTAB (anteriorly) Abdomen - Soft, NT, ND no hepatosplenomegaly, + BS Ext - Right groin oozing from venous catheter site, +2 d. pedis bilaterally, no C/C/E Pertinent Results: ECHO Study Date of [**2146-3-29**] Conclusions: The left atrium is normal in size. Left ventricular wall thickness and cavity size are normal. There is probably mild basal inferior wall hypokinesis with overall preserved LV ejection fraction (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild regional LV hypokinesis with preserved overall LVEF c/w CAD. C.CATH Study Date of [**2146-3-28**] COMMENTS: 1. Coronary angiography of this right dominant system revealed severe single vessel coronary artery disease. The left main coronary artery had no angiographically apparent flow limiting stenoses. The LAD had mild luminal irregularities. The LCX was a non-dominant vessel without lesions. The RCA was a dominant vessel with a 99% stenosis in the mid vessel with evidence of thrombus. 2. Resting hemodynamics were performed. Right sided pressures were severely elevated (mean RA pressure was 18 mm Hg). Pulmonary artery pressures were moderately elevated (PA pressure was 50/29 mm Hg). Left sided filling pressures were markedly elevated (mean PCW pressure was 29 mm Hg). Central arterial pressures were moderately elevated (aortic pressure was 161/104 mm Hg). Cardiac index was normal (at 3.2 L/min/m2). 3. Successful PCI of the RCA with two overlapping Cypher DES (3.5 x 8 mm and 3.0 x 23 mm). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severely elevated left and right sided filling pressures. 3. Successful Primary PCI of the RCA with two drug-eluting stents for an acute inferior myocardial infarction. [**2146-3-28**] 07:52PM GLUCOSE-121* UREA N-9 CREAT-0.9 SODIUM-140 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-30* ANION GAP-13 [**2146-3-28**] 07:52PM ALT(SGPT)-142* AST(SGOT)-107* LD(LDH)-319* ALK PHOS-82 AMYLASE-48 TOT BILI-0.7 [**2146-3-28**] 07:52PM LIPASE-29 [**2146-3-28**] 07:52PM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-2.4* MAGNESIUM-2.1 CHOLEST-228* [**2146-3-28**] 07:52PM %HbA1c-5.7 [**2146-3-28**] 07:52PM TRIGLYCER-114 HDL CHOL-42 CHOL/HDL-5.4 LDL(CALC)-163* [**2146-3-28**] 07:52PM WBC-11.9* RBC-5.34 HGB-16.5 HCT-48.8 MCV-91 MCH-30.8 MCHC-33.7 RDW-13.3 [**2146-3-28**] 07:52PM PLT COUNT-254 [**2146-3-28**] 07:52PM PT-12.7 PTT-29.1 INR(PT)-1.0 [**2146-3-28**] 06:31PM TYPE-ART PO2-303* PCO2-56* PH-7.28* TOTAL CO2-27 BASE XS--1 INTUBATED-NOT INTUBA [**2146-3-28**] 06:31PM HGB-16.8 calcHCT-50 O2 SAT-96 Brief Hospital Course: The patient is a 40 year old male with a history of heavy tobacco use, family history of CAD who presented with inferior MI s/p RCA stent x 2 1. CAD - The patient had a Cypher stent placed to the right coronary artery with no further events. He had a few isolated episodes of NSVT post-cath attributed to reperfusion. - The patient was continued on aspirin and must take Plavix for the next 9 months. He was placed on a statin with close monitoring of his LFTS which were slightly elevated on presentation given his history of EtOH use. He was titrated up to Toprol XL 50 mg and Lisinopril 5 mg. 2. HTN - The patient originally felt a little dizzy and lightheaded with Lopressor 25 mg TID with systolic blood pressures in the 90s. Therefore, he was changed to Toprol XL 50 mg without difficulty. He was also titrated to Lisinopril 5 mg. 3. CHF - The patient had a PAWP of 31 in the cath lab. His CXR showed no evidence of CHF. He was given lasix 20 IV x 2 total and auto-diuresed on his own, remaining euvolemic throughout the rest of his stay. - He had an echocardiogram which showed an EF of 55-60% with hypokinesis of the inferior wall. An echocardiogram should be repeated in 4 weeks post-MI to re-evaluate any residual wall motion abnormality. 4. Smoking cessation - The patient was encouraged to quit smoking. He has tried the nicotine patch and gum in the past without success. We discussed the possibility of wellbutrin, however, given his alcohol consumption, we felt it may be a risk in lowering his seizure threshold. The patient was encouraged to join group tobacco cessation therapy but he appeared hesitant. He will try to quit tobacco on his own but admits there is temptation given that most of the people he lives with at home smoke. Medications on Admission: Aspirin Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*9* 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST elevation inferior myocardial infarction Premature coronary artery disease Discharge Condition: Stable. Discharge Instructions: You MUST take your plavix every day for the next 9 months. Failure to do so may result in another heart attack or even death. Please call 911 or return to the ER if you experience any more chest pain. Followup Instructions: Please call to schedule an appointment with your primary care physician [**Last Name (NamePattern4) **] [**1-16**] weeks. You should have liver function tests drawn at this time. You will need to follow up with a cardiologist in 4 weeks. You may have a repeat echo at this time to evaluate the function of your heart.

Admission Date: [**2167-11-13**] Discharge Date: [**2167-11-27**] Date of Birth: [**2167-11-13**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [**Known lastname 75017**] [**Known lastname **] is the former 1.135 kilogram produce of a 31-2/7 week gestation pregnancy born to a 33-year-old G1, P0 now 1 woman. Prenatal screen: Blood type A-, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta strep status unknown. The mother's medical history was complicated by pneumonia requiring initiation of steroids. She continued on her steroid taper into her pregnancy. She developed gestational diabetes most likely secondary to the steroid taper. She was also a smoker and has an anxiety disorder. She suffered a cerebral vascular accident at age 18. She was monitored closely for the known intrauterine growth restriction and was noted to have absent diastolic flow on the day of delivery. She was taken to cesarean section for nonreasurring fetal heart rate tracing. There was large amount of blood noted at the time of delivery. The infant emerged apneic and required positive pressure ventilation and blow-by O2. Apgars were 5 at one minute and 7 at five minutes and 8 at 10 minutes. He was admitted to the neonatal intensive care unit for treatment of prematurity. Anthropometric measurements at the time of admission to the neonatal intensive care unit: Weight 1.135 kilograms, less than the 10th percentile, length 37 cm 25th percentile, head circumference 24.6 cm, less than 10th percentile. PHYSICAL EXAMINATION UPON DISCHARGE: Weight 1.345 kilograms, length 39 cm, head circumference 27 cm. General: Well appearing preterm male in room air. Skin warm and dry. Color pink. Well perfused. Head, ears, eyes, nose and throat, anterior fontanel open, level, sutures opposed, eyes clear, palate intact. Positive red reflex bilaterally. Chest: Breath sounds clear, equal, easy respirations. Cardiovascular: Regular rate and rhythm. No murmur. Normal S1, S2, femoral pulses +2. Positive palmar pulses. Abdomen soft, nontender, nondistended. No masses. Positive bowel sounds. Cord remnant on and drying. Extremities: Moving all stable hips. Neuro: Active with exam. Symmetric tone and movements. Positive suck, positive grasp. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: This infant required treatment with continuous airway pressure upon admission to the neonatal intensive care unit. His respiratory distress resolved and he weaned to room air by day of life #1. He continued in room air through the rest of his neonatal intensive care unit admission. He has had rare episodes of spontaneous apnea and bradycardia that have been monitored and with no further treatment provided. At the time of discharge he is breathing comfortably in room air 40-60 breaths per minute with oxygen saturations greater than 96%. 2. Cardiovascular: This infant has maintained normal heart rates and blood pressures. An intermittent murmur was noted from day of life 5 through 6 and is not audible at the time of discharge. Baseline heart rate is 130-170 beats per minute with a recent blood pressure of 56/28 mmHg, mean arterial pressure of 46 mmHg. 3. Fluids, electrolytes, nutrition: This infant had initial hypoglycemia requiring treatment with 20% glucose and water. He had an umbilical venous catheter placed for central access. Enteral feeds were started on day of life #2 and gradually advanced to full volume. He successfully weaned from the high glucose intravenous solution and has been off intravenous fluids for the 72 hours prior to delivery. He is currently being fed 150 mL per kilo per day of preemie Enfamil 28 calorie per ounce formula. His serum glucoses have been 57-80 mg per deciliter. At the time of discharge he weighs 1.345 kilograms. Serum electrolytes were checked several times in the first week of life and were within normal limits. 4. Infectious disease: Due to his respiratory distress and presentation at the time of birth and the unknown group beta strep status of his mother, this infant was evaluated for sepsis upon admission to the neonatal intensive care unit. A white blood cell count and differential were within normal limits. A blood culture was obtained prior to starting intravenous ampicillin and gentamycin. The blood culture was no growth at 48 hours and the antibiotics were discontinued. Urine CMV was sent but was negative. 5. Hematological: This infant is blood type O+ and is direct antibody test negative. His hematocrit at birth was 38. He did not receive any transfusions or blood products. He is being treated with supplemental iron. 6. Gastrointestinal: This infant required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life at 6.1 mg per deciliter. He was treated with phototherapy for approximately 96 hours. Most recent rebound bilirubin on [**2167-11-20**] was 1.6/0.5 mg per deciliter. 7. Neurology: A head ultrasound was performed on day of life #5 and showed a left germinal matrix hemorrhage. Repeat head ultrasound on [**2167-11-25**] showed the previously mentioned left germinal matrix hemorrhage but stable and no increased ventricular size. This infant has maintained a normal neurological exam during his admission. 8. Sensory: Audiology hearing screening has not yet been performed. It is recommended prior to discharge. Ophthalmology: This infant will require screening eye exams for retinopathy of prematurity starting at corrected age 33-34 weeks. 9. Placenta: The placental pathology was normal. 10. Psychosocial: This mother was very ill postoperatively from her cesarean section. She remained hospitalized until [**2167-11-25**]. The infant is being retro transferred to [**Hospital **] Hospital upon her request. [**Hospital1 35990**] social work was involved with this mother. The contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**] and she can be reached at [**Telephone/Fax (1) 70445**]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Transfer to [**Hospital **] Hospital for continuing level II care. PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital 75018**] Medical Center, [**Last Name (un) 75019**], [**Location 56504**] [**Numeric Identifier 75020**]. Phone number [**Telephone/Fax (1) 56498**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding. Preemie Enfamil 28 calorie per ounce formula at 150 mL per kilo per day by gavage every 3 hours. 2. Medications. Ferrous sulfate 25 mg per mL dilution, 0.1 mL p.o. once daily; vitamin E 5 units pg once daily. 3. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units (may be provided as a multivitamin preparation) daily until 12 months corrected age. 4. Car seat position screening is recommended prior to discharge. 5. State newborn screens were sent on [**11-16**] and [**2167-11-27**]. There has been no notification of abnormal results to date. 6. Immunizations. No immunizations have been administered thus far. 7. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following four criteria: 1) Born at less than 32 weeks; 2) Born between 32 and 35 weeks with two of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings; 3) Chronic lung disease 4)Hemodynamically significant congenital heart disease Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. This infant has not received rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable at at least 6 weeks but fewer than 12 weeks of age. DISCHARGE DIAGNOSES: 1. Prematurity at 31-2/7 weeks' gestation. 2. Intrauterine growth restriction. 3. Transitional respiratory distress. 4. Suspicion for sepsis ruled out. 5. Apnea of prematurity. 6. Unconjugated hyperbilirubinemia. 7. Profound hypoglycemia. 8. Last germinal matrix IVH. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**] Dictated By:[**Last Name (NamePattern1) 43348**] MEDQUIST36 D: [**2167-11-27**] 01:20:30 T: [**2167-11-27**] 12:40:47 Job#: [**Job Number 75021**]

Admission Date: [**2151-10-1**] Discharge Date: [**2151-10-5**] Date of Birth: [**2091-12-3**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13256**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: n/a History of Present Illness: 59 yo F w/ PMH of alcohol and hepatitis C cirrhosis with history of varices and upper GI bleed presents with loss of consciousnes and was Guiac positive with a HCT drop from 44-->33 in the setting of being intoxicated on alcohol who developed hematemesis in the ED. Per ED report, the patietn was alert and oriented x3 on admission, intoxicated, and hypotensive to systolic of 70s. She was given multiple listers of fluid and then developed hematemesis with vomiting bright red blood and clots. She had an NG tube placed and continued to vomit blood. She was started on an octerotid and PPI drip with boluses, given a dose of ceftriaxone and vancomycin and transffused 2u of PRBC. Her pressures continued to be low and she received a 4th L of fluid prior to transfer to the MICU. On arrival to the MICU, she was intubated and sedated. Review of systems: unable to obatin as patient is sedated Past Medical History: - Alcoholic cirrhosis- low grade varices- not banded, not bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint brandy per day for more than a year. She had tried detox once. Denies withdrawal seizures. - Chronic Back pain - Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown how she got it, denies IVDU, transfusions. Never had liver bx. - Hypertension - Alcoholic cirrhosis- low grade varices- not banded, not bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint brandy per day for more than a year. She had tried detox once. Denies withdrawal seizures. - Chronic Back pain - Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown how she got it, denies IVDU, transfusions. Never had liver bx. - Hypertension Social History: Lives in [**Location 686**] with her 16yo son. [**Name (NI) **] history of alcohol abuse, over 10 years. Current smoker. Denies other drug use. Has been in alcohol detox once - relaped shortly thereafter. Drinks [**2-8**] to 1 pint brandy per day though is actively trying to quit. Family History: Mother had MI Sister with diabetes. Many family members with alcohol abuse Physical Exam: Exam on Admission: General: sedateed and intubated, in NAD HEENT: Sclera anicteric. Intubated with blood in the ETT , unable to assess JVP CV: RRR, no MRG appreciated Lungs: Rhonchrousou breath sounds bilaterally Abdomen: soft, protuberant but nondistended. Hypoactive bowel sounds. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: sedated and inutbated AT DISCHARGE: O: AF 120s/70s 83-97 18 97%RA Gen: NAD, sitting in chair comfortable HEENT: MMM, hallitosis. CV: RRR, normal S1/S2, no m/r/g. Pulm: CTAB, no wheezes, rhonchi or rales. Abd: Soft, non-tender, obese. Neuro: AAO to person, place, time, president Pertinent Results: Labs on Admission: [**2151-10-1**] 02:15AM BLOOD WBC-7.2# RBC-3.03* Hgb-11.1*# Hct-33.1* MCV-109* MCH-36.7* MCHC-33.5 RDW-16.4* Plt Ct-78* [**2151-10-1**] 02:15AM BLOOD Neuts-37.2* Lymphs-54.5* Monos-5.9 Eos-1.8 Baso-0.7 [**2151-10-1**] 09:03AM BLOOD PT-22.6* PTT-34.9 INR(PT)-2.2* [**2151-10-1**] 02:15AM BLOOD Glucose-129* UreaN-18 Creat-1.0 Na-138 K-5.1 Cl-104 HCO3-22 AnGap-17 [**2151-10-1**] 07:40PM BLOOD ALT-28 AST-61* LD(LDH)-161 AlkPhos-97 TotBili-2.5* [**2151-10-1**] 02:15AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.5* [**2151-10-1**] 02:15AM BLOOD ASA-NEG Ethanol-292* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2151-10-1**] 09:13AM BLOOD Type-[**Last Name (un) **] pH-7.20* [**2151-10-1**] 02:36AM BLOOD Lactate-4.8* K-4.6 [**2151-10-1**] 09:13AM BLOOD freeCa-0.86* Labs on Discharge: [**2151-10-5**] 05:01AM BLOOD WBC-4.5 RBC-2.56* Hgb-8.7* Hct-26.2* MCV-102* MCH-34.0* MCHC-33.2 RDW-21.8* Plt Ct-57* [**2151-10-5**] 05:01AM BLOOD Glucose-122* UreaN-4* Creat-0.4 Na-136 K-3.5 Cl-107 HCO3-27 AnGap-6* [**2151-10-5**] 05:01AM BLOOD ALT-27 AST-55* AlkPhos-117* TotBili-1.9* [**2151-10-5**] 05:01AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.9 Imaging: EGD ([**2151-10-1**]): "Source of bleeding is identified as [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear at the GE junction, not bleeding at the time of the endoscopy. No interventions were done. Otherwise grade I varices at the lower third of the esophagus with no stigmata of bleeding. Moderate amount of old blood and clots in the stomach, with no other sources of bleeding identified in the stomach; Normal mucosa in the duodenum and otherwise normal EGD to third part of the duodenum." Portable Chest ([**2151-10-1**]): "Single frontal view of the chest was obtained. Cardiac mediastinal and hilar contours are unremarkable. Both lungs are clear with no focal consolidation, pleural effusion or pneumothorax." Portable Abdomen ([**2151-10-1**]): "Gaseous distention of a loop of small bowel in lower abdomen, with paucity of gas remaining throughout the abdomen. These findings are nonspecific, but cannot exclude partial small-bowel obstruction. No evidence of free intraperitoneal air, though image quality limits assessment. Nasogastric tube in place. Right-sided pelvic catheter consistent with a central venous access line." Brief Hospital Course: 59 year old female with a history of of hepatitis C and alcoholic cirrhosis and known Grade I varices who presented with UGIB secondary to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear. #UGIB- The patient has a history of esophageal varices and is followed by Dr. [**Last Name (STitle) **] for her cirrhosis. She is on nadalal as one of her home medications. She developed hematemesis in the ED, where she received 3L crystalloid and 2 units of PRBC. She was trasnferred to the MICU, and she had an EGD performed by GI which revealed [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears of the esophagus. She was monitored in the MICU and her HCT remained stable throughout her MICU stay. She was started on sucralfate and received 48 hours of a protonix drip. After transfer to the floor, she continued to remain hemodynamically stable, although did continue to have melanic stools. Her HCT continued to remain stable at discharge. She was sent home with sucralfate and pantoprazole daily, along with iron supplementation in the setting of acute blood loss. #Hypovolemic shock- Patient presented with hypotension and elevated lactate which resolved with fluid resusciation and blood products. Since her EGD, she remained hemodynamically stable, her lactate trended down, and she required no additional blood products. #Altered mental status- Patient was found altered at home while intoxicated. She had a positive flapping tremor and was started on lactulose at time of transfer from MICU. The patient was continued on a CIWA scale on the floor, and required minimal diazepam for symptoms. #Cirrhosis- Patient has alcoholic/HepC cirrhosis. SHe is followed in the liver clinic by Dr. [**Last Name (STitle) **]. She is still actively drinking per her postiive blood alcohol today in the ED. Her MELD score is 15. She has thormbocytopenia and known esophageal varices. She has no history of ascites or hepatic encephalopathy, however had a flapping tremor and was somnolent at time of d/c from MICU, which was persistent on the floor. She was treated with a 4d course of ceftriaxone in the setting of GI Bleed. #Alcohol abuse- Patient came to MICU intoxicated to >200 BAL. Social work was consulted. The patient demonstrated interest in attending AA after discharge. #Hypertension- Patient was normotensive during MICU admission, nadolol was restarted on transfer from MICU and continued on the floor. Her home lasix and lisinopril were held in the setting of GI bleeding, and she had no signs of fluid overload on the day of discharge so these were not restarted. #hypokalemia - K around 3.3-3.5. Unknown etiology. Was repleted with PO K. #Depression- Patient was restarted on citalopram once she was able to tolerate PO #Migraines- Fiorecet was held while in the hospital. The patient was full code throughout admission. TRANSITIONAL ISSUES: Pt will need weekly labs to follow hypokalemia and hematocrit for several weeks, has f/u appt with primary care [**10-14**]. Has f/u appointment with GI and will need repeat EGD in roughly 3 weeks per GI recommendations. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Furosemide 20 mg PO DAILY Hold for SBP<90 2. Spironolactone 50 mg PO DAILY Hold for SBP<90 3. Nadolol 20 mg PO DAILY Hold for SBP<90, HR<60 4. Acetaminophen-Caff-Butalbital [**2-8**] TAB PO Q8H:PRN headache 5. Citalopram 10 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Thiamine 100 mg PO DAILY Discharge Medications: 1. Nadolol 20 mg PO DAILY Hold for SBP<90, HR<60 2. Acetaminophen-Caff-Butalbital [**2-8**] TAB PO Q8H:PRN headache 3. Citalopram 10 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Thiamine 100 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*31 Tablet Refills:*3 8. Sucralfate 1 gm PO BID RX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*31 Tablet Refills:*4 9. Lactulose 30 mL PO TID RX *lactulose [Constulose] 10 gram/15 mL 15-30 mL by mouth use up to 4 times a day Disp #*1000 Milliliter Refills:*3 10. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*62 Tablet Refills:*3 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: [**Doctor First Name **]-[**Doctor Last Name **] Tears Alcoholic intoxication Secondary: Hepatitis C Virus Cirrhosis Migraines Hypertension Chronic low back pain Lower extremity edema Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were recently admitted to [**Hospital1 18**] after you were found to have altered mental status. While you were here, you had an EGD after some vomitting of blood which showed no change in your varices, but there was evidence of tearing which most likely caused the bleeding. There have been no changes to your home medications. It is imperitive that you discontinue drinking, as this was the most likely cause of your hospital admission. It was our pleasure to take care of you while you were a patient here. Please do not hesitate to contact us with any questions, comments or concerns. With Warm Regards, Your Inpatient Medicine Team Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2151-10-14**] at 2:10 PM With: Dr. [**Last Name (STitle) **] [**Name (STitle) **] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: LIVER CENTER When: FRIDAY [**2151-10-22**] at 11:00 AM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: FRIDAY [**2151-10-22**] at 9:00 AM With: ULTRASOUND [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

Admission Date: [**2200-2-24**] Discharge Date: [**2200-3-4**] Date of Birth: [**2123-2-5**] Sex: F Service: CARDIOTHORACIC Allergies: Nitroglycerin / Penicillins / Amoxicillin / Norvasc / Celecoxib / Adhesive Tape / Lovenox Attending:[**First Name3 (LF) 922**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2200-2-25**] - Coronary artery bypass grafting to three vessels. (Saphenous vein graft->Diagonal artery, first obtuse marginal artery and second obtuse marginal artery. [**2200-2-24**] - left heart Catheterization,coronary angiogram History of Present Illness: This 77 year old white female has known coronary artery disease, having undergone stenting of the LAD and circumflex vessels in the past. She presented with recurrent angina elsewhere and ruled in for a non ST myocardial infaction with Troponin of 1.19. She was transferred here and underwent catheterization on [**2-25**]. Catheterization revealed osteal circumflex and subtotal in stent circumflex stenosis. LV function has been shown to be ~55%. She was referred for surgical revascularization. Past Medical History: hypertension hyperlipidemia noninsulin dependent Diabetes mellitus Moderate aortic stenosis Chronic atrial fibrillation Congestive heart failure in past Coronary artery disease with percutaneous interventions in past Anxiety Cerbrovascular disease-60-70% bilateral carotid arteries H/O breast cancer, s/p right lumpectomy and radiation H/O cervical cancer, s/p hysterectomy and radiation appendectomy cholecystectomy H/O multinodular goiter S/P removal of a pylonidal cyst S/P bilateral carpal tunnel surgery S/P bone spur removal Osteoarthritis coccyx ulcer - stage IV Social History: The patient currently lives alone. Her husband has alzheimer's disease and lives in a care facility. She has one son who is handicapped and a grandson. She quit smoking 35 years ago; previously 4 ppd. She does not drink alcohol or use ilicit drugs. Family History: Family history negative for premature coronary artery disease or sudden death. Mother died of complications from alcoholism. Father died of pneumonia. Grandmother died of colon cancer. Physical Exam: Admission: VS - 97.3, 100/74, 16, 95%RA Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect appropriate. Patient lying supine post-cath. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple without lymphadenopathy. CV: Irregularly irregular, normal S1, S2. [**3-31**] holosystolic murmur loudest at the LUSB that radiates to both carotids. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: Brown skin changes around left lower leg. No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ Left: Carotid 2+ Femoral 2+ DP 2+ Pertinent Results: [**2200-2-24**] 04:45PM GLUCOSE-113* UREA N-11 CREAT-0.5 SODIUM-139 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11 [**2200-2-24**] 04:45PM ALT(SGPT)-18 AST(SGOT)-36 CK(CPK)-166* ALK PHOS-58 AMYLASE-16 TOT BILI-0.8 [**2200-2-24**] 04:45PM cTropnT-0.22* [**2200-2-24**] 04:45PM WBC-6.2 RBC-2.99* HGB-9.9* HCT-28.6* MCV-96 MCH-33.1* MCHC-34.6 RDW-14.7 [**2200-2-24**] 04:45PM WBC-6.2 RBC-2.99* HGB-9.9* HCT-28.6* MCV-96 MCH-33.1* MCHC-34.6 RDW-14.7 [**2200-2-24**] 04:45PM PT-17.2* PTT-31.9 INR(PT)-1.6* [**2200-2-24**] Cardiac Catheterization 1. Coronary angiography in this right dominant system revealed three vessel coronary artery disease. The LMCA had no angiographycally apparent coronary artery disease. The LAD was non-obstructed. The D1 had an ostial 80% lesion. The LCx had a subtotally occluded in-stent restenosis in the mid stent at the ostium of the vessel. The RCA was small caliber, with a 70% lesion proximally. 2. Resting hemodynamics revealed elevated left sided filling pressures with LVEDP of 20 mmHg. There was normal systemic arterial systolic and diastolic pressure with SBP of 109 mmHg and DBP of 72 mmHg. 3. There was a peak to peak transaortic gradient of 5 mmHg 4. Left ventriculography was not performed. [**2200-2-25**] ECHO The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-27**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2199-10-19**], the severity of mitral and tricuspid regurgitation has increased. Estimated pulmonary artery pressures are higher. Aortic stenosis is mild in severity. [**2200-3-2**] 06:13AM BLOOD WBC-9.7 RBC-3.01* Hgb-9.6* Hct-27.8* MCV-93 MCH-32.0 MCHC-34.6 RDW-16.0* Plt Ct-121* [**2200-3-3**] 05:04AM BLOOD PT-20.6* INR(PT)-1.9* [**2200-3-2**] 06:13AM BLOOD PT-19.8* PTT-30.8 INR(PT)-1.9* [**2200-3-1**] 05:30PM BLOOD PT-22.3* INR(PT)-2.1* [**2200-3-1**] 03:45AM BLOOD PT-20.0* PTT-35.0 INR(PT)-1.9* [**2200-2-28**] 02:10AM BLOOD PT-16.6* PTT-32.6 INR(PT)-1.5* [**2200-2-27**] 12:58AM BLOOD PT-16.3* PTT-31.4 INR(PT)-1.5* [**2200-2-26**] 03:09PM BLOOD PT-17.8* PTT-40.7* INR(PT)-1.6* [**2200-2-26**] 01:55PM BLOOD PT-18.0* PTT-34.4 INR(PT)-1.6* [**2200-2-26**] 02:20AM BLOOD PT-17.0* PTT-53.2* INR(PT)-1.5* [**2200-2-25**] 05:19PM BLOOD PT-16.8* PTT-80.5* INR(PT)-1.5* [**2200-2-25**] 05:10AM BLOOD PT-18.5* PTT-59.1* INR(PT)-1.7* [**2200-3-3**] 05:04AM BLOOD UreaN-22* Creat-0.6 Na-129* K-4.0 Brief Hospital Course: Ms. [**Known lastname 14330**] was admitted to the [**Hospital1 18**] on [**2200-2-24**] for a cardiac catheterization and further management of her myocardial infarction. A cardiac catheterization revealed two vessel disease with severe instent restenosis of her circumflex artery. Given the severity of her disease and the fact that she refused to take plavix, surgical revascularization was decided upon. Ms. [**Known lastname 14330**] was worked-up in the usual preoperative manner including a carotid ultrasound which showed mild right and moderate left internal carotid artery stenosis. Heparin was continued and she remained without chest pain. The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for assistance with her coccyx ulcer and appropriate dressings and barrier creams were applied. On [**2200-2-26**], Ms. [**Known lastname 14330**] was taken to the Operating Room where she underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next several hours, she awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. Diuresis towards her preoperative weight was begun. The coccyx wound is being treated with Aquacel AG daily. Surgical wounds are clean and dry. Pacing wires and CTs were removed according to protocol. Bactroban was administered for MRSA positive nasal swab. Lopressor and digoxin were given and advanced for rate control of her chronic atrial fibrillation and diuretics were continued, to be so until she achieves her preoperative weight. STOP [**3-3**] Medications on Admission: ativan 3 HS, atenolol 25, lipitor 80, ASA 325, digoxin 0.125, lisinopril 40, colace, coumadin 2.5, januvia 100, magnesium oxide 400, lasix 40 and KCl 10 every other day, MVI Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Digoxin 250 mcg Tablet Sig: [**12-27**] alter w/ 1 tab Tablet PO EVERY OTHER DAY (Every Other Day). 11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 12. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Warfarin 1 mg Tablet Sig: to be dosed per INR Tablet PO DAILY (Daily): Goal INR [**1-28**] INR 2.6 on [**3-4**]- no coumadin given. 14. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection Q12H (every 12 hours). 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass Hyperlipidemia Hypertension Atrial fibrillation non insulin dependent Diabetes mellitus Anxiety s/p Myocardial infarction Peripheral vascular disease Cerebrovascular disease Multinodular goiter Osteoarthritis h/o Cervical cancer Discharge Condition: deconditioned Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 8725**] Please follow-up with Dr. [**Last Name (STitle) 1057**] in [**1-29**] weeks. [**Telephone/Fax (1) 14331**] Please call for appointments Completed by:[**2200-3-4**]

Admission Date: [**2171-7-3**] Discharge Date: [**2171-7-6**] Date of Birth: [**2128-7-6**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 42-year-old man with a history of melanoma. His oncology history began in [**2170-8-5**] when he noted a large left axillary mass that was removed at [**Hospital6 302**] in [**Location (un) 5503**]. The pathology was metastatic melanoma. He subsequently had outside CT scan of his head, abdomen, and pelvis, which was normal. He completed radiation in [**2170-12-5**], and was started on alpha Interferon therapy in [**Month (only) 404**] also. In [**Month (only) **] of this year [**2170**], he noted left hand tremors both postural and action types. He had trouble holding objects in his left hand and they shook. There is no suggestion of seizure activity. He also experienced morning headaches, and he would wake up occasionally with nausea. He had a MRI gadolinium enhanced on [**2171-5-25**] which showed a nonenhancing parasagittal lesion supplementary of the motor cortex. He stopped the alpha interferon last month after his head MRI, and his tremors did resolve. PAST MEDICAL HISTORY: History of basal cell carcinoma. PAST SURGICAL HISTORY: Basal cell carcinoma, removal of lipomas. FAMILY HISTORY: Positive for hypothyroidism, hypertension. SOCIAL HISTORY: Patient is unmarried. He is a machinist. He smokes cigarettes two packs per day for 20 years. He stopped smoking 3.5 years ago. Drinks two beers per day. ALLERGIES: He has no drug allergies. REVIEW OF SYSTEMS: Negative for HEENT, neck, cardiovascular, pulmonary, gastrointestinal, gastrourinary, and musculoskeletal, and psychiatric systems. PHYSICAL EXAMINATION: His temperature was 98.8, blood pressure 136/90, heart rate of 80, respiratory rate of 20. Skin: Full turgor. HEENT was unremarkable. Neck was supple and there are no bruits. Cardiac examination reveals a regular, rate, and rhythm. Lungs are clear. Abdomen is soft, nondistended with good bowel sounds. Extremities were without edema. Neurologic examination: His language was fluent with good comprehension and naming. Pupils are equal and reactive to light 4-2 mm. EOMs are full. Visual fields are full to confrontation. Fundoscopic examination revealed sharp discs margins bilaterally. His face is symmetric. Facial sensation intact. Hearing was intact. Tongue was midline. There is no pronator drift. His muscle strengths were [**4-8**] in all muscle groups . Sensation was intact in proprioception. MRI showed a nonenhancing mass in the left premotor supplementary, motor cortex on the left parasagittal region. The gyri were thickened. Patient was brought to the operating room on [**2171-7-3**], where he had a motor cortex mapping brain lobe neuro-navigation and a left fronto-cranial tumor resection. This was uncomplicated. Procedure: No complications. Postoperatively, the patient was awake, alert, and oriented times three, moving all extremities, no drift. EOMs were full, symmetric smile. Dressing was clean, dry, and intact. He was monitored in the recovery room overnight, where his blood pressure was controlled as needed with Nipride. He had an arterial line placed. His motor strengths were all [**4-8**], and it looks like he had a slight slower right side fingertap that was noted on postoperative examination. Patient was transferred to the floor on [**7-4**]. His A-line was discontinued. His Foley was discontinued. His activity was advanced, and he was tolerating a regular diet at that point. Neuro-Oncology, Dr. [**Last Name (STitle) 724**], saw the patient on [**7-4**] also and asked that he follow up with him in the Brain [**Hospital 341**] Clinic in two weeks. Patient was doing well postoperatively, on the [**12-5**]. He had no diplopia, no blurred vision, symmetric spine, EOMs are full. He still had slight decrease in his right fine finger movements. His dressing was dry and intact and his steroids were tapered down to 4 mg q6h. Patient was discharged on [**2171-7-6**] neurologically intact. Steroids continued to be tapered down to off a very slow taper. DISCHARGE INSTRUCTIONS: Keep his incision clean, dry, and intact. On discharge day, they removed his dressing and the site was without any redness or edema. He should follow up in the Brain [**Hospital 341**] Clinic on [**7-15**], and he will have his staples removed at that time. DISCHARGE MEDICATIONS: 1. Decadron wean. 2. Zantac 150 mg po bid. 3. Percocet 1-2 tablets po q4-6h as needed for pain. 4. Dilantin 100 mg po tid. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2171-7-5**] 11:53 T: [**2171-7-13**] 09:26 JOB#: [**Job Number 45659**]

Admission Date: [**2103-5-19**] Discharge Date: [**2103-5-27**] Date of Birth: [**2080-7-19**] Sex: F Service: MEDICINE Allergies: Morphine / Dilaudid Attending:[**First Name3 (LF) 1055**] Chief Complaint: Back pain for one day Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 14164**] is a 22 year-old African-American woman with known [**Known lastname 14165**] cell disease, who presents with a 1-day history of right-sided posterior chest pain. She notes that she was well until 4-days prior to admission when she developed URI symptoms, including headache, rhinorrea, and generalized fatigue. She subsequently developed a cough, productive of small amounts of dark yellow sputum. Yesterday, she developed right-sided posterior chest pain, pleuritic in nature, worse with coughing, deep breathing and lying on the culprit side. She reports only mild SOB. She felt warm over the past few days, but did not measure her temperature. She denies chills. She is unsure whether she has received Pneumovax and Influenza vaccines. ROS is otherwise negative for other joint pain. No GI or urinary complaints. No lightheadedness, no dizziness. In the ED, vitals initially T 99.4, HR 80, BP 119/58, RR 16, oxygen saturation 95% on 3L, 88% on room air. A CXR revealed a RLL infiltrate. She was given Ceftriaxone 1 gm IV X1 and Azithromycin 500 mg PO QD. She was also given Morphine 1 mg IV X1, Benadryl 25 mg X1, and Dilaudid for pain control. Past Medical History: 1. [**Known lastname **] cell disease, with 1 admission per year since [**2100**] for acute pain crisis. 2. History of gonorrhea 3. Prior pneumonia versus acute chest syndrome in [**2100**] 4. History of pre-eclampsia during her first pregnancy 5. Known multiple RBC allo-antibodies and difficult cross-match Social History: She lives with her 2 children aged 4 and 2 years-old. She is an active smoker, and smokes about 5 cigarettes per day. She quit for about 3 years, but restarted last year. No EtOH consumption. She also denies illicit drug use. Family History: She lived in a [**Doctor Last Name **] home from the age of 5 onwards. Per OMR records, both her mother and father have [**Name2 (NI) 14165**] cell trait. Both her children have [**Name2 (NI) 14165**] cell trait. Physical Exam: Physical examination on admission: VITALS: T 99.4, HR 100, BP 110/55, RR 20, Sat 99% on 3 liters via NC. GEN: Sleepy. Scratching all over. Uncomfortable with motion. HEENT: Anicteric. EOMI. PERRL. Frontal bossing. LN: No cervical lymphadenopathy. RESP: Dullness to percussion at right base. Decreased air entry at right base, with basilar crackles. No bronchial breathing. + egophony, + whispered pectoriloquy. CVS: PMI not displaced. Normal S1, physiologic splitting of S2. No S3, S4. Soft, late systolic murmur at apex, non-radiating. GI: BS NA. Abdomen soft and non-tender. EXT: Strong pedal pulses. No pedal edema. Pertinent Results: Relevant laboratory data on admission: CBC: WBC 11.1, Hb 6.9, Hct 19.9, Platelet 552 NEUTS-54 BANDS-1 LYMPHS-35 MONOS-7 EOS-2 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1 HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-3+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-1+ OVALOCYT-1+ TARGET-2+ [**Name2 (NI) **]-2+ Chemistry: Na 138, K 4.7, Cl 106, HCO3 24, BUN 8, Creat 0.7, Glucose 0.7 Relevant imagind studies: [**2103-5-19**] CXR: Stable cardiac contours. Interval development of patchy opacity in right lower lobe, no pleural effusion. [**2103-5-20**] CXR: Heart size is within normal limits and there is no evidence for CHF. There is consolidation in the right middle and right lower lobes with an associated small right pleural effusion, increased when compared with the prior film of [**5-19**], 05. There is atelectasis at the left lung base as previously demonstrated. There is probably some associated collapse of the right lobe. IMPRESSION: Increase in extent of right middle lobe and right lower lobe consolidation with small right pleural effusion. Left basilar atelectasis. [**2103-5-21**] CXR: The cardiac silhouette is upper limits of normal in size and there is slight increase in pulmonary vascularity, consistent with the patient's known [**Year/Month/Day 14165**] cell status. There are multifocal areas of consolidation involving the right middle and both lower lobes, which have progressed in the interval. There are also bilateral probable small pleural effusions. IMPRESSION: Worsening multifocal consolidation suggesting multifocal pneumonia. [**Year/Month/Day **] cell lung is in the differential diagnosis if there are not infectious symptoms present. [**2103-5-22**] CXR: No significant interval change. [**2103-5-23**] CXR: Increased mild to moderate left pleural effusion. Persistent right middle and lower lobe infiltrate with right pleural effusion, stable. [**2103-5-24**] CXR: Slight interval improvement in right middle lobe aeration. Slight improvement in right pleural effusion. Stable left pleural effusion with left lower lobe retrocardiac atelectasis. [**2103-5-26**] CXR: Improving right middle lobe and left lower lobe opacities. There is a small left-sided pleural effusion unchanged. ******** [**2103-5-22**] ECHO: The left atrium is mildly elongated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 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. There is trivial mitral regurgitatino. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 22 year-old African-American woman with [**Year/Month/Day 14165**] cell disease admitted with respiratory symptoms and right-sided back pain, found to have RLL infiltrate + hypoxemia. 1) Pneumonia +/- acute chest syndrome: CXR on admission revealed a RLL infiltrate suspicious for pneumonia, although acute chest syndrome can not be ruled out. Examination was also remarkable for hypoxemia, with saturation in the low 80s. She was empirically started on Ceftriaxone and Azithromycin for coverage of Mycoplasma, Chlamydia, Hemophilus and pneumococcus, and hydrated. She was afebrile on admission, but subsequently developed a fever in hospital with rising WBC up to 34.6 on [**5-21**]. She also developed worsening hypoxemia on [**5-21**] with increasing SOB in the setting of decreasing hematocrit to 15.5, then 14.3. An ABG revealed pH 7.41/38/70. A repeat CXR was performed and remarkable for worsening RML/RLL pneumonia. Given the above as well as inability to transfuse PRBCs [**3-21**] no available cross-matched blood (multiple allo-antibodies), Ms. [**Known lastname 14164**] was transferred to the ICU on [**5-20**]. In the ICU, supportive care was provided. She was continued on Ceftriaxone and Azithromycin. Sputum cultures returned as OP flora, without predominance of organisms (can not rule out Chlamydia or Mycoplasma). Blood and urine cultures all returned negative. Serial CXRs initially revealed worsening picture, with interval development of a LLL infiltrate consistent with multilobar process, and bilateral pleural effusions. An echo was performed that showed normal EF>60%. The effusions were ultimately felt most likely [**3-21**] fluid overload in the setting of aggressive IVF administration, and she was diuresed with Lasix on [**5-23**] and [**5-24**]. She eventually improved and defervesced, with decreasing oxygen requirements and improved radiographic picture. Antibiotics were changed to PO Levofloxacin on [**5-24**], Ceftriaxone D/C'd on [**5-24**] (received 6 days), and Azithromycin D/C'd on [**5-25**] (received 7 days). She will complete a 14-day course (total) of Levofloxacin (last dose on [**2103-6-1**]). Of note, the effusions persist at discharge, stable in size. She also has persistent leukocytosis with WBC 16.2 at discharge. Both should improve with time. She will need follow-up imaging after completion of her antibiotic course to document complete resolution of infiltrate/effusion, as well as repeat WBC. If the effusions persist, then a thoracentesis would be indicated to rule out a parapneumonic effusion. She was given Pneumococcal, Meningococcal and Hib vaccines prior to discharge. She will follow-up with her PCP [**Name Initial (PRE) 176**] 1 week of discharge. 2) [**Name Initial (PRE) **] cell disease: Hematocrit on admission was 19.9 (around baseline), down to 15.3 on [**5-20**] with 2+ [**Month/Year (2) 14165**] cells on peripheral smear, then a nadir of 14.3 on [**5-21**]. The hematology service was consulted. Ms. [**Known lastname 14164**] has multiple allo-antibodies and HRB absent which is rare except in some African-Americans. The blood bank was unable to provide matched blood. She was transfused 1 unmatched unit on [**5-22**] after pre-medication with Prednisone 60 mg PO QD, without response. Further transfusion was therefore held. Per hematology, folate was increased to 5 mg PO QD. Her hematocrit slowly trended up to 22 at discharge. Of note, ferritin was sent to rule out concomitant iron deficiency, and returned elevated at 791. She had appropriate reticulocytosis to 22% in the setting of her anemia. She will follow-up with Dr. [**Last Name (STitle) **] in Hematology within 1 week of discharge. Treatment with hydroxyurea should be addressed. 3) Pain control: Pain control was achieved with Dilaudid IV prn and pre-medication with Benadryl. She was switched to PO OxyContin 10 mg PO BID and oxycodone for breakthrough on [**5-26**], with fair pain control. Tylenol around the clock and Naproxen were also added. She was discharged on OxyContin/Oxycodone/Naproxen/Tylenol + bowel regimen. 4) Bacterial vaginosis: Ms. [**Known lastname 14164**] was diagnosed with bacterial vaginosis prior to admission, treated with Flagyl. She completed a 5-day course of Flagyl in hospital, with resolution of her symptoms ([**5-22**] --> [**5-26**]). 5) Oral lesions: While in hospital, she developed oral lesions suspicious for oral HSV. She was started on Valtrex 1 gm PO TID with plan to complete 3 days. She will complete her course as an out-patient (last doses on [**2103-5-28**]). Medications on Admission: Folate 2 mg PO QD Metronidazole (has been taking only intermittently for bacterial vaginosis) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). Disp:*150 Tablet(s)* Refills:*1* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: Please take while on Oxycontin. Disp:*60 Capsule(s)* Refills:*0* 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: Start on [**5-28**], last dose on [**6-1**]. Disp:*5 Tablet(s)* Refills:*0* 4. Valacyclovir HCl 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for HSV for 3 doses: Please take 1 pill tonight, 1 pill tomorrow morning and 1 pill tomorrow night. . Disp:*6 Tablet(s)* Refills:*0* 5. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*25 Tablet Sustained Release 12HR(s)* Refills:*0* 6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: [**Month/Year (2) **] cell disease Anemia Pneumonia RBC antibodies Secondary diagnoses: Bacterial vaginosis Probable oral herpes simplex Discharge Condition: Patient discharged home in stable condition. Saturation 94-96% on room air. Hematocrit 22.5. Discharge Instructions: Please return to the hospital or call your PCP if you develop worsening respiratory symptoms, including increasing shortness of breath, or increasing cough. You should also return if you develop a fever. Please continue to take Levofloxacin daily, last dose on [**6-1**]. This is to treat your pneumonia. Start on [**5-28**]. Please note that we have also increased folate to 5 mg daily. Please take Oxycontin 10 mg twice daily for pain control. You can also take oxycodone 5 mg as needed every 4 to 6 hours for breakthrough pain. Note that we have given you 3 vaccines (Haemophilus influenza, Pneumococcal, and Meningococcal vaccines) Followup Instructions: Please call your PCP (Dr. [**Last Name (STitle) 14166**] [**Telephone/Fax (1) 14167**] and schedule an appointment to see him within 1 week of discharge. You will need a repeat CXR in the next 2 weeks. Please call Dr.[**Name (NI) 220**] office (Hematology) [**Telephone/Fax (1) 9645**], and schedule an appointment to see him within 1-2 weeks of discharge. Completed by:[**2103-5-27**]

Admission Date: [**2151-1-31**] Discharge Date: [**2151-2-16**] Date of Birth: [**2096-2-11**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 54 year old man admitted to Intensive Care Unit on [**2151-1-31**], from [**Hospital3 6265**] for evaluation of hematemesis, melena and abdominal mass. The patient had been doing well until the Tuesday prior to admission when he developed a headache at which point he took Vicodin and developed nausea and vomiting and abdominal pain. On the Thursday evening prior to admission, he states he passed out on the floor of the bathroom and had a fall secondary to severe pain. He states that he had loss of consciousness for about fifteen minutes. He denies head trauma. On the Saturday prior to admission, the patient states that he had some retching with blood. He presented to the Emergency Department at [**Hospital3 3583**] where he was admitted and found to have a hematocrit of 26.3, potassium 6.2, and he was also in acute renal failure. Abdominal CT indicated a large peripancreatic mass. The patient was transferred to [**Hospital1 69**] for further evaluation. On transfer, his white blood cell count was 28, and his creatinine was 3.4. PAST MEDICAL HISTORY: 1. History of spontaneous pneumothorax. 2. History of immune complex mediated glomerulonephritis. 3. History of peptic ulcer disease, status post surgery. 4. Acute renal failure. MEDICATIONS ON ADMISSION: Vicodin p.r.n. ALLERGIES: The patient states he is allergic to Sulfa, Aspirin and Naprosyn. SOCIAL HISTORY: The patient works in sales. He has a twenty pack year history of smoking. He denies alcohol or street drug use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On admission, the patient's temperature was 97.0, heart rate 107, respiratory rate 15, blood pressure 135/42, oxygen saturation 98% on two liters. In general, the patient was alert, in no acute distress. The neck was supple. Pulmonary examination indicated scant crackles bilaterally. Cardiovascular examination indicated regular rhythm, normal S1 and S2, and a II/VI systolic murmur. The abdomen was distended with decreased bowel sounds and mild diffuse tenderness to percussion. On extremity examination, the patient had 2+ peripheral pulses with no edema. His stool was guaiac negative. LABORATORY DATA: Initial laboratory studies indicated a white count 28.6, hematocrit 25.6, platelet count 404,000. Chem7 indicated a blood urea nitrogen 43 and a creatinine of 3.4. INR was elevated at 1.9. Liver function tests were within normal limits. Electrocardiogram indicated normal sinus rhythm, rate 99 beats per minute, normal axis, normal intervals and no ischemic changes. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit. Nasogastric lavage was performed which indicated the presence of coffee ground emesis. He was evaluated by the gastroenterology service and emergent endoscopy was performed which indicated the presence of a hiatal hernia as well as compression of the second and third part of the duodenum. A biopsy was taken at the compression site which indicated chronic inactive duodenitis and focal Brunner gland hyperplasia. There was also gastric mucocele metaplasia. CT of the abdomen indicated a 10 by 6.0 centimeter soft tissue mass within the mesentery just below the pelvic rim as well as a 10 by 16 centimeter mesenteric and retroperitoneal hematoma displaying the duodenum anteriorly and compressing the inferior vena cava. Significant mesenteric lymphadenopathy was also noted. Renal and surgery services were consulted. On the recommendation of the surgery service, a follow-up abdominal CT with p.o. contrast was completed which indicated persistent intra-abdominal hematoma but no intra-abdominal mass. The patient was also now noted to have increased liver function tests with an ALT of 622, AST of 649, and normal total bilirubin and alkaline phosphatase. As the patient's hematocrit continued to drop, a bleeding scan was conducted which indicated active bleeding into the abdomen with no clear source. The patient therefore received an angiogram which indicated the presence of a superior mesenteric artery aneurysm as well as active bleeding from the gastroduodenal artery which was embolized. The patient also developed shortness of breath following the administration of a total of fourteen units of packed red blood cells in the Intensive Care Unit. Chest x-ray indicated the presence of congestive heart failure and a possible left sided infiltrate. The patient was started on Lasix as well as Levaquin and Flagyl. A hepatitis panel was sent which was negative. ANCA was sent out of concern over possible polyarteritis nodosa, however, this study was negative. The patient was also started on total parenteral nutrition secondary to an expected ileus following embolization. While in the Intensive Care Unit following embolization, his transaminases trended downward, and his creatinine improved, and his hematocrit remained stable. The patient did develop transient episodic hypertension to a systolic pressure of 200 requiring Labetalol drip, however, this was successfully weaned and the patient was transitioned to Labetalol tablets. While in the unit, he also developed bipedal and scrotal edema, which again was thought secondary to volume overload in the setting of multiple transfusions. Echocardiogram conducted on hospital day number four indicated ejection fraction of greater than 55% with 1+ tricuspid regurgitation. On hospital day number six, the patient was transferred to the floor for additional workup of questionable abdominal mass. On repeat [**Location (un) 1131**] of the patient's existing CAT scans, it was determined that what was initially read as a mass on the first CT was likely to be extension of the hematoma. Follow-up imaging in four weeks was recommended. On his first day on the floor, the patient spiked a temperature to 101.3 degrees Fahrenheit. Repeat chest x-ray indicated worsening pulmonary infiltrates bilaterally. At this point, the patient was switched to Ceftazidime and Clindamycin to treat possible nosocomial pneumonia. Sputum and blood cultures were sent which were negative. The patient's pulmonary status improved significantly on intravenous antibiotics. As the patient was able to tolerate p.o. intake, his total parenteral nutrition was discontinued. However, the patient noted some pain with eating and was found to have a small lesion at the site of his denture insertion site. The patient was able to tolerate food after pretreatment with Viscous Lidocaine solution. Although the patient's initial abdominal pain subsided, he was maintained on Oxycontin for control of residual abdominal pain while on the floor. The patient's lower extremity edema decreased with the administration of intravenous and then subsequently p.o. Lasix. On hospital day number ten, the patient was noted to have increasing jaundice and altered mental status. Liver function tests at that time indicated an alkaline phosphatase of 1091 and total bilirubin of 11.4. His transaminases were only slightly elevated. A right upper quadrant ultrasound was performed which indicated a dilatation of the common bile duct as well as the presence of biliary sludge. There was no intrahepatic biliary duct dilatation and no gallstones. Endoscopic retrograde cholangiopancreatography was performed after consultation with the gastroenterology service. This study indicated a fifteen millimeter common bile duct which was stented as well as stenosis of the distal bulb. The patient's liver function tests, jaundice and mental status improved following endoscopic retrograde cholangiopancreatography. The patient was to have a follow-up endoscopic retrograde cholangiopancreatography in three months for stent removal. Although the patient's mental status did improve following endoscopic retrograde cholangiopancreatography, some residual symptoms of agitation and paranoia prompted a psychiatry consultation who recommended low dose of Haldol p.r.n. for worsening of these symptoms. However, the patient's mental status slowly returned to his baseline. The patient was evaluated by the physical therapy service who found that he would benefit from acute rehabilitation. At the time of this discharge summary, the patient was being screened for placement in an acute rehabilitation facility. DISCHARGE DIAGNOSES: 1. Superior mesenteric artery aneurysm. 2. Status post embolization of the gastroduodenal artery. 3. Biliary sludge. 4. Pneumonia. 5. Glomerulonephritis. 6. History of peptic ulcer disease. 7. History of pneumothorax. MEDICATIONS ON DISCHARGE: 1. Lasix 80 mg p.o. q.d. 2. Viscous Lidocaine 2% solution 15 ccs swish and spit with meals p.r.n. 3. Senna two tablets p.o. q.h.s. p.r.n. 4. Colace 100 mg p.o. b.i.d. 5. Boost t.i.d. with meals. 6. Protonix 40 mg p.o. b.i.d. 7. Labetalol 200 mg p.o. q12hours. 8. Albuterol and Atrovent MDI two puffs q4hours p.r.n. 9. Lipitor 10 mg p.o. q.d. 10. Nephrocaps 1 mg p.o. q.d. DISPOSITION: At the time of this dictation, the patient was being screened for placement in an acute rehabilitation facility. He was to have a follow-up endoscopic retrograde cholangiopancreatography with stent removal three months following discharge as well as a follow-up abdominal CT scan three weeks following discharge. He was to follow-up in [**Hospital **] Clinic. DISCHARGE DISPOSITION: Improved. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 194**] MEDQUIST36 D: [**2151-2-15**] 19:22 T: [**2151-2-15**] 19:42 JOB#: [**Job Number 96120**]

Admission Date: [**2135-12-26**] Discharge Date: [**2136-1-3**] Date of Birth: [**2080-2-9**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old man with multiple medical problems including insulin dependent diabetes secondary to severe pancreatitis in [**2123**], remote history of Hodgkin's disease in [**2113**] treated with among other things, radiation therapy which has left the patient with severe osteoporosis and resulting compression fractures, history of alcohol abuse, on chronic opioids for residual pain secondary to pancreatitis, who presented on [**12-26**] with delta MS. Per the patient's lifetime partner, the patient self increased his dose of opiate using approximately four patches of Fentanyl and increasing his Seroquel dose from 150 to 300 mg. He presented to the ED on [**2135-12-26**] with increased weakness, tremor, disorientation x2 months, worse over the prior three days. In the ED, the patient's temperature was 98.4, blood pressure was 136-145/60-70. His heart rate was 71-130. He was treated with Ativan 7 mg for what they thought was alcohol withdrawal, which increased the patient's sedation and subsequently his systolic blood pressure decreased to 88-97. Patient had a negative head CT. A lumbar puncture was attempted, but was not successful. Patient was started on acyclovir, Vancomycin for empiric meningitis coverage. The patient's Chem-7 at that time was significant for a glucose of 354, an anion gap of 13, 15 ketones in his urine. With these results, the ED started the patient on an insulin drip. His blood gas initially was 7.23/55/46, but then decreased to 7.16/56/260. The patient was minimally alert at this time. He had progressive somnolence. Patient was then started on BiPAP 10 of 5, and was admitted to the MICU. PAST MEDICAL HISTORY: 1. COPD. 2. Diabetes mellitus insulin dependent secondary to chronic pancreatitis. 3. Chronic alcohol induced pancreatitis status post debridement. 4. History of alcohol abuse. 5. Osteoporosis. 6. CHF with an ejection fraction of 40%. 7. Hodgkin's disease status post XRT, chemotherapy, splenectomy. 8. Hypothyroidism. 9. GERD. 10. Vocal cord paralysis. 11. Chronic pain on multiple narcotics. 12. Anxiety and depression. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient has a 40 pack year history of tobacco. No recent ethanol use. PHYSICAL EXAM: Temperature 98.5, blood pressure 104/64, heart rate 107. Cardiovascular: Patient has a 3/6 systolic murmur heard best at the left lower sternal border and at the apex. Abdomen is soft, nontender, nondistended, multiple surgical scars. Extremities: No cyanosis, clubbing, or edema. Pulses are [**12-30**]+ bilaterally. Neurologic: The patient responds to commands, is moving all four extremities. HOSPITAL COURSE: The patient was admitted to the MICU for further management. On [**2135-12-27**], he was intubated due to increased somnolence and hypoxia. On [**2135-12-28**], an EEG was performed, which was read as possibly consistent with encephalitis. Patient was then seen by the Neuro team, who recommended a MRI and LP. On [**2135-12-28**], the patient's temperature spiked to 101.6. He was continued on ampicillin, ceftriaxone, and acyclovir for possible meningitis. He was also started on a bicarb drip for metabolic acidosis. The patient was initially treated with Ativan for narcotic withdrawal, but then this was D/C'd and he was later started on a lower dose of Fentanyl. On [**2135-12-29**], the patient was transferred to the VICU. Analysis of the CSF fluid revealed 2 monocytes, 15 lymphocytes, 1 band. Gram stain was negative for PMNs, macrophages, or bacteria. Culture was negative. PCR for Listeria and HSV were negative. Results from the patient's MRI on [**2135-12-28**] revealed normal brain parenchyma. No blood breakdown or edema present. Overall impression was that the MRI was grossly normal, however, the study was limited by patient motion. In the MICU, the patient was extubated. His mental status continued to improve. He was continued on antibiotics for treatment of presumed community acquired pneumonia. He was noted to have eosinophilia, which improved over the course of his hospitalization. He was transfused with 1 unit of blood and transiently went into pulmonary edema in the setting of this transfusion. This resolved with Lasix and nebulizers. Acyclovir was D/C'd as the patient's MRI and lumbar puncture were negative. The patient was then transferred to the medical floor, where he was alert and oriented, able to ambulate with cane, and was tolerating good p.o. intake. He was seen by Physical Therapy, who felt that he would benefit from a rehabilitation stay. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To [**Hospital3 2558**] [**Hospital **] Hospital. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Insulin dependent diabetes. 3. History of chronic alcoholic-induced pancreatitis. 4. Remote history of alcohol abuse. 5. Severe osteoporosis. 6. Congestive heart failure with an ejection fraction of 40%. 7. Hodgkin's disease. 8. Hypothyroidism. 9. Gastroesophageal reflux disease. 10. Vocal cord paralysis exacerbated by recent intubation. 11. Chronic pain on multiple narcotics. 12. Anxiety and depression. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q.d. 2. Pantoprazole 40 mg p.o. q.d. 3. Lisinopril 5 mg p.o. q.d. 4. Morphine sulfate 15 mg p.o. q.6h. prn. 5. Clindamycin 600 mg IV q.8h. 6. Ceftriaxone 1 gram IV q.24h. 7. Docusate 100 mg b.i.d. 8. Fentanyl patch 150 mcg/hour transdermal patch q.72h. 9. Quetiapine fumarate 100 mg p.o. q.h.s. 10. Insulin-sliding scale with 7 units of glargine at bedtime. 11. Lorazepam 1-2 mg IV q.3-4h. prn. 12. Levothyroxine 125 mcg p.o. q.d. 13. Folic acid 1 mg p.o. q.d. 14. Multivitamin. 15. Pancrease four capsules p.o. t.i.d. with meals. 16. Tylenol prn. 17. Vitamin D. 18. Citalopram 40 mg p.o. q.d. 19. Calcium 500 mg p.o. t.i.d. 20. Antibiotic therapy to be completed on [**2136-1-10**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8184**], M.D. [**MD Number(1) 8185**] Dictated By:[**Last Name (NamePattern1) 9725**] MEDQUIST36 D: [**2136-1-3**] 10:42 T: [**2136-1-3**] 11:00 JOB#: [**Job Number 108105**]

Admission Date: [**2165-4-29**] Discharge Date: [**2165-5-15**] Service: MEDICINE Allergies: Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Chest pain, total body pain Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] y/o F with PMHx of CAD, CHF with EF of 40%, recent admission with respiratory failure requiring intubation who presents with total body pain and chest pain. The patient's current symptoms began on Saturday with nausea. The following day (one day prior to admission), the patient experienced aching throughout her body, including her back, chest, and the back of her head. This morning, the patient awoke from sleep at 6am due to right index finger pain, erythema, swelling, and calor which then spread to the rest of her body (back, chest, back of head). Finger pain is described as stiff, sore, and achy with associated calor. Total body pain is described as sharp body aches which is generalized, which lasted until she received Morphine in the ED. The patient describes chest pain along with her total body pain, and received SL Nitro x3 without relief. The pain had similar features to her prior anginal equivalent, during which she experienced chest pain, shortness of breath, and upper back pain, but her current pain consists of nausea without dyspnea or lightheadedness. . In the ER, vitals were T99.9 BP 156/61 P76 R18 PO2 100% 2L. Chest pain was [**7-18**] on arrival and she was started on a nitro gtt without significant relief of symptoms. However, symptoms resolved with morphine, currently 0/10. EKG revealed sinus rhythm with baseline LBBB and no acute EKG changes. She received Morphine and a 500cc bolus while en route with EMS, and received additional Morphine in the ED. . On evaluation on the floor, pt was asymptomatic and complaining of thirst. She denies PND, reports 2 pillow orthopnea which has remained unchanged for years. . . 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. Denies fevers/chills, night-sweats, abdominal pain, diarrhea, dysuria, rash. She does report (+) congestion/cough with white sputum since hospitalization, helped by albuterol. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: # Diabetes # Dyslipidemia # Hypertension # Coronary Disease - s/p NSTEMI [**9-16**] medically managed and Cath s/p stent in [**3-20**]. # Chronic systolic/diastolic congestive heart failure, most recent EF>60% # Chronic renal failure, stage III CKD - Dr [**Last Name (STitle) **] # Hypertension # Hyperlipidemia, intolerant of statins # Type 2 diabetes, diet-controlled # GERD # Breast Cancer - diagnosed in [**2145**], s/p lumpectomy in [**State 108**] # s/p total abdominal hysterectomy [**2094**] for fibroids # Cataracts Social History: She lives at home alone, but has family in the area. Social history is significant for the absence of current tobacco use, remote social tobacco use in college. There is no history of alcohol abuse. Has home [**Year (4 digits) 269**] w tele reports daily and PT. Presents from rehab following multiple admissions. Family History: There is no family history of premature coronary artery disease or sudden death. Her father had hypertension. Her sister is alive and healthy at 93. Physical Exam: On admission VS: T=98.6 BP=146/70 HR=75 R=20 PO2 sat= 100% 2L 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 of <9 cm. CARDIAC: RRR, normal S1, S2. GII systolic murmer at LSB, no gallops, rubs. S4 present at LSB and apex. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at bases b/l; no egophany. No wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. NABS. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ On discharge VS: 97.3, 120/47, 52, 18, 100%RA I/O: 120/350 today, [**Telephone/Fax (1) 93520**] yesterday GENERAL: AAOx3, pleasant elderly female in NAD. Fatigued, but interactive. HEENT: NCAT. Sclera anicteric. NECK: Supple with JVP of <9 cm while sitting at 90 degrees CARDIAC: RRR, normal S1, S2. S4 present at LSB and apex. LUNGS: mild kyphosis. Resp were unlabored, no accessory muscle use. soft crackles bibasilarly, breath sounds at bases decreased ABDOMEN: Soft, NTND. No HSM or tenderness. NABS. EXTREMITIES: No c/c/e. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: CXR ([**4-29**]): Two views are compared with the bedside examination obtained some 10 hours earlier, as well as previous examinations of [**4-16**] and [**2165-4-19**]. There has been clearing of the findings of CHF and bilateral pleural effusions, with residual rounded LV enlargement and atherosclerotic change involving the thoracic aorta. The lungs appear hyperinflated, suggestive of underlying obstructive disease; however, there is no focal airspace opacity. There is diffuse osteopenia with slight anterior wedging of several thoracic vertebrae and resultant slight kyphosis. There is no acute abnormality of the thoracic skeleton. . CXR ([**5-5**]): 1. Worsening pulmonary edema and increasing small pleural effusions. 2. Bilateral lower lobe airspace opacities, which may be due to dependent areas of pulmonary edema or superimposed secondary process such as aspiration or infectious pneumonia. Followup radiographs after diuresis may be helpful in this regard. . CXR ([**5-6**]) CHEST, AP: Mild interstitial edema has slightly worsened. Mild cardiomegaly and small bilateral pleural effusions are unchanged. Bibasilar consolidation is stable. The cardiac silhouette is normal. The aorta is calcified and tortuous. IMPRESSION: Slightly increased vascular congestion. . SUPINE ABDOMEN ([**5-6**]) Limited study with partially imaged left abdomen. Bowel gas pattern present is nonobstructive with air seen in non-dilated loops of small and large bowel. There is no free intraperitoneal air or pneumatosis. The cardiac silhouette is moderately enlarged. There is a questionable deep sulcus sign in the right hemithorax, which in the right clinical setting, may represent a pneumothorax. There is small opacification in the left lower lung. . CBC [**2165-5-13**] 05:15AM BLOOD WBC-8.3 RBC-3.41* Hgb-10.1* Hct-30.1* MCV-88 MCH-29.7 MCHC-33.7 RDW-15.2 Plt Ct-402 [**2165-5-12**] 04:35AM BLOOD WBC-8.4 RBC-3.45* Hgb-10.5* Hct-30.3* MCV-88 MCH-30.5 MCHC-34.7 RDW-14.9 Plt Ct-355 [**2165-5-11**] 06:10AM BLOOD WBC-7.8 RBC-3.28* Hgb-9.7* Hct-28.7* MCV-88 MCH-29.5 MCHC-33.7 RDW-15.0 Plt Ct-369 [**2165-5-10**] 05:20AM BLOOD WBC-6.0 RBC-3.09* Hgb-9.1* Hct-27.1* MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 Plt Ct-389 [**2165-5-9**] 05:30AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.1* Hct-27.2* MCV-86 MCH-28.9 MCHC-33.5 RDW-14.7 Plt Ct-341 [**2165-5-8**] 05:15AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.1* Hct-26.5* MCV-87 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-286 [**2165-5-7**] 06:02AM BLOOD WBC-6.6 RBC-3.02* Hgb-9.0* Hct-26.2* MCV-87 MCH-29.9 MCHC-34.5 RDW-14.8 Plt Ct-305 [**2165-5-6**] 12:48AM BLOOD WBC-7.4# RBC-3.03* Hgb-8.9* Hct-25.7* MCV-85 MCH-29.4 MCHC-34.7 RDW-14.8 Plt Ct-239 [**2165-5-5**] 04:10AM BLOOD WBC-4.5 RBC-2.71* Hgb-8.3* Hct-23.8* MCV-88 MCH-30.6 MCHC-35.0 RDW-14.9 Plt Ct-248 [**2165-5-4**] 07:30AM BLOOD WBC-4.9 RBC-3.01* Hgb-9.1* Hct-26.6* MCV-88 MCH-30.3 MCHC-34.3 RDW-15.0 Plt Ct-239 [**2165-5-3**] 05:05AM BLOOD WBC-5.7 RBC-3.06* Hgb-9.4* Hct-27.2* MCV-89 MCH-30.6 MCHC-34.4 RDW-15.3 Plt Ct-242 [**2165-5-2**] 05:25AM BLOOD WBC-5.8 RBC-3.36* Hgb-10.1* Hct-29.2* MCV-87 MCH-30.0 MCHC-34.6 RDW-15.0 Plt Ct-225 [**2165-5-1**] 07:30AM BLOOD WBC-8.6 RBC-3.31* Hgb-9.9* Hct-29.5* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-245 [**2165-4-30**] 10:50AM BLOOD WBC-7.8 RBC-3.29* Hgb-9.8* Hct-28.6* MCV-87 MCH-29.7 MCHC-34.1 RDW-15.2 Plt Ct-215 [**2165-4-30**] 07:25AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.3* Hct-29.9* MCV-89 MCH-30.7 MCHC-34.5 RDW-15.5 Plt Ct-245 [**2165-4-29**] 07:55AM BLOOD WBC-16.0*# RBC-3.75* Hgb-11.3* Hct-32.3* MCV-86 MCH-30.0 MCHC-34.9 RDW-15.6* Plt Ct-269 Coags [**2165-5-11**] 06:10AM BLOOD PT-12.7 PTT-30.2 INR(PT)-1.1 [**2165-5-10**] 05:20AM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0 [**2165-5-9**] 05:30AM BLOOD PT-12.0 PTT-28.0 INR(PT)-1.0 [**2165-5-8**] 05:15AM BLOOD PT-12.8 PTT-28.9 INR(PT)-1.1 [**2165-5-7**] 06:02AM BLOOD PT-12.6 PTT-31.4 INR(PT)-1.1 [**2165-5-6**] 01:01AM BLOOD PT-13.1 PTT-26.5 INR(PT)-1.1 [**2165-4-30**] 07:25AM BLOOD PT-13.2 PTT-28.4 INR(PT)-1.1 Chemistry [**2165-5-13**] 05:15AM BLOOD Glucose-117* UreaN-116* Creat-3.7* Na-131* K-3.5 Cl-78* HCO3-40* AnGap-17 [**2165-5-12**] 04:35AM BLOOD Glucose-121* UreaN-117* Creat-3.5* Na-131* K-3.7 Cl-78* HCO3-39* AnGap-18 [**2165-5-11**] 06:10AM BLOOD Glucose-131* UreaN-117* Creat-3.7* Na-130* K-3.8 Cl-79* HCO3-38* AnGap-17 [**2165-5-10**] 05:20AM BLOOD Glucose-118* UreaN-119* Creat-3.7* Na-130* K-4.0 Cl-79* HCO3-37* AnGap-18 [**2165-5-9**] 05:30AM BLOOD Glucose-109* UreaN-119* Creat-3.7* Na-129* K-3.2* Cl-79* HCO3-35* AnGap-18 [**2165-5-8**] 05:15AM BLOOD Glucose-111* UreaN-118* Creat-3.9* Na-128* K-3.4 Cl-77* HCO3-34* AnGap-20 [**2165-5-7**] 06:02AM BLOOD Glucose-115* UreaN-116* Creat-4.1* Na-125* K-3.3 Cl-76* HCO3-34* AnGap-18 [**2165-5-6**] 04:08PM BLOOD UreaN-112* Creat-4.2* Na-129* K-3.7 Cl-81* HCO3-32 AnGap-20 [**2165-5-6**] 12:48AM BLOOD Glucose-137* UreaN-108* Creat-4.4* Na-123* K-3.8 Cl-75* HCO3-29 AnGap-23* [**2165-5-5**] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3* Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19 [**2165-5-4**] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126* K-3.9 Cl-80* HCO3-29 AnGap-21* [**2165-5-3**] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125* K-4.2 Cl-81* HCO3-28 AnGap-20 [**2165-5-5**] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3* Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19 [**2165-5-4**] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126* K-3.9 Cl-80* HCO3-29 AnGap-21* [**2165-5-3**] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125* K-4.2 Cl-81* HCO3-28 AnGap-20 [**2165-5-3**] 05:05AM BLOOD Glucose-136* UreaN-91* Creat-3.6* Na-127* K-4.1 Cl-85* HCO3-29 AnGap-17 [**2165-5-2**] 05:25AM BLOOD Glucose-135* UreaN-84* Creat-3.1* Na-135 K-4.0 Cl-92* HCO3-28 AnGap-19 [**2165-5-1**] 07:30AM BLOOD Glucose-110* UreaN-82* Creat-3.0* Na-136 K-4.3 Cl-94* HCO3-32 AnGap-14 [**2165-4-30**] 10:50AM BLOOD Glucose-186* UreaN-81* Creat-2.9* Na-135 K-3.4 Cl-92* HCO3-32 AnGap-14 [**2165-4-30**] 07:25AM BLOOD Glucose-109* UreaN-81* Creat-2.9* Na-136 K-3.4 Cl-92* HCO3-32 AnGap-15 [**2165-4-29**] 07:55AM BLOOD Glucose-163* UreaN-84* Creat-2.9* Na-138 K-3.5 Cl-94* HCO3-30 AnGap-18 [**2165-5-13**] 05:15AM BLOOD Calcium-9.0 Phos-5.1* Mg-3.8* [**2165-5-12**] 04:35AM BLOOD Calcium-9.0 Phos-4.7* Mg-4.0* [**2165-5-11**] 06:10AM BLOOD Calcium-8.7 Phos-4.2 Mg-4.0* [**2165-5-10**] 05:20AM BLOOD Calcium-8.5 Phos-4.1 Mg-4.0* [**2165-5-9**] 05:30AM BLOOD Calcium-8.8 Phos-5.3* Mg-3.8* [**2165-5-8**] 05:15AM BLOOD Calcium-8.6 Phos-5.4* Mg-4.0* [**2165-5-7**] 06:02AM BLOOD Calcium-9.2 Phos-6.5* Mg-4.1* [**2165-5-6**] 12:48AM BLOOD Albumin-3.6 Calcium-9.2 Phos-5.8* Mg-3.6* [**2165-5-5**] 04:10AM BLOOD Calcium-8.9 Phos-6.1* Mg-3.3* [**2165-5-4**] 07:30AM BLOOD Calcium-9.1 Phos-5.1* Mg-3.0* [**2165-5-3**] 05:05AM BLOOD Calcium-9.1 Phos-4.2 Mg-3.0* [**2165-5-2**] 05:25AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.7* [**2165-5-1**] 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.9* [**2165-4-30**] 10:50AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.6 [**2165-4-30**] 07:25AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.5 [**2165-4-29**] 07:55AM BLOOD Calcium-9.9 Phos-4.2 Mg-2.5 Cardiac Enzymes [**2165-5-6**] 12:48AM BLOOD CK(CPK)-17* [**2165-5-5**] 04:10AM BLOOD CK(CPK)-11* [**2165-5-2**] 05:25AM BLOOD CK(CPK)-16* [**2165-5-1**] 09:14PM BLOOD CK(CPK)-20* [**2165-4-30**] 07:25AM BLOOD CK(CPK)-17* [**2165-4-30**] 03:40AM BLOOD CK(CPK)-15* [**2165-4-29**] 03:05PM BLOOD CK(CPK)-19* [**2165-4-29**] 07:55AM BLOOD CK(CPK)-20* [**2165-5-6**] 12:48AM BLOOD CK-MB-NotDone cTropnT-0.20* [**2165-5-5**] 04:10AM BLOOD CK-MB-1 cTropnT-0.19* [**2165-5-2**] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.09* [**2165-5-1**] 09:14PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2165-4-30**] 07:25AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2165-4-30**] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2165-4-29**] 03:05PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-[**Numeric Identifier 93521**]* [**2165-4-29**] 07:55AM BLOOD cTropnT-0.03* Brief Hospital Course: [**Age over 90 **]yoF with CAD s/p stent to mid-[**Name (NI) **], PTCA of jailed OM1, IVUS of LMCA with MLA presenting with body pain and chest pain. . # CORONARIES: Patient has h/o prior stent to [**Name (NI) **] and PTCA of jailed OM1 presenting with atypical chest pain not concerning for ACS. There were no significant EKG changes in light of LBBB (by Sgarbossa criteria), and CE's were negative. The patient was continued on Aspirin 162mg daily and Clopidogrel 75 mg daily per outpatient regimen. . # PUMP/CHF: Patient has a history of chronic systolic and diastolic heart failure with EF 40% [**3-/2165**], moderate (2+) MR, small secundum ASD with left-to-right shunt across the interatrial septum at rest. She appeared clinically fluid overloaded without hypoxia, with BNP >45,000. Pt had complex course on the medicine floor with multiple episodes of worsening resp status thought due to flash pulm edema. Initially, her symptoms responded to lasix and additional BP control. However, the renal function slowly worsened and she had a decreasing response to diuresis. Pt became progressively uremic and confused on [**5-5**] with mild respiratory distress. She was transferred to the CCU on [**5-6**] and received 240mg Lasix IV bolus followed by gtt. She was aggressively diuresed, per renal recs, started on Lasix 80mg PO BID. She has had good volume output with the lasix. Patient has been in good volume status since, has not had any further episodes of flash pulmonary edema. Has had fluctuating O2 requirements, at times saturating well on room air and other times requiring 2L of O2. . # Chronic renal failure: Stage III CKD, followed by Dr [**Last Name (STitle) **]. Patient has baseline Cr of 1.5 until [**Month (only) 956**] when baseline increased to 2.4. On this admission patient had worsening renal function with creatinine rising from 2.9 to 4.3. It was unclear whether the patient's increasing creatinine was due to dehydration vs volume overload - particularly given her recurrent episodes of flash pulmonary edema and CXR showing evidence of fluid overload. She was aggressively diuresed in the CCU and her volume status has been stable on 80 mg of PO lasix [**Hospital1 **]. Patient and family have decided to decline hemodialysis and focus more on comfort measures. # Renal Artery Stenosis: Patient with atrophic right kidney, left renal artery stenosis. Very likely that this is the reason that she is very difficult to diurese and the reason why she flashes easily. She was originally planned for renal artery stenting, but the procedure was held off because she was unstable, requiring CCU transfer. Goals of care were discussed with patient and renal stenting was tabled as patient decided against aggressive management and to focus more on comfort. . # Body Pain: Patient describes body pain since waking up in the morning of her admission. Unclear etiology, but likely viral symptoms vs non-specific findings [**3-12**] CHF exacerbation. Infectious workup was negative. Leukocytosis resolved on discharge. Patient has had 2 transient episodes of chest pain on this admission which was reproducible with palpation and worse with movement, likely of musculoskeletal etiology, relieved with 0.5 mg of PO morphine. . # Right Finger Pain: Pt initially presented with right index finger with erythema, swelling, calor consistent with gout; septic arthritis or osteomyelitis was less likely given no fevers, no effusion, no nidus of infection. Resolved without intervention. . # Hypertension: Patient's home antihypertensives were initially continued, but following her CCU transfer for recurrent flash pulmonary edema, she was changed to amlodipine, carvedilol, furosemide, and imdur. Following her CCU admission she has been stable with SBP ranging in 110s-130s. . # Hyperlipidemia: Pt is intolerant of statins, and was not given statins after discussion with her PCP [**Last Name (NamePattern4) **]: goals of the patient's care. . # Type 2 diabetes: diet-controlled. Covered with SSI in-house. . # GERD: Continued Famotidine 20 mg Tablet per outpatient regimen . # Goals of care: patient was made DNR/DNI while in the CCU. Patient and family decided against starting hemodialysis, preference was for comfort directed care. Just prior to discharge from the hospital, patient was asked to sign a DNR/DNI form which would continue her DNR/DNI status during transport and at the nursing facility, which she refused to sign. Patient repeatedly stated that she DID NOT want to be resuscitated, however refused to sign the form. She is amenable to her daughter (HCP) signing the DNR/DNI forms for her, however the daughter was not available prior to discharge to sign the papers. The daughter understands that she would be able to sign the DNR/DNI papers at the nursing facility. At the nursing facility, patient's care should be focused on comfort care. Medications on Admission: 1. Senna 8.6 mg [**Hospital1 **] 2. Famotidine 20 mg Tablet 3. Calcitriol 0.25 mcg Capsule PO QMOWEFR 4. Aspirin 162mg daily 5. Clopidogrel 75 mg daily 6. Cyanocobalamin 500 mcg daily **7. Hydralazine 10 mg q6hr **8. Isosorbide Mononitrate 20 mg [**Hospital1 **] 9. Docusate Sodium 100 mg [**Hospital1 **] 10. Felodipine 10 mg daily 11. Carvedilol 12.5 mg [**Hospital1 **] **12. Furosemide 40 mg Tablet [**Hospital1 **] 13. Iron (Ferrous Sulfate) 325 mg daily 14. Nitrostat 0.4 mg Tablet, Sublingual prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: up to 3 tablets as needed for chest pain 5 minutes apart. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS OFF (). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 16. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams PO once a day as needed for constipation. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Systolic and Diastolic Heart Failure Pulmonary Edema Left Renal Artery Stenosis Secondary Diagnosis: Hypertension Diabetes Coronary Artery Disease Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Lethargic but arousable Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You presented to the hospital for body pain and chest pain. Your EKG and blood tests did not show any evidence of a heart attack, but you were found to be in heart failure. While in the hospital, you had frequent episodes of shortness of breath was improved with starting you on Lasix to help remove fluid. During this admission, we had many discussions about whether or not to start dialysis. Your final decision was for dialysis not to be started, but instead to pursue hospice care instead. You will be discharged to a nursing facility where they can help with treating your symptoms and making you comfortable. . Your medications have changed, please only take the medications as listed below: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: up to 3 tablets as needed for chest pain 5 minutes apart. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS OFF (). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 16. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams PO once a day as needed for constipation. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every six (6) hours as needed for pain. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please call and schedule an appointment to see your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] ([**Telephone/Fax (1) 250**]), as needed.

Admission Date: [**2191-11-28**] Discharge Date: [**2191-12-21**] Date of Birth: [**2114-4-22**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Heparin Agents Attending:[**First Name3 (LF) 1283**] Chief Complaint: Mrs. [**Known lastname **] is s/p CABG [**2187**], and now has increasing SOB/DOE. She underwent cardiac catheterization [**11-24**] which showed patent LIMA-LAD, totally occluded SVG-OM and ectatic SVG-PDA, and an aortic valve area of 0.59cm2. She was admitted to [**Hospital 24356**] hospital for diuresis due to an elevated wedge pressure and then was transferred to [**Hospital1 18**] for surgery Major Surgical or Invasive Procedure: s/p redo sternotomy/CABGx1 SVG-PDA/AVR 21mm pericardial [**12-7**] History of Present Illness: Mrs. [**Known lastname **] is s/p CABG [**2187**], and now has increasing SOB/DOE. She underwent cardiac catheterization [**11-24**] which showed patent LIMA-LAD, totally occluded SVG-OM and ectatic SVG-PDA, and an aortic valve area of 0.59cm2. She was admitted to [**Hospital 24356**] hospital for diuresis due to an elevated wedge pressure and then was transferred to [**Hospital1 18**] for surgery. Past Medical History: CAD s/p CABG [**2187**] aortic stenosis h/o breast CA s/p lumpectomy and radiation therapy to R breast carotid stenosis-bilateral 50-70% lesions DM-type 2 elevated cholesterol venous stasis Physical Exam: discharge physical exam: T:98.1 P63 atrial fibrillation BP:123/62 RR:18 RA:SpO2 95% on RA weight:[**12-21**] 91.4kg Neurological exam:She is awake, alert, oriented x3, non-focal. Cardiovascular exam: regular rate and rhythm without rub or murmur Respiratory:breath sounds are clear without wheezes or rales GI:positive bowel sounds, soft, obese, non-tender, non-distended, no nausea Extremities:warm and well perfused, bilateral lower extremeties with mild erythema, chronic venous stasis changes with plaques. No warmth or tenderness. Sternal incision is clean and dry, there is an area at the at the proximal portion of the incision with 2 areas of scabbed skin tears. There is no erythema or drainage. The veing harvest site at the knee is clean, dry and intact Pertinent Results: [**2191-12-21**] 05:58AM BLOOD WBC-8.4 RBC-4.27 Hgb-12.9 Hct-37.9 MCV-89 MCH-30.3 MCHC-34.1 RDW-15.7* Plt Ct-277 [**2191-12-21**] 05:58AM BLOOD Plt Ct-277 [**2191-12-21**] 05:58AM BLOOD PT-20.3* PTT-32.6 INR(PT)-2.6 [**2191-12-21**] 05:58AM BLOOD Glucose-66* UreaN-16 Creat-1.0 Na-138 K-4.2 Cl-95* HCO3-34* AnGap-13 Brief Hospital Course: Mrs. [**Known lastname **] was admitted to [**Hospital1 18**] on [**11-28**] for pre-operative evaluation. She was started on IV heparin for her coronary disease. She was taken to the operating room on [**12-2**] and was induced with general anesthesia. It was then noted that she had purulent drainage from her lower extremeties in the area of the venous stasis. The surgery was canceled and she was transferred to the ICU to allow to awaken and she was started on antibiotics. A vascular surgery and infectious disease consult was obtained and patient underwent ultrasound studies of her LE which did not show any significant reflux and no arterial occlusion. With the antibiotics, the erythema and drainage improved and with continued Lasix the edema improved and patient was taken to the operating room on [**12-7**] for a redo sternotomy, CABGx1-SVG-PDA, and AVR with a 21 mm pericardial valve. The patient was transferred to the ICU in stable condition. She was weaned and extubated from mechanical ventilation on [**12-7**] without difficulty. She had episodes of nausea and was started on Reglan and an antiemetic with some relief. Her chest tubes and pacing wires were removed without incident. She was started on lo dose Lopressor which she tolerated well, and had escalating doses of Lasix to achieve adequate diuresis. She was transferred from the ICU to the regular floor on POD#5. In the early morning of POD 6, she developed atrial fibrillation which was rate controlled. She had some thrombocytopenia postoperatively and a heparin antibody test was found to be positive. A hematology consult was obtained and it was recommended that she be started on argatroban for anticoagulation. This was started as well as Coumadin and the argatroban was turned off when her INR became therapeutic. She underwent an ultrasound of her R arm due to swelling which did not show any venous clot or obstruction. During her postoperative course, she continued to be nauseaus, a KUB showed a lot of stool and she had an aggressive bowel regime. During this time, her PO intake was poor. A GI consult was obtained and it was recommended to continue the current therapy and by POD#13 the nausea was improving. On POD#12 it was noted that she was having some periods of bradycardia with the atrial fibrillation and it was decided to discontinue the Lopressor, after which there were no further pauses. Medications on Admission: aspirin 325mg qd lisinopril 5mg qd insulin 70/30 18 units qam, 15units qpm lopressor 50mg qam 25mg qpm nitropaste lasix 80mg iv qd Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 16. Insulin 70/30 70-30 unit/mL Suspension Sig: Five (5) units Subcutaneous twice a day. 17. Insulin Regular Human 300 unit/3 mL Syringe Sig: as directed Subcutaneous four times a day: BS 121-140 2units SC BS 141-160 3units SC BS 161-180 4units SC BS 181-200 5units SC BS 201-220 6units SC BS 221-240 7units SV . Discharge Disposition: Extended Care Facility: [**Location (un) **] at [**Location (un) 701**] Discharge Diagnosis: AS/CAD h/o CHF DM PVD s/p breast lumpectomy d/t CA s/p radiation to R breast carotid stenosis 50-70% bilaterally s/p CABG [**2187**] s/p redo sternotomy/AVR/redo CABG bilateral LE venous stasis bilateral LE cellulitis post op atrial fibrillation post op urinary retention post op gastroparesis/ileus/constipation +heparin antibodies Discharge Condition: good Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not drive for 1 month do not lift anything heavier than 10 pounds for 1 month do not apply lotions, creams, ointments or powders to your incisions Followup Instructions: follow up with Dr. [**Last Name (STitle) **] in 2 weeks follow up with [**Doctor Last Name **] in 2 weeks follow up with Dr. [**Last Name (STitle) **] in [**3-31**] weeks Completed by:[**2191-12-21**]