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Admission Date: [**2159-3-26**] Discharge Date: [**2159-4-2**] Date of Birth: [**2100-4-4**] Sex: M Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: This is a 63 year old male with a history of hypertension, hypercholesterolemia, who had new onset of exertional shortness of breath and was shoveling snow this past [**Month (only) 1096**]. The patient saw his primary care physician who referred the patient for exercise treadmill test which was done on [**2159-2-28**], and showed ejection fraction of 47%, minimal left ventricular reversible dilatation and moderately severe inferolateral reversible defect and inferolateral hypokinesis. The patient was then referred for cardiac catheterization. His catheterization was done on [**2159-3-16**], and showed an ejection fraction of approximately 50%, left internal mammary artery of approximately 50% distal and left anterior descending of approximately 80% distal stenosis and 80% stenosis at D1, 50% at mid diagonal, left circumflex total occlusion, 60% before left posterior descending artery and right coronary artery 70% ostial and total occlusion of mid. The patient was then evaluated for coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Status post brain abscess, on prophylaxis with Tegretol secondary to lung infection. 4. Status post gastrointestinal bleed and partial gastric resection. 5. Status post right hernia repair. SOCIAL HISTORY: The patient works at [**Company 52516**], married, smoked cigars. The patient quit approximately four years ago. He drinks two beers a day. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. once daily. 2. Tegretol 200 mg p.o. twice a day. 3. Procardia XL 40 mg p.o. once daily. 4. Zoloft 150 mg p.o. q.a.m. 5. Toprol XL 25 mg p.o. once daily. 6. Lipitor 10 mg p.o. once daily. 7. Zestril 2.5 mg p.o. once daily. REVIEW OF SYSTEMS: The patient denies visual changes, dysphasia, palpitations, melena, hematochezia, nocturia, weakness, numbness, transient ischemic attack, and cerebrovascular accident. PHYSICAL EXAMINATION: In general, the patient is pleasant male in no apparent distress. Heart rate is 66, blood pressure 134/90, respiratory rate 19, oxygen saturation 95% in room air. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The pharynx was clear. Examination of the neck revealed supple neck, no jugular venous distention, no bruits, and carotid pulses 1+ bilaterally. Examination of the lungs revealed lungs clear to auscultation bilaterally. Examination of the heart revealed regular rate and rhythm, without murmurs, rubs or gallops. Examination of the abdomen revealed positive bowel sounds, soft, nontender, nondistended, well healed midline supraumbilical incision. Extremities showed no cyanosis, clubbing or edema. Dorsalis pedis and posterior tibial pulses were 2+ bilaterally. Radial artery pulses were 2+ bilaterally. Neurologically, the patient was awake, alert and oriented times three. Sensory and motor examinations were grossly intact. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery service and underwent coronary artery bypass graft times three, left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to posterior descending artery. The patient's mean arterial pressure on transfer to the recovery room was 70, central venous pressure was 12. The patient was in normal sinus rhythm at 80 beats per minute. The patient was on Propofol drip titrated. On postoperative day number one, the patient was on Neo-Synephrine drip of 0.6 with low grade fever of 100; otherwise 90s. Normal sinus rhythm. Arterial blood gas was 7.41, 37, 88, 24 and 0, oxygen saturation 94% in room air. He was otherwise doing well. The patient was weaned off the Neo-Synephrine and chest tubes were removed. On postoperative day number two, the patient remained afebrile with stable vital signs. White blood cell count was 14.6 and hematocrit was 23.9. The patient required some Neo-Synephrine for pressure support. On postoperative day number three, the patient was completely off Neo-Synephrine and the patient had previously received blood for low hematocrit. Pulse was at 104, good pressure, saturating well. White blood cell count was down to 9.1 and hematocrit was 24.2. He was otherwise doing well. The patient was started on Lasix and was transferred to the floor in stable condition. On postoperative day number four, the patient had a low grade temperature of 100.3 and otherwise was doing well. He was in sinus rhythm, was taking good p.o. and making good urine. The patient's wires were removed. Metoprolol was increased to 25 mg twice a day. On postoperative day number five, the patient was complaining of not having any bowel movements. He was otherwise doing well. Pulse was 91, and blood pressure was 116/59. He was taking good p.o. and making good urine. The patient was given Magnesium Citrate which helped to have a bowel movement. On postoperative day number six, the patient was doing well, remained afebrile with stable vital signs and the white blood cell count was 7.6, hematocrit 26.6, platelet count 261,000 and creatinine 1.2. Otherwise, the patient was doing well. The patient was discharged home. CONDITION ON DISCHARGE: Good. DISPOSITION: Home. FINAL DIAGNOSIS: Coronary artery disease, status post coronary artery bypass graft times three. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. once daily. 2. Carbamazepine 200 mg p.o. twice a day. 3. Lasix 20 mg p.o. once daily for seven days. 4. Sertraline 150 mg p.o. q.a.m. 5. Metoprolol 25 mg p.o. twice a day. 6. Lipitor 10 mg p.o. once daily. 7. Colace 100 mg p.o. twice a day. 8. Dilaudid 2 to 4 mg p.o. q4-6hours p.r.n. pain. 9. Potassium Chloride 10 mEq p.o. once daily for seven days. FO[**Last Name (STitle) **]P PLANS: Please follow-up with Dr. ************ in one to two weeks, and please follow-up with Dr. [**Last Name (Prefixes) **] in four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 3118**] MEDQUIST36 D: [**2159-4-2**] 18:30 T: [**2159-4-2**] 18:40 JOB#: [**Job Number 52517**]

Admission Date: [**2138-12-7**] Discharge Date: [**2138-12-10**] Date of Birth: [**2063-4-26**] Sex: F Service: MEDICINE Allergies: Vioxx / Compazine / Phenergan Attending:[**First Name3 (LF) 2745**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 7474**] is a 75 y/oF with CKD Stage V (Renal=[**Location (un) 10083**] at [**Last Name (un) **]), CAD, Pulm HTN, UC s/p colectomy with ileostomy, who presents for shortness of breath and mental status changes. She was brought to the ED by her husband and family. She and the family report an increased ostomy output for the past several days, without specific quantification. She does have some new crampy lower abdominal pain which is new for her. The shortness of breath is worse with exertion and especially going up stairs, as well as worsened by supine position, but this has been building for about one month. She specifically denies chest pain or discomfort. She was recently admitted to the medical service [**Date range (1) 24726**] for UTI, and treated with ciprofloxacin. She continues to have b/l LE swelling and edema with superficial redness. On her left medial/inner thigh, she has a larger patch of hyperemetous skin with development of papules, also seen on her prior admission and treated with topical fungal medication. She takes PRN tylenol 4-6 per day by report. No other new medications and she and her husband deny other ingestions. In the ED, T 98.3, HR 76, BP 160/75 RR 20 Sat 100% on RA. Received 1l of bicarb in D5, vanc 2g IV x1, flagyl 500mg IV x1, mag 2gm IV x1. Past Medical History: # Chronic UTI - as above # End Stage Renal Disease - Cr 3.1-3.8 with GFR of 13ml/min baseline 3.4 [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] records. c/b renal osteodystrophy. # History of Nephrolithiasis # GERD with esophageal strictures and dysphagia. # ULCERATIVE COLITIS status post colectomy and ileostomy # CERVICAL SPONDYLOSIS with chronic low back pain # HYPERTENSION # VITAMIN D DEFICIENCY # ANEMIA - B12 deficiency and CKD. baseline Hct 29 [**10-15**] (range 29-32) # HYPERCHOLESTEROLEMIA # CORONARY ARTERY DISEASE - last echo [**3-14**]. LVEF 70%. no h/o MI # PULMONARY HYPERTENSION # VENOUS INSUFFICIENCY # SLEEP APNEA - uses CPAP at night. # Chronic LE cellulitis - treated with bilat unaboot mother died of MI at age 62, father died of stroke in 70s. sister with HTN and DM. Social History: Patient married. Lives in [**Location 3915**], MA with husband. 2 children, 3 grandchildren. Never smoker. Denies EtOH use. Patient ambulates with walker or uses wheelchair for very long distances. Able to ADLs. Family History: Mother died of MI at age 62, father died of stroke in 70s. sister with HTN and DM. Physical Exam: Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present, ostomy with green liquid stool output Extremities: Right: 3+, Left: 3+ Skin: Warm, Erythemous lesions on LE Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Pertinent Results: Bicarb Brief Hospital Course: In summary, Mrs. [**Known lastname 7474**] is a 75 y/o female with advanced CKD and ostomy, admitted with marked anion gap academia in setting of increased ostomy output and some worsening of renal failure. Anion Gap Acidosis. delta delta initially favoring slight mixed gap-nongap component, no osmolar gap. Lactate normal. Likely related to worsening of renal failure and increased ostomy output . Does have a significantly low baseline (mid teens) likely related to CKD and possibly RTA. Urine lytes and gap c/w RTA. - Hold further bicarb IV for now, likely restart PO bicarb. will d/w renal. - Management of CKD below. ACUTE ON CHRONIC RENAL FAILURE, CHRONIC KIDNEY DISEASE STAGE V. Worsened 3.0 ?????? 3.9 without appreciable drop in urine output according to the patient and husband. Now with improvement to 3.3. - Awaiting renal's decision re: initiation of HD timing - If HD this admit will need access; likely tunneled line; has seen transplant as outpatient for access options. INCREASED OSTOMY OUTPUT - consider c.diff enteritis given recent antibiotics, elevated WBC which responded with flagyl initiation, though would be rare to have enteritis without colon. - Continue IV flagyl for now - Check stool culture and c.diff (2nd today). ANEMIA. Dropping steadily since admit; hct 22 today (30 at admit). No obvious bleeding source or hematoma. Baseline B12 deficiency (repleted), MDS, CKD. - check hemolysis panel today (?history of this in the past per notes from several years ago) - T&S, would not transfuse unless <21 - Consider restart of epo - both MDS and significant CKD. - Guaiac ostomy output. DYSPNEA. Mostly exertional; likely related to acidemia and need for significant respiratory compensation for metabolic acidosis. Lungs clear on exam and imaging; oxygenating well. - Treatment of acidosis as above &#9658; CELLULITIS. unclear if this is a new finding of infection or related to venous stasis. Was being managed by derm as outpatient for venous stasis. - Received 1000mg IV Vancomycin in the ED, would continue given her improvement. Add on vanco level today - Continue topical antifungal powder - Bilat LE ultrasounds to r/o collections - done, negative for collections. UTI. +U/A, cipro started. Culture not sent at the time of UA - check culture - continue cipro x ~7 day course. MACROCYTOSIS. Ongoing x years. Does have history of B12 deficiency, getting monthly IM replacement and normal B12 (and folate) levels here. Also with history of ?MDS, followed by Dr. [**Last Name (STitle) 2148**] in the past. HYPERTENSION. Normotensive currently - Holding CCBs with peripheral edema; will monitor today and possible restart. CAD - ?On aspirin daily ?????? will check into GERD - continue protonix 40mg [**Hospital1 **] (on at home) MICU Course: Patient noted to have shortness of breath in setting of low bicarb and ongoing diarrhea. Likely secondary to worsening renal failure and increased ostomy output. Patient initially treated with IV bicarb, but as bicarb corrected, this was stopped. Noted to have elevated WBC so treated with vanco for cellulitis (b/l thigh cellulitis clinically improving on vanco), cipro for positive ua (UCx not sent), and flagyl for increased ostomy output (though patient is s/p colectomy for UC which has improved with flagyl). Renal is still deciding whether or not dialysis will be initiated. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: Acute on Chronic Renal Failure . Secondary: Metablic Acidosis Urinary Tract Infection Macricytic Anemia GERD Discharge Condition: Good Followup Instructions: 1) Please phone Dr. [**Last Name (STitle) 816**] to set-up a follow-up appointment to take place within 10 days of your discharge. At that time, please discuss HD axis options and ask him if he would like you to continue your Na Bicarb medication. . 2)Please phone Dr [**Last Name (STitle) 713**] at [**Telephone/Fax (1) 18593**] to set-up a follow-up appointment to take place within 10 days of your discharge. . 3) Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**] Date/Time:[**2138-12-19**] 11:15 . 4) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2138-12-26**] 11:00 . 5) Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2138-12-29**] 10:00

Admission Date: [**2200-6-26**] Discharge Date: [**2200-6-30**] Date of Birth: [**2156-9-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: 43M with 4 week history of exertional CP. Major Surgical or Invasive Procedure: CABG x 5(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **], PDA, PLB) [**2200-6-26**] History of Present Illness: This 43WM has a history of HTN, NIDDM, and ^ chol., and has had a 4 week history of exertional angina. He underwent cardiac cath on [**2200-6-13**] which revealed: LVEF:55%, 30%LM lesion, 90% proximal LAD lesion, 80%OM1 [**Last Name (un) 2435**]., 90%OM2 [**Last Name (un) 2435**]., 50% mid RCA lesion, 80% PDA [**Last Name (un) 2435**]., and an 80% focal PLB stenosis. He is now admitted for elective CABG. Past Medical History: Asthma COPD HTN ^lipids newly diagnosed NIDDM s/p hernia repair as a child Social History: He works as a restaurant operator and lives with his wife. Cigs: smoked 1.5 ppd x 27 years and quit in [**7-12**] ETOH: none Family History: +CAD-father had a CABG at age 55 Physical Exam: WDWNWM in NAD AVSS HEENT: NC/AT, EOMI, PERLA, oropharynx benign, adentulous Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. Lungs: Clear to A+P CV: RRR without R/G/M, nl. S1, S2 Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+=bilat. except PT 1+=bilat. Neuro: nonfocal Pertinent Results: [**2200-6-30**] 08:50AM BLOOD WBC-10.4 RBC-3.00* Hgb-9.2* Hct-26.6* MCV-89 MCH-30.7 MCHC-34.6 RDW-14.6 Plt Ct-187# [**2200-6-29**] 05:03AM BLOOD Glucose-147* UreaN-18 Creat-0.9 Na-139 K-4.4 Cl-103 HCO3-28 AnGap-12 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2200-6-28**] 7:38 AM CHEST (PORTABLE AP) Reason: etiology low O2 saturation [**Hospital 93**] MEDICAL CONDITION: 43 year old man with CAD s/p CABGx5 and ct removal REASON FOR THIS EXAMINATION: etiology low O2 saturation INDICATION: Coronary artery disease, status post CABG. COMPARISONS: [**2200-6-27**]. SINGLE VIEW CHEST, AP: There has been interval removal of the right IJ Swan-Ganz catheter. There is no pneumothorax. There is persistent, bibasilar atelectasis, which appears to be improving. The lungs are otherwise clear. The patient is status post median sternotomy and CABG. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**] Approved: SAT [**2200-6-28**] 12:34 PM Brief Hospital Course: The patient was admitted on [**2200-6-26**] and underwent a CABGx5(LIMA->mid LAD, SVG->prox. LAD, OM, PDA, PLB). The cross clamp time was 91 mins, total bypass time was 103 mins. He tolerated the procedure well and was transferred to the CSRU in stable condition on neo, propofol, and insulin. He was extubated on the post op night and had his chest tubes d/c'd and was transferred to the floor on POD#2. His wires were d/c'd on POD#3 and he was discharged to home in stable condition on POD#4. Medications on Admission: Toprol XL 50 mg PO BID ASA 325 mg PO daily Lipitor 10 mg PO daily Lisinopril 20 mg PO daily Wellbutrin 150 mg PO BID Advair 250/50 daily Metformin ER 500 mg PO BID Discharge Medications: 1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Metformin 500 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* 11. Glucometer, Test strips, lancets Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD Asthma COPD HTN Hernia repair DM2 Discharge Condition: Good. Discharge Instructions: Call with fever, rednes or drainage from incision or weight gain more htan2 pounds in one day or five in one week. No heavy lifting or driving until follow up with surgeon. Shower, no lotions creams or powders to incisions. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 1911**] 2 weeks Completed by:[**2200-6-30**]

Admission Date: [**2132-10-31**] Discharge Date: [**2132-11-7**] Date of Birth: [**2067-5-24**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Right arm pain at rest Major Surgical or Invasive Procedure: [**2132-10-31**] Coronary artery bypass graft x3 (Left internal mammary artery > left anterior descending, saphenous vein graft > R1, Saphenous vein graft > posterior descending artery) History of Present Illness: 65 year old male with a known history of CAD s/p PCI in [**2117**] with a mid LAD stent, hypertension, hyperlipidemia and atrial fibrillation s/p cardioversion in [**2129**]. He reports exertional chest pain for the last 3 weeks that radiates down the posterior side of his right arm. He typically feels the right arm discomfort at night after walking up stairs. He also notes occasional dyspnea with activity, but notes he continues to tolerate his active work schedule without difficulty. He is now being referred to cardiac surgery for possible revascularization. Past Medical History: Coronary artery disease s/p PCI in [**2117**]-- ACS Multilink stent of Mid LAD Atrial Fibrillation s/p Cardioversion [**2129**] Hypertension Hyperlipidemia NIDDM Sleep Apnea (does not use Cpap) Arthritis Social History: Lives with:wife Occupation:salesman for car dealership Tobacco:quit 11 years ago, 1.5 ppd x30 years ETOH:1-2 drinks/month Family History: Family History:His father and brother both died at age 45 from MI, Mother had stents in 70's Physical Exam: Pulse:42 Resp: 12 O2 sat:97/RA B/P Right:133/62 Left:127/74 Height:6' 3" Weight:276 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft, non-distended, non-tender [x] Extremities: Warm, well-perfused [x] Edema/Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: nd Left: nd DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Pertinent Results: [**2132-11-7**] 04:50AM BLOOD WBC-9.5 RBC-3.84* Hgb-10.8* Hct-31.7* MCV-83 MCH-28.0 MCHC-33.9 RDW-14.5 Plt Ct-309 [**2132-11-7**] 04:50AM BLOOD PT-14.0* PTT-26.2 INR(PT)-1.2* [**2132-11-7**] 04:50AM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-136 K-3.9 Cl-96 HCO3-30 AnGap-14 [**2132-10-31**] Echo:Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is on no pressors. AV-Pacing. Preserved biventricular systolic fxn. Trace - 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. [**2132-11-6**]: Head CT CLINICAL INDICATION: 65-year-old male status post fall on the head and face. Evaluate for intracranial hemorrhage. FINDINGS: There is no evidence for acute intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus. There is very mild cortical atrophy, likely secondary to age-related involutional changes. The right lens is absent. There is no evidence for bony fracture. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No evidence for acute intracranial process. Brief Hospital Course: Admitted same day admission and was brought to the operating room for coronary artery bypass graft surgery. See operative report for further details. He received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He continued to progress and early am of postoperative day two he went into rapid atrial fibrillation that was treated with IV Lopressor, IV Diltiazem, and increased Sotalol and he converted back to sinus rhythm in afternoon. He had another episode of atrial fibrillation which converted to sinus rhythm on POD # 4 after treatment. Chest tubes and pacing wires were removed per caridac surgery protocol. On POD 6 he was coughing and went to get up from his chair and fell forward on his face and head. He remained neurologically intact and his head CT was negative for intracranial bleed. Plastic surgery was consulted and used Dermabond for facial laceration closure. He continued to do well and physical therapy worked with him on strength and mobility. On POD 7 he was in sinus rhythm and taken off Diltiazem drio and converted to long acting po Cardizem. It was decided not to anticoagulate since patient was in sinus rhythm at the time of discharge. He was ambulating in the halls with assistance, tolerating a full oral diet and a his incision was healing well. He was discharged home with VNA services and all appropriate follow up appointments were made. Medications on Admission: AMLODIPINE 2.5 mg once daily ATORVASTATIN 40 mg once daily EXENATIDE 5 mcg/0.02 mL per dose 1 sq injection twice per day before meals EZETIMIBE 10 mg once daily FUROSEMIDE 40 mg once daily LISINOPRIL 10 mg once daily LORAZEPAM 0.5 mg twice per day as needed METFORMIN 250 mg once every evening NITROGLYCERIN SL 0.4 mg as needed for chest pain POTASSIUM CHLORIDE 10 mEq once daily SOTALOL 120 mg twice per day ASPIRIN 81 mg once per day FOLIC ACID Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal Q12H (every 12 hours) as needed for dry nares . Disp:*1 1* Refills:*0* 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*1 Tablet(s)* Refills:*2* 8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 9. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for anxiety . Disp:*15 Tablet(s)* Refills:*0* 10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. metformin 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for temperature >38.0. 13. sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 14. Cardizem CD 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* 15. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 1* Refills:*0* 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Coronary artery disease s/p CABG Atrial Fibrillation Hypertension Hyperlipidemia Diabetes Mellitus type 2 Sleep Apnea Arthritis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Trace Lower extremity 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) **] [**Telephone/Fax (1) 170**] [**2131-12-5**] at 1:45 PM Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] [**2131-12-9**] at 2:45 PM Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) 9145**] [**Telephone/Fax (1) 9146**] in [**3-3**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2132-11-7**]

Admission Date: [**2164-10-7**] Discharge Date: [**2164-11-15**] Date of Birth: [**2107-3-17**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 57 year old woman with a history of viral myocarditis at age 11 as well as a history of multiple abdominal surgeries including a Billroth II procedure, partial vagotomy and partial gastrectomy in [**2153**]. She had a Roux-en-Y gastrojejunostomy for poor gastric emptying in [**2156**]. In [**2160**] she had transverse colon volvulus and had a hemicolectomy with an ileosigmoid anastomosis. In [**2161**] she had a procedure for lysis of intra-abdominal adhesions and was admitted to the Cardiac Medicine Service on [**10-7**] with chest pain. The patient also presented with eight days of nausea, vomiting and weakness as well as decreased p.o. intake. On electrocardiogram at the time of admission she had marked ST elevations of 5 cm in V3 through V6. She was taken to the Cardiac Catheterization Laboratory on [**10-7**] which revealed angiographically normal coronary arteries. Her left ventriculogram showed an ejection fraction of 35% of unknown origin although the patient has a history of viral myocarditis at age 11. The patient had multiple echocardiograms during her admission which showed an ejection fraction of around 20 to 22% with severe global hypokinesis and a normal left ventricular size, also 3+ tricuspid regurgitation. After this, the patient continued to have nausea, vomiting and developed abdominal pain. Then she began to have peritoneal signs as well as coffee ground emesis. She had a computerized tomography scan of the abdomen which showed free air as well as free fluid in the abdominal cavity. The patient was taken to Surgery on [**10-9**]. At that time they noted a perforation of her previous jejunojejunostomy secondary to an adhesive obstruction. Procedure performed was a small bowel resection with reanastomosis of various parts of the small bowel as well as adhesiolysis. During the procedure, there were some small bowel contents filled into the intra-abdominal cavity and a Swan-Ganz catheter was placed. Postoperatively the patient had a long course in the Surgery Intensive Care Unit of approximately one month prior to being transferred to the Medicine Intensive Care Unit on [**2164-11-9**]. The Surgery Intensive Care Unit course was notable for worsening cardiomyopathy as well as a large fluid requirement. Then the patient began to develop ascites, bilateral pleural effusions as well as congestive heart failure. She was diuresed. They performed thoracentesis of both the left and right pleural space, both which were sterile without evidence of infection. The patient completed a course of Ampicillin, Ceftriaxone and Flagyl after the operation. The patient also has been followed throughout her course by Infectious Disease as well as Cardiology. The patient had several courses of pneumonia. She first developed a pneumonia with Senna Trepomonas. On [**10-18**], her sputum culture revealed 2+ Senna Trepomonas which was Levofloxacin sensitive as well as 2+ yeast. She was treated for two weeks with Levofloxacin. After that she was extubated, however, ended up being reintubated three days later because of increasing secretions. They did more sputum cultures on [**10-22**] and then she grew out Senna Trepomonas as well as Methicillin-resistant Staphylococcus aureus. She was treated for two weeks with a two week course of Vancomycin. The patient also began to have some diarrhea. They did multiple Clostridium difficile samplings. On [**10-23**], her Clostridium difficile toxin was positive and she was treated with a course of Flagyl. The patient was again extubated after she seemed to be improving at the end of [**Month (only) **]. However, after several days she again began to fail and had to be reintubated on [**11-8**]. At that time she was transferred to the Medicine Intensive Care Unit Service. PAST MEDICAL HISTORY: 1. Multiple abdominal surgeries as in history of present illness. 2. Migraines. 3. Agoraphobia. 4. Panic disorder. 5. Sinusitis, status post surgery. 6. Cardiomyopathy with an ejection fraction of 22%. 7. Migraines. 8. Hypothyroidism. 9. Peptic ulcer disease. 10. Hypertension. 11. Viral myocarditis at age 11. 12. Phototoxicity from Gentamicin. MEDICATIONS ON ADMISSION: 1. Toprol XL 25 mg q. day 2. Prozac 3. Klonopin 4. Levoxyl 5. Prilosec 6. Prempro 7. Compazine 8. Seroquel 9. Fioricet ALLERGIES: The patient is allergic to Sulfa and gentamicin. SOCIAL HISTORY: She is a clinical psychologist and has a history of eating disorders as well as possible abuse of psychotropic medications. PHYSICAL EXAMINATION: Physical examination on [**2164-10-8**], at the time of admission revealed the patient was afebrile, pulse was 85, her blood pressure was 117/62, she was sating 96% on room air. Generally, she is cachectic. Neck had a jugulovenous pressure of 6. Chest was clear to auscultation bilaterally. Cardiovascular: She had a normal S1 and S2, regular rate and rhythm. No murmurs, rubs or gallops. Abdomen: She has decreased bowel sounds, however, she was soft, nondistended with mild left lower quadrant tenderness. No rigidity or guarding. Extremities: She had no edema and 2+ pulses bilaterally. LABORATORY DATA: Labs at the time of admission included a white count of 21.9, hematocrit 49.6, platelets 567. Chem-7 Sodium was 129, potassium 3.1, chloride 85, bicarbonate 19, BUN 52, creatinine 4.1 and glucose 111. Calcium was 6.5, magnesium 1.3, CK 509, trended down to 350. Her chest x-ray was negative. Electrocardiogram showed sinus with a rate of 100, left axis deviation, ST elevations inferiorly as well as V3 through V6 of up to [**Street Address(2) 32524**] depression V1 through V2. Right side leads were negative. Echocardiogram showed an ejection fraction of 25%, severe global hypokinesis, decreased left ventricular function and 1+ mitral regurgitation. HOSPITAL COURSE: [**Hospital Unit Name 196**] and Surgical Intensive Care Unit course as above. The patient was transferred to Medicine Intensive Care Unit on [**11-9**]. At the time of transfer to our service the patient was afebrile. She had a pulse of 79, blood pressure 100/56 sating 100% on a ventilator set with pressure support of 18 and positive end-expiratory pressure of 5, FIO2 40%. Arterial blood gases at that time on those settings was 7.49, 3.8, 156, 30. Her labs at the time of transfer to us were white count 17.4 which was trending down from 22.5. Her hematocrit was 29.3, platelets 350, sodium 134, potassium 4.3, chloride 99, bicarbonate 27, BUN 38, creatinine 0.8, glucose 128, calcium 8.5, phosphorus 3.0 and magnesium 2.2. Her micro-data summarized for hospital course, basically all her blood cultures were negative. She had cultures done [**10-7**] times two, [**10-17**] times three, [**10-18**] times two, [**10-20**] times two and [**11-8**] times three. Her sputum cultures as in history of present illness on [**10-18**] grew Senna Trepomonas sensitive to Levofloxacin and yeast. [**10-21**] was normal oropharyngeal Flora, [**10-22**] was Senna Trepomonas Methicillin-resistant Staphylococcus aureus, [**11-4**] Senna Trepomonas Methicillin-resistant Staphylococcus aureus, [**11-8**] she had 2+ gram negative rods and 1+ gram positive cocci. Urine cultures had evidence of yeast and her stool was positive for Clostridium difficile on [**10-23**], negative for Clostridium difficile times five on all other testings. Pleural fluid samples on [**10-19**] had polys no organisms, on [**11-3**] had neither polys nor organisms. The patient was transferred to us with her main issue being failure to wean from ventilator as well as question of how to best manage her congestive heart failure and cardiomyopathy. She also at that time was reported to have increased white count and glucose as well as a history of anxiety and benzodiazepine addiction. Medications on transfer included intravenous Lasix prn, Lopressor, Captopril, subcutaneous Heparin, Fioricet, Prozac, Levoxyl, Klonopin, Haldol, TUMS, magnesium oxide, iron, Prevacid and after transfer to our service we titrated up her Captopril, we added Aldactone and we also added Digoxin. Throughout her six days on our service her heart failure remained very well compensated with no evidence of pulmonary congestion or lower extremity edema. We tried to wean down her pressure support over the first several days, however, the patient was not able to successfully be weaned. On [**11-12**], the patient had a tracheostomy placed at the bedside without any complications. She continued to receive her tube feeds. She had some slightly liquid stools, therefore we changed her tube feeds to a tube feed with more fiber. Physical therapy and occupational therapy interviewed the patient. It was decided that after the tracheostomy the patient would need time to let that heal so it was decided to just continue the tube feeds and let her have a swallow evaluation and otorhinolaryngology evaluation after discharge to a rehabilitation facility. After tracheostomy was placed, we checked mechanics, her NIF was 10, her vital capacity was 750, title volume 400 and her RISB was 42.5. She received some Ultram from the tracheostomy pain. We weaned off her Haldol. The patient remains stable and plan to change her Lopressor and Captopril to a q. day medication. DISCHARGE STATUS: Discharge to rehabilitation with tracheostomy and nasogastric tube for tube feedings. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Toprol XL 25 mg per gastrostomy tube q. day 2. Vasotec 20 mg q. day 3. Aldactone 25 mg q. day 4. Lasix 40 mg q. day 5. Digoxin 0.125 mg q. day 6. Prozac 60 mg q. day 7. TUMS 2 tablets b.i.d. 8. Magnesium oxide 400 mg b.i.d. 9. Prevacid 30 mg q. day 10. Heparin 5000 units subcutaneously b.i.d. 11. Iron elixir 325 mg t.i.d. 12. Klonopin 1 mg q. 6 hours prn 13. Levoxyl 150 mcg q. day 14. Fioricet prn pain 15. Tube feeds with Ultracal at 55 cc/hr 16. Tylenol 650 mg prn DISCHARGE DIAGNOSIS: 1. Small bowel resection on reanastomosis for small bowel perforation 2. Cardiomyopathy with ejection fraction of 22% 3. Panic disorder and agoraphobia 4. Hypertension 5. Hypothyroidism 6. Peptic ulcer disease 7. Hypertension 8. Congestive heart failure 9. Migraine DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Last Name (NamePattern1) 1203**] MEDQUIST36 D: [**2164-11-14**] 16:23 T: [**2164-11-14**] 16:54 JOB#: [**Job Number **]

Admission Date: [**2102-6-23**] Discharge Date: [**2102-7-7**] Date of Birth: [**2027-4-28**] Sex: F Service: SURGERY Allergies: Oxycontin / Morphine Attending:[**First Name3 (LF) 1**] Chief Complaint: FEVER AND RESPIRATORY DISTRESS Major Surgical or Invasive Procedure: S/P TOTAL THYRODECTOMY S/P TRACHEOSTOMY S/P PEG S/P PICC History of Present Illness: This is a 75 year old woman with with a recent admission to ICU status post fall with mental status changes tongue swelling necessitating tracheostomy placement for airway protection admitted for fever and respiratory distress. Patient was transferred from [**Hospital3 **] after she was noted to be febrile, tachypneic, found to have UTI. She was given vancomycin and transferred to [**Hospital1 18**] for evaluation of tracheostomy replacement as this was thought to be the cause of her episode of respiratory distress. Pt underwent FNA on [**6-15**] which revealed cytology consistent with Hurthle cell carcinoma. The thyroid mass deviates the trachea, but does not invade the airway. The patient's mental status fluctuates widely at baseline, some days speaking via PM valve, others only nodding yes or no. The patient was unable to answer questions on admission regarding [**Hospital3 **]. Past Medical History: 1. Progressive encephalopathy/Dementia leading to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 27194**] [**Month (only) 547**] [**2101**]- prolonged hospital course c/b status epilepticus, ARF, tension PNTX, tracheostomy & peg tube. 2. dementia- Chronic Microvascular Angiopathy 3. urinary incontinence since [**2099**] 4. chronic low back pain/degenerative disk disease s/p failed back surgery, epidural steroid injections, nerve blocks, facet injections, trigger point injections 5. hyperlipidemia 6. hypertension 7. major depression- ? catatonia 8. UTI- enterobacter- resistant to ceftriaxone, cipro sensitive, cefepime sensitive. 9. Hurthle Cell Thyroid Cancer- Newly dx via FNA on [**2102-6-15**]. Social History: She currently is at [**Hospital3 **] but previously lived at home with her husband. She is independent of her ADL's. She quit smoking tob in [**2049**]; ~10 pack year history. Occasional EtOH. Denies illicit drug use. Husband, [**Name (NI) 892**] [**Name (NI) 3647**], is HCP ([**Telephone/Fax (1) 36275**]). Son [**Telephone/Fax (1) 36276**]. daughter [**Name (NI) 8513**] [**Name (NI) 3647**] [**Telephone/Fax (1) 36278**]. Family History: Mother died of [**Name (NI) 11964**]. Two sisters are healthy. Youngest child with mental retardation; lives in group home. Physical Exam: T: 97.6 HR: 74 BP: 127/75 RR: 18 O2SAT:97 on Trach mask GEN: awake, alert, oriented to person, able to speak/mouth a few words at a time, obese HEENT: NC/AT. Fixates on examiner and won't follow object to eval. EOM. PERRL. OP clear, dentures. MMM. Neck: trach cannula and collar in place. unable to assess JVP [**1-5**] obesity, no carotid bruits Chest: transmitted bronchial breath sounds CV: s1, s2; heart sounds partially obscured by breath sounds ABD: PEG in LUQ dressed with gauze. multiple bruises, less than 1cm, c/w heparin injection sites. soft, obese, nontender. nabs Ext: 2+ pulses throughout. no c/c/e Neuro: Oriented to person, not place or time. 2/4 strength in all 4 extremities. Sensation intact. Pertinent Results: [**2102-7-2**] 09:39PM BLOOD WBC-12.8*# RBC-3.38* Hgb-10.2* Hct-29.4* MCV-87 MCH-30.0 MCHC-34.5 RDW-15.7* Plt Ct-413 [**2102-7-3**] 02:22AM BLOOD WBC-10.5 RBC-3.14* Hgb-9.4* Hct-27.6* MCV-88 MCH-30.1 MCHC-34.2 RDW-15.8* Plt Ct-378 [**2102-7-4**] 01:23AM BLOOD WBC-7.6 RBC-2.89* Hgb-8.8* Hct-25.4* MCV-88 MCH-30.7 MCHC-34.9 RDW-15.6* Plt Ct-378 [**2102-7-5**] 04:04AM BLOOD WBC-8.3 RBC-3.00* Hgb-9.0* Hct-26.2* MCV-88 MCH-29.9 MCHC-34.2 RDW-15.9* Plt Ct-397 [**2102-7-6**] 02:08AM BLOOD WBC-6.4 RBC-2.95* Hgb-8.7* Hct-25.8* MCV-88 MCH-29.6 MCHC-33.8 RDW-15.5 Plt Ct-420 [**2102-7-7**] 04:13AM BLOOD WBC-5.6 RBC-3.05* Hgb-9.0* Hct-26.7* MCV-88 MCH-29.6 MCHC-33.7 RDW-15.5 Plt Ct-410 [**2102-6-29**] 10:35PM BLOOD PT-11.2 PTT-21.5* INR(PT)-0.9 [**2102-7-2**] 09:39PM BLOOD Glucose-178* UreaN-15 Creat-0.8 Na-133 K-4.5 Cl-97 HCO3-24 AnGap-17 [**2102-7-3**] 02:22AM BLOOD Glucose-143* UreaN-16 Creat-0.9 Na-133 K-4.1 Cl-96 HCO3-26 AnGap-15 [**2102-7-4**] 01:23AM BLOOD Glucose-135* UreaN-12 Creat-0.8 Na-133 K-4.3 Cl-97 HCO3-25 AnGap-15 [**2102-7-5**] 04:04AM BLOOD Glucose-137* UreaN-16 Creat-0.8 Na-134 K-4.2 Cl-99 HCO3-25 AnGap-14 [**2102-7-6**] 02:08AM BLOOD Glucose-105 UreaN-20 Creat-0.8 Na-136 K-4.2 Cl-100 HCO3-26 AnGap-14 [**2102-7-7**] 04:13AM BLOOD Glucose-128* UreaN-23* Creat-0.7 Na-139 K-4.0 Cl-103 HCO3-28 AnGap-12 [**2102-7-2**] 09:39PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2 [**2102-7-3**] 02:22AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.3 [**2102-7-4**] 01:23AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.8 [**2102-7-5**] 04:04AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0 [**2102-7-6**] 02:08AM BLOOD WBC-6.4 RBC-2.95* Hgb-8.7* Hct-25.8* MCV-88 MCH-29.6 MCHC-33.8 RDW-15.5 Plt Ct-420 [**2102-7-7**] 04:13AM BLOOD WBC-5.6 RBC-3.05* Hgb-9.0* Hct-26.7* MCV-88 MCH-29.6 MCHC-33.7 RDW-15.5 Plt Ct-410 CHEST PORT. LINE PLACEMENT [**2102-7-3**] 11:53 AM CHEST PORT. LINE PLACEMENT Reason: PICC position? [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with encephalopathy, tracheostomy, admitted for fever/UTI, now with new tachypnea, O2 desaturation REASON FOR THIS EXAMINATION: PICC position? REASON FOR STUDY: Assessment of PICC line position in a patient that is admitted with fever. FINDINGS: Tracheostomy tube is 6.3 cm above the carina. The right subclavian line has its tip projecting over the mid SVC. There is worsening of atelectasis and effusion in the left lower lobe. The remainder of left lung and right lung is clear. There is no pneumothorax. Mediastinum is widened; this might be due to patient positioning. The hilar areas are congested. This is unchanged compared to previous study. IMPRESSION: New right PICC line in proper position. No pneumothorax. Worsening left lung base atelectasis and effusion. Brief Hospital Course: 1) Fever- Patient was admitted with elevated WBC to 18 and UA indicative of UTI. Patient recieved one dose of vancomycin prior to admission. She was treated with levofloxacin for her UTI. Pre-vancomycin blood cultures from [**Hospital3 **] hospital were followed and grew 2/6 bottles of Strep pyogenes. The patient was treated with vancomycin on admission and then switched to Penicillin G for her Strep bacteremia. Penicillin G treatment should continue for a total of 14 days, total ([**2102-7-7**] is day 10 of 14). . 2) Respiratory status- Patient's respiratory status on admission was stable. Bronchoscopy was performed and reveal trach was in good position and now upper or lower airway obstructions were present. No modification of tracheostomy was deemed necessary. Patient pulled out her trach tube was coded for respiratory distress and transferred to the MICU. Following replacement of her trach, she had no further issues respiratory wise until her total thyroidectomy on [**2102-6-30**]. Prior to transfer to the floor following her total thyroidectomy, she again became tachypnic and was trasnferred to the SICU where she was placed on mechanical ventilation. By POD 4 she was placed onto CPAP which she tolerated well and was placed on trach mask on POD 6. Since then she has been stable but requires suction of her trach Q2-4hrs or prn. . 3) Hurthle Cell Thyroid CA- Endocrine consulation was obtained with concern for malignancy. Underwent total thydriodectomy on [**2102-6-30**]. Pathology report is still pending. . 6) Hypertension Patient was continued on Metoprolol 75mg [**Hospital1 **] and captopril 12.5 PO tid . 7) Seizure prophylaxis - Patient was kept at lower dose Leviracetam (Keppra) 500mg PO tid per recommendation of [**Name6 (MD) **] attending MD, no seizure activity was noted during the hospitalization. Neurology was consulted in the SICU, and was not concerned that she may be having seizures, but more likely tardive dyskinesia. They obtained a EEg and recommends followup with neurology either and [**Hospital1 **] or [**Hospital1 18**]. They will notify [**Hospital1 **] of the findings of the EEG when available. Medications on Admission: Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QSUN Acetaminophen 325 mg PO Q4-6H PRN Cholecalciferol (Vitamin D3) 400 unit PO DAILY Calcium Carbonate 500 mg PO BID Tablet, Chewable PO DAILY Ranitidine HCl 15 mg/mL Syrup (150) mg PO BID Regular Insulin Sliding Scale Metoprolol 100mg PO TID Levetiracetam 500 mg PO BID Captopril 12.5 mg PO TID Fluticasone 110 mcg 2 puffs [**Hospital1 **] Albuterol Sulfate 0.083 % neb Q6H PRN Miconazole Nitrate 2 % Powder topical TID PRN Discharge Medications: 1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*2 2* Refills:*2* 2. Bromocriptine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*2 2* Refills:*2* 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*2 2* Refills:*2* 7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. Disp:*2 2* Refills:*2* 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*2 2* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 10. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO DAILY (Daily). Disp:*30 Packet(s)* Refills:*2* 11. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for SBP <115, HR < 55. Disp:*30 Tablet(s)* Refills:*2* 12. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*30 Tablet(s)* Refills:*2* 13. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: do not exceed 4gm per day . Disp:*30 Tablet(s)* Refills:*2* 15. Penicillin G Potassium 4 MU PO Q4H Until [**2102-7-11**] Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: HUERTHLE CELL NEOPLASM; S/P TRACH AND PEG Discharge Condition: STABLE Discharge Instructions: PICC CARE, PEG SITE AND DRAIN CARE (FLUSH PEG WITH 200CC NS Q8HRS), TRACH CARE AND SUCTION Q2-4 HRS OR PRN Followup Instructions: F/U WITH NEUROLOGY AT [**Hospital1 **] OR [**Hospital1 18**] (WILL RECEIVE A CALL FROM NUEROLOGY DEPARTMENT AT [**Hospital1 18**] REGARDING EEG DONE [**2102-7-7**]) F/U WITH DR. [**Last Name (STitle) **] IN [**12-5**] WEEKS F/U WITH PCP [**Last Name (NamePattern4) **] [**12-5**] WEEKS

Admission Date: [**2168-4-18**] Discharge Date: [**2168-4-23**] Date of Birth: [**2099-10-15**] Sex: F Service: CARDIOTHORACIC Allergies: Keflex Attending:[**First Name3 (LF) 1406**] Chief Complaint: Coronary artery disease. Major Surgical or Invasive Procedure: [**2168-4-18**]: Emergent coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending artery, and reverse saphenous vein grafts to the right coronary artery, first obtuse marginal artery and second obtuse marginal artery. History of Present Illness: 68 year old female with known hypertension and a significant tobacco history reports chest tightness and throat pain that worsens with exertion for the past few months. [**4-12**] She had a positive stress test and was sent for a cardiac cath. Cath reveals left main and multivessel coronary disease. Cardiac surgery was consulted for urgent revascularization. Past Medical History: Hypertension Hyperlipidemia Social History: Married. Lives with husband. [**Name (NI) 1139**]: 55 pack-year. quit 3 years-ago ETOH: none Family History: Her mother had CHF and died at age 89 of a stroke. Her father had arteriosclerosis and died in his 60s. Her maternal grandmother had an aortic aneurysm Physical Exam: VS: T: 99.4 HR: 76 SR BP: 125/72 RR 20 Sats: 97% RA WT: 86.2 General: 68 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur Resp: bibasilar crackles GI: benign Extr: warm 2+ edema. Left inner thigh ecchymotic Incision: sternal and LLE w/steri-strips clean, dry, intact no erythema Neuro: awake, alert oriented Pertinent Results: [**2168-4-22**] WBC-9.1 RBC-3.41* Hgb-10.1* Hct-29.5* MCV-87 MCH-29.6 MCHC-34.2 RDW-15.2 Plt Ct-185 [**2168-4-18**] WBC-6.5 RBC-4.15* Hgb-12.2 Hct-35.0* MCV-85 MCH-29.5 MCHC-34.9 RDW-14.1 Plt Ct-240 [**2168-4-22**] Glucose-109* UreaN-11 Creat-0.5 Na-138 K-4.5 Cl-102 HCO3-29 [**2168-4-18**] Glucose-113* UreaN-28* Creat-0.7 Na-141 K-4.1 Cl-106 HCO3-27 Micro: [**2168-4-18**] MRSA SCREEN (Final [**2168-4-22**]): No MRSA isolated. CXR: [**2168-4-21**]: Cardiomediastinal silhouette is stable. Right internal jugular line is unchanged, unremarkable. Bibasal atelectasis is noted, slightly worse on the right. Small bilateral pleural effusion is unchanged. Minimal left apical pneumothorax is still present, slightly decreased since the prior study. Echo: [**2168-4-18**] Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% >= 55% Aorta - Ascending: 3.4 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.0 cm Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: No MVP. Mild to moderate ([**12-6**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. PERICARDIUM: No pericardial effusion. Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. There is no mitral valve prolapse. Mild to moderate ([**12-6**]+) mitral regurgitation is seen. Trivial TR. Trivial PI. There is no pericardial effusion. Post_Bypass: The patient is in sinus rhythm on a phenylephrine infusion, with a cardiac output of 5.5L/min. The biventricular systolic function is preserved (hyperdynamic LV). The visible contours of the thoracic aorta are intact. Trace to Mild MR. [**First Name (Titles) 88610**] [**Last Name (Titles) 72424**] 50%. Preserved RV systolic function. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2168-4-18**] where the patient underwent Emergent coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending artery, and reverse saphenous vein grafts to the right coronary artery, first obtuse marginal artery and second obtuse marginal artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring on low dose vasopressors. The patient was extubated POD1, alert, oriented and breathing comfortably. She was neurologically intact. She was transfused 2 units of PRBC for HCT 24 to 29.0 She titrated off pressors with SBP 95-100 hemodynamically stable. Low dose beta-blockers were initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA services in good condition with appropriate follow up instructions Medications on Admission: Plavix 75 mg daily, Metoprolol 25 mg [**Hospital1 **], omega-3 fatty acids 1000 mg [**Hospital1 **], ICAPS as directed 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. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. vitamin A-vitamin C-vit E-min Capsule Sig: One (1) Capsule PO QID (4 times a day). 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day: take with furosemide . Disp:*20 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease Hypertension Hyperlipidemia 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**] 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 Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 170**] Date/Time:[**2168-5-11**] 1:15 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Location (un) 551**] [**Hospital Unit Name **] WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2168-4-27**] 10:45 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Location (un) 551**], [**Hospital Unit Name **] Cardiologist:Dr. [**Last Name (STitle) 7047**] [**Telephone/Fax (1) 8725**] [**2168-5-17**] at 3:40 15 [**Name (NI) **] Brothers [**Name (NI) **] [**Name (NI) **] [**Location (un) **], MA Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 17025**] [**Telephone/Fax (1) 6699**] in [**3-8**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2168-4-26**]

Admission Date: [**2114-3-27**] Discharge Date: [**2114-3-29**] Date of Birth: [**2091-12-16**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 330**] Chief Complaint: Altered mental status, tylenol overdose Major Surgical or Invasive Procedure: None History of Present Illness: 22 F with history of ETOH abuse, IVDU of heroin, cocaine, and unknown street drugs, bipolar disorder, transferred from [**Location (un) **] hospital with tylenol overdose. (The patient was not able to give much of this history because of drowsiness, so much of this history was given by her mother.) She took 15 tylenol pm last night, sometime between evening and midnight. She usually takes 4 tylenol PM every night to help her sleep, but last night she couldn't sleep, so she took 15 tylenol PM. According to her mother, she took klonepin yesterday as well (her daughter had told her she had taken it), but she doesn't know the amount. Patient does not take any medications on home regimen. . According to the patient and her mother, the patient was not taking 15 tylenol PM as a suicide attempt. The patient states that she did not wish to hurt herself, but took the pills because she couldn't sleep or rest. She said she usually takes Tylenol PM and thought that taking more pills would increase the effect of helping her sleep. She reports abdominal pain, aching in her muscles "all over", sleepiness, "feel like I have the flu". . Her mother had actually taken her to [**Hospital3 **] hospital 2 days ago, on Sunday afternoon at 2:30 pm, because she was "acting funny", sitting on the floor, not answering questions, looking disheveled, acting belligerent and temperamental, which is very uncharacteristic for the patient per mother. [**Name (NI) **] mother states that her daughter "can be really difficult, but is the type who will never leave the house without a perfectly matched outfit and makeup". Her boyfriend and mother assumed that she was "strung out on drugs". She was taken by ambulance to [**Hospital3 **] hospital on Sunday at 2:30 pm and returned home by 7:30 pm from the hospital. Her mother does not know what transpired during her ED visit on Sunday. She was not with her daughter during that hospital visit, but after she returned from the hospital, her daughter seemed more back to her normal self per mother. . Late on Monday night, mother called ambulance since patient seemed obtunded and ill. At OSH, she had vomiting, dry heaves, nausea, restlessness; she was given zofran 8 mg IV. EMS found BG 32, was given D25; BG 162 on arrival to OSH; BG decreased to 70 and was given D50 on floor. AST >10,000, ALT >5,000, Cr 2.13, TBili 4.8, DBili 2.9, Alk phos 127. ABG: 7.32 / 24 / 121 / 12 on 2L nc. She had an abdominal US and was found to have liver and renal failure. She received NAC 7g load plus 2.5g by 4 am Tuesday before being transferred to [**Hospital1 18**] ED. . In the [**Hospital1 18**] ED, vitals were T 97.7, HR 132, 105/47, RR 26, 100% 3L nc on admission. Hepatology was consulted and recommended 17 mg/kg/hr IV NAC infusion. Toxicology was also consulted. INR 14.1, liver enzymes pending, acetaminophen level was negative. Received 2250 ml NS in ED, received [**2106**] ml NS at OSH. She was transferred to MICU Green. . In subsequent information obtained from the patient's mother in private: the patient has a history of bipolar disorder, she has tried to slash her wrists in past suicide attempts, she refuses all treatment and is noncompliant with medical recommendations and medications, she has signed AMA out of a psychiatry hospital, she has boyfriend with Hepatitis C, and she takes heroin or any IV drugs whenever she has access. . REVIEW OF SYSTEMS: Patient cannot answer questions due to obtundation. +abdominal pain. +generalized pain which does not localize. No fever, no chills, no vomiting, no diarrhea, no blood per rectum. Past Medical History: - ETOH abuse: 60 beers + 1 bottle rum + 1 bottle jagermeister per week - Hepatitis C - Chronic tylenol PM use: 4 pills per night for at least the past few years - IV drug use: heroin, cocaine, possibly other drugs - Illicit drug use: unprescribed klonepin, percocet - Bipolar disorder: refuses medical treatment and signed out AMA from psychiatric [**Hospital1 **] - Previous suicide attempts: slashing wrists Social History: ETOH: Per mother, she drinks 60 beers ("at least two 30-packs"), a bottle of rum, and some jagermeister per week. Her mother estimates that the amount is more than that, since that is what she witnesses herself, but she does not see what her daughter drinks when she is out of the house. She drinks a beer every morning before going to work, and she often skips work because she is inebriated. . IV drugs: Per mother and patient, she has used heroin and cocaine in the past. . Other drugs: She has a history of using percocet and klonopin for non-medical reasons and without a prescription. Her mother reports that it is very easy to gain access to these drugs in her neighborhood. . ADLs: She works as a roofer for her father. She shows up to work approximately 10-15 days out of each month because of her ETOH and drug use, but she is able to keep her job because she works for her father. She lives at home with her mother, who works nights. Her mother states that "it's impossible to keep track of her" and feels that since she is an adult at 22, she can lead her own life. She has a boyfriend who has hepatitis C. She has not been tested for HIV or hepatitis. Family History: No liver disease in first degree relative. [**Name (NI) **] family member or frequenter to the house currently ill. Physical Exam: VS: 97.7 / HR 125-135 / 107/47 / 20 / 98% 4L nc (85% on RA) GEN: Drowsy, irritable, restless, cannot answer questions. Falls asleep in the middle of history-taking and exam. Can move around on the bed without being limited by pain. Tachypneic. HEENT: Subtle ecchymoses over eyelids bilaterally, no ecchymoses behind ears. PERRL, no scleral icterus, cannot perform EOM exam due to lack of concentration, cannot assess nystagmus. Nasal turbinates clear with normal nasal septum. Dry mucous membranes. NECK: No LAD, soft, supple. No carotid bruits heard. No thyroid masses or thyromegaly. CV: Regular, tachy. [**1-2**] flow SEM heard best at apex, no rub or gallop, clear S1 and S2 with no S3 or S4 LUNGS: Quiet rhonchi and bibasilar rales, no wheezing. ABD: Soft, normoactive BS, nondistended. Diffusely tender with mild palpation, especially in right quadrant and epigastrium, no rebound, moderate guarding. No bruits heard. BACK: Mild costovertebral tenderness. Ext: No track marks on arms. Asterixis present bilaterally. No cyanosis, no clubbing, no edema. Neuro: Oriented to person, place, year. CN 2-12 intact as tested. 5 motor in arms and legs. 2+ reflexes in triceps, biceps, patellar, Achilles. Toes downgoing. Did not assess gait. Pertinent Results: [**2114-3-27**] 08:37PM TYPE-[**Last Name (un) **] TEMP-36.9 PO2-32* PCO2-31* PH-7.30* TOTAL CO2-16* BASE XS--10 INTUBATED-NOT INTUBA [**2114-3-27**] 08:37PM LACTATE-5.2* [**2114-3-27**] 08:37PM freeCa-0.88* [**2114-3-27**] 08:17PM GLUCOSE-120* UREA N-30* CREAT-2.6* SODIUM-139 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-15* ANION GAP-26* [**2114-3-27**] 08:17PM CALCIUM-8.0* PHOSPHATE-5.1* MAGNESIUM-2.4 [**2114-3-27**] 08:17PM URINE HOURS-RANDOM [**2114-3-27**] 08:17PM URINE UCG-NEGATIVE [**2114-3-27**] 08:17PM WBC-12.3* RBC-2.08* HGB-6.9* HCT-19.6* MCV-94 MCH-33.3* MCHC-35.4* RDW-13.5 [**2114-3-27**] 08:17PM PLT COUNT-108* [**2114-3-27**] 08:17PM PT-42.5* PTT-57.0* INR(PT)-4.8* [**2114-3-27**] 12:36PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.025 [**2114-3-27**] 12:36PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-TR [**2114-3-27**] 12:36PM URINE RBC-0-2 WBC-0 BACTERIA-0 YEAST-MOD EPI-0 [**2114-3-27**] 12:33PM LACTATE-6.8* [**2114-3-27**] 12:28PM GLUCOSE-134* UREA N-32* CREAT-2.5* SODIUM-136 POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-15* ANION GAP-27* [**2114-3-27**] 12:28PM LD(LDH)-8210* DIR BILI-2.5* [**2114-3-27**] 12:28PM CALCIUM-8.2* PHOSPHATE-5.4* MAGNESIUM-2.8* [**2114-3-27**] 12:28PM HAPTOGLOB-37 [**2114-3-27**] 12:28PM WBC-19.0* RBC-2.62* HGB-8.5* HCT-24.8* MCV-95 MCH-32.5* MCHC-34.3 RDW-13.5 [**2114-3-27**] 12:28PM PLT COUNT-118* [**2114-3-27**] 12:28PM PT-31.6* PTT-46.8* INR(PT)-3.4* [**2114-3-27**] 12:28PM PT-31.6* PTT-46.8* INR(PT)-3.4* [**2114-3-27**] 12:15PM AMMONIA-69* [**2114-3-27**] 12:09PM TOT PROT-5.3* IRON-224* CHOLEST-88 [**2114-3-27**] 12:09PM calTIBC-229* FERRITIN-GREATER TH TRF-176* [**2114-3-27**] 12:09PM TRIGLYCER-89 HDL CHOL-50 CHOL/HDL-1.8 LDL(CALC)-20 [**2114-3-27**] 12:09PM OSMOLAL-308 [**2114-3-27**] 12:09PM TSH-0.40 [**2114-3-27**] 12:09PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2114-3-27**] 12:09PM Smooth-NEGATIVE [**2114-3-27**] 12:09PM [**Doctor First Name **]-NEGATIVE [**2114-3-27**] 12:09PM TSH-0.40 [**2114-3-27**] 12:09PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2114-3-27**] 12:09PM Smooth-NEGATIVE [**2114-3-27**] 12:09PM [**Doctor First Name **]-NEGATIVE [**2114-3-27**] 12:09PM AFP-<1.0 [**2114-3-27**] 12:09PM HIV Ab-NEGATIVE F [**2114-3-27**] 12:09PM HCV Ab-POSITIVE [**2114-3-27**] 11:38AM TYPE-ART TEMP-36.3 PO2-120* PCO2-29* PH-7.33* TOTAL CO2-16* BASE XS--9 INTUBATED-NOT INTUBA [**2114-3-27**] 11:38AM LACTATE-6.7* [**2114-3-27**] 11:38AM O2 SAT-97 [**2114-3-27**] 11:38AM freeCa-0.85* [**2114-3-27**] 10:14AM TYPE-ART TEMP-36.1 RATES-/24 O2 FLOW-2 PO2-51* PCO2-31* PH-7.30* TOTAL CO2-16* BASE XS--9 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2114-3-27**] 10:14AM LACTATE-8.3* [**2114-3-27**] 09:07AM PO2-78* PCO2-34* PH-7.30* TOTAL CO2-17* BASE XS--8 [**2114-3-27**] 09:07AM GLUCOSE-172* LACTATE-9.5* NA+-133* K+-5.2 CL--100 [**2114-3-27**] 08:45AM GLUCOSE-180* UREA N-34* CREAT-2.5* SODIUM-133 POTASSIUM-5.2* CHLORIDE-93* TOTAL CO2-12* ANION GAP-33* [**2114-3-27**] 08:45AM estGFR-Using this [**2114-3-27**] 08:45AM ALT(SGPT)-9260* AST(SGOT)-[**Numeric Identifier 29620**]* ALK PHOS-122* AMYLASE-108* TOT BILI-4.2* [**2114-3-27**] 08:45AM LIPASE-186* [**2114-3-27**] 08:45AM CALCIUM-8.7 PHOSPHATE-5.8* MAGNESIUM-3.0* [**2114-3-27**] 08:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2114-3-27**] 08:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2114-3-27**] 08:45AM URINE HOURS-RANDOM UREA N-263 CREAT-92 SODIUM-17 [**2114-3-27**] 08:45AM URINE UCG-NEGATIVE OSMOLAL-396 [**2114-3-27**] 08:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [**2114-3-27**] 08:45AM WBC-23.1* RBC-3.37* HGB-11.2* HCT-32.0* MCV-95 MCH-33.3* MCHC-35.0 RDW-13.3 [**2114-3-27**] 08:45AM NEUTS-91* BANDS-0 LYMPHS-1* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2114-3-27**] 08:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2114-3-27**] 08:45AM PLT SMR-LOW PLT COUNT-148* [**2114-3-27**] 08:45AM PT-102.0* PTT-53.7* INR(PT)-14.2* [**2114-3-27**] 08:45AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.020 [**2114-3-27**] 08:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2114-3-27**] 08:45AM URINE RBC-[**1-29**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2114-3-27**] 08:45AM URINE AMORPH-FEW . EKG: Sinus tachycardia Low QRS voltage - clinical correlation is suggested Since previous tracing of [**2114-3-28**], axis less rightward Intervals Axes Rate PR QRS QT/QTc P QRS T 123 148 90 284/357.28 47 64 29 . CXR [**2114-3-29**]: The ET tube tip is 6 cm above the carina. The left internal jugular line tip is terminating in the low SVC. There is no pneumothorax or apical hematoma identified. The NG tube tip terminates in the stomach. There is no significant change in bilateral perihilar and lower lobe consolidations. Small bilateral pleural effusion cannot be excluded though there is no evidence of large pleural fluid. . CT Head/Chest/Abd/Pelv [**2114-3-29**]: NON-CONTRAST HEAD CT: There is diffuse edema of the brain parenchyma with loss of [**Doctor Last Name 352**]- white matter differentiation and obliteration of the ventricular system. There is also obliteration of all basilar cisterns. Obliteration of the pre- mesencephalic space suggests bilateral uncal herniation. Complete obliteration of ambient cistern suggests transtentorial herniation. There is also complete obliteration of CSF space at foramen magnum suggesting tonsillar herniation. No focal mass lesion is seen. No major or minor vascular territorial infarct is detected. No shift of normal midline structure is seen. The surrounding bony and soft tissue structures are unremarkable with no evidence of fracture. The maxillary sinuses are normal.The ethmoid sinuses , frontal sinuses and Sphenoid sinuses demonstrate mucosal thickening. IMPRESSION: Severe diffuse brain edema with obliteration of all CSF spaces with uncal, downward transtentorial and tonsillar herniation. . CT chest [**2114-3-29**]: IMPRESSION: 1. No evidence of acute bleeding is seen within the chest, abdomen or pelvis to explain the patient unresponsiveness. 2. Small bilateral pleural effusions, more prominent on the left side. 3. Bilateral ground-glass opacities and consolidations, centered on the bronchovascular bundle, which may suggest aspiration pneumonitis. 4. Anasarca and ascites. . TTE [**2114-3-27**]: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. No aortic regurgitation is seen. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular function. Resting tachycardia. No obvious structural valvular disease but evaluation limited due to marked tachycardia. . Abdomen US [**2114-3-27**]: IMPRESSION: 1. Normal-appearing liver without focal lesion identified. 2. Diffuse bilateral renal cortical echogenicity consistent with diffuse parenchymal disease. 3. Gallbladder wall edema without evidence of acute cholecystitis which may be seen with liver disease and hypoalbuminemia. Brief Hospital Course: 22 F with history of heavy ETOH abuse, HCV, IVDU of heroin, cocaine, and unknown street drugs, bipolar disorder, transferred from [**Hospital3 **] Hospital and admitted to MICU with tylenol overdose, renal failure, and altered mental status, improved for the first 3 days, then evolved to brain death due to brain herniation. . # Acute fulminant liver failure: Patient has a history of heavy ETOH abuse, HCV, with fulminant liver failure precipitated by tylenol overdose. MELD was 50 with a 98% predicted mortality on admission. Acetaminophen level was negative, AST [**Numeric Identifier 29620**], ALT 9260, INR 14.1, TB 4.2 on admission. She had been loaded with N-acetylcysteine IV infusion at [**Location (un) 21541**] Hospital, and then was transferred to the [**Hospital1 18**] ED. Hepatology consult and Toxicology consult were called and gave initial recommendations on NAC dosing. . In the MICU, 17 mg/kg/hr NAC per hour was started at the time of admission. Her initial workup covered viruses, toxins, drugs, autoimmune, shock liver, hemochromatosis, liver cancer, and sepsis as an alternative impetus for liver failure. She was HBV immune (HBsAb positive), HCV Ab positive, HIV negative, CMV negative, Monospot negative, [**Doctor First Name **] negative, AFP negative, TIBC low (229), ferritin >[**2106**] (inflammation). Urine toxin screen was positive for cocaine. Serum toxin screen was negative (included opiates, cocaine, benzodiazepines). TTE was ordered to assess possibility of shock liver, in addition to assessment of flow murmur on exam; TTE showed hyperdynamic LV systolic function with EF > 75%. EKG showed sinus tachycardia. Patient was guaiac positive with brown stool in the vault. Free calcium was 0.85 and was aggressively repleted. Normal serum glucose was maintained with D50 and slow D5W infusion. . Hepatology consult assessed that the patient would not be a liver transplant candidate, due to her continued heavy ETOH abuse, continued illicit IV drug use, nonprescribed heavy klonepin and percocet use, and previous consistent refusal of medical treatment and recommendations (history of signing out against medical advice from hospitals). This plan was discussed with her mother, father, aunt, and family, who understood and agreed. . MICU and hepatology team discussed intracranial pressure monitoring using a bolt, and it was agreed that no bolt would be placed, as patient was not a liver transplant candidate. Neurologic exam was performed every hour. Her neurologic exam on admission showed pupils constricting briskly 4 to 3 mm on the right and 4 to 3 mm on the left, and she was drowsy but oriented to person, place, year. She required a high dose of propofol to maintain proper sedation. On [**3-28**], when sedation was turned down to test mental status, she withdrew appropriately to painful stimuli, and pupils were briskly reactive. . The patient had an episode of vomiting and for concern of airway protection and aspiration, she was sedated, intubated, and LIJ central line and arterial line was placed [**3-28**]. She was noted to have diffuse ecchymoses over the eyelids, behind her ears, and on bilateral abdomen, thought to be secondary to coagulopathy. This elicited concern for a retroperitoneal bleed, but since patient was not a candidate for surgical repair at the time, and since the patient's clinical status was very tenuous and she was not safe to leave the ICU, CT was not performed at this time. . On [**3-29**] AM, sedation was turned down to test mental status, and she withdrew more slowly to painful stimuli, and pupils were still equally reactive. Ecchymoses had expanded anteriorly over abdomen, but abdomen was soft with bowel sounds and hematocrit was maintained > 21 with pRBC transfusions. On [**3-29**] AM, with no change in medications or sedation for the past hour, she was noted to have sudden spike of BP >200/>110 and HR 150s. She was given ativan 1 mg IV and labetalol 10 IV and her BP immediately returned to 110/60 and HR 70s. Neurologic exam was performed and vitals were measured every hour with no change. . On [**3-29**] early afternoon, neurologic exam suddenly showed right pupil 5 mm nonreactive and left pupil slow to react 4 to 3 mm. Sedation was turned off and patient no longer reacted to painful stimuli. Mannitol and CT head, chest, abdomen, pelvis were ordered. Within minutes, the patient's pupils became fixed and dilated. CT head showed uncal, transtentorial, and tonsillar herniation. Neurology reported brain death on [**3-29**]. Organ bank assessed patient as candidate for heart donation only due to hepatitis C. The patient was subsequently given further support for cardiac care for organ donation from [**3-29**] to [**3-30**]. . # Coagulopathy/bleeding: Since admission, her hematocrit continued to decrease and her INR continued to increase. She received a total of 4 pRBC, 12 FFP, and 1 cryoprecipitate transfusions over 3 days before death. INR was initially 14.1 and was maintained with a goal INR < 4.0; cryoprecipitate was given for fibrinogen < 100; RBC transfusion was given for hematocrit < 21 or for an acute drop. . # Respiratory insufficiency: The patient was hyperventilating with large tidal volumes. She was intubated and on AC after an episode of vomiting, for airway protection. CXR showed bilateral basilar infiltrates concerning for early acute lung injury versus aspiration, and patient was started on levofloxacin to cover for possible aspiration pneumonia. . # ETOH/opiate withdrawal: She was on propofol gtt which controlled withdrawal well. On [**3-29**] AM, she had one episode of BP 200/110, HR 150s. She was given ativan 1 mg IV and labetalol 10 IV with immediate resolution. . # Renal failure: She received several boluses of NS IVF for prerenal azotemia and Cr 2.5 on admission with no Cr baseline. Her renal function worsened and renal was consulted on [**3-28**]. Urine output was sufficient, and she did not require HD or CVVH. She was placed on a phosphate binder. It was possible that her renal failure occurred in conjunction with liver failure and/or was associated with cocaine-induced vasoconstriction. . # Hematemesis: Patient had small coffee ground gastric fluid and orogastric tube was placed to low suction. She was placed on pantoprazole IV BID. . # Leukocytosis: WBC 23.1 on admission resolved to 6.3 after one day. Antibiotics were started on [**3-28**] due to CXR infiltrates. Blood cultures on [**3-27**] showed positive gram stain, and on [**3-31**] and [**4-2**] grew out Corynebacterium species and Fusobacterium nucleatum, beta lactamase negative. Surveillance blood cultures on [**3-28**] and [**3-29**] showed no growth or were still pending (no growth yet) by [**4-3**]. Sputum cultures on [**3-28**] grew out Streptococcus pneumoniae and MSSA on [**4-2**], both sensitive to levofloxacin. Urine culture showed 1000 organisms of gram positive organism, likely staphylococcus. . # Hypoglycemia: Patient had one episode of fingerstick glucose 32, and was given D50. D5W infusion was continued with subsequent normal fingerstick glucose readings, which were checked every hour. . # Prophylaxis: She was placed on pneumoboots with no subcutaneous heparin. She was given PPI IV BID for hematemesis. . # Code: Her code was full until her death on [**3-29**]. Medications on Admission: Tylenol PM 4 pills per night . ALLERGIES: PCN Discharge Medications: Patient expired on [**2114-3-29**]. Discharge Disposition: Expired Discharge Diagnosis: Patient expired on [**2114-3-29**]. Discharge Condition: Patient expired on [**2114-3-29**]. Discharge Instructions: Patient expired on [**2114-3-29**]. Followup Instructions: Patient expired on [**2114-3-29**]. Completed by:[**2114-4-10**]

Admission Date: [**2113-8-19**] Discharge Date: [**2113-8-30**] Service: NEUROSURGICAL HISTORY OF PRESENT ILLNESS: This is a 76-year-old man brought into [**Hospital3 **] Emergency Department after an unwitnessed syncopal episode. The patient recalled going for a walk in the afternoon and then no memory of events until he was brought to the Emergency Room on [**2113-8-19**]. He was reportedly found down by bystanders on the sidewalk "confused". EMS was called and they found the patient alert with stable vital signs, unremarkable exam and no complaints. In the Emergency Department, exam was remarkable only for systolic murmur which was old. Electrocardiograms were unchanged from prior. A head CT with and without contrast, however, revealed a large left frontal parietal mass presumed to be metastases given his history of small cell lung cancer. He was given then Dilantin 300 mg p.o. and Solu-Medrol 85 mg intravenous. He initially presented with the right lower lobe lung nodule in [**2112-7-26**] and a cough with weight loss. In addition, he had postobstructive pneumonia. A bronchoscopic biopsy revealed small cell lung cancer. Bone scan and head CT in [**2112-8-26**] were negative. He was billed as a limited stage and underwent four cycles of carboplatin and etoposide between [**2112-9-25**] and [**2112-12-26**], resulting in resolution by radiologic studies at least of his mass. Subsequent surveillance chest x-rays every three months have all been negative. The last one was on [**8-9**]. PAST MEDICAL HISTORY: 1. Type 2 diabetes x30 years 2. Hypertension x10 years 3. Status post stroke 10 years ago with loss of his left peripheral vision 4. Left upper extremity weakness 5. Dysphagia 6. Benign prostatic hypertrophy 7. Hypercholesterolemia 8. Peripheral vascular disease 9. Hypertension 10. Penile prosthesis 11. Small cell lung cancer as described above ALLERGIES: The patient has no known drug allergies. MEDICATIONS FROM OLD DISCHARGE SUMMARY: 1. Lasix 20 mg b.i.d. 2. Toprol XL 50 q.d. 3. Aspirin 325 q.i.d. 4. Ramipril 5 mg b.i.d. 5. Pravachol 20 q.d. 6. Flomax 0.4 7. Insulin 70/30 10 units in the a.m., 12 units q p.m., now 15 units q p.m. as per patient REVIEW OF SYSTEMS: No chest pain, no palpitations, no bowel or bladder incontinence, no nausea, vomiting or shortness of breath. No acute bloody stools. s SOCIAL HISTORY: Married. He is a retired accountant. He smokes three packs a day for 35 years and he does drink. FAMILY HISTORY: Significant for diabetes. EXAM ON ADMISSION: VITAL SIGNS: Temperature 97.6??????, pulse 70, pressure 100/58, respirations 17, 97% on room air. GENERAL: He is a pleasant man in no acute distress. HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic, atraumatic. Mucous membranes moist, anicteric. No evidence of tongue laceration. NECK: Supple, no lymphadenopathy, no carotid bruits. CARDIOVASCULAR: Regular rate and rhythm, 2/6 systolic murmur in the left upper sternal border. CHEST: Clear bilaterally. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds, no palpable hepatosplenomegaly. He was guaiac negative. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGIC: Alert and oriented to person, place, but not time. He said it was [**2114-6-25**]. Motor [**3-30**] extensors, left upper extremity wrist [**4-29**], otherwise. Light touch was grossly intact. Cranial nerves II through XII grossly intact with a left homonymous hemianopsia which is old. Finger to nose, heel to shin slow but intact. No pronator drift. Deep tendon reflexes were symmetric and toes were downgoing bilaterally. LABORATORIES AND IMAGING: White count 4.5, hematocrit 37, platelet count 133. His chem-7 was significant for a creatinine of 1.7. His baseline is between 1.2 and 1.6. Electrocardiogram was not changed from prior and a head CT on admission showed a 4.1 x 3.7 cm enhancing mass in the left frontal lobe extending to the frontal [**Doctor Last Name 534**] of the left ventricle with effacement of sulci on the right consistent with metastatic disease, new since the [**12-26**] exam. In addition, a chronic right occipital infarct which is unchanged. HOSPITAL COURSE: The patient was admitted to the O-Med service. He was ruled out by CKs, continued on aspirin and beta blockers. In addition, he was started on intravenous steroids and put on seizure precautions, as well as given Dilantin. The patient, in addition, his p.o. intake was encouraged and his creatinine returned to baseline. In conjunction with his oncologist, neurosurgery was consulted in addition radiation oncology was consulted, as well. The patient underwent work up to determine extent of his metastatic disease, including an MRI of his head which was again consistent with metastatic disease as well as a CT of his lung, abdomen and pelvis, which showed no metastatic disease in the abdomen or pelvis. No liver lesions, adrenal lesions, however his lung mass appeared to have increased in size. In conjunction with oncology, radiation oncology and neurosurgery, it was decided that the patient would go for resection of the brain metastasis. He was transferred to the neurosurgical service on [**2113-8-24**] and underwent craniotomy on [**2113-8-24**] with resection of the left frontal brain lesion. Surgery proceeded without any complications. A surgical drain was put in which was left there and the drain was pulled [**2113-8-26**]. The patient continued to do well and transferred from the Intensive Care Unit to the floor where he remained stable neurologically. At that time, the patient remained alert and awake, arousable, oriented to person with good strength in all extremities, no pronator drift, looking in all directions. On the floor, had some problems with [**Name2 (NI) **] pressure control. His Toprol was changed to Lopressor 75 t.i.d., did well with that. He was seen by physical therapy and the plan was to discharge this patient with inpatient rehabilitation. DISCHARGE DIAGNOSES: 1. Brain metastases of small cell lung cancer 2. Status post resection mass DISCHARGE MEDICATIONS: 1. Decadron 0.5 mg po q8h x1 day 2. Lopressor 75 mg po t.i.d. 4. Insulin 70/30 15 units subcutaneous q a.m. 5. Boost shakes b.i.d. 6. Regular insulin sliding scale 7. Dilantin 100 mg po t.i.d. 8. Zantac 150 mg po b.i.d. 9. Lasix 20 mg po b.i.d. 10. Ramipril 5 mg po b.i.d. DISCHARGE CONDITION: Stable DISCHARGE STATUS: Discharge to rehabilitation FOLLOW UP in Brain [**Hospital 341**] Clinic [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 8853**] MEDQUIST36 D: [**2113-8-29**] 09:58 T: [**2113-8-29**] 10:11 JOB#: [**Job Number 108076**]

Admission Date: [**2199-9-1**] Discharge Date: [**2199-9-19**] Date of Birth: [**2128-3-9**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1271**] Chief Complaint: Headache Major Surgical or Invasive Procedure: Right Craniotomy for SDH [**2199-9-3**] Redo Right craniotomy for SDH [**2199-9-10**] History of Present Illness: This is a 71 year old man who presents with approx 1 month of left sided weakness and speech difficulty. This worsened gradually, and initially he felt that it may have just been his neuropathy acting up. He has also been feeling some headaches, which he describes as bifrontal headaches which were helped with motrin. A few days before presentation, his daughter noted that his left arm was becoming clumsy while turning of the lamp or while using a spoon. He also noted that his left leg while dressing. He denied a history of trauma to his head. Past Medical History: pituitary tumor s/p resection, DMII, neuropathy, obesity s/p gastric bypass surgery, melanoma removal from face and OSA Social History: He lives with his wife, nonsmoker, no EtOH, 3 kids Family History: non-contributory Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: scar from melanoma rsxn left face Pupils: [**3-30**] EOMs full, no nystagmus Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-28**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. slight dysarthria, no paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4to2 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**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-2**] except 4+/5 left deltoid and IP. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Handedness: Right At discharge: Pertinent Results: [**9-1**] CT Head- IMPRESSION: Complex heterogeneous right subdural collection suggestive of mostly subacute subdural hematoma with areas of hyperdensity which may indicate more acute component. Right-to-left subfalcine herniation. 9 mm rightward shift of septum pellucidum. [**2199-9-1**] CXR AP and lateral views of the chest demonstrate clear lungs without effusion or pneumothorax. The heart size is normal. The mediastinal contours are unremarkable. IMPRESSION: Normal chest. CT head [**2199-9-3**] Post-surgical changes from recent right frontoparietal craniotomy with right-sided drainage catheter in the surgical bed. The degree of subfalcine herniation, sulcal effacement and local mass effect appears slightly improved compared to most recent examination. CXR [**2199-9-3**] In comparison with the study of [**9-1**], there has been placement of an endotracheal tube with its tip approximately 5.5 cm above the carina. Nasogastric tube tip appears to extend only to the upper portion of the stomach with the side hole within the lower esophagus. Low lung volumes may account for some of the prominence of the transverse diameter of the heart. CT head [**2199-9-4**] Slight increase in size of previously noted acute subdural hematoma, no change in midline shift. CT Head [**9-5**] No change when compared to previous scan on [**9-4**] LENIs [**9-9**] - negative for DVT. CT Head [**9-10**] (post op) 1. Decreased size of right subdural hematoma with decreased mass effect. 2. New subarachnoid hemorrhage in the right sylvian fissure and right frontal sulci. CT Head [**9-12**] Slight increase in right frontal wedge-shaped hypodensity with mild increase in size likely related to evolution without a significant increase in mass effect. Decrease in the previously noted right sided subdural fluid collection with dense foci. No new hemorrhage. Carotid US [**2199-9-17**] No evidence of significant carotid artery stenosis bilaterally. Echocardiogram [**2199-9-18**] The left atrium is normal in size. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased peak transvalvular velocity consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No cardiac source of embolism identified. Preserved global and regional biventricular systolic function. Minimal aortic valve stenosis. Compared with the prior study dated [**2193-6-5**] (images unavailable for review), minimal aortic valve stenosis is appreciated. Brief Hospital Course: On [**9-1**] Mr. [**Known lastname 45777**] was admitted to the neuro ICU and started on Keppra for seizure prophylaxsis. He remained stable neurologically and radiologically and was cleared for transfer to the floor on [**9-2**]. Surgery was scheduled for [**9-3**] for craniotomy and evacuation of hematoma. Preop and consent were obtained. He proceeded to the OR on [**2199-9-3**] for a right craniotomy for subdural evacuation. A JP drain was left in place. He remained intubated post-op and he went to CT for a scan that showed some acute blood. He has left sided weakness. He was transfered to the NICU. On [**2199-9-4**], he was extubated and his strength was slowly improving. CT head showed a small amount of acute blood and he was given platelets. In total he received 2 units of platelets and his platelet count remained above 100k. A repeat CT head on [**9-5**] showed no change when compared to previous scan. His subdural drain remained in place and was removed in the late afternoon. He was transferred to a step-down bed from the SICU that evening. The morning of [**9-6**] the patient had a repeat Head CT demonstrating no change in right frontoparietal hyperdensity and no new hemorrhage. The patient mental status waxed and waned over the course of the day. Patient failed speech and swallow and it was recommended to keep the patient NPO. NG tube was placed in order to get medications and nutrition. On [**9-9**] LENIs was obtained to rule out DVT which was essentially negative. A repeat Head CT showed slight increase in right Frontoparietal collection. As a result, a Brain MRI Stroke protocol was obtained as he had not improved neurologically which demonstrated no brainstem hemorrhage. [**9-10**] MRI head demonstrated the right frontoparietal subdural and subarachnoid hemorrhage with mass effect and midline shift which are unchanged as compared to the prior CT scan. He was taken to the OR on [**9-10**] for a redo right craniotomy for SDH evacuation. A post-op CT showed improvement with a decreased size of right subdural hematoma with decreased mass effect and a new subarachnoid hemorrhage in the right sylvian fissure and right frontal sulci. The patient was taken to SICU-B after surgery intubated. He remained intubated in the morning [**9-11**] with reported seizure activity (right arm and right downward gaze fixation) treated with increased keppra and continuous EEG. The patient was also pan cultured for fever. A CT-scan was re-ordered demonstrating a right frontal infarct. Dilantin was added to seizure prophylaxis. Vancomycin, tobramycin, and cefepime were added after Bronch cx returned positive for gram positive rods and cocci and gram negative rods. Urine cultures returned positive for Enterococcus. The patient remained intubated with no change in neuro exam overnight. Patient continued to have febrile temperatures overnight. The morning of [**9-12**], the patient continued to have seizure episodes. Neuroepilepsy was consulted for seizure work-up and recommendations, endocrine service was consulted for work-up of endocrine issues and recommendations, and a repeat head CT was ordered. Patient was overnight without seizures and afebrile throughout [**9-13**]. Urine cultures and bronchalveolar lavage cultures returned with antibiotic sensitivities; antibiotics were tailored as per sensitivity testing. The patient continued to progress in his physical exam with increased movement in his right upper and lower extremit, minimal movement of left upper extremity and withdrawal to pain on left lower extremity, following commands, and opening his eyes to voice. The plan was to begin considering possible extubation. On [**9-14**], the patient continued in the Surgical intensive care unit. The ventilator was weaned and the patient was extubated. The patient was weak, but opened his eyes to voice and was oriented to person place and time. The patient was able to move all four extremities antigravity to command. The patient moves the left arm and leg after a delay. The left side is weakner than the right. The patient had a bowel movement. On [**9-16**] pt was doing well. He was AOx3 and was more interactive with staff and family. He was transferred to the SDU in stable condition. His abx were narrowed to Cefepime and the plan was to continue for a total fo 14 days. On [**9-17**] a carotid US was done per Neuro-Vascular service and there was no significant stenosis. He was changed to floor status. On [**9-18**] his calcium was repleted. He was neurologically stable. Cefepime was changed to Bactrim for oral therapy. IV meds were discontinued. He was approved for PT. Central line was discontinued. Patient taking oral intake without issues. Overnight, the patient had no complaints. Patient did take out dobbhoff tube despite restraints. His echo was without source of embolus. On [**9-19**] the patient was without complaints. His neurologic exam was stable and strength in left upper and lower extremities progressed. Patient's restraints were discontinued. Lasix were given for signs of fluid overload in lower extremities. His staple were removed in routine fashion. Now DOD, he is afebrile, VSS, and he himproved neurologically. He is tolerating an oral diet without issues. He was evaluated by pt/ot/speech who recommended rehab. On [**2199-9-19**], He was stable for discharge to rehab and will f/u accordingly. Medications on Admission: bromocritine/clobentasol/lasix40'/hydrocortisone /levothyroxine/testosterone/vit D/multivitamin Discharge Medications: 1. bromocriptine 2.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. clotrimazole 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 3. testosterone cypionate 200 mg/mL Oil Sig: One (1) Intramuscular Q2WK (). 4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 7. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. codeine sulfate 30 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, ha. 9. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID (2 times a day). 11. phenytoin 125 mg/5 mL Suspension Sig: One [**Age over 90 1230**]y (150) mg PO Q8H (every 8 hours). 12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for pruritis. 13. hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 14. hydrocortisone 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)). 15. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 16. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): cont until [**9-25**]. 18. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: subdural hematoma obstructive sleep apnea pituitary insufficiency Thrombocytopenia Recurrent SDH anemia right frontal infarct Post-op fever Seizures malnutrition dysphagia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this after follow up with us ??????You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2199-9-19**]

Admission Date: [**2124-7-3**] Discharge Date: [**2124-7-8**] Date of Birth: [**2054-8-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: [**7-4**] MVrepair (#34 [**Company 1543**] ring)/MAZE History of Present Illness: 69 yo M with MR/MVP referred for cath to further evaluate. Cath showed 3+ MR and he was referred for surgery. Past Medical History: HTN, lipids, MVP/MR, chronic anemia, persistent afib, CHF, arthritis, tonsillectomy, right hernia repair, arthroscopic bilat knee surgery. Social History: retired firefighter [**1-26**] cigarettes, cigars daily x 40 years 3 beers/day Family History: NC Physical Exam: NAD Lungs CTAB Heart RRR Abdomen benign Extremities warm, no edema Neuro nonfocal Pertinent Results: RADIOLOGY Final Report CHEST (PORTABLE AP) [**2124-7-6**] 7:47 AM CHEST (PORTABLE AP) Reason: eval ptx [**Hospital 93**] MEDICAL CONDITION: 69 year old man s/p MVR REASON FOR THIS EXAMINATION: eval ptx STUDY: Single portable AP chest radiograph. INDICATION: Status post mitral valve replacement, please evaluate for pneumothorax COMPARISON: [**2124-7-5**]. FINDINGS: Study is limited by tubing from breathing mask overlying the right apex which is the region of interest. Subtle lucency remains in this area, however, exact extent of right apical pneumothorax is indeterminate. There is no shift in the mediastinum to suggest a tension component. The lungs are otherwise clear. There is a small left pleural effusion. Median sternotomy wires remain intact. IMPRESSION: Limited radiograph given overlying tubing in the right apex. However, there is likely unchanged to slight improvement of right apical pneumothorax and repeat radiograph is recommended after overlying tubing has been removed. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 4391**] DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Approved: [**Doctor First Name **] [**2124-7-6**] 4:35 PM [**2124-7-7**] 05:40AM BLOOD WBC-13.6* RBC-2.67* Hgb-9.1* Hct-25.9* MCV-97 MCH-34.0* MCHC-34.9 RDW-13.0 Plt Ct-130* [**2124-7-7**] 05:40AM BLOOD PT-14.5* INR(PT)-1.3* [**2124-7-7**] 05:40AM BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-138 K-4.4 Cl-101 HCO3-31 AnGap-10 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 77822**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77823**] (Complete) Done [**2124-7-4**] at 12:43:46 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2054-8-13**] Age (years): 69 M Hgt (in): 70 BP (mm Hg): 140/80 Wgt (lb): 160 HR (bpm): 80 BSA (m2): 1.90 m2 Indication: Intraoperative TEE for MVR/MAZE ICD-9 Codes: 428.0, 427.31, 786.05, 440.0, 424.0 Test Information Date/Time: [**2124-7-4**] at 12:43 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW5-: Machine: [**Pager number 28384**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *6.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.5 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.8 cm <= 5.0 cm Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Aorta - Sinus Level: *3.8 cm <= 3.6 cm Aorta - Ascending: *4.2 cm <= 3.4 cm Aortic Valve - LVOT diam: 2.2 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Marked LA enlargement. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Dilated LV cavity. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root. Moderately dilated ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Mild mitral annular calcification. Calcified tips of papillary muscles. Eccentric MR jet. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: 1. The left atrium is markedly dilated. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. 2. The left ventricular cavity is dilated. There is hypokinesis of the mid to apical segments of the septal and lateral walls). Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse of the anterior and posterior leaflets. An posteriorly eccentric, directed jet of Moderate to severe (3+) mitral regurgitation and a centrally directed jet is seen . The mitral valve annulus is dilated measurng 4.5 cm in the transcommisural view and 5.4cm in the anterior-posterior view. 7. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including epinephrine and phenylephrine and was in a sinus rhythm. 1. There is a mitral valve ring in place, gradient across the mitral valve is1mmHg with a CO of 3.5L/min. The PHT 47ms, with a MVA of 2.4cm2. 2. There is global left ventricular systolic dysfunction with an estimated LVEF of 35 %. 3. Right ventricular systolic function is abnormal; the RV appears moderatly dilated and moderately hypokinetic post-bypass. 4. Aortic contours are intact post-decannulation.. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2124-7-7**] 05:40AM 13.6* 2.67* 9.1* 25.9* 97 34.0* 34.9 13.0 130 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2124-7-7**] 05:40AM 106* 13 1.0 138 4.4 101 31 10 [**7-8**] INR 1.6 Brief Hospital Course: He was admitted preoperatively for IV heparin after stopping his coumadin. He was taken to the operating room on [**7-4**] where he underwent a MV repair and MAZE procedure. He was transferred to the ICU in stable condition on epi, neo and propofol. He was extubated post operatively. Coumadin for restarted for history of atrial fibrillation. He had a small right apical pneumothorax which was increased in size after pulling his chest tubes. He continued to progress and was discharged to home in stable condition on POD #4 . His coumadin will be followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] and this was discussed with Dr. [**Last Name (STitle) 4469**]. Medications on Admission: zocor 80, omeprazole 20, lasix 20', lopressor 50(3), iron 65, coumadin 2.5(4x wk)/5mg (3xwk) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 6. Outpatient Lab Work INR drawn on Monday [**2124-7-10**] with results sent to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] at ([**Telephone/Fax (1) 40360**]. INR goal of [**2-26**].5. 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 4 days: Decrease dose to 400 mg PO daily for 7 days after [**Hospital1 **] dose completed. Decrease to 200 mg PO daily after 400 mg dose completed. Disp:*45 Tablet(s)* Refills:*2* 11. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime for 1 days: Alt. 2.5 mg with 5 mg PO daily Take 5 mg [**7-8**]. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: MVP/MR s/p MV repair HTN, lipids, , chronic anemia, persistent afib, CHF, arthritis, tonsillectomy, right hernia repair, arthroscopic bilat knee surgery. 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 for 10 weeks from surgery. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 4469**] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Will need an INR on Monday with results sent to the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] at ([**Telephone/Fax (1) 40360**] with a goal INR of [**2-26**].5 for atrial fibrillation (spoke with Dr. [**Last Name (STitle) 4469**] [**2124-7-7**]) Completed by:[**2124-7-8**]

Admission Date: [**2148-8-4**] Discharge Date: [**8-11**] /[**2148**] Date of Birth: [**2148-8-4**] Sex: M Service: NB This is an interim summary covering from [**2148-8-4**] through [**8-11**]. [**Hospital **] transferred to Neonatology Service because of the development of medical necrotizing enterocolitis. HISTORY OF PRESENT ILLNESS: Baby baby [**Name (NI) 4549**] is a [**2049**] gram product of a 31 and 6/7 weeks twin gestation born to a 28- year-old G3, P0, now 2 woman. Prenatal screens - A positive, antibody negative, hepatitis surface antigen negative, rubella immune, RPR nonreactive, GBS unknown. This pregnancy is remarkable for in [**Last Name (un) 5153**] fertilization, dichorionic, diamniotic twin complicated by preterm labor cervical shortening at 24 weeks. The mother was treated with bed rest and magnesium sulfate. Betamethasone given on [**2148-6-10**]. She remained on bed rest that [**Doctor First Name **]- [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for one month and discharged home on PO terbutaline. She presented on the night of the delivery with spontaneous labor with spontaneous rupture of membranes 37 minutes prior to delivery. Vertex, vertex presentation, prompting cesarean section delivery. Per parents' wished, did not want to try a labor. The infant emerged initially with good tone and cry, however then developed apnea, large amount of oropharyngeal secretions that were suctioned. The baby required bag, mask ventilation and further suctioning of orogastric fluid. Apgars were 5, 7, and 8. PHYSICAL EXAMINATION: Weight [**2048**], 75th percentile; length 44 cm, 75th percentile; head circumference 32 cm, 90th percentile; anterior fontanel soft and flat. Palate intact. Nondysmorphic facies. Breath sounds coarse with fair air entry after intubation. S1 and S2 normal intensity. No murmurs. Perfusion fair. Soft abdomen with no organomegaly. Three-vessel cord. Normal male genitalia. Appropriate for gestational age. Tone appropriate for gestational age. Hips stable. HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname **] continued to have respiratory distress. The infant was intubated, received 2 doses of Surfactant and was extubated to nasal cannula oxygen at 24 hours of age. He remains stable on nasal cannula oxygen, 13 cc. He has occasional apnea bradycardia and is not currently received methylxanthine therapy. CARDIOVASCULAR: No issues. FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was [**2048**] grams. Initially started on 80 cc per kg per day of D10W. Enteral feedings were initiated on day of life No. 1. He is currently on 140 cc per kg per day, 50 cc of per day of which is breast milk - premature Enfamil 20 calorie. GASTROINTESTINAL: Bilirubin on day of life 2 was 7.9/0.3. He was placed on phtx with a current bili of HEMATOLOGY: Hematocrit on admission was 47.8. He has not required any blood transfusions. INFECTIOUS DISEASE: CBC and blood cultures obtained on admission. CBC was benign. Blood cultures remained negative at 48 hours at which time ampicillin and gentamycin were discontinued. On [**8-11**] infant developed bloody stools with an abdominal film consistent with NEC. He was made NPO and placed on Vanc/Gent/Clinda and switched after 48 hours to Amp/Gent/Clinda and treated for 14 days during which time he was kept NPO. NEUROLOGIC: Appropriate for gestational age. Screening HUS done on [**8-14**] DISCHARGE DIAGNOSES: Premature twin No. 1, 31 6/7 weeks gestation. Respiratory distress syndrome. Rule out sepsis with antibiotics. Hyperbilirubinemia Necrotizing enterocolitis DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-393 MEDQUIST36 D: [**2148-8-11**] 21:59:57 T: [**2148-8-11**] 23:05:54 Job#: [**Job Number 63961**]

Admission Date: [**2178-1-20**] Discharge Date: [**2178-1-23**] Date of Birth: [**2129-10-5**] Sex: F Service: MEDICINE Allergies: Zosyn / Quinolones / Ceftriaxone / Flagyl / Keppra / Lisinopril / Naprosyn / Bactrim DS / Phenytoin / Nitrofurantoin / Sulfa (Sulfonamide Antibiotics) / Zofran / IV Dye, Iodine Containing Attending:[**First Name3 (LF) 6701**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 48-year-old female with PMHx of spina bifida, HTN, MR, paraperesis, non-epileptic [**First Name3 (LF) 54422**], and urostomy with chief complaint of abdominal pain. This occured 2 days prior to arrival, pain was diffuse (9.5/10), gradually increasing in severity. Associated with: nausea and vomiting (food contents, non-bloody); patient denies f/c, new n/t/w, HA/neck pain, change in vision, CP, SOB, cough, change in BM (1 on day prior, non-bloody), GU s/sx. Review of OMR reveals that the patient has been admitted several times for abdominal pain that presented similarly and had a negative work up including CT abdomen, RUQ U/S and HIDA scan. On her [**Month (only) 116**] admission she was treated with an aggressive bowel regimen and discharged after having daily stools. Also, the patient was recently admitted for spastic movements that were determined not to be [**Month (only) 54422**]. She then went to the ED again last week with spastic movements in renal ultrasound that neurology felt were consitent with her non-epileptic [**Month (only) 54422**]. In the neurology consult note from this ED visit her abdomen was noted to be diffusely tender and somewhat distended. . In the ED VS: 96.5 72 111/68 18 99% 2L. Exam was notable for distended abdomen that was mildly distended diffusely tender to palpation. She was guaiac negative. Labs notable for alk phos of 113 and U/A negative (bacteruira from ileal condiut). Patient had Abd Xray and CT scan which were unremarkable (stool present, no SBO, no abscess, no pancreatitis or other acute process). CXR showed no abnormality. Patient given morphine x2 and Zofran and admitted for pain control. . On the floor, patient was sleeping but when awoken states that her abdomen is painful and distended. (Of note, the above HPI is from the patient's presentation to the ED). She has since been admitted to the medical ICU for her diffuse fixed drug reaction/dermatologic condition). Past Medical History: 1. Asthma/COPD 2. Hypertension 3. GERD 4. Urostomy 5. h/o VRE pyelonephritis 6. Spina bifida (myelomengiocele) 7. Paraplegia (documented, though patient can walk) 8. Depression 9. Mild mental retardation 10. Psychogenic dysarthria and tremor 11. [**Month (only) **] vs. pseudoseizures - EEG work-up at [**Hospital3 **] in [**2165**] frequent runs of regular bifrontal sharp delta activity although the clinical events which occurred during the record were not associated with EEG change 12. Atopic dermatitis 13. Back pain 14. Genital herpes 15. Uterine fibroid 16. Uterine prolapse 17. Diverticulosis 18. External hemorrhoids Social History: Lives alone in an apartment in [**Location (un) 86**]. She is able to transfer w/ wheelchair. Reports [**Location (un) 269**] assistance once a week in her home. Tobacco: 1 PPD EtOH: Drinks 2-3 beers a day. Illicits: Denies IVDU ever. History of smoking crack cocaine, claims to have stopped using cocaine 3 years ago. Family History: 3 healthy children. Mother - died of lung cancer. Father - killed by his girlfriend. Not in contact with her brother and sister. Physical Exam: VS: 98.4 98.4 116/57 78 18 94% 2L. GEN: obese, awake HEENT: EOMI, PERRLA no scleral icterus CV: RRR nl S1 S2 LUNGS: CTAB/L ABD: +BS, distended and tympanic, diffusely TTP all over abdomen even with distraction, urostomy bag with small amount of urine, no rebound, +voluntary guarding. EXT: warm, well perfused 2+ distal pulses b/l NEURO: A&Ox3, able to answer questions appropriately On transfer: VS: afebrile, BP 111/67, HR: 71, SP02: 100% RA General: Intubated, sedated Chest: Coarse breath sounds throughout, no crackles Cardiac: Regular rate and rhythm, no murmurs, rubs, or gallops Abd: +BS, well-healed surgical incision, soft Pertinent Results: [**2178-1-22**] WBC-11.3*# Hgb-11.5* Hct-35.1* MCV-93 Plt Ct-226 Glucose-77 UreaN-9 Creat-0.8 Na-136 K-4.4 Cl-102 HCO3-25 Calcium-8.4 Phos-3.2 Mg-2.2 . [**2178-1-21**] ALT-10 AST-13 AlkPhos-119* TotBili-0.4 . [**2178-1-20**] Neuts-60.1 Lymphs-30.9 Monos-4.0 Eos-4.3* Baso-0.7 Lactate-1.4 . EKG ([**2178-1-21**]): Sinus rhythm. RSR' pattern in leads V1-V2 may be a normal variant. Baseline artifact in the limb leads makes assessment of those leads difficult. Since the previous tracing of [**2178-1-20**] there is probably no significant change but unstable baseline in the standard limb leads makes comparison difficult. . CXR 2V ([**2178-1-20**]): No acute cardiopulmonary pathology. . CT abdomen/pelvis with contrast ([**2178-1-22**]): 1. No acute abdominal pathology. 2. Status post urinary diversion with ileal conduit, with prominence of the lower ureters, unchanged since the prior study. Stable bilateral renal cortical scarring, stable. 3. Fibroid uterus. 4. Spina bifida with meningocele, unchanged. . Recent labs from [**2178-1-13**] at 1400: . 135 107 8 100 AGap=11 . 4.4 21 0.8 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes . Ca: 7.6 Mg: 1.9 P: 2.7 ALT: 8 AP: 89 Tbili: 0.4 Alb: 3.0 AST: 16 LDH: 257 Dbili: TProt: [**Doctor First Name **]: Lip: . Wbc: 11.2 Hgb: 10.9 Hct: 33.3 Plt: 218 N:76.5 L:17.2 M:1.8 E:4.2 Bas:0.4 PT: 13.1 PTT: 30.0 INR: 1.1 Lactate:1.6 [**2178-1-20**] 01:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 [**2178-1-20**] 8:18 pm URINE Site: CATHETER **FINAL REPORT [**2178-1-23**]** URINE CULTURE (Final [**2178-1-23**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: This is a 48-year-old female with spina bifida and long standing urostomy, mild mental retardation, and prior bullos skin lesions admitted [**2178-1-20**] for abdominal pain, suspected related to constipation; overnight with fever to 103 and development of bullous skin lesions, concerning for drug reaction. Patient is being transferred to [**Hospital1 112**] for further burn care. . BULLOUS HYPERSENSITIVITY DRUG REACTION: New onset diffuse erythema and bullae in areas of friction noticed on hospital day 2, following fever to 103 evening prior. Progressive throughout the day, with increasing blistering, particular in axilla, neck folds, back, thighs, and shins. Dermatology was actively involved in patient's care. Zofran suspected to be causative [**Doctor Last Name 360**], with morphine and divalproex less likely. (Patient has had at least 4 previous bouts of drug reactions, and has required intubation for laryngeal and angioedema). Recommended transfer to [**Hospital6 **] Burn Unit for close monitoring due to rapid progression of bullae. Zofran was stopped. Skin biopsy performed by dermatology with path pending. Patient was given over 2 Liters of IV hydration in the ICU; hydration was stopped when IV access was lost. Pain control was with IV morphine, but then switched to PO after IV access was lost. Patient received 1 dose of IVIG (1g/kg/d); she was in the middle of her second dose before she lost IV access. She should get a total of 4 doses of IVIG over 4 days. She was given methyprednisolone 40mg IV once. . 2) ACCESS: Patient lost access on the morning of [**1-23**]. Peripherals and PICC were unable to be placed due to patient's extensive blistering. A right IJ was eventually placed for access. . 3) RESPIRATORY STATUS: On the morning of [**1-13**], patient had increasing stridor and increased work of breathing in addition to angioedema. She has required intubation in the past for respiratory decline in the setting of bullous hypersensitivity reaction. She was intubated prophylactically prior to transfer to [**Hospital1 112**]. Induction was with etomidate and succ, and sedation/pain control was maintained with midazolam and a morphine drip (to avoid further drug exposures). She remains on neo 0.9, but this can probably be weaned prior to transfer or right afterward. Initial abg showed 7.28/52/93 on Fi02 100%, TV 500, RR 16, PEEP 5. Subsequently, RR was increased to 18 and PEEP was increased to 10. Repeat gas is 7.35/43/94. . 3) KLEBSIELLA UTI: Noted on hospital day 2. Recurrent UTIs in this patient with urostomy due to spina bifida. Patient was seen by her primary care physician who thought that because recent u/a was negative, patient was probably colonized with klebsiella and antibiotics were not warranted at this time. If antibiotics are needed, patient can be started on meropenem. . (4) ASTHMA/COPD: Continued on montelukast per home regimen. . (5) NON-EPILEPTIC SEIZURE DISORDER: No concerning seizure activity during this hospital stay. Continued on divalproex 250mg PO BID per home regimen. . (6) DEPRESSION: Continued on citalopram 20mg PO daily and quetiapine 25mg PO QHS per home regimen. . If you have any questions, please call the [**Hospital Ward Name 121**] 7 MICU at: [**Telephone/Fax (1) 109836**] and ask for the resident on call. Medications on Admission: on last discharge [**2177-11-28**]: Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN skin irritation Montelukast Sodium 10 mg PO/NG DAILY Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever Pantoprazole 40 mg PO Q24H Order date: [**6-15**] @ 1209 Citalopram Hydrobromide 20 mg PO/NG DAILY Quetiapine Fumarate 25 mg PO/NG HS Docusate Sodium 100 mg PO BID Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Heparin 5000 UNIT SC TID Thiamine 100 mg PO/NG DAILY In addition per OMR notes: divalproex 250 mg Tab, Delayed Release Oral 1 Tablet, Delayed Release (E.C.)(s) Twice Daily - prescribed by PCP Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for skin irritation. 2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal pain. 10. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. immune globulin(hum),capr(IGG) 10 % Injectable Sig: One (1) Intravenous DAILY (Daily) for 4 days. 15. phenylephrine HCl 10 mg/mL Solution Sig: One (1) Injection TITRATE TO (titrate to desired clinical effect (please specify)). 16. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 17. propofol 10 mg/mL Emulsion Sig: One (1) Intravenous TITRATE TO (titrate to desired clinical effect (please specify)). 18. midazolam 5 mg/mL Solution Sig: One (1) Injection TITRATE TO (titrate to desired clinical effect (please specify)). 19. morphine (PF) in D5W 100 mg/100 mL (1 mg/mL) Parenteral Solution Sig: One (1) Intravenous INFUSION (continuous infusion). 20. methylprednisolone sodium succ 40 mg Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Abdominal pain - Constipation. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Patient is being transferred to [**Hospital1 112**] Burn Care Unit, floor 8C. Number there is: [**Telephone/Fax (1) 109837**]. Accepting physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 55378**]. Followup Instructions: Name: [**Last Name (LF) 5240**],[**First Name3 (LF) 5241**] Location: [**Hospital6 5242**] CENTER Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 798**] Appointment: [**Telephone/Fax (1) 766**] [**2178-2-2**] 11:20am [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]

Admission Date: [**2162-6-23**] Discharge Date: [**2162-7-14**] Date of Birth: [**2109-7-26**] Sex: M Service: SURGERY Allergies: Aloe Attending:[**First Name3 (LF) 598**] Chief Complaint: abdominal compartment syndrome [**3-16**] pancreatitis Major Surgical or Invasive Procedure: 1. Exploratory decompressive laparotomy. [**6-24**] 2. Application of open abdominal dressing. [**6-28**] 3. Repair of perforated cecum. [**7-1**] 3. Closure of open abdomen History of Present Illness: 60M +EtOH + seizures who presented to OSH [**6-23**] afternoon with altered ms, abdominal pain, SOB. High DDimer, high bandemia and SOB was concerning for PE presentation -> CT chest obtained, negative. Seized at OSH CT scan, found to be in status epilepticus, intubated and xferred to [**Hospital1 18**] ER. Patient became hypotensive in ED, given 5L of IVF, started on pressors with benzodiazpine gtt. Patient has received 19L of crystalloid total, and he has had worsening renal failure (rapid rise in cr from 1.4 to 2.1, marked oliguria, rising CK's despite seizure history, and concerning abdominal exam). Non-contrast CT scan in ED demonstrated pancreatic tail inflammation, no free air, min fluid in the pelvis. We were initially consulted for management of pancreatitis, but concern grew for abdominal Compartment syndrome. Past Medical History: * Alcoholism - multiple withdrawal episodes, unclear if DTs or alcohol-related seizures * Chronic back pain * Rib fracture ~1 year ago? * Seizure - Pt was not drinking and had a witnessed seizure. Got admitted to [**Hospital1 2025**] and was started on Keppra aproximately ~3 years ago. * PFO " Cyst in the brain" * Hyperlipidemia * GERD * Psoriasis PAST SURGICAL HISTORY: * Lumbas spine surgery * Knee surgery Social History: He lives by himself in [**Location (un) **], MA. He works driving his own 18-wheel truck. He has history of chronic alcoholism; it is unclear if he has history of DTs or alcohol-related seizures. He smokes 1 pack-per-day and has been doing so for 20-30 years. Family denies that he uses drugs. Family History: No family history of seizures, no DM (maybe uncle), no stroke, mother with heart attack and father with heart attack. No early MI. Father's side with prostate and lung cancer and breast cancer. Physical Exam: 99.4 98.4 85 145/90 18 97% RA AOX3 NAD RRR CTAB Abd soft non tender non distended inc: CDI ext: no edema Pertinent Results: [**2162-7-14**] 06:50AM BLOOD WBC-11.6* RBC-2.62* Hgb-8.7* Hct-26.8* MCV-103* MCH-33.3* MCHC-32.4 RDW-14.1 Plt Ct-346 [**2162-7-13**] 06:50AM BLOOD WBC-13.0* RBC-2.42* Hgb-8.5* Hct-25.3* MCV-105* MCH-35.3* MCHC-33.7 RDW-14.6 Plt Ct-286 [**2162-7-12**] 08:05AM BLOOD WBC-15.6* RBC-2.72*# Hgb-9.2*# Hct-28.0* MCV-103* MCH-33.9* MCHC-32.9 RDW-14.1 Plt Ct-354# [**2162-7-11**] 08:19AM BLOOD Hct-26.4* [**2162-7-11**] 05:55AM BLOOD WBC-12.7* RBC-2.03* Hgb-7.2* Hct-21.5* MCV-106* MCH-35.4* MCHC-33.4 RDW-14.8 Plt Ct-183 [**2162-7-10**] 06:32AM BLOOD WBC-16.1* RBC-2.50* Hgb-8.8* Hct-26.7* MCV-107* MCH-35.1* MCHC-32.9 RDW-14.8 Plt Ct-229 [**2162-7-9**] 07:00AM BLOOD WBC-14.5* RBC-2.70* Hgb-9.1* Hct-28.2* MCV-105* MCH-33.7* MCHC-32.2 RDW-14.5 Plt Ct-408 [**2162-6-28**] 09:52PM BLOOD Hct-33.5* [**2162-6-27**] 11:51AM BLOOD WBC-12.6* RBC-3.18* Hgb-11.3* Hct-35.3* MCV-111* MCH-35.6* MCHC-32.1 RDW-14.2 Plt Ct-121* [**2162-6-27**] 12:23AM BLOOD WBC-11.2* RBC-3.04* Hgb-11.4* Hct-33.6* MCV-110* MCH-37.5* MCHC-33.9 RDW-15.0 Plt Ct-104* [**2162-6-26**] 11:27AM BLOOD WBC-10.1 RBC-3.03* Hgb-10.9* Hct-33.5* MCV-111* MCH-36.1* MCHC-32.6 RDW-14.2 Plt Ct-130* [**2162-6-26**] 03:28AM BLOOD WBC-11.0 RBC-3.06* Hgb-11.2* Hct-33.9* MCV-111* MCH-36.5* MCHC-33.0 RDW-15.0 Plt Ct-109* [**2162-6-25**] 02:04AM BLOOD WBC-11.4* RBC-3.37* Hgb-12.4* Hct-36.8* MCV-109* MCH-36.8* MCHC-33.6 RDW-14.9 Plt Ct-106* [**2162-6-24**] 10:15PM BLOOD WBC-10.3 RBC-3.26* Hgb-12.0* Hct-35.6* MCV-109* MCH-36.9* MCHC-33.8 RDW-15.0 Plt Ct-99* [**2162-6-24**] 05:38PM BLOOD WBC-14.6* RBC-3.77* Hgb-13.8* Hct-41.2 MCV-109* MCH-36.5* MCHC-33.4 RDW-14.7 Plt Ct-122* [**2162-6-24**] 11:40AM BLOOD WBC-14.0* RBC-3.68* Hgb-13.5* Hct-39.7* MCV-108* MCH-36.6* MCHC-33.9 RDW-14.9 Plt Ct-122* [**2162-6-24**] 02:08AM BLOOD WBC-17.5* RBC-4.22* Hgb-15.9 Hct-44.5 MCV-105* MCH-37.5* MCHC-35.7* RDW-14.5 Plt Ct-126* [**2162-6-23**] 06:00PM BLOOD WBC-19.3* RBC-3.94* Hgb-14.1 Hct-42.0 MCV-107* MCH-35.7* MCHC-33.5 RDW-13.6 Plt Ct-153 [**2162-6-24**] 05:38PM BLOOD Neuts-84* Bands-8* Lymphs-3* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2162-7-6**] 10:17AM BLOOD PT-16.0* PTT-38.7* INR(PT)-1.4* [**2162-7-14**] 06:50AM BLOOD Glucose-94 UreaN-33* Creat-2.4* Na-138 K-3.4 Cl-103 HCO3-25 AnGap-13 [**2162-7-13**] 06:50AM BLOOD Glucose-98 UreaN-42* Creat-3.3* Na-135 K-3.2* Cl-99 HCO3-24 AnGap-15 [**2162-7-12**] 08:05AM BLOOD Glucose-163* UreaN-49* Creat-4.3* Na-136 K-3.2* Cl-98 HCO3-23 AnGap-18 [**2162-7-11**] 05:55AM BLOOD Glucose-109* UreaN-46* Creat-4.8* Na-133 K-3.3 Cl-96 HCO3-24 AnGap-16 [**2162-7-10**] 06:32AM BLOOD Glucose-101* UreaN-39* Creat-5.0*# Na-136 K-3.3 Cl-99 HCO3-25 AnGap-15 [**2162-7-9**] 07:00AM BLOOD Glucose-130* UreaN-62* Creat-7.4*# Na-136 K-3.5 Cl-97 HCO3-23 AnGap-20 [**2162-7-8**] 01:04AM BLOOD Glucose-120* UreaN-47* Creat-6.2*# Na-139 K-3.8 Cl-99 HCO3-24 AnGap-20 [**2162-7-7**] 02:28AM BLOOD Glucose-117* UreaN-78* Creat-9.8* Na-138 K-4.4 Cl-101 HCO3-18* AnGap-23* [**2162-7-6**] 01:45AM BLOOD Glucose-112* UreaN-73* Creat-9.4*# Na-140 K-4.2 Cl-104 HCO3-21* AnGap-19 [**2162-7-5**] 01:33AM BLOOD Glucose-94 UreaN-58* Creat-7.9*# Na-140 K-4.5 Cl-102 HCO3-23 AnGap-20 [**2162-7-4**] 02:04AM BLOOD Glucose-118* UreaN-42* Creat-6.0*# Na-141 K-4.1 Cl-103 HCO3-28 AnGap-14 [**2162-7-3**] 03:10PM BLOOD Glucose-164* UreaN-31* Creat-4.8*# Na-140 K-3.9 Cl-102 HCO3-29 AnGap-13 [**2162-7-3**] 01:09AM BLOOD Glucose-136* UreaN-57* Creat-8.0*# Na-138 K-4.4 Cl-101 HCO3-24 AnGap-17 [**2162-6-24**] 10:15PM BLOOD Glucose-144* UreaN-33* Creat-3.7* Na-138 K-3.4 Cl-108 HCO3-20* AnGap-13 [**2162-6-24**] 05:38PM BLOOD Glucose-182* UreaN-32* Creat-3.5* Na-135 K-3.6 Cl-106 HCO3-17* AnGap-16 [**2162-6-24**] 11:40AM BLOOD Glucose-180* UreaN-30* Creat-3.1* Na-136 K-3.0* Cl-102 HCO3-22 AnGap-15 [**2162-6-24**] 02:08AM BLOOD Glucose-248* UreaN-28* Creat-2.1* Na-133 K-3.6 Cl-100 HCO3-20* AnGap-17 [**2162-6-23**] 06:00PM BLOOD Glucose-69* UreaN-21* Creat-1.8* Na-138 K-3.1* Cl-103 HCO3-21* AnGap-17 [**2162-7-2**] 02:04AM BLOOD ALT-28 AST-35 AlkPhos-210* Amylase-29 TotBili-0.4 [**2162-6-30**] 01:19AM BLOOD ALT-45* AST-48* AlkPhos-314* Amylase-31 TotBili-0.3 [**2162-6-29**] 02:22AM BLOOD Amylase-40 [**2162-6-28**] 01:16AM BLOOD Amylase-56 [**2162-6-27**] 05:24AM BLOOD CK(CPK)-1345* Amylase-62 [**2162-6-27**] 12:23AM BLOOD ALT-72* AST-173* AlkPhos-156* TotBili-0.7 [**2162-6-26**] 11:27AM BLOOD ALT-74* AST-183* CK(CPK)-2663* AlkPhos-136* TotBili-0.7 [**2162-6-26**] 03:28AM BLOOD ALT-73* AST-225* CK(CPK)-3718* AlkPhos-116 Amylase-65 TotBili-0.8 [**2162-6-25**] 10:12AM BLOOD CK(CPK)-6058* [**2162-6-25**] 02:04AM BLOOD ALT-71* AST-275* CK(CPK)-7772* AlkPhos-72 Amylase-85 TotBili-0.6 [**2162-6-24**] 10:15PM BLOOD CK(CPK)-8790* [**2162-6-23**] 06:00PM BLOOD ALT-33 AST-69* LD(LDH)-459* CK(CPK)-364* AlkPhos-64 Amylase-152* TotBili-1.2 [**2162-7-2**] 02:04AM BLOOD Lipase-34 [**2162-6-29**] 02:22AM BLOOD Lipase-57 [**2162-6-27**] 05:24AM BLOOD Lipase-91* [**2162-6-26**] 03:28AM BLOOD Lipase-65* [**2162-6-25**] 02:04AM BLOOD Lipase-64* [**2162-6-24**] 05:38PM BLOOD Lipase-96* [**2162-7-14**] 06:50AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.4* [**2162-7-13**] 06:50AM BLOOD Calcium-7.6* Phos-4.5 Mg-1.7 [**2162-7-12**] 08:05AM BLOOD Calcium-7.8* Phos-5.8* Mg-2.4 [**2162-7-1**] 09:30AM BLOOD Calcium-8.3* Phos-2.4* [**2162-6-30**] 01:19AM BLOOD Calcium-7.8* Phos-2.0* Mg-2.3 [**2162-6-29**] 02:50PM BLOOD Calcium-8.0* Phos-1.6* Mg-2.2 [**2162-6-24**] 02:08AM BLOOD Albumin-2.5* Calcium-6.7* Phos-3.4 Mg-5.4* [**2162-6-23**] 06:00PM BLOOD Albumin-2.1* Calcium-6.0* Phos-2.9 Mg-4.0* Iron-65 Cholest-80 [**2162-6-23**] 06:00PM BLOOD calTIBC-148* VitB12-337 Folate-7.5 Ferritn-1849* TRF-114* [**2162-7-8**] 06:58AM BLOOD Vanco-19.2 [**2162-6-26**] 07:32AM BLOOD Vanco-25.3* [**2162-7-1**] 09:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2162-7-6**] 09:13PM BLOOD Type-ART pO2-120* pCO2-35 pH-7.38 calTCO2-22 Base XS--3 [**2162-7-6**] 07:38PM BLOOD Type-ART pO2-113* pCO2-37 pH-7.37 calTCO2-22 Base XS--3 [**2162-6-24**] 02:25AM BLOOD Type-MIX pO2-59* pCO2-37 pH-7.37 calTCO2-22 Base XS--3 Comment-GREEN TOP [**2162-6-24**] 02:09AM BLOOD Type-ART pO2-89 pCO2-32* pH-7.42 calTCO2-21 Base XS--2 [**2162-6-23**] 07:34PM BLOOD Type-ART Temp-36.7 Rates-/16 Tidal V-500 PEEP-5 FiO2-100 pO2-122* pCO2-23* pH-7.32* calTCO2-12* Base XS--12 AADO2-591 REQ O2-94 Intubat-INTUBATED Vent-CONTROLLED [**2162-7-6**] 01:59AM BLOOD Lactate-1.0 [**2162-7-5**] 01:37AM BLOOD Glucose-95 Lactate-1.0 [**2162-7-4**] 02:17AM BLOOD Glucose-108* Lactate-0.8 - - IMAGING: [**6-23**] CXR: ETT in place. NGT to be advanced [**6-23**] NC Head CT: No intracranial process [**6-23**]: Abd/ Pelvis CT w/o contrast: Fat stranding surrounding the tail of the pancreas, with thickening and stranding of the left anterior pararenal fascia, most compatible with pancreatitis. Bilateral nephograms, concerning for acute renal failure, although there is some continued excretion into the ureters. Trace free fluid within the abdomen. No loculated collections seen. NGT coiled within the stomach. Further assessment limited due to lack of IV contrast. [**6-23**] CXR: Low lung volumes, ETT 1.2 cm above carina, RIJ tip in RA [**6-24**] TTE: mild symmetric LVH. LV cavity unusually small. Focal wall motion abnormality cannot be fully excluded. LVEF low-normal(50-55%). Trace AI. Trivial MR. [**6-25**]: EEG =No ictal activity, background activity was slow and suppressed suggesting moderate to severe encephalopathy [**6-28**] CXR= ETT 7cm above carina [**6-28**] AXR= Configuration of Dobbhoff feeding tube compatible with positioning in the distal duodenum. Nasogastric tube terminates in the stomach. Bilateral pleural effusions are noted. [**6-30**] CT A/P: Diffuse inflammatory stranding, trace fluid w/o drainable collections. Areas of necrosis in panc head and tail. [**7-1**] CXR: No evidence of interval changes. [**7-2**] KUB: Gastric and Dobbhoff tubes in appropriate positions [**7-4**] CXR: There is no new infiltrate [**7-5**]: Unchanged, ? retrocardiac atelectasis. [**7-6**] IR: Uncomplicated placement of a double-lumen tunneled hemodialysis catheter through the left internal jugular venous approach . Brief Hospital Course: The patient was admitted to ICU on [**6-23**]: Overall pt was admitted for sepsis secondary to pancreaitits with renal failure, seizures and abdominal compartment syndrome. Seizures EEk-- treated with Keppra. Renal failurelast HD [**4-10**]. Electrolytes stable wnl, BUN, Creatin normalizing, thought to be secondary to sepsis and ATN which ultimately resolved (followed by nephrology) and surgery for abdominal syndrome. Pancreatitis also resolved (amylase lipse wnl, liver enzymes also trending to wnl). ICU events: EVENTS: [**6-24**]: Decompressive laparotomy,Transferred to TICU [**6-25**]: Seen by renal, plan dialysis tomorrow. Access planned first thing in AM pre-dialysis. [**6-26**]: CVVH started. Hemodynamically stable. HIT sent. Vanc dosing adjusted. [**6-27**]: Vanc/Zosyn d/c'd, increased CVHHD rate to remove 150 cc/hour [**6-28**]: To OR for partial closure/DHT in duodenum. Postop bladder P 22. ETT advanced 2cm. TFs Nutren 2.0@15 per trauma. PIPs improved 40s->35. CVVHD circuit clot per Nsg->estimate patient lost up to 200cc blood. Renal CVVHD goal neg 150cc/h. Tachy 100s, metop IV. Brief desat w/coughing, thick ETT sputum suctioned, improved. [**6-29**]: Vanc/Levo/Flagyl resumed for WBC 24.6. CVVHD stopped, line removed. Will start HD in AM. [**6-30**]: HD line placed, CT A/P, intermittant dialysis c/ 2.5 L removed [**7-1**]: IHD neg 3L. Keppra dosed for IHD. Vanc trough 19.4. Aline replaced. To OR for abdominal closure, peaks 31. Midaz/Fent gtts weaned to prn. [**7-2**]: TF still held. HD planned for Saturday. Insulin gtt off, NPH 10'' and RISS started. [**7-3**]: Dialysis with 3L neg. Versed off. On dex. Weaned to [**11-19**]. Fluconazole added. Mucus plugging episode c/ tachypnea and hypoxia, back on CMV. [**7-4**]: Bronched/BAL with removal of mucus plugs. No TFs. Needs tunneled line monday then ?SBT/extubation. ?pulling on ETT ON, CXR to reconfirm position. [**7-5**]: fever pan cultureed, tunneled line for tomorrow, extuabte then. Nephro tf started. [**7-6**]: Fluc dcd, extubated [**7-7**]: vanco, levo, flagyl d/c;d per ID. Passed S/S- clears. Creon started for diarrhea. -2L dialysis. Standing PO lopressor. [**7-8**]: Last HD, pt was transfered to floor [**7-9**]: Pt on regular renal diet, worked with PT [**7-10**]: diarrhea (likely [**3-16**] pancreatitis) c-dff neg, WBC 16 [**7-11**]: retal tube removed [**7-13**]: remove HD catheter, WBC 11.6, pt afebrile, workign with PT, reg diet 6:2 discharge in stable condition to rehab MICRO: [**6-23**] LP - 2+ PMNs, 2900 RBCs (in 4th tube, +xanthochromia), Final neg organ Urine - NG [**6-23**] cdiff neg [**6-23**] blood cx - neg [**6-24**] blood cx - neg [**6-24**] Stool - pan-negative [**6-24**] peritoneal fluid NG [**6-28**] blood cx -neg [**6-28**] blood cx -neg [**6-29**] sputum: neg [**6-28**] rectal swab grew VANCOMYCIN RESISTANT ENTEROCOCCUS [**6-29**] stool: neg [**6-29**] sputum: ng [**6-29**] catheter tip: NG [**6-29**] stool: Cdiff neg [**7-4**] BAL,cx: NG [**7-5**] Sputum: NGF [**7-5**] Ucx:NGF [**7-5**] MRSA screen negative [**7-6**] Bl Cx: P [**7-6**] CVL tip: NG - Neuro: Pt has history of one prior seiure 3 yrs ago, known area of encephalomalacia and possibly arachnoid cyst L superior frontal involving the cortex, HTN. Seizure at OSH was prolonged GTC but duration not clear (through ativan 12mg andfosphenytoin 1g) then persistent rythmic chewing on arrival to our ED. He remained on EEG for > 48hrs with no seizure activity. Etiology or seizures unclear ([**Name2 (NI) **] withdrawl vs other). Pt was placed on Keppra 1g/day and extra 500mg after each HD. Neurology recommends MRI of head when feasible given the presentation with prolonged seizure and follow up. - CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: GI/GU/FEN: initialy patient was made NPO with IV fluids. Pt abdmon was closed on [**7-1**]. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. pt had signigicant diarrhea thought to be secondary to pancreatitis, c- diff negative. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Pt was treated with antibiotics Vanc and Zosyn which were d/c on [**6-27**]. no clear organism was identified as source of infection. Pt WBC trended down off of antibiotcs and pt was afebrile at discharge. Skin: pt had significant erythema especially on the buttox bilaterally. Intially thought to be secondary to diarrhea. creams were applied, rectal tube was placed for dirrhea. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, working with physical therapy, voiding, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: CURRENT MEDICATIONS: Keppra Atenolol Chlorthalidone Prilosec Methadone 40 mg Tab Discharge Disposition: Extended Care Facility: [**Hospital6 31006**] of [**Location (un) **] Discharge Diagnosis: sepsis secondary to pancreatitis, urosepsis, seizures Discharge Condition: alert and oriented, tolerating regular diet, making good urine, electrolytes stable, no seizures since early admision, working with physical therapy. Discharge Instructions: You are recovering from pancreatitis, severe systemic infection, seizures and renal failure. You need to have your labs drawn every day or every other day at rehab and electrolytes followed to be sure that your kidney function continues to improve. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *Any new signs of seizure activity, including lip smaking, twitching, change in mental status, fainting, shaking. *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You have decrease in urination. You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees. Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-21**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Call Dr. [**First Name (STitle) **] in neurology or your local neurologist for follow up for seizures in [**2-13**] weeks PCP for history of renal failure or local nephrologist or Dr. [**Last Name (STitle) 9125**] ad [**Hospital1 18**] if your electrolytes are not improving or you are not making urine. General surgeon Dr. [**Last Name (STitle) **] to follow your abdmoninal incision. Follow up in [**2-13**] weeks. Call [**Telephone/Fax (1) 600**] for an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

Admission Date: [**2112-5-13**] Discharge Date: [**2112-5-19**] Date of Birth: [**2062-10-17**] Sex: M Service: MEDICINE Allergies: Bactrim / Sulfa (Sulfonamides) / Seroquel Attending:[**First Name3 (LF) 425**] Chief Complaint: Chest pain, DOE Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 49 yo M with IDDM with hx of smoking and hemoptysis who presents with 4 days of waxing and [**Doctor Last Name 688**] chest pain and dyspnea on exertion. He describes initial pain starting 4 days prior to admission. He desribes sharp chest pain located in the center of his chest that occurred while at rest and resolved spontaneously. He has had continued shortness of breath. Then on wednesday (3 days prior to admission) he awakened in the morning with severe pressure in his chest. The pain was severe for approximately an hour and then also resolved. Since then he has had on and off severe dull, very heavy chest pain. It again recurred this morning and has persisted. Other qualities to the pain are that it is better with sitting up and worse with lying flat, does not radiate to the back, and somewhat worse with deep breaths and coughing. During the last few days, he has had brief periods of activity intermittent with dyspnea on exertion. However, today he was so fatigued that he was unable to let his friend into his house. Also he has had a cough for approximately 2-3 days and increasing sputum. Initially the sputum was lime green, but now has bloody streaks (this AM with increased blood). He was febrile Wednesday AM to 102.3 but has not taken his temp since then. . While in the ED, he Tm 99.6 103 153/90 30 94%RA. Gave ASA 325 P xx 1 metoprolol 5 mg x 1, heparin gtt bolus, then 1000 U/hr, versed IV x 1, plavix 600 mg x 1 Past Medical History: [**2083**]: L knee gun shot wound [**2104**]: L knee total arthroplasty [**2105**]: L knee fusion Hepatitis B Hepatitis C genotype 1, viral load [**2109**] >6 million Diabetes II (last HbA1c 5.6) HTN GERD PTSD BPH Depression Former IVDA Obstructive sleep apnea Social History: Social history is significant for the presence of current tobacco use. There is no history of alcohol abuse. Also has history of IVDA but >8 years ago. Reports being in the military and worked as a SEAL. Lives alone but rents the apartment above him to a friend. [**Name (NI) **] is divorced and has two children that he has not recently seen. Family History: Parents died at a young age. Physical Exam: Blood pressure was 113/67 mm Hg right while seated 111/73 left arm. Pulse was 79 beats/min and regular, respiratory rate was 22 breaths/min. t 98.9 02 sat 98% RA Generally the patient was diaphoretic and in mild distress, and somewhat jaundiced. The patient was oriented to person, place and time. There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple but JVP was not seen. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. There were no thrills, lifts or palpable S3 or S4. The heart sounds were distant revealed a normal S1 and the S2 was normal but distant. ?possible rub heard on sitting up. The abdominal aorta was not palpable. Abdomen was distended with mild tenderness of the RUQ with voluntary guarding. The extremities had no pallor, cyanosis, clubbing or edema. LLE with multiple scars consistent with prior surgeries. Liver percussed to approx 6 cm Pulses: Right: Femoral 2+ DP 2+ PT 2+ Left: Femoral 2+ DP 1+ PT 1+ Guaiac neg per ED Pertinent Results: [**2112-5-13**] 01:50PM BLOOD WBC-6.5 RBC-3.47* Hgb-11.1* Hct-31.0* MCV-89 MCH-32.1* MCHC-35.9* RDW-14.2 Plt Ct-107* [**2112-5-19**] 09:06AM BLOOD WBC-3.5* RBC-3.45* Hgb-10.9* Hct-31.9* MCV-93 MCH-31.7 MCHC-34.2 RDW-14.7 Plt Ct-123* [**2112-5-13**] 01:50PM BLOOD Neuts-67.4 Lymphs-25.2 Monos-5.1 Eos-2.0 Baso-0.3 [**2112-5-13**] 01:50PM BLOOD PT-17.0* PTT-28.4 INR(PT)-1.6* [**2112-5-19**] 09:06AM BLOOD PT-18.1* PTT-74.6* INR(PT)-1.7* [**2112-5-13**] 01:50PM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-133 K-3.9 Cl-100 HCO3-24 AnGap-13 [**2112-5-19**] 09:06AM BLOOD Glucose-99 UreaN-18 Creat-0.2* Na-138 K-4.2 Cl-104 HCO3-24 AnGap-14 [**2112-5-13**] 01:50PM BLOOD ALT-82* AST-66* LD(LDH)-243 CK(CPK)-115 AlkPhos-83 TotBili-0.6 [**2112-5-13**] 08:00PM BLOOD CK(CPK)-92 [**2112-5-14**] 05:20AM BLOOD CK(CPK)-60 [**2112-5-13**] 01:50PM BLOOD CK-MB-5 cTropnT-1.46* [**2112-5-13**] 08:00PM BLOOD CK-MB-NotDone cTropnT-1.30* [**2112-5-14**] 05:20AM BLOOD CK-MB-NotDone cTropnT-1.21* [**2112-5-14**] 05:20AM BLOOD Calcium-8.8 Phos-5.1* Mg-2.2 Cholest-125 [**2112-5-14**] 05:20AM BLOOD Triglyc-122 HDL-27 CHOL/HD-4.6 LDLcalc-74 [**2112-5-13**] 02:00PM BLOOD Lactate-1.6 [**2112-5-13**] 01:50PM BLOOD AFP-1.1 [**2112-5-13**] 04:39PM BLOOD %HbA1c-5.4 ........... CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is no evidence of acute aortic dissection or pulmonary embolism. Large pleural or pericardial effusion is identified. There is coronary artery calcifications, otherwise, the heart and great vessels appear unremarkable. There is scattered non-pathologically enlarged mediastinal lymph adenopathy with no appreciably enlarged nodes noted within the axilla or hila. Evaluation of the lung parenchyma displays diffuse increased interstitial markings extending to the periphery (Kerley B lines) with scattered areas of ground-glass opacity. These findings are most consistent with interstitial edema and congestive heart failure (CHF). Additionally, there is a more focal area of consolidation noted along the major fissure within the right middle lobe (3:64). This may also be related to underlying CHF but focal infiltrative process cannot be excluded. There is bilateral dependent atelectasis. The airways are patent to the subsegmental level. Limited examination through the upper abdomen displays fatty infiltration of the liver but is otherwise unremarkable. BONE WINDOWS: No suspicious blastic or lytic lesions are identified. IMPRESSION: 1. No evidence of acute pulmonary embolism or aortic dissection. 2. Diffuse increased intersitial markings with scattered ground-glass opacities are most consistent with findings of interstitial edema and CHF. Additionally, a more focal area of consolidation is noted within the right middle lobe which may represent a superimposed infectious process. No large pleural effusions are identified. 3. Fatty infiltration of the liver. .... TTE: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (ejection fraction 30 percent) secondary to severe hypokinesis of the anterior septum and anterior free wall, with extensive apical akinesis and focal apical dyskinesis (no definite apical thrombus seen). There is no ventricular septal defect. Right ventricular chamber size is normal. There is focal hypokinesis of the apical free wall of the right ventricle. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2110-8-25**], intercurrent extensive anterior myocardial infarction is evident. ..... Cardiac catherization: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed single vessel disease. There was a cloacal LMCA which was free of critical stenoses. The LAD was totally occluded just distal to S1 and filled distally via left-to-left and right-to-left collaterals. The LCx was diffusely diseased throughout with an aneurysmal segment in the mid-vessel and 30-40% stenoses in the OM1 and OM2 branches. The RCA was also diffusely diseased with an aneurysmal mid-segment and plaquing up to 40%. 2. Limited resting hemodynamics revealed severely elevated left heart filling pressures with an LVEDP of 30mmHg. The opening aortic pressure was 119/75mmHg. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe diastolic left ventricular dysfunction. .... Myocardial viability test: INTERPRETATION: Following injection of of Thallium Chloride while the patient was at rest, static SPECT images were obtained and analyzed 20 minutes post-injection. The patient returned 24 hours later and SPECT images were again obtained. The left ventricular cavity size is enlarged. 20 minute images reveal defects in the distal anterior wall, apex, and septum. 24 hour images reveal improved uptake in the septum. Defects in the distal anterior wall and apex appear unchanged. IMPRESSION: Multiple defects in the distal anterior wall, apex, and septum with evidence of viable myocardium in the septum. Brief Hospital Course: ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS 49 yo man with history of DM, Hep C, htn and hypercholesterolemia admitted with chest pain and large anterior STEMI. . 1)STEMI: Patient presented with symptoms and clinical syndrome consistent for a completing STEMI. Description of symptoms starting approx 4 days prior to presentation and lack of CK elevation supported that the myocardial damage was done several days prior to admission. Echocardiogram showed severely decreased anterior wall motion. Cardiac catherization done at the end of the hospitalization showed occluded LAD with some collateral flow but no intervention was performed (given concern for both viability of the myocardium, compliance with plavix and fear of steal flow to a potentially non-viable area from a viable one). Given that he had severe decreased anterior motion he will need chronic anticoagulation given high risk for apical thrombus. He is likely a candidate for an ICD placement but this will need to be discussed as an outpatient. For futher evaluation of the myocardium, a nuclear viability test was done that shows an area of viability in the septum. Patient was discharged prior to these results. For secondary prevention and treatment of MI, he was started/continued on aspirin lisinopril, metoprolol, and lipitor 80mg He was discharged with instructions to follow up with the [**Hospital3 **] for management of his INR. . 2) Pleuritic chest pain/pericarditis: Throughout the hospitalization the patient had pleuric chest pain. This was thought to be most likely caused by pericarditis after the myocardial infarction. He was treated with pain medications but NSAIDS were avoided. PE was ruled out with a CTA. . 3) Hypertension: Blood pressure control was managed with titration of the lisinopril and metoprolol with the decrease of lisinopril to 5 mg to keep the BP in the low-normal range. . 4) Rhythm: Remained in normal sinus, continued metoprolol 5) Pump: With systolic and diastolic dysfunction. Initially presented with what appeared to be fluid overload as a result of his MI. Patient diuresed a large amount without diuretics. Will need outpatinet echo and possible ICD placement in approx 3 weeks (40 days post MI) . 6) Hemoptysis: Initially presented in the setting of pleuritic chest pain and thus was concerning for PE. However this was ruled out. It seemed to be decreasing as he got further treatment for his community acquired pneumonia, but had not completely resolved. Thought likely secondary to tracheobronchitis. CTA did not show any concerning lesions. . 7) Fever- febrile at home cause was likely with bronchitis/pneumonia. [**Month (only) 116**] have also been in the setting of either infarction or pericarditis. Treated with 7 days of levofloxacin. Afebrile while inpatient. . 8) Hepatitis C: appears to have poor follow up but does have documented high viral load with poor serotype. Viral load was 792,000 IU/mL. LFTs at baseline. Decreased liver span and possible cirrhosis given elevated INR at baseline. Will need outpatient follow up. . 9) Hypertension: initially hypotensive, stopped clonidine, transitioned to toprol XL. . 10) DM: Currently well controlled. HBA1c 5.4. Will give home dose of lantus unless NPO (then will give 1/2 dose) and follow with sliding scale QID . 11) History of osteomyelitis: not active issue, will treat pain. Medications on Admission: - doxepin 300 mg bedtime - clonidine 0.3 [**Hospital1 **] - clonazepam 1 mg b.i.d. - methadone 180 mg once daily x 8 years ([**Hospital 2514**] clinic- [**Telephone/Fax (1) 10301**]) - Lantus 18 units bedtime - OxyContin 60 mg b.i.d. - promethazine 150 mg bedtime - Protonix 40 mg b.i.d. - lisinopril 40 mg daily. - Aspirin 81 mg - bowel meds Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Doxepin 25 mg Capsule Sig: Twelve (12) Capsule PO HS (at bedtime). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for Chest pain: take tablets every 5 minutes for chest pain. If you take more than 2, call EMS. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Promethazine 25 mg Tablet Sig: Six (6) Tablet PO HS (at bedtime) as needed. 13. Insulin Glargine 100 unit/mL Cartridge Sig: Eighteen (18) units Subcutaneous at bedtime: and resume your normal sliding scale. 14. Methadone 40 mg Tablet, Soluble Sig: Four (4) Tablet, Soluble PO once a day: Total dose 180mg daily. 15. Methadone 10 mg Tablet Sig: Two (2) Tablet PO once a day: Total dose 180mg daily. 16. Outpatient Lab Work Please check INR on [**5-20**] (fingerstick) and fax results to [**Telephone/Fax (1) 3534**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: 1. ST elevation Myocardial Infarction Secondary: 1. Leg/Chest pain Discharge Condition: Stable to be discharged to home Discharge Instructions: You had a myocardial infarction. It is very important that you take all of your medications to prevent a new heart attack or congestive heart failure. You were started on Coumadin (warfarin) which is a blood thinner. This medication requires twice weekly monitoring of blood levels. This will be followed by the [**Hospital 3052**] in the [**Hospital Ward Name 23**] Building. You were also started on aspirin which also thins the blood, atorvastatin (Lipitor) for high cholesterol, Toprol XL and Lisinopril for high blood pressure. If you have chest pain, shortness of breath, sensations of heart pounding, sweating, nausea, vomiting, or feel similar to prior to this admission, please come back to the emergency department. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 10302**] on [**6-8**] at 2:20 PM in the [**Hospital Ward Name 23**] [**Location (un) 436**]. Call [**Telephone/Fax (1) 1989**] if you need to reschedule this appointment. . Please follow up with Dr. [**Last Name (STitle) 7341**] on [**6-9**] as previously scheduled: Provider: [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-6-9**] 1:30 . [**Hospital 191**] [**Hospital3 **] will call you to arrange follow up with them so they may monitor your coumadin levels. Additionally a nurse will come to your house to check your INR starting tomorrow.

Admission Date: [**2119-4-2**] Discharge Date:[**2119-5-19**] Date of Birth: [**2119-4-2**] Sex: M Service: NB HISTORY: Baby [**Name (NI) **] [**Known lastname 46082**] number 1 is a former 1585 gram product of a 29 week twin gestation pregnancy, born to a 40 year old G2 P1-3 woman whose pregnancy was apparently uncomplicated until she was admitted to [**Hospital1 190**] on [**3-30**] with vaginal bleeding and preterm labor. Spontaneous rupture of membranes occurred on day of delivery. On the day prior to delivery, on the morning of delivery, labor progressed, and breech presentation of one twin prompted delivery via cesarean section. PRENATAL SCREENS: A positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, GBS status unknown. No risks factors for sepsis noted at time of delivery. At delivery, the infant emerged vigorous and was noted to have mild to moderate respiratory distress. He was given blow- by O2, stim and CPAP. Apgars were 7 at 1 minute, 8 at 5 minutes. Baby was transferred to the newborn intensive care unit after visiting briefly with parents in the delivery room. PHYSICAL EXAMINATION ON ADMISSION: Pink, active, non dysmorphic infant, well saturated and perfused. Increasing work of breathing was noted during the early part of the NICU course. Skin was notable for scattered petechiae about the upper trunk and neck. Bruising was noted about the flank and buttocks. 5 mm superficial laceration on left buttock was noted. HEENT was within normal limits. Normal regular rate and rhythm. S1 and S2. No murmur. Lungs crackly, with shallow bilateral breath sounds. Abdomen benign. No hepatosplenomegaly. Normal premature genitalia, male. Both testes in canal. Hips normal. Back with blind ending sacral dimple. Neurologic nonfocal and age appropriate. HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY. Infant required intubation and received 2 doses of surfactant. Was on the conventional ventilator until day of life 3. At that time, he was loaded with caffeine citrate, with transition to CPAP 5 cm, less than 30 percent O2. Remained on CPAP until day of life 27, when he required re-intubation for increased apnea and bradycardia. At that time, he was noted to have a positive blood culture. See "infectious disease," below. He remained on the ventilator until day of life 33, when he again transitioned to CPAP. He remained on prong CPAP until day of life 37, when he transitioned to nasal cannula O2. He currently is on nasal cannula O2 100 percent, 25-75 cc. Baseline breath sounds of 40-60, clear and equal. Caffeine was discontinued on day of life 15 due to episodes of supraventricular tachycardia (see "cardiovascular," below). The baby has an occasional episode of desaturations at this point in time. The baby did not require any pressor support during this admission. 2. CARDIOVASCULAR. The baby was noted to have a large PDA on day of life 2 on echocardiogram. He received his first course of indomethacin. On day of life 15, was noted to have episodes of supraventricular tachycardia. He had no cardiovascular instability during this episode. He received 2 doses of adenosine to break the supraventricular tachycardia. On day of life 18, he had recurrence of the SVT. At this point in time, the caffeine had been discontinued for several days. This lasted [**1-1**] minutes. It broke without intervention. Cardiology consultation was obtained to rule out congenital heart disease and to assist with ectopy management. Ultimate disease was probable premature atrial contractions with a wandering atrial pacer. He is having some junctional beats. Plan is to discuss with Cardiology followup plan at time of discharge, with probable return to see Cardiology after discharge to Holter monitor, to determine whether ectopy continues after discharge. At the time of this dictation, the baby has had an irregular heartbeat intermittently. Has had no further supraventricular tachycardia. The baby again showed symptoms of a patent ductus arteriosus. Had an echocardiogram on [**4-28**], day of life 26. The echo showed a moderate PDA with left to right flow. On [**5-3**], he received a second course of indomethacin. On [**5-4**], an echo showed no PDA. The baby current has a baseline heart rate of 130-160's. He has no murmur, with baseline blood pressures in the 60-70's systolic, diastolic 30-40's, means in 40-50's. 3. FLUID AND ELECTROLYTES. Birth weight 1590 grams, 90th percentile. Current weight 2625, 50th, greater than 50th percentile. Admission length 40 cm, greater than 50th percentile. Current length 44 cm, greater than 25th percentile. Admission head circumference 28.5 cm, 75th percentile. Current head circumference 32 cm, 50th percentile. The baby initially was NPO and had a double lumen UVC line inserted. Received parenteral nutrition and enteral lipids until his respiratory status stabilized. On day of life 5, enteral feedings were introduced. He achieved full enteral feedings by day of life 12. He is currently feeding 130 cc/kg/day of breast milk 26. This was achieved by adding 4 calories/oz of HMF and 2 cal/oz of MCT. He is also receiving supplemental FeSO4 25 mg/ml, 0.2 ml daily, which equals 2 mg/kg/day. He is voiding and stooling and requiring some gavage feedings. Last electrolytes on [**5-6**] showed sodium 140, potassium 4.9, chloride 105, CO2 22. AST at that time was 20, ALT 9, alkaline phosphatase 301. He is due for nutrition labs again on [**5-23**]. BUN and creatinine on [**5-2**] were BUN 13, creatinine 0.6. 4. GASTROINTESTINAL. Baby had a peak bilirubin on day of life 3 of 7.2/0.4/6.8. Responded to double phototherapy. Had a rebound bilirubin on day of life 8 of 5/0.3/4.7. 5. HEMATOLOGY. His blood type is A positive. He received 2 transfusions so far during this admission, the last one on [**5-4**]. Last hematocrit on [**5-13**] was 37.2. 6. INFECTIOUS DISEASE. Upon admission, the blood culture and CBC were sent and he was started on 48 hours of ampicillin and gentamicin. At 48 hours, the baby was clinically well and the antibiotics were discontinued. On day of life 20, he had another CBC and blood culture sent because of increase in apnea and bradycardia. This was within normal limits, with a white count of 13.6, 31 polys, 6 bands, 37 lymphocytes and platelet count of 563, hematocrit of 30. He was placed back on positive airway pressure, which resolved his increase in apnea and bradycardia. He did have a urine sent for CMV because of his sibling's diagnosis of having urine positive for CMV. This baby's urine has remained negative. On day of life 26, the baby again had increase in apnea and bradycardia while on CPAP. He had a blood culture and a CBC sent. His white count was 14.8, with 75 polys, 5 bands, platelets 484, hematocrit 29. Blood culture grew out Staph aureus. He had been started on vancomycin and gentamicin. Culture was sent. Lumbar puncture ultimately was done. This showed 1 red cell, 2 white cells, protein 87, glucose 50. Cultures remained negative. He was transitioned to oxacillin and received 14 days of treatment for Staph aureus from his negative culture. Oxacillin was discontinued on [**5-17**]. During his treatment with oxacillin, he had serial liver function tests and CBC's drawn, as stated above. 7. NEUROLOGY. [**Known firstname **] has had serial head ultrasounds, all within normal limits, the last one being on [**5-3**] at 33- 3/7 weeks gestation. It was neurologically appropriate for gestational age. 8. SENSORY. Audiology screening has not been done at the time of dictation. Ophthalmology - Eye exam on [**5-1**] showed immature retina, zone 2, with plan to follow up in 2 weeks. 9. INTEGUMENTARY. He has been noted to have a strawberry hemangioma on his scrotum. 10. PSYCHOSOCIAL. Parents have been visiting frequently, and look forward to transitioning home with [**Known firstname **] and his brother [**Name (NI) **] to join his sister, [**Name (NI) 3608**]. CONDITION AT TIME OF TRANSFER: Stable. Transfer to [**Hospital1 35174**] service. Primary pediatrician is Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], [**Location (un) 2274**]. CARE RECOMMENDATIONS: 1. Continue breast milk 26, 130 kg/day p.o. and p.g. 2. Medications - FeSO4 as above, 0.2 ml p.o. daily of 25 mg/cc, which equals 2 mg/kg/day. 3. Car seat screening not done at time of dictation. 4. State newborn screening - Serial screens have been done. Last one on [**4-16**], within normal range. 5. Immunizations received - None to date. 6. Immunizations recommended: Synergist RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks. 2) Born between 32-35 weeks with two of the following: day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. 3) With chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. 7. Followup appointment with primary care pediatrician per routine. Early intervention, VNA, cardiology. DISCHARGE DIAGNOSES: 1. Former 29 week twin #1 of 2. 2. Status post respiratory distress syndrome. 3. Status post rule out sepsis with antibiotics. 4. Status post Staph aureus bacteremia. 5. Status post PDA treated with indomethacin. 6. Supraventricular tachycardia, ectopic beats. 7. Strawberry hemangioma. 8. Immature retinas. [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2119-5-19**] 00:45:02 T: [**2119-5-19**] 03:09:13 Job#: [**Job Number 61015**]

Admission Date: [**2138-7-25**] Discharge Date: [**2138-8-2**] Date of Birth: [**2078-12-25**] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Cortisone / Iodine Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: Transferred form [**Hospital3 **] HOspital for evalulation and treatment for persistent Right pleural effusion with CT output 3L/day. Major Surgical or Invasive Procedure: chest tube placement--right History of Present Illness: 59F h/o advanced metastatic (poorly dif invasive ductal CA) with mets to bone who had recent managment of OSH for pericardial effusion that required s/p windows [**6-24**], [**6-30**] who had bilateral CT for effusions c/b persistent R pleural effusion with CT output >3L/day despite pleurodesis X2 that required transfer to CT surgical service at [**Hospital1 18**] on [**7-25**] for further management. Pt continues on aggressive IV fluids for replacement of fluid losses through chest tube. Pt received 25mg IV adriamycin on [**7-25**] prior to transfer. Her vitals on admission were as follows: 96.6 103 114/53 19 100% 4liters. Pt has had ongoing high output from CT which is being matched with IV fluids/albumin. She had CT torso and echo done with EF >55%. Cardiology was consulted for assistance in management. Right SC line was d/c and tip sent for culture after blood cx returned with CNS 2/2 bottles. She continues on vancomycin and levofloxacin. She was transferred to the CSRU last night after having ongoing CT output on floor and worsening clinical status. The CT was removed this AM despite high output. She has had worsening respiratory status through the day today. She became letharic and hypoxic. She was emregently intubated and chest tube was placed at bedside with 1L output initially. ABG now improving with ph going from 7.05 to 7.24 She has had falling cell counts since admission with WBC going from 5.1 to 1.7, Hct from 31.8 to 23.9, plat # 148 to 85. OSH events: -pericardial drainage with a partial pericardiectomy for presentation with cardiac tamponade -[**2138-6-30**] repeat pericardial drainage and drainage of right/left pleural space with resultant pericardial drain and bilateral -Right pleurodesis with doxycylcine on [**7-12**] and [**2138-7-17**] - PEG placement [**2138-7-10**] with [**Female First Name (un) **] esophagitis noted. Chemotherapy history: Pt received taxotere weekly 9 cycles (3weeks on 3weeks off) [**4-20**] -[**1-20**]. She progressed after this. She then received gemzar [**Date range (1) 44594**]. She then presented with pleural and pericardial fluid from OSH. She was started on weekly adriamycin 2 or 3 doses while at OSH. (outpatient Oncology RN- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 44595**] X 2333 Past Medical History: [**Female First Name (un) 564**] esophagitis s/p PEG [**6-21**], metastatic BReast Cancer on Chemotherapy, s/p radiation therapy, port placement Right subclavian, Left mastectomy [**2-17**], Hypertension, chronic pain Social History: lives w/ husband in RI. Very supportive family. Family History: n/a Pertinent Results: Micro from OSH: BCx ([**7-1**]) 1/4 bottles + staph aureus, [**Last Name (un) 36**] to Levo UCx ([**7-1**]) negative Pericardial fluid: negative cytology Pericardial bx: negative for malignancy Pleural fluid: transudative CT scan ([**7-27**]): L pleural effusion, upper lobes consolidated (PNA vs lymphangitic tumor spread), small R PTX, diffuse bone mets, mediastinal & para-aortic retroperitoneal LAD, moderate ascites, 3 spleen lesions. MIcro culture data - negative [**Date range (1) 44596**]. [**2138-7-25**] 10:38PM GLUCOSE-314* UREA N-23* CREAT-0.5 SODIUM-118* POTASSIUM-6.6* CHLORIDE-98 TOTAL CO2-21* ANION GAP-6* [**2138-7-25**] 10:38PM ALT(SGPT)-39 AST(SGOT)-15 LD(LDH)-334* CK(CPK)-35 ALK PHOS-169* AMYLASE-14 TOT BILI-0.3 [**2138-7-25**] 10:38PM ALBUMIN-2.0* CALCIUM-6.5* PHOSPHATE-1.7* MAGNESIUM-2.1 IRON-24* CHOLEST-131 [**2138-7-25**] 10:38PM WBC-5.1 RBC-3.53* HGB-11.0* HCT-31.8* MCV-90 MCH-31.3 MCHC-34.7 RDW-17.5* Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2138-7-31**] 03:41AM 2.5* 3.14* 9.6* 27.9* 89 30.7 34.5 17.4* 72* Source: Line-art DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2138-7-30**] 02:19AM 92.6* 0 4.8* 2.4 0.2 0.1 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Spheroc Ovalocy Schisto Tear Dr [**2138-7-30**] 02:19AM NORMAL1 1+ 1+ 1+ 1+ NORMAL 1+ 1+ OCCASIONAL OCCASIONAL 1 NORMAL MANUALLY COUNTED BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2138-7-31**] 03:41AM 72* Source: Line-art BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2138-7-30**] 02:19AM 380 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2138-7-30**] 9:05 PM Reason: r/o pulm edema, effusions. [**Hospital 93**] MEDICAL CONDITION: 59yo F with malignant pleural effusions from metastatic breast cancer. now extubated. REASON FOR THIS EXAMINATION: r/o pulm edema, effusions. REASON FOR EXAMINATION: Evaluation of pulmonary edema in patient with bilateral minor pleural effusion due to lung cancer. Portable AP chest radiograph compared to [**2138-7-29**]. The patient was extubated in the meantime interval. The right internal jugular line tip is 1 cm below the cavoatrial junction. The heart size and the mediastinal contours are unchanged. There is worsening of bilateral pulmonary edema as well as of left lower lobe consolidation. The bilateral pleural effusion is grossly unchanged. There is no evidence of pneumothorax with the technical limitation of this film. The tip of the right chest tube is unchanged. IMPRESSION: 1. Meanwhile extubation of the patient. 2. Worsening of the bilateral pulmonary edema. Brief Hospital Course: 59F h/o metastatic BRCA mets to bone on CTX, recurrent pericardial effusion s/p pericardial windows [**6-24**], [**6-30**] @ OSH, persistent R pleural effusion with CT output 3L/day tx'd from [**Hospital3 44597**]. Pt received 25mg IV adriamycin on [**7-25**] prior to transfer. Patient was admitted to floor and was treated aggressively w/ IV fluids/ albumin for replacement of fluid losses through chest tube. CT torso and echo done with EF >55%. Cardiology was consulted for assistance in management. Right SC line was d/c and tip sent for culture after blood cx returned with CNS [**3-20**] bottles. Vancomycin and levofloxacin started and continued until [**2138-7-31**]. HD#[**5-21**]-Overnight she was transferred to ICU for ongoing CT output on floor and worsening clinical status. The CT was removed this AM despite high output. She developed worsening resp status, letharic and hypoxia requiring emergent intubation and chest tube was placement at bedside with 1L output initially. ABG now improved, but w/ continued falling cell counts since admission with WBC going from 5.1 to 1.7, Hct from 31.8 to 23.9, plat # 148 to 85 and metabolic acidosis. HD6-Oncology consulted by Thoracic Surgery. Presentation of significant surgical risk and continued chemotherapy no indicated due to patient condition discussed w/ patient and husband as well as discussion of code status. Pt and husband in agreement of DNR/DNI status, and discussed w/ family and Attending Thoracic Surgeon. Social Worker support provided. HD 7- Patient decision to become comfort measures only and plan for discharge w/ Hospice Care. Family in agreement and w/ patient HD 8- Hospice plans made for discharge next day. Medical arrangements make, medication presriptions provided to Hospice. Pt to be discharged w/ chest tube, extra dressings and pleurovac provided to Hospice personel Medications on Admission: [**Female First Name (un) 564**] esophagitis s/p PEG [**6-21**], metastatic BReast Cancer on Chemotherapy, s/p radiation therapy, port placement Right subclavian, Left mastectomy [**2-17**], Hypertension, chronic pain Discharge Medications: 1. Morphine 10 mg/5 mL Solution Sig: Fifteen (15) cc PO Q4H (every 4 hours). Disp:*150 cc* Refills:*0* 2. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q2H (every 2 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q4H (every 4 hours) as needed for secretions. Disp:*30 Tablet, Sublingual(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**First Name9 (NamePattern2) 269**] [**Location 7188**] [**Location (un) 44598**]Hospice Discharge Diagnosis: [**Female First Name (un) 564**] esophagitis s/p PEG [**6-21**], metastatic BReast Cancer on Chemotherapy, s/p radiation therapy, port placement Right subclavian, Left mastectomy [**2-17**], Hypertension, chronic pain Discharge Condition: fair Discharge Instructions: Provide palliative care, comfort measures only for patient. Administer medications as needed and as directed as stated on discharge instructions. Completed by:[**2138-8-12**]

Admission Date: [**2120-2-26**] Discharge Date: [**2120-2-28**] Date of Birth: [**2034-8-16**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 30**] Chief Complaint: Pleuritic chest pain Major Surgical or Invasive Procedure: Heimlich valve at [**Hospital3 3765**] for PTX History of Present Illness: 85M with a PMh s/f severe COPD on chronic O2, complete heart block s/p PMP [**7-21**], PVD s/p bilateral carotid endarterectomies in [**2111**], HTN, HLD presents to presented to [**Hospital3 7569**] w/chief complaint of chest pain and shortness of breath since the AM. He had a recent hospitalization for MI and PNA, and had completed a 2 week course of PNA on Sunday. At home, he denied any F, C, N/V, but endorsed pleureitic L sided chest pain and shortness of breath. . He initally was taken to [**Hospital3 **], and was given nitro gtt, briefly was on a heparin gtt, and was given Levofloxacin for a worsening LLL PNA. The plan was then to transfer to [**Hospital1 **] since this is where he receives his cardiology care, for sats 70's-80's on facemask prior to switching to nrb, then improved to low 90s for a cards evalulation. While he was in the ambulance, radiology at [**Location (un) **] stat notified our ED of a finding of a 30% left PTX. The ambulance was thus directed to the nearest hospital, which turned out to be [**Hospital1 **]. At [**Hospital1 **], his left PTX was relieved with a Heimlich valve device, which on our repeat CXR shows resolution. The patient then reported improved SOB, but still some mild L CP with inspiration. . In the ED, initial VS were: 99.0 110 170/91 20 98% cont neb . Labs were notable for HCT 36.2, INR 1.4. . He was given Aspirin 325mg, and 4 mg Morphine Sulfate. . CXR was notable for interval resolution of the PTX. . On arrival to the MICU, he is AAOx3, surrounded by his family, and comfortable. His family says that he had a slightly worse cough,a lthough he has a chronic cough at baseline, although he denies his cough is any worse. Past Medical History: Severe COPD on chronic oxygen treatment Complete heart block, status post pacemaker implantation in [**7-/2116**], peripheral vascular disease, status post bilateral carotid endarterectomies in [**2111**]. Hyperlipidemia HTN Social History: He is married. His wife lives at home. He has a former 40 pack-year history of smoking; he has not smoked for 19 years. He has rare alcohol intake. Family History: Mother and father passed from CAD. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:afebrile BP:142/63 P:90 R:20 O2:96% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition, R eye corneal scar, L lower eye lid scar from prior surgery Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, 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 GU:foley in place . DISCHARGE PHYSICAL EXAM Vitals: T:96.2 BP:90s-110s/40s-60s P:70s-80s R:18 O2:95% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition, R eye corneal scar, L lower eye lid scar from prior surgery Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, 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 GU:foley in place Pertinent Results: [**2120-2-26**] 08:35PM GLUCOSE-133* UREA N-18 CREAT-0.9 SODIUM-137 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15 [**2120-2-26**] 08:35PM cTropnT-<0.01 [**2120-2-26**] 08:35PM ALBUMIN-4.0 [**2120-2-26**] 08:35PM WBC-11.0 RBC-4.23* HGB-12.1* HCT-36.2* MCV-86 MCH-28.7 MCHC-33.5 RDW-14.5 [**2120-2-26**] 08:35PM NEUTS-85.6* LYMPHS-9.1* MONOS-4.5 EOS-0.6 BASOS-0.2 [**2120-2-26**] 08:35PM PLT COUNT-259 [**2120-2-26**] 08:35PM PT-14.5* PTT-37.2* INR(PT)-1.4* CXR [**2-26**]: IMPRESSION: Bibasilar opacities, left greater than right, raises concern for an infection/pneumonia and/or aspiration. Blunting of the left costophrenic angle may be due to a small pleural effusion. Bibasilar atelectasis. A tubular structure/catheter extending into the left lung apex with possible tiny left apical pneumothorax remaining. However, suggest followup with removal of external artifact for better evaluation. Upright PA and lateral views may be helpful for further evaluation when/if patient able. CHEST (PORTABLE AP) Study Date of [**2120-2-28**] The left pigtail is in place. The left lower lobe consolidation has substantially improved. Heart size and mediastinum are overall unchanged. The assessment of the lung bases still demonstrate bilateral pleural effusion, small on the right and most likely small to moderate on the left. Brief Hospital Course: 85M with a PMh s/f severe COPD on chronic O2, complete heart block s/p PMP [**7-21**], PVD s/p bilateral carotid endarterectomies in [**2111**], HTN, HLD presents with pleuritic pain and found to have a L PTX. # PTX/Chest Pain: Has remained hemodynamically stable since arrival to the hosptial. Has a Heimlich valve device in place, and is oxygenating well, without new development of PTX. Most likely the pt developed a PTX from the bursting of a bleb as a complication of severe COPD. The pt was ruled out for an MI with CE. He was weaned down to 2L of O2 NC which is his home O2 requirement. Interventional pulmonology removed the Heimlich valve without complication. . # LLL infiltrate: CXR this hospitalization shows a LLL opacity. The pt just completed a two week course of antibiotics prescribed by his PCP for treatment of pneumonia. The pt was afebrile, without a leukocytosis and cough. There was no evidence of infection currently and most likely this radiographic reminence from resolving prior pneumonia. No further antibiotics were given during this hospitalization. . # Acute Urinary Retention: The pt has known BPH and is on Terazosin at home. He claims that for prior hospitalizations he has required urinary catheterization for obstruction as well. He was having difficulty voiding during this hospitalization. A bladder scan revealed >1L of urine in his bladder. A foley catheter was placed to relieve this obstruction. It was then removed and a repeat voiding trial was obtained which showed him to be retaining 600cc of urine in his bladder. A foley catheter was re-inserted and a follow up appointment was made with Urology for removal. We increased his dose of Terazosin from 2mg to 5mg daily prior to discharge. . # Severe COPD on chronic oxygen treatment: Patient was quickly weaned back down to home O2 requirements (2-3L 02 NC), without any extra wheezing on exam. We continued his home Advair, Tiotroprium and nebulizers prn. . # Elevated INR: Chronic problem noted in this pt seen on labs from [**2111**] where is INR was also noted to be 1.4. Pt is not on warfarin currently. His albumin was wnl and there was no active signs of bleeding. . # Hyperlipidemia/PVD: We continued aspirin 81 mg Daily Plavix 75 mg Daily Zocor 10 mg Daily Lisinopril 10 mg Daily . # Chronic Lower Extremity Edema- we continued Lasix 20 mg QAM Lasix 10 mg QPM . # Restless Leg Syndrome: continued Mirapex 0.5 mg QHS . # Transitional- Prior to discharge a urinary catheter was placed to relieve his urinary obstruction from BPH. He has a follow up appointment with urology to have this removed. He also has a follow up appointment with his PCP as well. Medications on Admission: Oxygen 3-liters/hr aspirin 81 mg Daily Alphagan 0.15% Eye dropps 1 [**Hospital1 **] Plavix 75 mg Daily Advair 250-50 1 inh [**Hospital1 **] Lasix 20 mg QAM Lasix 10 mg QPM Prinivil 10 mg Daily Multivitamin 1 capsule Mirapex 0.5 mg QHS Zocor 10 mg Daily Atenolol 50 mg PO/NG DAILY Tiotropium Bromide 1 CAP IH DAILY Terazosin 2.5 mg PO DAILY Discharge Medications: 1. Home Oxygen 3L / hr 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 7. furosemide 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)). 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. terazosin 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 14. atenolol 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary Diagnosis: Pneumothorax Urinary Retention Secondary Diagnosis: Hyperlipidemia Peripheral Vascular Disease Lower Extremity Edema Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital after having a chest tube placed at [**Hospital3 **] for a collapsed lung. The chest tube was removed and your lung has remained inflated. We also discovered that you are not completely empyting your bladder with urination. We placed a urinary catheter to help relieve this obstruction. We have made a follow up appointment for you with urology regarding this matter. The following changes have been made to your medications: INCREASE Terazosin 5mg daily START Fluticasone Propionate 1 spray per nostril daily for nasal congestion Please see below for follow up appointments that have been made on your behalf. Please call Dr. [**Last Name (STitle) 1911**] to schedule follow up. Followup Instructions: Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2515**] [**Last Name (NamePattern1) **] JR. Location: [**Name2 (NI) **] FAMILY MEDICINE Address: [**Apartment Address(1) 17034**], [**University/College **],[**Numeric Identifier 17035**] Phone: [**Telephone/Fax (1) 17030**] When: Wednesday, [**2119-3-7**]:30 AM Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2120-3-6**] at 4:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2127-5-18**] Discharge Date: [**2127-5-27**] Date of Birth: [**2080-7-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Seizure/ Found down Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: Patient is a 46y/o M with PMH of MVA with traumatic brain injury [**11-16**], and EtOH abuse admitted on [**2127-5-18**] after being found down for an unknown period of time. The patient has 2 witnessed GTC events and was brought to ED by EMS on a nasal trumpet. He found found to have a temp of 100.8, BP 202/123. Lactate 13 with EtOH 87. He was intubated for airway protection. Initally, there was some blood noted in his OP, but trauma eval was negative. In addition his temperature was 100.6, and he was cultured and received Ceftriaxone 1 g and Vanc 1 g IV. Neurology eval in the ED was notable for a left lateral gaze preference. recommended an LP which was negative for meningitis. In the MICU he was treated with EtOH withdrawal with ativan and valium, with large benzo requirements (>200mg on [**5-21**]). He underwent EGD for +NG lavage and was found to have portal hypertensive gastropathy with an area of ulceration was seen on the lesser curvature that was clipped. Neurology evaled the patient and he was started on keppra. EEG negative (on benzos). He is now stablized for transfer to the medical floor for continued management. Past Medical History: EtOH abuse Social History: homeless, goes often to Pine street Inn and [**Doctor Last Name **] [**Doctor Last Name 1924**]. used to work as telemarketer, but currently not employed due to ETOH use. admits to extensive EtOH abuse (drinks daily x20 years, drinks several beers daily, 1 quart of gin, + vodka). smokes [**1-10**] ppd x10 years. +marijuana use a few days ago, +cocaine use (last time a few months ago), denies heroin or PCP. Family History: father and brother with etoh use Physical Exam: Admission Exam: GENERAL: intubated, sedated, opened eyes to voice and able to squeeze hands bilaterally, did not move toes to command HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA. Neck: c-collar in place CARDIAC: Regular rhythm, tachy. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Clear to auscultation bilaterally ABDOMEN: NABS. Soft, non-tender, non-distended, liver 2 cm below costal margin EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses, stigmata of chronic liver dz. NEURO: Opens eyes to command and squeezes hand; babinski downgoing, reflexes 2+ patellar and brachial Per neuro initial eval: "On the sedation, he is withdrawing from noxious stimuli with his 4 limbs. Opened his eyes and nodded to the examiner. He has a LEFT gaze preference and does not cross the midline toward the RIGHT. His pupils 2 to 1 mm (on sedation) but PERLA. No facial asymmetry. Closes his eyes purposely. His gag reflex is +. His corneal reflexes are positive. DTRs 2+ throughout with bl withdrawal to plantar" Transfer to Medicine Exam: VS: 99.8 106/84 102 18 97% on RA GENERAL: AA male sitting in bed, poor hygeine, eating dinner in sloppy fashion. HEENT: PERRLA, +anisocoria (L>R). scleral icterus, no sublingual jaundice. MMM, no oral lesions. no LAD. JVD flat without market response to hepatojugular reflex. CARDIAC: Regular rhythm, tachy. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Clear to auscultation bilaterally, decreased BS at bases. ABDOMEN: no caput medusa. no surgical scars. no tenderness of palpation. liver appears nodular to palpation. neg g/rt. no ascitic fluid wave. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. +onochomycosis. SKIN: No rashes/lesions, ecchymoses, stigmata of chronic liver dz. NEURO: AOx2, speech appears slurred. Contemplative about quitting etoh. No asterixis. Pertinent Results: [**2127-5-18**] 06:05PM BLOOD WBC-11.8* RBC-3.75* Hgb-11.6* Hct-35.9* MCV-96 MCH-30.9 MCHC-32.2 RDW-13.9 Plt Ct-118* [**2127-5-18**] 06:05PM BLOOD Neuts-89.8* Lymphs-6.5* Monos-2.7 Eos-0.8 Baso-0.3 [**2127-5-18**] 06:05PM BLOOD PT-16.3* PTT-22.2 INR(PT)-1.5* [**2127-5-18**] 06:05PM BLOOD Glucose-202* UreaN-7 Creat-0.8 Na-140 K-3.7 Cl-88* HCO3-24 AnGap-32* [**2127-5-18**] 06:05PM BLOOD ALT-55* AST-356* CK(CPK)-296* AlkPhos-214* TotBili-2.8* [**2127-5-18**] 06:05PM BLOOD Lipase-122* [**2127-5-18**] 06:05PM BLOOD cTropnT-<0.01 [**2127-5-19**] 12:03AM BLOOD CK-MB-3 cTropnT-0.01 [**2127-5-18**] 06:05PM BLOOD Albumin-4.0 Calcium-8.4 Phos-5.6* Mg-1.3* [**2127-5-18**] 06:05PM BLOOD Osmolal-313* [**2127-5-18**] 06:05PM BLOOD ASA-NEG Ethanol-87* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [**5-18**] EKG Probable sinus tachycardia. Prominent precordial lead QRS voltage raises the consideration of left ventricular hypertrophy, although is non-diagnostic. Non-specific ST-T wave abnormalities. Clinical correlation is suggested. No previous tracing available for comparison. . [**5-18**] CT head FINDINGS: There is no intracranial edema, mass effect, or vascular territorial infarction. An ovoid hyperdensity overlies the cribriform plates and measures 14 x 14mm (2:9), possibly representing a meningioma. Ventricles and sulci are normal in size and in configuration. Extracranial soft tissue structures are unremarkable. Mild mucosal soft tissue thickening is noted at the right maxillary sinus. Fluid in the posterior nasopharynx extends into the ethmoid air cells bilaterally. Otherwise, the paranasal sinuses and mastoid air cells are clear. There is no fracture. IMPRESSION: 1) Extra-axial ovoid hyperdensity overlying the cribriform plates, without mass effect, possibly representing a meningioma. Further characterization with MR [**First Name (Titles) 151**] [**Last Name (Titles) **] is recommended. 2) No intracranial hemorrhage. . [**5-18**] CT C-spine w/o contrast: FINDINGS: There is no intracranial edema, mass effect, or vascular territorial infarction. An ovoid hyperdensity overlies the cribriform plates and measures 14 x 14mm (2:9), possibly representing a meningioma. Ventricles and sulci are normal in size and in configuration. Extracranial soft tissue structures are unremarkable. Mild mucosal soft tissue thickening is noted at the right maxillary sinus. Fluid in the posterior nasopharynx extends into the ethmoid air cells bilaterally. Otherwise, the paranasal sinuses and mastoid air cells are clear. There is no fracture. IMPRESSION: 1) Extra-axial ovoid hyperdensity overlying the cribriform plates, without mass effect, possibly representing a meningioma. Further characterization with MR [**First Name (Titles) 151**] [**Last Name (Titles) **] is recommended. 2) No intracranial hemorrhage. . [**5-19**] Liver U/S FINDINGS: Examination is somewhat limited due to difficulty with patient positioning as well as overlying bowel gas. Allowing for this limitation, liver is diffusely echogenic without focal lesion. There is no intra- or extra-hepatic biliary dilatation. Common bile duct measures 6 mm in caliber. There are no gallstones. Pancreas is not well visualized. There is no ascites. Spleen is not enlarged measuring 8.2 cm in length. The main portal vein is patent and demonstrates antegrade flow. Velocity within the main portal vein measures 17.4 cm/sec. Flow within the right portal vein is noted and is antegrade. Flow within the left portal vein is reversed, compatible with portal hypertension. SMV and splenic vein are patent. IVC, right hepatic vein, left hepatic vein, and middle hepatic vein are all patent and unremarkable. IMPRESSION: 1. Diffusely echogenic liver, commonly seen with fatty infiltration. Other, more advanced forms of liver disease such as cirrhosis or fibrosis can have a similar appearance and cannot be completely excluded by ultrasound. 2. Flow reversal within the left portal vein, compatible with portal hypertension. Flow within the main portal vein is antegrade. There is no splenomegaly or ascites. [**5-19**] CXR FINDINGS: In comparison with the study of [**5-18**], the endotracheal tube remains about 4.5 cm above the carina. Nasogastric tube is coiled in the stomach with the tip projected close to the cardioesophageal junction. The lungs are essentially clear and there is no evidence of vascular congestion or pleural effusion. . [**5-20**] EEG IMPRESSION: This is a normal routine EEG in the waking and sleeping states. The generalized low voltage fast beta rhythms may be seen with medication side effects (e.g. benzodiazepines and barbiturates) or may be seen with anxiety. No focal slowing, epileptiform discharges or electrographic seizures were recorded. . EGD - [**5-19**] Normal mucosa in the esophagus. Erythema, congestion, petechiae and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy (endoclip). Normal mucosa in the duodenum. Otherwise normal EGD to third part of the duodenum Recommendations: Avoid all NSAIDS and [**Doctor Last Name **]-2 inhibitors. Take tylenol for pain (max of 2 grams per day). D/C octreotide. Continue PPI IV BID. . MRI: FINDINGS: There is no evidence of hemorrhage, edema, midline shift, or infarction. The ventricles and sulci are prominent for age suggesting atrophy. There is right maxillary sinus mucosal thickening. No diffusion abnormalities are seen. Overlying the cribriform plate is a T1 bright 12 x 16-mm oval structure (series 3, image 10) which loses signal on fat suppression. The intracranial and vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. IMPRESSION: 1. No infarct or acute intracranial hemorrhage. 2. Incidental note made of a lipoma adjacent to the cribriform plate. 3. Atrophy. Brief Hospital Course: ASSESSMENT AND PLAN: 46 year old man with history of traumatic brain injury and alcohol abuse now with new onset tonic clonic seizures, though to be due to alcohol withdrawal. #. Seizure: Felt most likely to be related to EtOH withdrawal. He also has a history of heavy alcohol use, and alcohol level on admission consistent with withdrawal. Given his head injury and focal slowing on EEG, felt to have a significant risk of seizure recurrence. Got meningitic doses of antibiotics in ED, had negative LP for meningitis. Neurology followed, recommended Keppra for seizure prophylaxis. Treated with valium CIWA scale. MRI showed incidental cribiform lipoma but no evidence of acute stroke or intracranial mass/structural lesions to explain seizures. PT consulted, recommended patient safe to be discharged to [**Hospital1 **]. He was set up with neurology follow-up as outpatient. # EtOH Withdrawal - pt had large benzo requirements on admission (>200mg valium) now improving. Valium CIWA scale, treated with thiamine/folate/MVI. SW/Addictions were consulted, recommended discharge to [**Hospital1 **] for alcohol rehab, to which patient agreed (is contemplative about quitting). # GIB - In ED, reportedly had >600cc bright red NG drainage. Underwent EGD with clipping of ulcers. Scope also suggestive of portal gastropathy. HCT stable on floor. Continued oral PPI on discharge. Kept active T&S, and adequate PIV access during admission. # EtOH Liver Disease - LFTs with AST/ALT ratio > 2 consistent with alcoholic hepatitis. Discriminant function 23 on admission. RUQ with portal HTN. Liver followed. Hepatitis serologies showed borderline hepatitis B. Mild fevers, likely due to alcoholic hepatitis. Infectious work-up negative (negative blood, urine cultures, CXR). # Tongue lesion - needs dental f/u on discharge given risk for head/neck cancer from alcohol and tobacco abuse. # Tobacco abuse - smoking cessation # Hypertension: Added amlodipine. # Cocaine/Marijuana use - SW consulted. Going to [**Hospital1 **] for [**Hospital **] rehab. Medications on Admission: Unknown Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: 1' Diagnosis Alcohol Related Seizures Delerium Tremens Alcohol Abuse Portal Gastropathy Discharge Condition: afebrile, hemodynamically stable, off valium Discharge Instructions: You were admitted with seizures. This was thought to be due to your alcohol use. You required intubation in the intensive care unit. You have agreed to go into an alcohol rehab program. Please take your medications as directed. Return to the hospital for chest pain, blood coming from your throat or your stools, seizures, abdominal pain, or any other symptoms not listed here concerning enough to warrant physician [**Name Initial (PRE) 2742**]. Followup Instructions: with your PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] MEDICAL FOUNDATION [**Telephone/Fax (1) 11463**]. with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] in epilepsy clinic [**Telephone/Fax (1) 3294**] in 1 month. Friday [**2127-6-27**] at 1:00 pm. Completed by:[**2127-5-29**]

Admission Date: [**2131-11-16**] Discharge Date: [**2131-11-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4219**] Chief Complaint: Anemia Major Surgical or Invasive Procedure: None History of Present Illness: Briefly, 85 yo woman w/ transfusion dependant myelofiborisis, diastolic CHF, small bowel AVM's, chronic venous insufficiency who was transferred from rehab for anemia on [**11-16**] (HCT 21). In ED CXR showed early RLL infiltrate w/ pulm edema and she was admitted to Medicine w/ dx of symptomatic anemia, aspiration PNA, and CHF. She was treated w/ IVF's, PRBCs, and 40mg lasix IV, and was placed initially on levoflox and flagyl for presumed aspiration PNA. On HD #2 patient found to be hypotensive, tachycardic, febrile, increasing O2 requirement after receiving 40 mg IV lasix, and was treated with IVF's, dopamine, ceftaz and levo and transferred to the MICU. Concern was for sepsis (fever, low WBC, tachycardia thought to be sedondary to PNA) vs hypotension, but the patient responded well to IVF boluses and PRBC's, and pressors were weaned off by HD #3. The pt denies dyspnea, chest pain. She does report recent increase in LE edema and orthopnea. She denies any recent fever, chills, weight loss, chest pain, palps, cough, abd pain, dysuria, melena, and hematochezia. Past Medical History: 1. Myelofibrosis with myeloid metaplasia, diagnosed [**2124**]. The patient has been transfusion dependent, requiring frequent admissions for transfusions. She was managed with prednisone 20 mg qod and thalidomide but now on hold per by Dr. [**Last Name (STitle) **]/[**Last Name (STitle) **] 2. AVMs in the small bowel diagnosed by capsule endoscopy, but she has been guaiac negative during her admissions in the past. EGD in [**5-/2130**] was normal. 3. H/O left pleural effusion of unknown etiology 4. Spinal stenosis 5. Glaucoma 6. Synovial cyst- This was visualized by ultrasound and CT on [**2130-6-24**]. 7. H/O CHF - TTE [**2131-2-9**] mild LA enlargement, LVEF > 55%, 1+ MR, mild PA systolic HTN, minimal AS, trace AR 8. Lung nodules Social History: The patient lives in a second-floor apartment in a subsidized housing. She has not wanted to pursue nursing home options. She has a son who is involved in her care. Pt also has a home health aide and housekeeper who come on a regular basis for a total of about 3 hours per day. No ETOH, tobacco, or drug use. Family History: Mother had gastric cancer. Physical Exam: VITALS: 98.1, 100/50, 96, 20, 96% 2L GEN: cachectic appearing woman breathing uncomfortably HEENT: anicteric, OP clear w/ MMM PULM: crackles 1/2 up bilaterally, no wheezes CV: reg s1/s2, +3/6 systolic murmur at apex0 ABD: +BS, soft, NT, ND EXT: warm, [**2-1**]+ pitting edema to the thighs B NEURO: CN 2-12 intact, a/o x 3 Pertinent Results: [**2131-11-15**] 03:00PM WBC-1.3* RBC-2.68* HGB-7.9* HCT-21.7* MCV-81* MCH-29.6 MCHC-36.6* RDW-15.3 [**2131-11-15**] 03:00PM PLT SMR-VERY LOW PLT COUNT-14* LPLT-3+ [**2131-11-15**] 03:00PM PT-14.2* PTT-34.7 INR(PT)-1.4 [**2131-11-15**] 03:00PM GRAN CT-740* [**2131-11-15**] 03:00PM ALBUMIN-3.2* CALCIUM-7.2* PHOSPHATE-3.7 MAGNESIUM-2.2 [**2131-11-15**] 03:00PM CK-MB-1 cTropnT-<0.01 [**2131-11-15**] 03:00PM GLUCOSE-95 UREA N-20 CREAT-0.7 SODIUM-138 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-13 [**2131-11-16**] 06:40AM CK-MB-NotDone cTropnT-<0.01 proBNP-9785* [**2131-11-16**] 06:40AM CK(CPK)-9* [**2131-11-16**] 03:53PM LACTATE-1.3 [**2131-11-16**] 05:06PM LACTATE-2.5* [**2131-11-16**] 08:42PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2131-11-16**] 08:42PM URINE [**Month/Day/Year 3143**]-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2131-11-16**] 08:42PM URINE RBC-[**3-3**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2131-11-16**] 08:42PM CK-MB-NotDone cTropnT-<0.01 [**2131-11-16**] 08:42PM CK(CPK)-7* Brief Hospital Course: The patient is an 85 yo woman w/ transfusion dependant myelofiborisis and diastolic CHF was sent from rehab to ED for treatment of HCT 21. On arrival in the ED, T 96.3, BP 104/54, HR 95, O2 sat 92% RA-->98% 2L/m. A CXR showed an early RLL infiltrate and pulmonary edema. She was admitted to Medicine with a diagnosis of symptomatic anemia, aspiration PNA, and CHF. She was treated w/ 3L NS, 2units PRBCs, and 40mg lasix IV. The day after admission, she had temp of 100.0 and was treated with levoflox 250mg IV and flagyl 500mg IV. UOP was 1600cc overnight. At 3:45pm the next day, the patient was given lasix 40mg IV. 35 minutes later she was found to have BP 75/39, HR 120, RR 24, and O2 sat 96% on 2L--> 100% NRB. Temp at that time was 101.8 rectal. She was treated w/ 1L NS, dopamine by PIV, and ceftaz 2gm, and levaquin 500mg. Within the hour, BP increased to 92/34, HR 110. The MICU team was then consulted for evaluation. The patient was transferred to the MICU for treatment of possible sepsis thought most likely secondary to PNA. She was treated with vanocmycin and ceftaz. The patient was transferred out the floor. Her antibiotics were switched to vancoycin and ceftriaxone with a plan to treat for a 10 day course. She was gently diuresed with lasix 10mg IV QD. We continued to transfuse for hct<21 and platelets<15. The patient continued to have increasing amounts of rectal bleeding thought secondary to internal hemorroids in the setting of platelets <20. A GI consult was called. The patient refused an exam, but the GI team advised continuing to give platelets and PRBC. On [**2131-11-20**], the patient chose to change her code status from full code to DNR/DNI. Later that day, the patient began to have hematuria and [**Date Range **] tingled sputum. Her breathing became more labored. She improved with lasix and morphine, but continued to become intermittently hypotensive and was again spiking fevers. A family meeting with the patient and her son lead to a decision to make the patient CMO. All treatments other than lasix/morphine/and ativan were stopped. The patient was started on a morphine drip on [**2131-11-22**] and passed away on [**2131-11-23**]. The family was notified and refused autopsy. Medications on Admission: Tucks Hemorrhoidal Oint 1% 1 Appl PR [**Hospital1 **]:PRN Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR [**Hospital1 **]:PRN Vancomycin HCl 1000 mg IV Q 12H Ceftazidime 2 gm IV Q12H Pantoprazole 40 mg PO Q24H Heparin 5000 UNIT SC TID Docusate Sodium 100 mg PO BID:PRN Acetaminophen 325-650 mg PO Q4-6H:PRN traZODONE HCl 25 mg PO HS:PRN Senna 1 TAB PO BID:PRN Zinc Sulfate 220 mg PO DAILY Ascorbic Acid 500 mg PO DAILY Vitamin D 400 UNIT PO DAILY Calcium Carbonate 1000 mg PO TID W/MEALS Alendronate Sodium 70 mg PO QWED Cyanocobalamin 50 mcg PO DAILY Folic Acid 1 mg PO DAILY Discharge Medications: Expired Discharge Disposition: Extended Care Facility: Meadowbrook - [**Location (un) 2624**] Discharge Diagnosis: Myelodyplastic Sepsis Discharge Condition: Expired [**2131-11-23**] Discharge Instructions: Expired [**2131-11-23**] Followup Instructions: Expired [**2131-11-23**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

Admission Date: [**2142-4-25**] Discharge Date: [**2142-4-29**] Date of Birth: [**2079-6-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: Chief Complaint: shortness of breath Reason for MICU transfer: tachypnea Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: This is a 62-year-old gentleman with HIV (not compliant with HAART, most recent CD4 220), DM2 with nephropathy (baseline Cr 1.8-2.0), Hodgkin's and Burkitt's lymphoma (s/p doxorubicin, vinblastine, dacarbazine now in remission), CHF (EF 22% in [**1-/2142**]) with recent admission to [**Hospital1 18**] from [**Date range (1) 39579**] for RLL pneumonia treated with 10 days of levofloxacin (end date [**2142-4-26**]). He was discharged to rehab. He presented to PCP today with SOB and orthopnea (needs to sit in a chair to sleep). Denies chest pain. Continues to have non-productive cough, anorexia and fatigue. Denies fever. He also notes increased abdominal distention but regular non-bloody bowel movements and regular urination. CXR in [**Hospital 3390**] clinic today revealed large right sided effusion. In the ED, initial vitals were 98.5 90 136/96 24 100% 4L. Labs notable for WBC 9.1 with 1% band, 3% myelo, 3% meta, Cr 1.8 (baseline ~2), BUN 36, Na 132, K 5.3, lactate 2.8, ALT 105, AST 83, AP 605. UA with 100+ protein, no WBCs. Blood and urine cultures sent. CT torso with contrast showed simple large right pleural effusion with RLL collapse and abdominal free fluid. He received cefepime, vancomycin and metronidazole. Zofran given for nausea. Paracentesis not attempted due to poorly identified effusion. Over ED course, dyspnea increased to 30-40, sats 92% RA and 94% on 2L so admitted to MICU. IP [**Name (NI) 653**], planning for thoracentesis in AM. Most recent vitals: 82 130/82 20 94% 2L. In the MICU, patient reports feeling better, breathing is comfortable. He states his dry weight is 149lb. He weighs in at 154lbs today. He received Torsemide 40 mg IV 1x and got a had a diagnostic thoracentesis which revealed a transudative effusion. Cultures of fluid are pending. CXR after tap revealed some resolution of effusion. He was also found to be somewhat hyperkalemia to 5.5 but more torsemide was not given because of concern regarding renal function due to his chronic DM related renal disease as well as recent contrast administration. Currently, he reports that he feels much better and does not have SOB when sitting or lying down. He denies any pain but says that this abdomen continues to feel distended. Past Medical History: - NSTEMI [**9-/2140**] medically managed - HIV (CD4 198 [**2142-1-17**] and VL 84,000 [**2140-12-14**]) - HIV cholangiopathy - DM, type II, uncontrolled (most recent HA1c 9.0 on [**2142-1-17**]) - CKD - Cardiomyopathy with EF 20% on [**2140-2-11**] likely secondary to doxorubicin, although HIV and/or ischemia may have contributed - Pleural effusions - Burkitt's lymphoma ([**2134**]) - Hodgkins lymphoma (last cycle [**8-5**], stable disease) Social History: Came from rehab. Denies smoking, but prior smoker. Occasional EtOH. No drug use. Originally from [**Country **]. Family History: Mother alive with gastric cancer. Father died of Alzheimer's and ?cancer. Physical Exam: ADMISSION EXAM: Vitals: 97.7 84 132/93 25 98%2L 70kg General: Alert, oriented, no acute distress, using neck accessory muscles for respiration HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated to mid neck sitting upright, no LAD CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM heard best at LLSB, no rub/gallop Lungs: Decreased breath sounds at right base ([**11-27**] way up), no W/R/R Abdomen: distended, soft, non-tender, +ascites, bowel sounds hypoactive Ext: warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation . DISCHARGE EXAM: VS - Temp 97.9F, BP 110/62, HR 86 , RR 18, O2-sat 98% RA GENERAL - NAD, comfortable, appropriate HEENT - sclerae anicteric NECK - supple, JVD ~6 cm. HEART - RRR, nl S1-S2, 2/6 systolic murmor at base LUNGS - decreased breath sounds at right base, otherwise CTA. ABDOMEN - Mild distended, non tender, normal bowel sounds EXTREMITIES - Feet shiny and without hair, pulses 1+, 2+ pitting edema NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Admission labs: [**2142-4-25**] 04:50PM BLOOD WBC-9.1 RBC-3.39* Hgb-11.3* Hct-35.4* MCV-104* MCH-33.3* MCHC-32.0 RDW-17.8* Plt Ct-402 [**2142-4-25**] 04:50PM BLOOD Neuts-59 Bands-1 Lymphs-23 Monos-11 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-3* [**2142-4-25**] 05:05PM BLOOD PT-14.2* PTT-33.0 INR(PT)-1.3* [**2142-4-25**] 04:50PM BLOOD Glucose-197* UreaN-36* Creat-1.8* Na-132* K-5.3* Cl-98 HCO3-24 AnGap-15 [**2142-4-25**] 04:50PM BLOOD ALT-109* AST-83* CK(CPK)-74 AlkPhos-605* TotBili-0.7 [**2142-4-25**] 04:50PM BLOOD CK-MB-2 cTropnT-<0.01 [**2142-4-26**] 04:38AM BLOOD CK-MB-2 cTropnT-<0.01 [**2142-4-26**] 04:38AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1 [**2142-4-25**] 04:50PM BLOOD Osmolal-294 Radiology CXR ([**2142-4-26**]) FINDINGS: As compared to the previous radiograph, the patient has undergone a right thoracocentesis. The extent of the right pleural effusion has substantially decreased. There is an opacity at the right lung base, likely reflecting reexpansion lung edema. No evidence of pneumothorax. No change in appearance of the left lung and of the cardiac silhouette. Cytology - pleural fluid Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes and lymphocytes. [**2142-4-28**] 6:11 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2142-4-29**]** C. difficile DNA amplification assay (Final [**2142-4-29**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [**2142-4-26**] 6:45 am PLEURAL FLUID GRAM STAIN (Final [**2142-4-26**]): 3+ (5-10 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 [**2142-4-29**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2142-4-27**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): BLOOD CULTURES: NO GROWTH TO DATE [**2142-4-29**] 05:08AM BLOOD WBC-6.7 RBC-3.30* Hgb-10.7* Hct-34.4* MCV-104* MCH-32.4* MCHC-31.0 RDW-18.2* Plt Ct-387 [**2142-4-29**] 05:08AM BLOOD Glucose-131* UreaN-40* Creat-1.9* Na-136 K-4.6 Cl-99 HCO3-28 AnGap-14 [**2142-4-29**] 05:08AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.9 Brief Hospital Course: This is a 62-year-old gentleman with HIV CD4 220, DM2, CKD, Hodgkin's/Burkitt's lymphoma, CHF (LVEF 22%) with recent RLL pneumonia and interval development of right pleural effusion. While in the emergency department, patient had respiratory rates in the 30 - 40s and was admitted to ICU for tachypnea. # RIGHT PLEURAL EFFUSION: Patient presented to PCP's office for worsening dyspnea, was found to have increased pleural effusion. Patient was sent to ED and subsequently admitted to the MICU for tachypnea. His effusion was drained by IP. The fluid did not appear pustular on thoracentesis and patient felt much improved after fluid removal. CHF exacerbation seems most probable given recently reduced torsemide, abdominal distention with free fluid, simple appearing effusion, and weight gain. Patient was initially treated with vancomycin and cefepime, but the vancomycin was stopped after plerual fluid gram stain showed no microorganisms. Cefepime was also later discontinued. Pleural culture and cytology both returned negative. # ACUTE ON CHRONIC CHF EXACERBATION: Suspected secondary to torsemide being held since recent admission and recent pneumonia. Patient received IV torsemide on arrival to MICU. He received 80mg lasix IV after transfer to the floor on HD2. He was then transitioned to home dose of PO torsemide 20mg [**Hospital1 **] with good response. # DIARRHEA: C.diff negative. Likely in setting of recent antibiotics. # CHRONIC RENAL FAILURE: Suspected secondary to DM2, creatinine currently at baseline. # TRANSAMINITIS: Likely congestive hepatopathy, vs HIV cholangiopathy. LFTs were trended and remained stable. . # HIV: Last CD4 count of 220 in [**2142-3-27**] with HIV PCR VL 780. CD4 nadir has been in the 70s; patient recently initiated HAART therapy, but compliance is uncertain. Last admission team suspected [**Female First Name (un) **] esophagitis and potentially HIV encephalopathy. During this admission, patient was continued Abacavir, Atazanavir, Lamivudine and Ritonavir. Continued atovaquone for PCP [**Name Initial (PRE) 1102**]. Will continue fluconazole for 2 weeks through [**2142-5-9**]. A repeat viral loa # DM2: HBA1C 8.4 most recently, compliance is difficult. During admission, patient was maintained on an insulin sliding scale with QID fingerstick checks and glargine 15 units qHS. Held glipizide during admission. He is to be restarted on his home dose medications after discharge. # HYPONATREMIA: Mild, suspect hypervolemic secondary to heart failure. Patient was diuresed with toresemide and sodium remained stable. Na 136 at discharge. Medications on Admission: 1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO once a day. 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. glipizide 10 mg Tablet Sig: 1.5 Tablets PO once a day. 6. Epivir 150 mg Tablet Sig: One (1) Tablet PO once a day. 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO three times a day. 9. ritonavir 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain. 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Ensure Liquid Sig: One (1) shake PO three times a day. 13. Eucerin Cream Sig: One (1) application Topical twice a day as needed for rash. 15. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours): started [**2142-4-17**], ending [**2142-4-26**]. 16. fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 7 days: started [**2142-4-18**], ending [**2142-4-24**]. 17. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) drop to right eye Ophthalmic QID (4 times a day) for 5 days: started [**2142-4-18**], ending [**2142-4-22**]. 18. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 19. insulin lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous as directed: see insulin sliding scale. Discharge Medications: 1. Abacavir Sulfate 600 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atazanavir 300 mg PO DAILY 4. Atovaquone Suspension 1500 mg PO DAILY 5. Fluconazole 200 mg PO Q24H 6. Gabapentin 300 mg PO Q12H 7. Glargine 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 8. LaMIVudine 150 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Nystatin Oral Suspension 5 mL PO TID 11. RiTONAvir 100 mg PO DAILY 12. Torsemide 20 mg PO BID 13. GlipiZIDE XL 10 mg PO DAILY 14. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO TID pain Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] [**Location (un) 1821**] Discharge Diagnosis: Congestive Heart Failure Exacerbation, Pleural Effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Last Name (Titles) 39580**], It was a pleasure taking care of you during your hospitalization. You were admitted with shortness of breath and swelling in your legs. You were initially place in the medical ICU where the fluid in your lungs was drained. You were given some diuretic medications (Toresemide and Furosemide) with decrease of your swelling. Please take Torsemide 20mg by mouth twice a day every day. Please weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs. It is very important that you continue taking your antiretroviral medications for your HIV. Please also take Fluconazole 200 mg once a day for treatment of you fungal esophagitis through [**2142-5-9**] The following changes were made to your medications: -- START taking Torsemide 20mg twice a day Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2142-5-16**] at 10:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST PROCEDURAL CENTER When: MONDAY [**2142-5-21**] at 8:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: MONDAY [**2142-5-21**] at 8:30 AM [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

Admission Date: [**2142-12-27**] Discharge Date: [**2142-12-31**] Date of Birth: [**2066-5-31**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 64**] Chief Complaint: R hip pain Major Surgical or Invasive Procedure: s/p R THR History of Present Illness: 76 yo F w/long standing cardiac history (followed by [**Hospital1 18**] cards Dr. [**Last Name (STitle) 9764**] including severe AS and MR, with longstanding h/o R hip pain, difficulty with ADLs, and limited ROM. She was thought to meet clinical and radiographic criteria for R hip total arthroplasty. She was not cleared from a cardiac perspective, however, despite extensive work up and discussion about resolving cardiac issues surgically before undergoing orthopaedic intervention, she refused cardiac treatment and elected to undergo R THR, understanding the substantial risks posed by this. The patient was otherwise feeling well prior to the procedure, and now presents for R THR. Past Medical History: Past Medical History: Rheumatic heart disease as a child with above-mentioned severe aortic stenosis and 4+ mitral regurgitation, no evidence of any coronary disease to my knowledge. She also has hypertension. She apparently has had syncope twice in the past, and of course, has severe heart murmurs. She has GERD, but no ulcer history and chronic anemia. History of colon cancer resection [**2132**] and osteoarthritis. Surgical History: [**2132**] partial colectomy for cancer, no subsequent problems, [**2139**] left distal radius ORIF. Social History: Russian physician, [**Name10 (NameIs) 4183**] to USA in [**2130**]. Lives locally with son and husband. G1, P1 nonsmoker, denies alcohol use, rarely able to exercise. Family History: Non-contributory Physical Exam: Russian interpreter present, but we are able to communicate somewhat even in the absence of the interpreter. Her English is reasonable. She is 5 feet, 3 inches, 155 pounds with a BMI of 27.5. Focal examination revealed prior workup showing right hip flexion only to 100 degrees. Leg lengths equal, 10 degrees internal, 20 degrees external rotation right hip with pain at the extremes. Retained [**4-27**] hip flexion and abductor strength. Good vascular inflows without peripheral edema. Brief Hospital Course: On [**2142-12-27**] patient was brought to the operating room and underwent right total hip replacement. The case was uncomplicated with 500cc EBL. Please see Dr. [**Last Name (STitle) **] operative note for details. Post-operatively, the patient was transferred overnight to the ICU for overnight monitoring given her significant cardiac issues. The patient was treated with 24 hours of antibiotic for prophylaxis of infection. Lovenox was given for DVT prophylaxis and TEDS and pneumoboots were used. The patient was made WBAT on the operative extremity with posterior hip precautions and physical therapy assisted with mobilization. Home medications were restarted. On POD 1, she was found to have hct 25 and low UO of 25-20cc. she was otherwise stable for a HD standpoint. The patient was transfused 1U for this, with appropriate bump in her hct and UO. The patient was transferred to the floor in stable condition on POD 2. Per medical recommendations to keep hct>30, received 2U additional units on POD 2 but was otherwise HD stale. 20IV lasix x1 was given afterwards for prevention of fluid overload. Otherwise, pt did very well w/o any cardiac issues. Prior to discharge the patient was afebrile with stable vital signs. Pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. Patient was discharged in stable condition on POD 4. Medications on Admission: HCTZ 12.5 mg every other day, isosorbide 5 mg sublingual p.r.n. rarely, metoprolol 25 mg q.p.m., Diovan 80 mg q.h.s., Prilosec 200 mg daily, albuterol 90 mcg 1-2 puffs p.r.n., calcium, multivitamins. She takes naproxen 375 mg 3 times a day, which does not seem to bother her GERD but does not help with the hip. Acetaminophen 500 mg t.i.d. Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*90 Tablet(s)* Refills:*0* 2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30ml injection Subcutaneous Q12H (every 12 hours) for 3 weeks. Disp:*42 30ml injection* Refills:*0* 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing, SOB. 5. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 6. Isosorbide Dinitrate 5 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual TID PRN () as needed for PRN chest pain. 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 3 weeks: After finishing lovenox course. Disp:*21 Tablet(s)* Refills:*0* 10. Multi-Vitamin Hi-Po Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: R hip OA Discharge Condition: Good Discharge Instructions: Seek immediate medical attention for fever >101.5, chills, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. Wound Care: OK to shower but do not soak incision until follow up appointment, at least. Pat incision dry after showering. Staples will be removed in clinic at follow-up appointment Activity: WBAT RLE. No strenuous exercise or heavy lifting until follow up appointment, at least. Posterior hip precautions. Anticoagulation: Take lovenox 30 mg sc bid x 3 weeks and then take aspirin 325 mg [**Hospital1 **] x 3 weeks. [**Month (only) 116**] discontinue all blood thinners 6 weeks post-operatively. Other: Do not drive or drink alcohol while taking narcotic pain medications. Resume all home medications. Call your surgeon to make follow up appointment Physical Therapy: Weight bearing as tolerated R leg; posterior hip precautions Treatments Frequency: Staples to be removed at follow up appointment; change dressing as need daily, otherwise, may leave open to air; Ok to shower once incision is dry Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2143-1-11**] 1:30 Completed by:[**2142-12-31**]

Admission Date: [**2149-10-9**] Discharge Date: [**2149-10-17**] Date of Birth: [**2073-7-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 21990**] Chief Complaint: bright red blood in stool Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 76F with no prior history of GI bleed, HTN, Sciatica who was at rehab for back pain, who for the past 2 weeks has had constipation & crampy abdominal pain associated with increased belching, flatus. Patient is written for narcotics for pain control of sciatica but is unaware of whether she's taken them. On the morning of admmission she had 4 episodes of blood per rectum with initial bowel movements, which relieved her abdominal discomfort, and were described as dark maroon blood mixed with stool progressing to BRBPR. Patient denies any associated lightheadedness, dizziness, CP, SOB, change in vision, hematuria, epistaxis, ASA, NSAID, or EtOH use. Patient has never had a colonoscopy and there is no family history of colon cancer. Patient denies weight change or change in appetite. She says she and staff at rehab have disagreed about bowel regimen, and she may not have been receiving one regularly. Past Medical History: HTN Sciatica, L4/5 lumbar spondylolisthesis--seen by ortho. Shoulder injury--associated with weakness. OA--knees, bilat. Cervical Joint Disease Depression Narrow angle glaucoma Social History: Patient emigrated from [**Location (un) **] > 50 yrs ago. Used to work as a translator. Currently lives in senior housing in JP with 12 yr old granddaughter. Lives in elder housing with her 12 year old grandaughter. Per OMR, DSS was to get involved given that granddaughter was not in school: "complicated family dynamics". Per pastor who is friend of the patient, the child is in school and issue is resolved for now. She denies any EtoH, tobacco, or illicit drug use. Family History: Patient denies any family history of colon cancer. patient has one living relative who is [**Age over 90 **] years of age. Physical Exam: Vitals - T:98.7 BP:155/66 HR:62 RR:16 02 sat:94 RA GENERAL: laying in bed, NAD SKIN: 8cm vertical old, small multiple subcentimeter hypopigmented macules on lower extremities, well healed incision scar on mid abdomen, warm and well perfused, no excoriations or no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pale conjunctiva, patent nares, dry mucus membranes, good dentition, supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, soft SEM @ RUSB LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact Pertinent Results: [**2149-10-9**] 12:15PM PT-12.4 PTT-31.3 INR(PT)-1.1 [**2149-10-9**] 12:15PM PLT COUNT-327 [**2149-10-9**] 12:15PM NEUTS-68.9 LYMPHS-22.7 MONOS-6.3 EOS-2.0 BASOS-0 [**2149-10-9**] 12:15PM WBC-4.2 RBC-3.39* HGB-10.9* HCT-31.3* MCV-92 MCH-32.1* MCHC-34.8 RDW-13.2 [**2149-10-9**] 12:15PM CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.2 [**2149-10-9**] 12:15PM GLUCOSE-105 UREA N-10 CREAT-0.9 [**Month/Day/Year 11516**]-123* POTASSIUM-4.7 CHLORIDE-87* TOTAL CO2-26 ANION GAP-15 [**2149-10-9**] 12:39PM HGB-11.0* calcHCT-33 [**2149-10-9**] 03:45PM PLT COUNT-287 [**2149-10-9**] 03:45PM NEUTS-69.9 LYMPHS-23.7 MONOS-4.2 EOS-2.1 BASOS-0.1 [**2149-10-9**] 03:45PM WBC-4.4 RBC-3.58* HGB-11.6* HCT-33.5* MCV-94 MCH-32.4* MCHC-34.6 RDW-13.4 [**2149-10-9**] 07:06PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2149-10-9**] 07:06PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002 [**2149-10-9**] 07:06PM URINE OSMOLAL-113 [**2149-10-9**] 09:36PM HCT-28.3* . [**2149-10-10**] 04:57AM BLOOD WBC-8.7# RBC-3.77* Hgb-11.9* Hct-34.9* MCV-93 MCH-31.5 MCHC-34.1 RDW-13.5 Plt Ct-288 [**2149-10-10**] 07:04PM BLOOD Hct-34.5* [**2149-10-11**] 05:55AM BLOOD WBC-8.0 RBC-3.50* Hgb-11.0* Hct-33.0* MCV-94 MCH-31.5 MCHC-33.4 RDW-13.9 Plt Ct-273 [**2149-10-11**] 05:55AM BLOOD Glucose-71 UreaN-5* Creat-0.6 Na-139 K-3.6 Cl-102 HCO3-25 AnGap-16 [**2149-10-17**] 05:40AM WBC 5.4 Hgb 10.3* HCT 30.9* MCV 95 Plt 256 [**2149-10-17**] 09:55AM HCT 33.3* . [**10-10**] Colonoscopy: Findings: Excavated Lesions Multiple diverticula with medium openings were seen in the whole colon.Diverticulosis appeared to be severe. A single diverticulum with signs of inflammation was seen in the ascending colon.Diverticulosis appeared to be of mild severity. Impression: Diverticulosis of the whole colon. Diverticulum in the ascending colon . [**10-15**] Tagged RBC Findings: Negative GI bleeding study. . [**10-13**] MRI L-spine: The alignment of the lumbar spine demonstrate minimal anterolisthesis at L4-L5. The signal intensity in the vertebral bodies is slightly heterogeneous, likely consistent with degenerative changes. The intervertebral disc space at L1-L2 appears unremarkable. At L2-L3 no significant neural foraminal narrowing or spinal canal stenosis is identified. L3-L4 demonstrates disc desiccation and mild posterior diffuse disc bulge producing mild bilateral neural foraminal narrowing, no frank evidence of nerve root compression is detected. Bilateral hypertrophy of the articularjoint facets as well as the ligamentum flavum is observed at this level. At L4-L5, there is evidence of disc desiccation, mild posterior broad-based disc bulge producing bilateral neural foraminal narrowing, right greater than left with possible contact on the right [**Name (NI) 5774**] nerve root, please correlate specifically with this finding, bilateral articular joint facet hypertrophy is also noted associated with bilateral ligamentum flavum thickening. At this level, there is evidence of significant spinal canal stenosis, the thecal sac measures approximately 6 mm in the anterior, posterior diameter. At L5-S1, there is evidence of disc desiccation, posterior broad-based disc bulge producing bilateral neural foraminal narrowing and significant spinal canal stenosis, left greater than right with possible contact on the [**Name (NI) 13032**] nerve root. Bilateral articular joint facet hypertrophy and ligamentum flavum thickening is noted at this level. There is also evidence of irregular contour of the inferior endplate at L5 consistent with a Schmorl's node and bone marrow replacement for fat in the endplates. Vacuum phenomena is also detected in the intervertebral disc space. The sacroiliac joints, visualized aspect of the retroperitoneum and vascular structures appear grossly normal. IMPRESSION: Multilevel degenerative changes of the lumbar spine as described in detail above. At L4-L5, there is evidence of disc desiccation and posterior broad-based disc bulge producing right side neural foraminal narrowing with possible contact on the right nerve root of [**Name (NI) 5774**]. At L5-S1, there is evidence of a left paracentral disc protrusion producing left side neural foraminal narrowing and possible contact on the left [**Name (NI) 13032**] nerve root, moderate-to-severe spinal canal stenosis is identified at this level. Brief Hospital Course: 76 year old female with history of HTN and sciatica presented with 4x BRBPR in setting of 2 weeks intermittent constipation. Brief hospital course by problem: 1.Diverticular bleed - The patient presented with BRBPR x4 and gassy abdominal pain in the setting of intermittent constipation of several weeks duration. GI was consulted, a NG lavage in the ED was negative, and the patient was treated with fluid resucitation with her systolic pressure running below baseline in the 110s. Hematocrit on admission was 31.3 and stable for the first 12 hours. She had no white count, temperature or acute abdominal pain. She was transferred to the MICU for observation overnight and prep for a colonoscopy in the am. She had one episode of hypotension into the 90s associated with lightheadedness and one bloody BM overnight. Her hct dropped to 28.3 and early on [**10-10**] she was transfused 2 u PRBCs with an increase back to 34.9. She went for colonoscopy where numerous diverticula were seen throughout the colon, at least one with evidence of inflamation. Though no source of acute bleeding was seen, diverticuli were felt to be the etiology of bleed. She was transferred to the floor and remained hemodynamically stable. On [**10-12**] however, she experienced renewed melanotic stools and was transferred to the MICU for observation. Her hematocrit remained >30, and she returned to the floor on [**10-13**]. Late on [**10-14**] her first bowel movement since her MICU stay was streaked with bright red blood, and she was sent for a tagged red blood cell scan which did not demonstrate any bleeding. She remained hemodynamically stable and passed another stool with difficulty on [**10-16**] that was formed, brown, but streaked with bright red blood, thought likely secondary to hemorrhoids. Her HCT was stable and was at baseline (33.3) on the morning of discharge. She will need to continue on an aggressive bowel regimen to prevent constipation as this may have aggravated what was surely underlying but silent diverticular disease. . 2.HTN: The patient has a history of hypertension on HCTZ and CCB. These were held on [**10-9**] and [**10-10**] secondary to bleeding, but were restarted on [**10-11**] as the patient was hemodynamically stable. . 3.Sciatica - The patient continued to complain of lower back pain radiating into her leg consistent with her well documented hx of sciatica and L4/5 disease. She was seen by orthopaedics, who had recommended medical treatment and physical therapy with followup with ortho-spine if symptoms persist. She comes to [**Hospital1 18**] from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] where she has been receiving rehabilitation for this condition. She was continued on Tylenol and opioids for breakthrough pain. It appears her Amitryptiline had been recently discontinued. Opioids were initially used cautiously and at low doses given constipation and its role in potentially instigating her bleed, with minimal requests. Pain control was adequate at rest, but she was unable to ambulate. She complained of increased left lower extremity weakness and was sent for an MRI of her lumbar spine. MRI demonstrated the following findings: 1. Multilevel degenerative changes of the lumbar spine; 2. At L4-L5, there is evidence of disc desiccation and posterior broad-based disc bulge producing right side neural foraminal narrowing with possible contact on the right nerve root of [**Name (NI) 5774**]; 3. At L5-S1, there is evidence of a left paracentral disc protrusion producing left side neural foraminal narrowing and possible contact on the left [**Name (NI) 13032**] nerve root, moderate-to-severe spinal canal stenosis is identified at this level. She was examined by the spine team who felt that she would likely benefit from an inpatient pain consult and outpatient work-up of her spine findings. They deferred surgical intervention at this point given her unresolved GI bleeding issues. The chronic pain team was consulted and deferred steroid injection, saying that it might aggrevate her GI bleeding. Under their recommendation she was started on neurontin 300mg TID to assist with the pain. She is to follow up with orthopedics and chronic pain clinics as an outpatient. . She is being discharged to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] on standing Tylenol and neurontin with oxycodone for breakthrough pain. We have reinforced the importance of continuing a bowel regimen if she continues narcotic pain medication. . 4. Hyponatremia: Patient had a serum Na of 123 at presentation. Per her PCP, [**Name10 (NameIs) **] was 138 on [**9-24**]. Hyponatremia was thought likely secondary to volume depletion in the context of blood loss +/- cathartic diarrhea. The urine was paradoxically dilute with Uosm =113. A serum [**Month/Year (2) **] post-fluid repletion was 140. . 5. Social: Patient was very distressed on [**10-11**] am regarding a situation with her non-biological 12 year old granddaughter [**Name (NI) 17976**], who is in her care. Her estranged biological daughter [**Name (NI) 107509**] was threatening to call DSS to remove [**Last Name (un) 17976**] from a friend's apartment where she's staying. DSS was involved in past, but the patient's pastor confirms that she has helped to resolve that issue by enrolling [**Last Name (un) 17976**] in school. The daughter additionally came to the hospital to convey the message that patient is drug seeking. The patient denied overuse of medications, and this accusation was not verified by her pastor or primary care physician. . Dispo: The patient was discharged back to her rehabilitation center in stable condition with instructions to return to the hospital if she has another bowel movement with significant blood loss (more than bright red blood streaking) or if she becomes hemodynamically unstable. Code: FULL. Medications on Admission: Tylenol Valium 5 mg prn Oxycodone 5mg prn Timolol ophth Verapamil 240 mg qd HCTZ 25 mg qd Ibuprofen 600mg QID Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 3. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours): Hold for SBP <100; HR <55. 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP<95. 5. Docusate [**Last Name (un) **] 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 1 weeks: Take for breakthrough pain. Avoid if possible if constipated. Disp:*28 Tablet(s)* Refills:*0* 7. Pantoprazole 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* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnoses: 1)Diverticular bleeding 2)Sciatica from lumbar degenerative disease and disc compression of nerve roots Secondary Diagnoses: 1)Hypertension Discharge Condition: Hemodynamically stable. HCT 33.3 (baseline). No large bloody stool since [**10-12**]. Since then she has had 2 formed stools with a small amount of blood streaking on the outside. Discharge Instructions: You have been diagnosed with diverticular bleeding, a condition in which abnormal outpouchings in the wall of your intestines can cause rapid bleeding via your rectum. We treated you with fluids and a blood transfusion for support and completed a colonoscopy to locate any specific sources of the bleeding. It was this test that showed the diverticula (outpouchings). Constipation may cause diverticula or cause them to bleed. It is very important that you continue on the regimen we've outlined to keep your bowels moving regularly. Your outpatient doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 9004**] to adjust your pain medications, since opioid narcotics (oxycodone, morphine, etc.) can aggravate constipation, especially if you are not taking other agents to keep your bowels moving. We continued to treat your sciatica with pain medication. We obtained an MRI of the lumbar spine which showed disc protrusion and possible compression of some of your lumbar nerve roots which would explain your symptoms. You were evaluated by orthopedics who deferred surgical intervention at this point given your other medical issues. By their recommendation you were evaluated by the chronic pain clinic who decided not to give you a steroid injection at this point, but recommended adding neurontin to your medications for pain management. We started this medication as well. You are being discharged to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] where physical therapists and doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] with you more to treat this condition. We are recommending that you take tylenol four times a day and oxycodone as needed for breakthrough pain. We have also added a new medication (protonix) to help prevent your stomach from forming ulcers which may bleed. Please take this medication as prescribed. Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6924**], to schedule a follow-up visit once you leave rehab. You should also modify your diet to include adequate fiber as this may help prevent constipation and diverticular disease. If you experience any blood in your stools (more than just blood streaks), black stools, maroon-colored stools, or change in your bowel movements, you should contact your primary care physician or go to the emergency room. Please also seek medical attention if you experience chest pain, shortness of breath, dizziness, lightheadedness or weakness. Followup Instructions: - Please contact Dr. [**Last Name (STitle) 6924**] at [**Hospital3 4262**] Group to schedule a followup visit once you are discharged from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] Rehabilitation. - Please keep your previously scheduled appointment for your eye testing and with your eye doctor, [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. on [**2149-10-20**] 10:30 and 11:00. If you need to reschedule, please call his office at [**Telephone/Fax (1) 253**]. - Please also follow-up with your neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2149-11-6**] 12:00. If you need to reschedule, please call her office at [**Telephone/Fax (1) 541**]. - Please also follow-up with your chronic pain clinic appointment on [**2149-12-3**] at 1:40pm. It is located in the pain management center which is in the [**Hospital Ward Name 1950**] Building Fth Floor. - You also have a follow-up appointment with Dr. [**Last Name (STitle) **] in orthopedics on [**2149-11-6**] at 1:40 pm. Completed by:[**2149-10-17**]

Admission Date: [**2142-7-17**] Discharge Date: [**2142-7-20**] Date of Birth: [**2107-5-28**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Egg / Shellfish Attending:[**First Name3 (LF) 2186**] Chief Complaint: Tylenol/barb Overdose Major Surgical or Invasive Procedure: femoral line Intubation/Extubation History of Present Illness: 35 yo F w/Hx of depression and 4 prior suicide attempts, presenting after being found unresponsive (unclear for how long she was down, pt last seen the day before at 10 pm) in her group home on the morning of admission. A suicide note was apparently found. She was intubated in the field. Per pt's pharmacy, pt has access to Fioricet/trazodone/Effexor XR/clonazepam/lorazepam/risperdal. . In the ED, pH 7.25 ([**Last Name (un) **]), lactate 9.0, tox screen + for barbiturate and Tylenol level 267. Received activated charcoal and Mucomyst 10 gr PO. Hypotensive to the 60s (SBP), started on norepinephrine with good response. Past Medical History: - Major Depression and anxiety disorder - s/p multiple suicide attempts w/OD, prefers Fioricet (this is the 5th attempt, 3rd in the last 18 months). She completed a fioricet detox program on [**3-6**], but then in [**Month (only) 205**] had another ICU stay at the [**Hospital1 112**] for Fioricet/Tylenol OD, peak tylenol level was 148 ~4h psot-injestion. No LFT abnormalities at the time. Graduated from a treatment program at the [**Hospital1 882**] [**7-13**]. Also has been hospitalized at the [**Hospital1 2177**], [**Hospital1 336**]. - Idiopathic Sz disorder - Eczema - Asthma - RA Social History: PO narcotic user (h/o fioricet abuse), never used IV drugs. + tob hx, no EtOH. Has a sister, who is involved. Recently broke up w/fiance 6 weeks ago. Lives in a boarding house or group home. On SSDI. Family History: NC Physical Exam: Vs: T 98.7 HR 77 BP 117/94 RR 18 O2Sat 97% RA FS 93 Gen: NAD at rest. HEENT: Pupils 5 mm, equal, reactive to light. EOMI. MM moist, OP clear. Lungs: few crackles at bases b/l CV: RRR, no MRG Abd: +BS, S/NT/ND Extr: warm, no LE edema Pertinent Results: [**2142-7-17**] 10:17AM BLOOD WBC-5.4 RBC-4.13* Hgb-13.3 Hct-37.3 MCV-90 MCH-32.3* MCHC-35.8* RDW-12.5 Plt Ct-197 [**2142-7-17**] 01:15PM BLOOD Neuts-76* Bands-3 Lymphs-14* Monos-6 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2142-7-17**] 10:17AM BLOOD PT-13.2 PTT-21.3* INR(PT)-1.1 PT peaked at 14.7, then returned to [**Location 213**]. [**2142-7-17**] 10:17AM BLOOD Plt Ct-197 [**2142-7-17**] 10:17AM BLOOD Fibrino-281 [**2142-7-17**] 01:15PM BLOOD Glucose-210* UreaN-12 Creat-0.8 Na-143 K-3.4 Cl-115* HCO3-13* AnGap-18 [**2142-7-17**] 10:17AM BLOOD ALT-12 AST-17 AlkPhos-66 Amylase-56 TotBili-0.2 LFTs remained within normal limits throughout hospitalization [**2142-7-17**] 01:15PM BLOOD Calcium-6.7* Phos-2.1* Mg-1.2* [**2142-7-17**] 02:59PM BLOOD Albumin-3.2* . [**2142-7-17**] 10:17AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-267.5* Bnzodzp-NEG Barbitr-POS Tricycl-NEG [**2142-7-17**] 05:29PM BLOOD Acetmnp-29.5* [**2142-7-18**] 09:23AM BLOOD Acetmnp-NEG [**2142-7-18**] 04:36PM BLOOD Acetmnp-NEG . ABGs: [**2142-7-17**] 11:30AM BLOOD Type-ART Rates-14/ pO2-359* pCO2-33* pH-7.25* calHCO3-15* Base XS--11 Intubat-INTUBATED Vent-CONTROLLED [**2142-7-17**] 05:31PM BLOOD Type-ART pO2-113* pCO2-32* pH-7.31* calHCO3-17* Base XS--9 [**2142-7-18**] 06:10AM BLOOD Type-ART Temp-37.1 Rates-/22 PEEP-5 FiO2-40 pO2-201* pCO2-29* pH-7.37 calHCO3-17* Base XS--6 Intubat-INTUBATED Vent-SPONTANEOU . [**7-17**] CXR: IMPRESSION: 1. Mild congestive heart failure. 2. ET tube at the carina and should be pulled back 3 cm for optimal positioning. . [**7-18**] CXR: New bibasilar consolidation consistent with aspiration pneumonia. Upper lungs clear. ET tube and nasogastric tube in standard placements. . Day of discharge Labs: [**2142-7-20**] 06:20AM BLOOD WBC-3.4* RBC-3.28* Hgb-10.6* Hct-29.8* MCV-91 MCH-32.2* MCHC-35.5* RDW-12.8 Plt Ct-147* [**2142-7-20**] 06:20AM BLOOD Glucose-94 UreaN-5* Creat-0.5 Na-142 K-4.1 Cl-113* HCO3-19* AnGap-14 [**2142-7-20**] 06:20AM BLOOD ALT-19 AST-19 AlkPhos-67 TotBili-0.2 [**2142-7-20**] 06:20AM BLOOD Albumin-3.2* Mg-1.5* Brief Hospital Course: 35 yo F w/significant psych Hx and multiple suicide attempts, admitted unresponsive, presumably after OD. (Most likely Fioricet.) Now extubated, off pressors. . 1) Tylenol Overdose: Level 267 on admission, decreased to 0 within 24h. In the ED she received activated charcoal and mucomyst 10g PO. Mucomyst was continued for 11 doses total (stopped when LFTs showed no sign of increase above normal). Coags and LFTs remained wnl. Mucomyst then discontinued. . CXR suggested pneumonia, possibly related to aspiration, so clinda was started. Mental status improved and the patient was extubated on HD #2. . 2) Barbiturate Overdose: Pt was found unresponsive and intubated in the field. By HD #2 mental status was improving and pt was extubated. By the time of discharge mental status was normal. Pt was kept on a CIWA scale and monitored for signs of withdrawal throughout hospital course. Vital signs remained stable. . 3) Hypotension: Initially hypotensive with SBP in the 60s. On levophed for BP support with good response, but then weaned off after fluid resuscitation. [**Last Name (un) **] stim test had an inadequate bump, but hypotension had already resolved so steroids were not started. Monitored bp which remained stable and was 115/79 on day of discharge. . 4) Aspiration pneumonia: Bibasilar consolidation noted on CXR. Will continue treatment with clindamycin for 7 days (day [**1-8**]). . 5) Asthma: Continued inhalers. . 6) Psych/suicide attempt: Psychiatry followed patient during hospital stay. Pt had a 1:1 sitter throughout hospital course. Risperidone was given prn for anxiety. Patient will have psychiatric hospitalization for suicide attempt after discharge from medical service now that patient is medically cleared. . 7) Proph: PPI, SC heparin was discontinued due to PTT elevation, PTT then normalized. . 8) Code status: Full . 9) Dispo: Patient medically cleared on [**2142-7-20**] for transfer to psychiatric care. She is afebrile, temp 97.2, heart rate 68, bp 117/79 and oxygen saturation 97% on room air. Her Tylenol level is now undetectable and LFTs within normal limits. Aspiration pneumonia treated with Clindamycin and to complete 7 day course of antibiotics. Medications on Admission: Butalibitol-APAP-caffeine (picked up 50 pills on [**7-15**] from [**Company 25282**]) Effexor XR 150 [**Hospital1 **] Clonazepam 1 [**Hospital1 **] Risperdal Lorazepam Ambien Lamictal 50 [**Hospital1 **] ?Wellbutrin Ranitidine Metylprednisolone Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Clindamycin HCl 150 mg Capsule Sig: Four (4) Capsule PO Q8H (every 8 hours) for 5 days. 7. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**] Discharge Diagnosis: Medication (Fioricet) overdose Discharge Condition: Stable Discharge Instructions: Please call your Primary Care Physician or return to the hospital if you experience chest pain, shortness of breath, fevers, chills or other concerning symptoms. Followup Instructions: Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1617**] [**Telephone/Fax (1) 355**] [**12-3**] weeks after discharge from the hospital.

Admission Date: [**2178-3-16**] Discharge Date: [**2178-3-20**] Date of Birth: [**2110-6-6**] Sex: M Service: OME HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 68742**] is a 67-year-old male with metastatic renal cell carcinoma, admitted to begin cycle 1, week 2 high-dose IL-2 on the select IL-2 protocol. His oncologic history began in the winter of [**2175**], when he developed a right varicocele and hematuria with CT confirming a right renal mass. On [**2176-1-20**], he underwent right laparoscopic nephrectomy with an 11-cm tumor noted, clear cell histology [**Last Name (un) 19076**] grade 2 with positive renal vein involvement, but all lymph nodes negative. He enrolled in an NIH adjuvant vaccine trial for 8 to 9 months, but was removed from that due to development of lung nodules. Serial scans confirmed growth and he began cycle 1, week 1 high-dose IL-2 on the select IL-2 trial on [**2178-2-24**], receiving 7 of 14 doses, with course complicated by dyspnea, hypoxia and neurotoxicity. He was admitted on [**2178-3-9**] for week #2 of therapy, but a pericardial effusion was noted and he underwent a pericardial window via left mini-thoracotomy. He tolerated this procedure well. He is now admitted for week 2 of therapy. His echocardiogram today reveals a small pericardial effusion without tamponade, which appears loculated. Left ventricular EF is greater than 65%. Chest x- ray reveals a small left pleural effusion with worsening left lower lobe opacity. His shortness of breath had improved and he had no fevers or chills. He was cleared to restart high- dose IL-2 therapy. PAST MEDICAL HISTORY: Hypertension, status post left adrenalectomy and splenectomy secondary to adenomyolipoma, in [**2169-7-5**], complicated by subdiaphragmatic abscess, hepatitis A as a teenager, ventral hernia repair, OA and gout. ALLERGIES: No known drug allergies. MEDICATIONS: Lipitor 10 mg daily, Toprol XL 25 mg daily, on hold, aspirin on hold, Lasix on hold. PHYSICAL EXAMINATION: GENERAL: Elderly male in no acute distress. Performance status 1. Appears fatigued. VITAL SIGNS: 97.6, 83, 20, 134/74, O2 saturation 95% in room air. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Moist oral mucosa without lesions. NECK: Supple. LYMPH NODES: No cervical, supraclavicular, bilateral axillary or bilateral inguinal lymphadenopathy. HEART: Regular rate and rhythm, S1 and S2 with distant heart sounds. CHEST: Dull to percussion at the left base with absent breath sounds at the left base. Clear to auscultation on the right. ABDOMEN: Round, obese, positive bowel sounds, soft, nontender, no hepatomegaly. EXTREMITIES: Trace lower extremity edema. NEURO EXAM: Nonfocal. SKIN: Patchy macular rash over bilateral extremities. ADMISSION LABS: WBC 10.8, hemoglobin 13.2, hematocrit 40, platelet count 732,000, BUN 16, creatinine 1.2, sodium 136, potassium 4.9, chloride 102, CO2 29, glucose 119, CK 41, ALT 57, AST 32, albumin 2.9, INR 1.2, calcium 8.4, phosphorus 3.5, magnesium 2.3, total bilirubin 0.6. HOSPITAL COURSE: Mr. [**Known lastname 68742**] was admitted and underwent central line placement to begin therapy. His admission weight was 120 kg. He received interleukin-2 600,000 international units per kg, equaling 72 million units IV q.8h. x14 potential doses. During this week, he received 3 of 14 doses, with his course complicated by tachypnea, hypoxia and hypotension. He required ICU transfer at that time. He was treated with CPAP and was weaned to O2 by nasal cannula. He was ruled out for an MI by cardiac enzymes. He was placed on Levophed and IV fluid for hypotension. Blood cultures were sent to rule out infection, and he was maintained on vancomycin and cefepime. He transferred back to the floor 2 days later, one weaned from blood pressure support. One set of blood cultures drawn from arterial line on [**2178-3-18**] revealed 1 of 2 bottles positive for staph coag negative, felt to be a contaminant. He had followup blood cultures x2 sets on [**2178-3-19**], without evidence of growth. His antibiotics were continued until his blood cultures returned. His central line was discontinued and he was discharge to home on [**2178-3-20**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home with his wife. DISCHARGE DIAGNOSES: Metastatic renal cell carcinoma, status post cycle 1, week 2 high-dose IL-2 on the select IL-2 protocol, complicated by shock and hypoxia. DISCHARGE MEDICATIONS: Keflex 500 mg p.o. b.i.d., Ativan 1 mg q.4h. p.r.n. nausea/vomiting, Lomotil 1-2 tablets 4 times a day p.r.n. diarrhea, Zantac 150 mg p.o. b.i.d. p.r.n. heartburn, Toprol XL 25 mg daily, Lipitor 10 mg daily, Sarna lotion topically, Eucerin cream topically. FOLLOWUP PLANS: Mr. [**Known lastname 68742**] will return to clinic in 4 weeks after CT scans to assess disease response. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 19077**] Dictated By:[**Last Name (NamePattern1) 18853**] MEDQUIST36 D: [**2178-5-8**] 15:37:16 T: [**2178-5-10**] 18:09:27 Job#: [**Job Number 68747**] cc:[**Numeric Identifier 68748**] [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 68744**], [**Hospital **] [**Hospital 17436**] Hospital [**Street Address(2) 68745**] [**Location (un) 24402**], [**Numeric Identifier 68746**]

Admission Date: [**2103-7-21**] Discharge Date: [**2103-7-26**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: 1)Cardiac catheterization with thrombectomy and balloon angioplasty of a bare metal stent in a venous graft to the obtuse marginal artery. . 2) Intubation/Ventilation . 3) Right subclavian central line History of Present Illness: CHIEF COMPLAINT: Chest pain . EVENTS / HISTORY OF PRESENTING ILLNESS: [**Age over 90 **] year old male with CAD (s/p CABG and multiple stents to the venous grafts), hypertension, type II diabetes, and chronic renal insufficency who presented with suddent onset chest pain and respiratory distress starting at 6a.m. on day of admission. The patient felt this was the same type of pain as his past myocardial infarction. The patient did not have nausea or vomiting. . In the ED, vital signs were as follows: HR-108-120, BP: 128-254/100-164, RR: 32, O2sat: 93-100% on CPAP at 5cm H20. On exam, patient was diaphoretic with cool extremities, there was JVD, bibasilar rales, and bilateral pedal edema. EKG showed ST elevations in aVR and V1-V3. Cardiac enzymes showed a CPK of 125, MB-8, and Trop T 0.21. The patient was given morphine, Aspirin 325mg, metoprolol, Plavix 600mg, integrillin, heparin drip, nitro drip, Lasix 40mg. The patient continued to have respiratory distress an arterial blood gas showed a ph of 7.15, pC02 of 54, and a pO2 of 74 and was therefore intubated with an 8.0 ETT with ventilator settings of Assist control mode with a respiratory rate of 12, tidal volume of 550ml, and PEEP of 7.5, and FiO2 of 100% and an NG tube was placed. He was then brought urgently to the catheterization lab. On review of symptoms, he was intubated/sedated and unable to obtain history. Past Medical History: 1. CAD s/p CABG with 3 venous grafts(SVG->LAD, SVG->LCx, SVG->PDA '[**86**].) Status post stent in [**2099**] (3.5 x 23 mm and 3.5 x 8 mm Cypher in SVG->PDA). Status post stent in [**2103**](3.5 x 18mm Vision RX bare metal stent in the SVG-OM with TIMI 3 flow.) Cath [**2-7**] with: Three vessle coronary disease. 90% mid-vessel stenosis of the SVG to OM with TIMI 2 flow. 40% stenosis of the SVG to PDA prior to the Taxus stent. Total occlusion of the SVG to LAD graft. LVEDP of 26mm Hg. Moderate left ventricular diastolic dysfunction. Successful stention of the SVG-OM graft with a 3.5x1 8mm bare metal stent. ECHO ([**2101-12-8**]): Elongated LA. Normal LV wall thickness and cavity size. LVEF of 50% with mild hypokinesis of the anterior septum, anterior free wall, and apex. Dilated RA. Normal RV chamber size and free wall motion. No AS, or AR. 1+ MR and1-2+ TR. There was moderate pulmonary artery systolic hypertension. 2. HTN 3. Hyperlipidemia 4. Peripheral vascular disease status post bypass [**2088**] 5. DM Type II (not on oral hypoglycemics) 6. Chronic renal insufficiency- baseline Cr of 1.7-2.0 7. Gout 8. Status post right cataract surgery Social History: The patient lives with daughter and wife. [**Name (NI) **] 8 children. Ambulates at home. Denies tobacco, alcohol, and illegal drug use. Family History: Non contributory. Physical Exam: VS: T: 99.0 , BP: 135/68 , HR: 65 , RR: 100% O2sat on AC/16/500/5/50% Wt: 68kg Gen: Slender elderly male who is intubated and sedated. HEENT: Normal cephalic and atraumatic. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of less than 10cm. CV: PMI located in 5th intercostal space, midclavicular line. regular rate, normal S1, S2. No S4, no S3. No murmurs. Chest: No chest wall deformities, scoliosis or kyphosis. Bibasilar crackles. Abd: Soft, non-tender and non-distended, No hepatosplenomegally or tenderness. No abdominal bruits. Ext: Warm, 2+ pedal edema bilaterally. Skin: Minimal stasis dermatitis, No ulcers, scars, or xanthomas. Pulses: Right: Carotid 1+ without bruit; DP 1+; PT 1+ Left: Carotid 1+ without bruit; DP 1+; PT 1+ Neur: Opens eyes to painful stimulus. Moving all four extremities. Pertinent Results: EKG ([**2103-7-21**]): Sinus Tachycardia with a rate of 117bpm. Nml PR and QRS intervals. Mildly prolonged QT interval. Nml axis. LVH. ST elevations in aVR, V1-V3. ST depressions in I, II, aVF, V5-V6. T wave inversions in I, and aVL. Compared to prior EKG: Sinus Tachycardia, worsening of ST elevation in aVR and V1-V3. Though, in the past, minimal ST elevations were present in those leads. . CXR ([**2103-7-21**]): The cardiac silhouette size remains borderline enlarged but stable. Extensive degenerative changes are noted throughout the thoracic spine. There is mild cardiogenic hydrostatic edema with small bilateral pleural effusions. . CARDIAC CATHETERIZATION ([**2103-7-21**])SVG-RCS with 40% stenosis. SVG-OM with previous stent occluded and thrombus. SVG-OM thrombectomy with balloon angioplasty (22atms)resulting in normal flow. LVEDP 25. Right renal artery with no critical lesions. Left renal artery with mild ostial disease. . ECHO ([**2103-7-21**]): Dilated LV with LVEF depressed (20%) Inferior akinesis/hypokinesis, anterior hypokinesis, septal akinesis/hypokinesis, and apical akinesis/dyskinesis. Nml RV size with depressed RV funcion. No AS. No pericardial effusion/tamponade. . ECHO ([**2103-7-23**]): Mild LA enlargement. Mild symmetric LVH with normal cavity size. There is mild hypokinesis of the distal septum and distal inferior wall. Left ventricular ejection fraction of 30-35%. Mild RA dilation. Normal RV chamber size and mild RV hypokinesis. Trace AR, ([**1-2**]+) MR, (1+) TR. Compared to study on [**2103-7-21**], there is improvement in LV function. . [**2103-7-21**] WBC-14.4*# RBC-4.99 Hgb-16.4 Hct-51.2 MCV-103* MCH-32.9* MCHC-32.0 RDW-16.0* Plt Ct-212 [**2103-7-26**] WBC-7.5 RBC-3.43* Hgb-11.3* Hct-33.3* MCV-97 MCH-32.8* MCHC-33.8 RDW-15.7* Plt Ct-189 . [**2103-7-21**] PT-11.4 PTT-26.3 INR(PT)-1.0 [**2103-7-26**] PT-11.8 PTT-27.1 INR(PT)-1.0 . [**2103-7-21**] Glucose-201* UreaN-28* Creat-2.0* Na-140 K-4.4 Cl-104 HCO3-24 AnGap-16 [**2103-7-26**] Glucose-134* UreaN-35* Creat-2.0* Na-138 K-4.2 Cl-101 HCO3-27 AnGap-14 . [**2103-7-21**] ALT-53* AST-40 AlkPhos-145* Amylase-29 TotBili-0.8 [**2103-7-22**] ALT-39 AST-57* . [**2103-7-21**] CPK-125 [**2103-7-21**] CPK-95 [**2103-7-21**] CPK-773* [**2103-7-21**] CPK-603* [**2103-7-22**] CPK-354* . [**2103-7-21**] CK-MB-8 [**2103-7-21**] cTropnT-0.21* [**2103-7-21**] CK-MB-95* MB Indx-12.3* cTropnT-3.10* [**2103-7-21**] CK-MB-49* MB Indx-8.1* [**2103-7-22**] CK-MB-23* MB Indx-6.5* cTropnT-1.88* . [**2103-7-21**] 08:15AM BLOOD Triglyc-153* HDL-37 CHOL/HD-3.5 LDLcalc-62 . [**2103-7-21**] Blood gas in ED: pO2-54* pCO2-74* pH-7.15* calTCO2-27 Base XS--4 [**2103-7-21**] Blood gas before extubation: pO2-90 pCO2-40 pH-7.45 calTCO2-29 Base XS-3 . [**2103-7-21**] %HbA1c-5.8 . [**2103-7-21**] HIV AB - negative, HCV Ab - negative . [**2103-7-21**] Urine Culture. Enterococcus greater than 100,000 organisms. Sensitive to ampicilln, nitrofurantoin, and vancomycin. Resistant to tetracycline. Brief Hospital Course: ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN MULTI DISCIPLINARY ROUNDS : Mr. [**Known lastname **] is a [**Age over 90 **] year old man with a history of CAD (s/p CABG and mult. stent placements), type II diabetes, hypertension, and hyperlipidemia who presented with chest pain and shortness of breath and found to have an ST elevation myocardial infarction based on EKG and cardiac enzymes. Status post cardiac catheterization with thrombectomy and balloon angioplasty of the SBG-OM graft. . CAD/STEMI: Patient is s/p cardiac cath with thrombectomy and balloon angioplasty of the SBG-OM graft. Cardiac enzymes were cycled with a peak CPK of 773 and a peak CK-MB of 95. The fact that the patient had thrombosis of a bare metal stent in the SBG-OM graft while on a home dose aspirin and Plavix is concerning for some sort of hypercoagulable state. The patient was therefore started on Plavix 75mg PO BID. The patient was continued on aspirin 325 mg daily, continued on Integrilin for 18 hours after catheterization, atorvastatin 80 mg, and a nitro drip (which was later weaned.) Metoprolol was titrated up to 75 mg PO TID. The patient was also started on isosorbide 30mg TID. An ACE inhibitor was held until hospital day 4 because of the history of chronic renal insufficiency and the recent cardiac catheterization dye load. The lisinopril then was started and titrated up to 20mg Daily. A lipid panel showed and HDL of 37 and LDL of 62, . Pump/CHF: Patient has history of LVEF of 50% with diastolic dysfunction repeat ECHO showed and an ejection fraction of 20% with inferior, septal, and anterior hypokinesis. On admission exam, the patient had bilateral crackles and pedal edema. Admission chest x-ray showed infiltrates. Therefore the patient was given Lasix 20mg IV for three days. The patient was 4.5 liters negative for the length of stay with decreasing oxygen requirement (now on room air) and resolved pedal edema. The patient will be discharged on his home dose of Lasix 20mg PO Daily. The patient was maintained on a beta blocker and an ACE inhibitor was started on hospital day 4. . Rhythm: Patient stayed in normal sinus rhythm. Occasional premature atrial beats. . Resp: On admission to the CCU, the patient was intubated/sedated. The ventilator setting were weaned and the patient passed a pressure support trial. An arterial blood gas before extubation showed a ph of 7.45, pCO2 of 40, and pO2 of 90. On the evening of admission, the patient was extubated successfully. Since that time the patient has had decreasing oxygen requirement and was discharged on room air. . Hypotension: On transport from the cath lab, the patient became bradycardic and hypotensive (SBP to the 80's.) The patient was given atropine with good response. The patient was also started on a neosynephrine drip which was quickly weaned. This episode was thought to be due to a post-cath vaso-vagal event or recent administration of propofol. There was concern from a cardiac tamponade and/or ACS an ECHO was rapidly performed and ruled this out. The patient did not have any more hypotensive episodes. . Respiratory Acidosis: ABG on admission showed a ph of 7.20 pCO2 of 58, and pO2 of 314 consistent with respiratory acidosis. The respiratory rate was increased and repeat ABG showed a pH of 7.47, pCO2 of 29, and pO2 of 193. . DM type II: A HbA1c was 5.8%. The patient was maintained on an insulin sliding scale. The patient was restarted on his home dose of glipized before discharge. . ID/Fever: On [**2103-7-21**], the patient had rectal temperature to 102.4. The patient was started on a course of levofloxacin for possible pneumonia (equivocal infiltrate on CXR). Blood cultures were negative and and urine cultures grew enterococcus sensitive to ampicillin, nitrofuratoin, and vancomycin. The patient was started on a 10 day course of amoxicillin on [**2103-7-24**] and remained afebrile throughout the rest of his stay. . Renal Function: Patient has history of chronic renal insufficiency with a baseline Cr of 1.8-2.0, and received Acetylcysteine x2 after catheterization. His renal function remained stable and he is discharged on lisinopril 20mg. . Hematuria: Mr. [**Known lastname **] developed hematura on aspirin, Plavix, heparin, and Integrilin. Because of clots, urology was consulted and a 3 way catheter was placed and irrigated. The catheter was removed the next day w/o complication and he was urinating wihtout difficulty on discharge. . Prophy: The patient was maintained on a bowel regimen, proton pump inhibitor, and Heparin SQ. . Access: Right SCV line was placed on [**2103-7-21**] and removed on [**2103-7-23**]. Patient had peripheral IV access at that time. . Code: Full . Contact: [**Name (NI) 29880**], [**Telephone/Fax (1) 29881**]. Granddaughter, [**Name (NI) **], [**Telephone/Fax (1) 29882**]. . Dispo: The patient was discharged to the floor on [**2103-7-25**]. The patient was seen by physical therapy and sent home with services. The patient will follow up with his cardiologist and primary care doctor. Medications on Admission: 1. Colchicine 0.6 mg po qod 2. Allopurinol 100 mg po qod 3. Lisinopril 40 mg po daily 4. Atorvastatin 20 mg po daily 5. Aspirin 325 mg po daily 6. Hexavitamin po daily 7. Glipizide 5 mg po daily 8. Furosemide 20 mg po daily 9. Clopidogrel 75 mg po daily 10. Nitroglycerin 0.3 mg Tablet sl prn 11. Isosorbide Dinitrate 30mg po tid 12. Metoprolol Tartrate 75 mg po bid 13. Ferrous Sulfate 325mg po daily 14. Docusate Sodium 100 mg PO BID 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 BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 8 days. Disp:*32 Capsule(s)* Refills:*0* 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain. 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. Isosorbide Dinitrate 30 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1) ST elevation myocardial infarction 2) Congestive heart failure 3) Hypoxic respiratory failure 4) Urinary tract infection Discharge Condition: good; stable/normal vital signs, tolerating po, ambulating with assistance. Discharge Instructions: During this hospitalization, you were diagnosed with a heart attack. The type of heart attack you had is called an ST elevation myocardial infarction. You underwent a cardiac catheterization to help open up the vessels in your heart. . It is very important that you take all of your medications. It is especially important that you take your Plavix and aspirin. You should take your aspirin once a day and your Plavix twice a day. Under no circumstance should you stop taking these medications without speaking to your cardiologist. If you become sick and vomit and are not able to take your aspirin or plavix, please contact your cardiologist. . If you have chest pain, shortness of breath, dizziness, or feel hot/sweaty, please call your doctor or go to the nearest emergency room. Please call your doctor if you have any other concerns. We also found that you have a urinary tract infection for which you will need to finish about 1 week of antibiotics. If you develop fevers, chills, nausea, vomiting, abdominal pain and diarrhea, or any other problems then please seek medical advice. Followup Instructions: Please follow up with your cardiologist. You have an appointment with Dr. [**Last Name (STitle) **] on [**2103-8-1**] at 11:30am at [**Hospital3 29818**] [**Apartment Address(1) 29883**]. Please call [**Telephone/Fax (1) 5985**] if you have any questions. . Because you were in the hospital, you should follow up with your primary care doctor. You have an appointment with DR. [**First Name (STitle) **] [**Name8 (MD) 29884**], MD on [**2103-7-25**] at 2:15pm. Please call [**Telephone/Fax (1) 7976**] with any questions. . You also have an appointment with [**First Name5 (NamePattern1) 6811**] [**Last Name (NamePattern1) 29885**] [**Doctor Last Name **] on [**2103-8-6**] at 11:00am. Please call [**Telephone/Fax (1) 7976**] with any questions.

Admission Date: [**2119-6-7**] Discharge Date: [**2119-7-18**] Date of Birth: [**2063-7-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: evacuation of abdominal wall hematoma and paracentesis re-exploration of abdominal wall hematoma with surgicel packing History of Present Illness: 55yoF with alcoholic cirrhosis s/p TIPS [**1-/2118**] found down by her husband. The patient has a history of depression which her husband, [**Name (NI) **], reports has been exacerbated lately by several stressful situations including her chronic back pain, finances, etc. She was last seen to be interactive and appropriate at 06:00am this morning by her husband. [**Name (NI) **] son saw her at 11am, but thought the patient was asleep and did not attempt to wake her. She was subsequently found down on the floor by her husband at 3pm, 9 hours after last being seen, who describes her as being in a fetal position with her eyes rolled to the back of her head and her mouth wide open. Her husband began to lift the patient off the floor and she bit him on the shoulder and did not appear to recognize him. She was take to [**Hospital6 33**] where she was was found to be responsive to verbal stimuli but unable to interact appropriately. She was intubated. Coffee grounds returned from her OGT and she was hypotensive in the 80's/40's. FS was 22 and received glucose, T was 94.6, and she was placed on a bear hugger. pH was 6.8, lacate 25, creatine 3.2, bicarb 4. She was received 2 amps bicarb, 1 amp D50, and blood cultures were drawn from her central line. She was started on bicarb drip, levophed gtt for SBP 80's. She not making urine after 6L IVF. She was transferred to [**Hospital1 18**] for further management. R IJ was placed at the OSH and 2 peripheral IVs. . Per the husband's report, the patient does have a history of surreptitious alcohol ingestion on occasion but he has not noticed or detected any alcohol use recently. He denies the likelihood of illicit drug use or prescription drug overdose, stating the only medication she has access to is Tramadol, which she had not been taking. He denies recent vocalizations by the patient regarding suicidal ideation. . In the [**Hospital1 18**] ED, initial VS: 123 113/29 27 100% The patient was noted to have 150cc dark coffee ground output from her OGT, but stool was guiac negative. Hepatology was consulted, and the patient was started on an Octreotide gtt and Pantoprazole gtt, and aggressive flushing of the OGT was recommended. She was ordered to be transfused 1 unit PRBC. She was empirically treated with Vanc/Levo/Flagyl and CT torso was obtained, which showed no evidence of infection or acute bleed. She received 8L IVF in the ED, and was increased on Levophed 0.4mcg/kg/hr. Renal was consulted as the patient had a poor UOP and was acidotic, and CVVH vs hemodialysis was discussed. The patient was given Calcium gluconate 2gm, Bicarb gtt @150cc/hr, and was prepared for possible CVVH tomorrow. Transfer VS were: 112/47, HR 117, 99% 60% PEEP 5, TV 450 . On arrival to the MICU, the patient was intubated and opening her eyes to verbal stimuli but not following commands. Her husband was available to give a brief history, which is detailed above. Past Medical History: - Alcoholic cirrhosis s/p TIPS placement [**1-/2118**] (per GI OSH neg hepatitis serology, had pos Anti-SMA but neg [**Doctor First Name **]) - h/o GIB [**11/2117**] s/p banding of esophageal varices - h/o myomectomy Social History: - Tobacco: Has not smoked since her 20s. - EtOH: History of heavy alcohol use x 20 years, sober since [**8-25**]. - Illicit Drugs: Remote cocaine history. - Lives with her husband. Family History: Father with CAD. Otherwise non-contributory. Physical Exam: Admission physical exam VS: 98.9 126 -> 110 139/55 -> 92/49 24 99% GEN: Intubated, NAD HEENT: Pupils small (<1mm) but equal and reactive to light, sclear anicteric, MMM, no jvd, intubated with ETT in place CV: Tachycardic, regular rhythm, normal S1/S2, GII holosystolic murmer at LSB, S3 heard best at LSB RESP: CTAB anteriorly and laterally with with good air movement throughout, no wheezes/rales/rhonchi ABD: Soft, mild abdominal distension without appreciable fluid wave, diffuse tenderness to palpation in RUQ and LUQ without rebound or guarding but with grimacing on exam. +b/s EXT: no c/c/e, 2+ DP pulses b/l SKIN: no rashes/no jaundice NEURO: Responds to verbal stimuli but does not follow commands Pertinent Results: [**2119-6-6**] 10:50PM BLOOD WBC-10.7 RBC-2.80* Hgb-9.9* Hct-30.2* MCV-108* MCH-35.2* MCHC-32.7 RDW-14.6 Plt Ct-47* [**2119-6-6**] 10:50PM BLOOD PT-19.0* PTT-41.5* INR(PT)-1.7* [**2119-6-6**] 10:50PM BLOOD Glucose-170* UreaN-24* Creat-3.2* Na-146* K-4.1 Cl-98 HCO3-14* AnGap-38* [**2119-6-6**] 10:50PM BLOOD ALT-204* AST-1699* CK(CPK)-1496* AlkPhos-145* TotBili-4.2* DirBili-3.2* IndBili-1.0 [**2119-6-6**] 10:50PM BLOOD Albumin-2.8* Calcium-6.0* Phos-8.1* Mg-1.7 [**2119-6-6**] 10:43PM BLOOD Glucose-148* Lactate-14.6* Na-142 K-4.3 Cl-101 calHCO3-14* [**2119-7-5**] 05:00PM BLOOD WBC-11.1* RBC-3.29* Hgb-10.1* Hct-26.6* MCV-81* MCH-30.8 MCHC-38.0* RDW-17.6* Plt Ct-115* [**2119-7-5**] 11:26AM BLOOD PT-19.2* PTT-43.1* INR(PT)-1.7* [**2119-7-5**] 11:26AM BLOOD Glucose-125* UreaN-24* Creat-2.0* Na-140 K-3.7 Cl-106 HCO3-19* AnGap-19 [**2119-7-5**] 03:09AM BLOOD ALT-16 AST-60* AlkPhos-45 TotBili-11.9* [**2119-7-18**] 06:04AM BLOOD WBC-17.2* RBC-3.54* Hgb-11.1* Hct-32.4* MCV-92 MCH-31.3 MCHC-34.2 RDW-20.9* Plt Ct-215 [**2119-7-18**] 06:04AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-140 K-3.8 Cl-112* HCO3-19* AnGap-13 [**2119-7-18**] 06:04AM BLOOD ALT-12 AST-42* AlkPhos-85 TotBili-5.4* [**2119-7-18**] 06:04AM BLOOD Calcium-8.0* Phos-2.1* Mg-1.6 Imaging summary: - [**6-7**] liver u/s: 1. TIPS patent. No prior ultrasound is available to compare the velocities. High velocities can suggest interval hyperplasia in the TIPS. 2. Cholelithiasis. 3. Diffuse symmetric thickening of the wall of the gallbladder, likely related to chronic liver disease. 4. Fatty liver. Other forms of more advanced liver disease such as fibrosis or cirrhosis cannot be excluded. 5. Liver vessels are patent. Reverse flow is seen in the left and right anterior portal vein. The right posterior portal vein is not visualized due to breathing artifact - [**6-15**] fluid study: negative for malignancy - [**6-22**]: Flexsig no active bleeding - [**6-23**]: endoscopy: no active bleeding - [**6-25**]: CT abdomen: 15-cm left anterior abdominal/pelvic wall hematoma and correlation with trauma or intervention is suggested. No free intraperitoneal air with extensive ascites and cirrhotic liver as before. Unchanged hepatic hypodensities, too small to be characterized. Unchanged multiple vertebral body compression fractures - [**6-26**]: GIB study: No active GI bleeding during the imaged time period - [**2119-6-27**] EGD no active bleeding - [**2119-7-4**] CT ab/pelv LLQ abdominal wall hematoma - [**2119-7-4**] Colonoscopy no active bleeding - [**2119-7-5**] Paracentesis 2+PMNs, no microorg. . - [**2119-7-6**] Paracentesis 2+PMNs, no microorg. - [**7-8**] CXR: Moderate bilateral pleural effusions, edema and lower lobe atelectasis/pneumonia - [**7-9**] CXR: Minimal improvement of pulmonary edema which is still severe - [**2119-7-12**] paracentesis - [**2119-7-12**] ucx 10-100,000 VRE - [**2119-7-11**] UA few bac, 19 RBC, 9 WBC Brief Hospital Course: 55yoF with alcoholic cirrhosis s/p TIPS [**1-/2118**] found down by her husband and admitted to MICU with GIB and resp failure. Improved in the MICU and was extubated [**6-14**]. On the floor, Ms. [**Known lastname 696**] was noted to have AMS likely [**1-18**] Korsakoff's amnesia. 1. Abdominal wall hematoma: pt began to complain of pain at site of what was originally though to be a ventral hernia in LLQ. the abd protrusion was palpated and had crepitus and could be reduced, so no action was taken and mass was thought to be a hernia at that time. Pt was supposed to go for colonoscopy but K+ was low, so it was delayed until [**2119-7-4**]. pt felt diarrhea had improved this day. Creatinine was elevated to 2.1 and this thought to be [**1-18**] poor renal perfusion. pt started on albumin 100mg. Renal u/s was negative for obstruction. Her hct was 17.5 at midnight and pt received 2 units PRBC, repeat hct was 24.8. Pt's abdominal protrusion had approx doubled in size and was very tender. Pt went to GI suite for colonoscopy, which did not show a source of bleeding. After colonoscopy, abdominal protrusion was over twice as large as in the AM and continued to progress rapidly throughout day. It developed a bluish appearance - surgery was consulted and pt sent for non con CT which showed a hematoma. Repeat Hct after CT was 21.0, so pt given another unit of PRBC and also transfused 1 unit FFP, and 100mg cryoprecipitate. Cr was down to 2.0 after albumin but jumped again in the PM to 2.3, likely [**1-18**] ongoing blood loss. 2. post-operative course: Patient was taken for evacuation of hematoma on [**2119-7-5**] and [**7-6**] with intraop 2L paracentesis. Intraop: 1u prbc, 1u FFP, albumin. Patient extubated and responsive postop. Patient transfused 2u PRBC's for Hct 25 in setting of active bleeding. Additional 7u PRBC next 2 nights. JP putting out sanguineous fluid, Hct decreasing. Transfused 2u PRBC, 2 FFP, 1 cryo. Direct pressure applied to LLQ. JP Hct sent. Ceftriaxone started for SBP per Hepatology recs. on [**7-7**] U PRBC given, started 1/2cc per cc replacement of JP output. UOP adequate. Pain control adequate. on [**7-8**], 2u FFP given for INR 1.7. High JP output continued, so NS repletion increased to cc per cc. Pt later became acutely dyspneic with desaturation to high 70s. CXR was consistent with flash pulmonary edema. IVF were discontinued, and pt responded well to BiPAP and 40 IV Lasix. Pt later weaned to nasal cannula. IVF repletion of JP output resumed at 1/2cc per cc ratio. Remained persistently tachycardic throughout. Increasing PVCs improved with K repletion. Regular diet started. Overnight, she had a burst of tachycardia to the 170s, EKG unchanged and troponin was negative. She was transferred from the ICU to the floor on [**7-10**]. She complained of shortness of breath during the day when she was sitting but also had a component of anxiety. She ambulated, was tolerating a regular diet, and making good urine. She continued on her ceftriaxone. On [**7-12**], she underwent a diagnostic and therapeutic paracentesis, 3L was taken off and sent for studies, which showed clearance of her SBP. She was switched to ciprofloxacin. She ambulated with physical therapy. Tolerating regular diet. 3. Mental status: On transfer to the floor from MICU, the patient was noted to be confused with AMS. Differential was initially anoxic brain injury vs. hepatic encephalopathy vs. delerium vs. withdrawal. Psych and neuro were consulted. Benzos were weaned. Lactulose was provided and an MRI brain revealed no evidence of anoxic brain injury. Given the prominence of the patient's confabulations and the absence of memory loss, it was suspected by neurology that the patient was suffering from Korsakoff's amnesia. The patient's family was informed of this diagnosis. 4. GIB: Patient with coffee grounds out of NG tube on admission and noted to have bright red blood coming from NG tube during first several days of admission. She was started on Octreotide and Pantoprazole gtt's. She was given 1u plts, 3u FFP, 3u PRBC's, 10 mg IV Vitamin K through admission. Liver was consulted, and felt since imaging showed patent TIPS that UGIB from portal HTN was unlikely. Pt was eventually scoped which showed 2cm non-bleeding ulcer with clot overlying and she was given an NG tube holiday to prevent irritation and allow healing. Also showed mild portal gastropathy. Hct was stable by call out of MICU. On the floor, the patient was HD stable. On [**6-23**], it was noted that the patient was tachycardic to the 140s. HCT fell from 34.4 to 28.7 and BRBPR was noted. The patient had undergone a sigmoidoscopy to evaluate for ?ischemic colitis the day prior without a bleeding source noted. On the AM of [**6-23**] she underwent an endoscopy also without evidence of a bleeding source. The patient was transfused with appropriate HCT response and remained stable without BRBPR afterward. Source of bleeding was likely hemorrhoidal. From [**6-27**] - [**6-29**] she was transfused 4u pRBCs total. 5. Hypotension: Fluid resuscitated with crystalloid and colloid. Started on Levophed gtt. Arterial line placed. She was given broad spectrum ABx (Vanc/Zosyn) and the only culture which grew out was MSSA in her sputum. Echo was normal. Of note, after weaned from pressors and stabilized, necessitated diuresis for volume overload/pulmonary edema. 6. Renal failure: Felt to be ATN due to hypotension vs HRS vs mild rhabdomyolysis given mildly elevated CK's. She was initially on a HCO3 gtt, and was fluid resuscitated. Electrolytes were very abnormal (K, Phos, and Ca) and were repleted aggressively until they normalized. She never needed dialysis and her renal function improved. 7. Alcoholic Cirrhosis s/p TIPS: Patient with US in the ED showing patent TIPS. She received IV thiamine and IV Folate. She was started on Lactulose and Rifaxamin after extubation; and liver recommended starting Pentoxyfyline x30 days when pt able. Repeat U/S on [**2119-7-15**] again showed patent TIPS 8. AFib: She had an episode of AFib with RVR that flipped back to NSR with IV Metoprolol. No further issues. Medications on Admission: - Folic Acid 1 mg daily - Thiamine HCl 100 mg daily - Ciprofloxacin 250 mg daily for SBP prophylaxis - Pantoprazole 40 mg EC daily - Simethicone 80 mg qid - Furosemide 20 mg daily - Spironolactone 100 mg daily - Docusate Sodium 100 mg [**Hospital1 **] prn - Senna 8.6 mg Tablet: 1-2 Tablets [**Hospital1 **] prn - Tramadol 25 mg q12h prn pain: No more than 50 mg/day. Discharge Medications: 1. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. pentoxifylline 400 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO TID (3 times a day). 5. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. insulin lispro 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous ASDIR (AS DIRECTED). 8. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. 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. 12. MagOx 400 mg Tablet Sig: One (1) Tablet PO once a day. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Outpatient Lab Work Labs twice weekly for chem 10 fax results to [**Telephone/Fax (1) 697**] attention [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator 16. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 18. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: abdominal wall hematoma alcoholic cirrhosis ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hepatobiliary service at [**Hospital1 18**] after evacuation of your abdominal wall hematoma. You have 2 JP drains in what used to be the hematoma cavity, which have put out serosanguinous and ascites fluid. Drain care: Your drains will be left in place until output is minimal and you are seen in [**Hospital 702**] clinic. Please continue drain dressings and emptying drains daily. Diet: continue on a regular diet with supplements to increase caloric intake. Activity: Please ambulate as tolerated multiple times per day. Medications: Continue on discharge medications and all home medications. We have increased your lasix to 40 mg [**Hospital1 **] from your home 20 mg daily dose. Followup Instructions: Provider: [**Name10 (NameIs) 703**] [**Location 704**] [**Location 705**] / IOUS [**Location 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2119-7-24**] 9:00 Provider: [**Name10 (NameIs) 706**] CARE,FIVE [**Name10 (NameIs) 706**] CARE UNIT Phone:[**Telephone/Fax (1) 446**] Date/Time:[**2119-7-26**] 8:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2119-7-26**] 3:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2119-7-18**]

Admission Date: [**2122-3-28**] Discharge Date: [**2122-3-31**] Date of Birth: [**2041-6-29**] Sex: F Service: MEDICINE Allergies: Morphine / Motrin / Levaquin Attending:[**First Name3 (LF) 689**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 80yo female with multiple medical problems including hypertension, recent ICU admission with pulmonary edema and ARDS, and previous admission for septic hip treatment was admitted with shortness of breath and chest pain. . She has had several recent admissions to [**Hospital1 18**] within the last 3 months. - [**Date range (1) 44958**] - She was admitted with a right septic hip and underwent a washout and repair. She was discharged to complete a 6 week course of nafcillin - [**Date range (1) 44959**]/09 - She was hospitalized with shortness of breath. During that admission, she was found to have bilateral infiltrates consistent with multifocal pneumonia and superimposed pulmonary edema, as well as diffuse alveolar hemorrhage. For the pneumonia, she was treated with broad spectrum antibiotics of vancomcyin, zosyn, and azithromycin. For the pulmonary edema, she was treated aggressively with diuretics, nitroglycerin, and beta blockers. For the diffuse alveolar hemorrhage, she was treated for a short time with steroids complicated by delirium and underwent an extensive autoimmune work-up which was negative. She was discharged to rehab with 2L O2 and furosemide 40mg PO bid. . While at Rehab, she has developed multiple complications, including delirium, acute renal failure, fever, chest pain, and shortness of breath. Her delirium was thought likely related to medications (received a short course of baclofen), infection, and renal failure. Regarding her acute renal failure, her creatinine increased to 2.6 from 1.5 within 2 days after discharge, her furosemide and anti-hypertensives were discontinued, and she was started on IVF. Regarding her fever, she was febrile as high as 102 at the rehab. Regarding her chest pain and shortness of breath, she was evaluated by a pulmonary consultant on the day of her transfer and she was thought to be in a CHF exacerbation. . Upon arrival to the ED, temp 100.2, HR 86, BP 133/50, RR 18, Pulse ox 77% on room air. While in the ED, she remained afebrile, normotensive, and 96-10% on NRB. She received SL NG x 3 and was then started on a nitro drip for chest pain. She had blood cultures drawn and received zosyn. She also received zosyn for pneumonia, was started on a heparin drip for treatment of a presumed pneumonia, and also given fentanyl 25mcg IV x 1 for treatment of chest pain. . Upon arrival to the floor, she initially reported [**7-24**] chest pain, which she describes as located across her left anterior chest, character is pleuritic, duration is intermittent, worsened with deep inspiration or movement, and reliever with hydromorphone and rest. Additional review of systems is notable for the following: shortness of breath, fatigue, back pain (chronic and unchanged), lower extremity swelling, and neck pain (chronic and unchanged). Her delirium has markedly improved according to her daughters. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools, red stools. He denies shaking chills, rigors. dysuria, diarrhea, abdominal pain, cough, sputum production. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. . Past Medical History: 1. Coronary Artery Disease s/p CABG and bioprosthetic AVR in [**2119**] 2. Diastolic Heart Failure 3. Type 2 Diabetes Mellitus complicated by neuropathy 4. Chronic Renal Insufficiency 5. Hypertension 6. Diverticulitis 7. Hyperlipidemia 8. Hypothyroidism 9. Endometriosis . PAST SURGICAL HISTORY: 1. s/p R Hip hemiarthroplasty after fracture in [**2111**]. 2. Right hip washout and head replacement [**2122-1-17**] 3. s/p b/l TKR 4. s/p appendectomy, 5. s/p TAH-BSO, 6. status post right carpal tunnel release, status post tonsillectomy. 7. s/p Nissen 8. s/p CABG in [**5-20**] . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CABG, in [**2119**] anatomy as follows: LIMA --> LAD . Percutaneous coronary intervention: not applicable Social History: - Home: previously lived independently on [**Location (un) **]; was living with her daughter / health care proxy in preparation for an upcoming right hip revision until her multiple, recent hospitalizations; currently at [**Hospital 100**] Rehab - Tobacco: Denies - Alcohol: previous history of alcohol abuse > 30 years ago Family History: Non-contributory Physical Exam: VS: T 96.7 / HR 75 / BP 126/42 / RR 27 / Pulse ox 100% on 15L NRB Gen: WDWN elderly female in mild respiratory distress requiring NRB. 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 elevated JVP to the earlobe. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**3-20**] mechanical systolic murmur at the LUSB. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Well-healed anterior midline sternotomy scar. bibasilar crackles with right middle lung crackles as well Abd: Obese, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: trace - 1+ bilateral lower extremity edema. No femoral bruits. Right hip without evidence of inflammation - no erythema, tenderness, pain, or swelling Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs [**2122-3-28**] 02:00PM BLOOD WBC-15.3* RBC-2.84*# Hgb-9.0* Hct-25.1* MCV-88 MCH-31.7 MCHC-35.9* RDW-15.6* Plt Ct-227 [**2122-3-28**] 02:00PM BLOOD Neuts-88.7* Lymphs-8.4* Monos-2.3 Eos-0.4 Baso-0.2 [**2122-3-28**] 02:00PM BLOOD PT-14.1* PTT-31.7 INR(PT)-1.2* [**2122-3-28**] 02:00PM BLOOD Glucose-126* UreaN-17 Creat-1.5* Na-135 K-4.7 Cl-103 HCO3-21* AnGap-16 [**2122-3-28**] 02:00PM BLOOD CK-MB-NotDone proBNP-9713* [**2122-3-28**] 02:00PM BLOOD cTropnT-0.27* [**2122-3-28**] 10:28PM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9 [**2122-3-29**] 05:18AM BLOOD calTIBC-185* VitB12-564 Folate-3.8 Ferritn-661* TRF-142* [**2122-3-28**] 02:16PM BLOOD Lactate-1.2 [**2122-3-28**] 10:28PM BLOOD CK-MB-NotDone cTropnT-0.20* [**2122-3-29**] 05:18AM BLOOD CK-MB-NotDone cTropnT-0.15* [**2122-3-28**] 10:28PM BLOOD CK(CPK)-55 [**2122-3-29**] 05:18AM BLOOD CK(CPK)-28 [**2122-3-28**] 10:28PM BLOOD Glucose-123* UreaN-19 Creat-1.7* Na-138 K-5.6* Cl-104 HCO3-22 AnGap-18 [**2122-3-29**] 05:18AM BLOOD Glucose-97 UreaN-20 Creat-1.8* Na-134 K-4.7 Cl-101 HCO3-23 AnGap-15 [**2122-3-29**] 01:58PM BLOOD Glucose-123* UreaN-22* Creat-1.7* Na-136 K-4.2 Cl-99 HCO3-24 AnGap-17 [**2122-3-29**] 05:18AM BLOOD WBC-10.6 RBC-2.74* Hgb-8.5* Hct-24.6* MCV-90 MCH-31.0 MCHC-34.5 RDW-15.8* Plt Ct-208 . Discharge labs: [**2122-3-31**] 05:55AM BLOOD WBC-7.8 RBC-2.90* Hgb-9.1* Hct-25.4* MCV-88 MCH-31.3 MCHC-35.7* RDW-15.7* Plt Ct-310 [**2122-3-31**] 05:55AM BLOOD Plt Ct-310 [**2122-3-31**] 05:55AM BLOOD Glucose-117* UreaN-26* Creat-1.9* Na-133 K-4.3 Cl-93* HCO3-27 AnGap-17 [**2122-3-31**] 05:55AM BLOOD CK(CPK)-12* [**2122-3-31**] 05:55AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.2 [**2122-3-29**] 05:18AM BLOOD calTIBC-185* VitB12-564 Folate-3.8 Ferritn-661* TRF-142* . [**2122-3-29**] CXR: There is fluctuating appearance of the parenchymal opacities consistent with recurrent pulmonary edema. Compared to the most recent chest radiograph from [**2122-3-28**], there is interval progression of parenchymal opacities involving the entire lungs that is worrisome for interval worsening of pulmonary edema. No appreciable pleural effusions have been seen, although small amount of pleural fluid cannot be excluded. No changes in the sternotomy wires position as well as in the cardiomediastinal contour have been demonstrated. The fluctuating character of the parenchymal opacities is more consistent with pulmonary edema than infection, although underlying foci of infection or ARDS cannot be completely excluded. . [**2122-3-29**] LENIs: IMPRESSION: No evidence of DVT seen in either lower extremity. . [**2122-3-29**] Renal US : IMPRESSION: No evidence of hydronephrosis although the right kidney appears smaller than the left. Brief Hospital Course: This is a 80yo female with history of multiple medical problems including recent right hip infection, diastolic dysfunction, recent hospitalization with intubation, and Type 2 Diabetes Mellitus was admitted with shortness of breath. . 1. Shortness of Breath: Etiology of her shortness of breath is likely multifactorial. Differential diagnosis includes congestive heart failure exacerbation related to her recent medication changes and fluid administration, pneumonia in the setting of rehab stay / recent hospitalization / recent intubation, and splinting secondary to her chest pain. An additional possibility includes pulmonary embolism given her recent hospitalization and immobilization. Unfortunately she is not a candidate for a CTA at this time due to her renal failure, and VQ scan would likely not be helpful due to her diffuse and patchy infiltrates. She was briefly started on heparin gtt on admission. Bilateral LENI's were negative on [**3-29**]. Pulm was consulted and thought CHF most likely and PE unlikely so heparin gtt was stopped, vanco/zosyn for HAP were started on [**3-28**] and continued. The pt was diuresed initially on lasix gtt which was transitioned to [**Hospital1 **] lasix prior to transfer. At the time of transfer, she continues to c/o inability to take a deep breath but EKG is without changes and pt has only slight crackles on exam. Would recommend pt be kept only slightly negative at OSH as her Cr remains above baseline at 1.9. . 2. Chest Pain: Etiology of her chest pain is unclear. Differential includes pain related to pneumonia, GERD and esophageal irritation s/p intubation and NGT placement on prior admission. Pt c/o odynophagia but has no evidence of aspiration. Pericarditis, pulmonary embolism, or costochondritis were all considered unlikely. Her description of her pain is also not consistent with acute coronary syndrome, and her ECG is also unremarkable for ACS. She was treated for HAP as above and given dilaudid PRN with poor control of her pain at baseline. In future, GI or ENT could be consulted to evaluate this odynophagia. PPI was continued here. . 3. Fever and Leukocytosis Most likely [**2-16**] pneumonia. At the time of transfer to the OSH, blood and urine cultures remain without growth and rapid viral testing was negative. The pt is being continued on vanco/zosyn for HAP. The pt needs to be on bactrim s/p osteo for 6 months but this is on hold while pt on vanco/zosyn. This should be restarted after current abx finished. . 4. Acute Renal Failure Etiology of her acute renal failure likely secondary to dehydration and aggressive diuresis. Avoided further nephrotoxins, held ACEI and NSAIDs. In future, would recommend gentle diuresis. . 5. Coronary Artery Disease Continued aspirin and statin. CP not thought c/w ACS. Elevated trops in setting of unremarkable CK and MB were thought [**2-16**] renal failure. ECG unchanged. Beta blocker held in setting of CHF exacerbation and ACEI held in setting of ARF. . 6. Anemia Patient's hematocrit has decreased from 33 at last discharge to 25 here this admission. Hct remained stable until discharge. Iron studies d/w anemia of chronic disease. Retic count elevated at 2.4 prior to discharge. Would recommend continuing to trend Hct and guaiac of stools. . 7. Hypothyroidism Stable, continued levothyroxine . #. Code: FULL CODE, confirmed with patient and daughter #. Communication: Patient; Daughter and HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 44960**] Medications on Admission: REHAB MEDICATIONS: 1. Levothyroxine 100 mcg PO Qday 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, 3 patches 12hrs on, 12 hours off 3. Omeprazole 20mg PO daily 4. Simvastatin 40 mg PO Qday 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet PO BID 6. Bisacodyl 10mg PR daily prn 7. Tylenol 975mg PO tid 8. Aspirin 81 mg PO Qday 9. Calcium Carbonate 350 mg PO TID 10. Cholecalciferol (Vitamin D3) 800 unit PO Qday 11. Vitamin B12 500mcg PO daily 12. Conjugated Estrogens 0.3 mg PO Qday 13. Ferrous Sulfate 325 mg (65 mg Iron) PO Qday 14. Gabapentin 200mg PO tid 15. Heparin 5000 units SC bid 16. Insulin humalog sliding scale Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Lispro 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous ASDIR (AS DIRECTED). 9. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Vancomycin 1000 mg IV Q48H Day 1 - [**2122-3-28**] 20. Piperacillin-Tazobactam Na 2.25 g IV Q6H Day 1 - [**2122-3-28**] 21. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN Please hold for RR < 12 and/or sedation. Thanks. 22. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Discharge Diagnosis: Hospital acquired Pneumonia diastolic CHF Acute on Chronic renal failure CAD Anemia Discharge Condition: stable. O2 sat mid 90's on 2L NC. Afebrile. Not tachycardic. BP stable Discharge Instructions: You were admitted here with CHF exacerbation. While you were here, you were diuresed. You were also treated for hospital acquired pneumonia. You were briefly started on a heparin drip for possible pulmonary embolism but this was stopped when pulmonary consult thought this diagnosis was very unlikely. You continue to complain of chest pain despite on EKG changed and we think this could be due to mechanical trauma from recent intubation and NG tube. . Please follow up as below. . Please see attached for your medications at transfer. . Please call your doctor or return to the ED if you have any chest pain, increasing shortness of breath, vomitting, blood in your stools or any other concerning symptoms. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: [**Hospital **] clinic: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2122-4-23**] 10:00 CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-4-29**] 1:30 Please follow up with Dr. [**Last Name (STitle) **] as directed by the staff at [**Hospital1 **] [**Location (un) 620**] Completed by:[**2122-3-31**]

Admission Date: [**2163-10-14**] Discharge Date: [**2163-10-17**] Service: CCU CHIEF COMPLAINT: Substernal chest pain. HISTORY OF PRESENT ILLNESS: This is an 85 year-old female with known coronary artery disease status post an inferior myocardial infarction in [**2161**], hypertension, increased cholesterol, tobacco, who presented with three days of substernal chest pain. She went to her primary care physician and was found to have electrocardiogram changes (deepened T wave inversions in V1 through V6, 2, 3, AVL). She was chest pain free throughout her primary care physician's visit. She was sent to the [**Hospital1 190**] Emergency Room, where she had increasing chest pressure 7 out of 10 substernally with associated diaphoresis, sinus bradycardia at 45 beats per minute, systolic blood pressure dropped to the 70s and her electrocardiogram was notable for 2 to [**Street Address(2) 1755**] elevations in V1 through V6 and additionally reciprocal T wave inversions in 2, 3, and AVF. She received half dose of Integrilin, heparin, aspirin, beta blocker, and was taken directly to the cardiac catheterization laboratory. There she was found to have left main coronary artery disease that was short, a left anterior descending artery that had a proximal tubular lesion to 80% prior to diagonal, mild to moderate diffuse disease, mid left anterior descending coronary artery, TIMI two flow slowly distally. The left circumflex had diffuse disease to 40% involving CX and obtuse marginal, collateral to right coronary artery. The right coronary artery was mildly calcified, tubular 80 to 90% proximal to the mid stenoses, competitive flow seen in RPL, diffuse disease in the mid right coronary artery. The proximal left anterior descending coronary artery was dilated with 2.5 by 15 mm open sail at 6 atmospheres and was stented. There was no residual stenosis, TIMI two fast flow was observed. The cardiac catheterization was also notable for a cardiac output of 2.7, cardiac index of 1.8, wedge pressure of 29, elevated filling pressures with a PA diastolic pressure of 26. The left ventriculogram was not performed. The patient received intravenous Lasix and was transferred to the Coronary Care Unit. She was hemodynamically stable throughout her catheterization. PHYSICAL EXAMINATION: Vital signs on admission, temperature 96.5. Blood pressure 108/38. Heart rate 56. Respiratory rate 15 to 20 sating 95 to 97% on 2 liters. In general, the patient was talkative and in no acute distress. Her oropharynx was clear without lesions. She had no JVD. No carotid bruits. She had a regular rate and rhythm with mild 2 out of 6 early systolic ejection murmur at the bilateral sternal borders as well as a positive S3. Her lungs were clear to auscultation. She was without wheezes. Her abdomen was soft, nontender, nondistended. She had normoactive bowel sounds and no organomegaly. Her right groin had a small hematoma without a bruit. She had 1+ pedal pulses bilaterally and no edema. PAST MEDICAL HISTORY: 1. The patient has a history of coronary artery disease with an myocardial infarction in [**2163**]. 2. Increased cholesterol. 3. Hypertension. 4. Osteoporosis. CARDIAC MEDICATIONS ON ADMISSION: Aspirin 325 mg po q.d., Digoxin 0.25 mg po q.d., Atenolol 25 mg po q.d., Lipitor 20 mg po q.d. SIGNIFICANT LABORATORY FINDINGS ON ADMISSION: Her white blood cell count was 11.3, hematocrit 41.3, platelets 239. Chemistries sodium 140, potassium 5.3, BUN 24, creatinine 0.9, glucose 125, CK on admission 136, MB fraction 8, troponin 6.3. ALT 24, AST 19. Electrocardiogram on admission as stated above in the history of present illness. HOSPITAL COURSE: 1. Cardiac: Ischemia; the patient finished her course of Integrilin and heparin. She was maintained on aspirin, Plavix and Lipitor. She remained chest pain free subsequent to her initial presentation in the Emergency Department. Her peak CKs were 260, her peak MB was 28 and her peak cardiac index was 10.8. She had no further dynamic electrocardiogram changes throughout her stay. Given the minimal CK leak presumably the patient had an interrupted acute myocardial infarction that was amenable to angioplasty of the proximal left anterior descending coronary artery. Pump; the patient was noted to have high filling pressures intracath. She was diuresed adequately and started on an ace inhibitor as well as a beta blocker when her pressures tolerated it. Her outpatient Digoxin was not continued on admission, nor included in her outpatient regimen. The patient had an echocardiogram performed on [**2163-10-17**]. The ejection fraction was notably 30 to 35%. She had moderate symmetric left ventricular hypertrophy, moderate global left ventricular hypokinesis, inferior severe hypokinesis. Overall her left ventricular systolic function was moderately decreased. She had 2+ aortic insufficiency. Also the ascending aorta was noted to be mildly thickened. Rhythm; the patient had some episodes of sinus bradycardia during sleep as low as 40 beats per minute. These sinus bradycardic episodes were asymptomatic and resolved with awakening and activity. 2. Pulmonary: The patient had no supplemental oxygen requirements during her hospitalization and did well from a pulmonary standpoint. The patient was seen by physical therapy during this hospitalization and was able to ambulate back to her baseline level of function. The patient was also advised repeatedly on this admission to quit smoking cigarettes. The patient was not ready to quit at this time. FOLLOW UP APPOINTMENTS: The patient will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 111570**] in Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] clinic. The patient will be called on [**2163-10-18**] with the appointment time and place. The patient was also instructed to call her primary care physician, [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 410**], and set up a follow up appointment with him in the ensuing weeks. FOLLOW UP ISSUES: 1. The patient was provided with visiting home nurse services in order to obtain some medication teaching. ALLERGIES ON DISCHARGE: The patient has no known drug allergies. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Plavix 75 mg po q.d. to complete a thirty day course and the patient was written a prescription for an additional 26 days to complete thirty days. 3. Lipitor 20 mg po q day. 4. Zestril 2.5 mg po q.d. 5. Atenolol 25 mg po q day. 6. Miacalcin 2200 IU per ml. 7. Multivitamin. 8. Calcium carbonate. 9. Vitamin D as she was taking before. 10. The patient's Digoxin was discontinued and she will not be resuming this medication. CODE STATUS: Full code. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Doctor Last Name 111571**] MEDQUIST36 D: [**2163-10-18**] 15:22 T: [**2163-10-21**] 09:04 JOB#: [**Job Number 7070**]

Admission Date: [**2137-8-16**] Discharge Date: [**2137-8-29**] Service: MEDICINE Allergies: Atenolol Attending:[**First Name3 (LF) 3984**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: endotracheal intubation tracheotomy tube placement placement of PEG (feeding) tube History of Present Illness: 86 year old male with pmh of COPD, CAD, HTN, DMII who was feeling weak and having difficulty standing at the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] and was found to have an O2 sat of 46% on 2L NP, and only marginal improvement to 63% on 5L NP. He was placed on NRB and transported to [**Hospital1 18**]. Full vitals prior to transfer were T 98.4, BP 149/84, P121, RR22. Allergies atenolol and Tylenol #3. . In the [**Hospital1 18**] ED, he was able to state his name, though appeared distressed. He was moving all of his extremities. Intial vitals were: T: 100.5 BP 133/68, HR 114, Sat 100% on NRB with a RR in the 30s. His rectal temperature was 101 F. He was intubated and sedated on fentanyl and Versed. He had a CXR that showed multifocal pneumonia. He was given 1g tylenol, 750mg of IV levofloxacin and 750cc of NS. EKG showed, sinus tach at 111, LAD, NI, TWF in aVL, poor baseline. On transfer vitals: T 98.3 HR 101 BP 110/61 Sat 98% on CMV mode, TV 500, FiO2 50%, RR 24 and PEEP 5. . On transfer to the MICU, he is intubated and completely sedated. Not responding to commands. Past Medical History: (Per OMR) DM (DIABETES MELLITUS) LUNG DISEASE, CHRONIC OBSTRUCTIVE HYPERTENSION, ESSENTIAL LOW BACK PAIN FTT (Failure to Thrive) in Adult Hypotension BLINDNESS - LEGAL HISTORY CORNEA TRANSPLANT GLAUCOMA - PRIMARY OPEN ANGLE DEPRESSIVE DISORDER CANCER OF PROSTATE TUBERCULOSIS BRONCHIECTASIS CORONARY ARTERY DISEASE RECTAL BLEEDING Social History: Former truck driver, and prior worked in a defense factory. Currently residing in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. HCP [**Name (NI) **] [**Name (NI) **], daughter [**Name (NI) 40477**] [**Name (NI) **]. Also, granddaughter in the area, involved in his care. - Tobacco: Quit smoking 20 years ago, smoked from 18 - 65; used to smoke 1PPD - Alcohol: Heavy drinker while a smoker - Illicits: Unknown Family History: DM in father and mother. [**Name (NI) **] cancers. Physical Exam: Admission Exam: Vitals: T: 98.5 BP: 119/63 P: 101 R: 20 O2: 100% on CMV, 500, 50%, 14 and 5. General: Intubated, sedated not responding to commands HEENT: Sclera anicteric, Cataracts bilterally, non-responsive pupils (blind) mildly dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Mechanical breath sounds with minimal wheezing. Rhonchi in the right upper lung zone CV: Normal rate Regular rate, II/VI holosystolic murmur obscuring S1 no rubs, gallops Abdomen: soft, mildly distended, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, + clubbing on right hand, missing 4 digits on left hand, chronic venous stasis changes on bilateral lower extremities, and multiple 1cm areas of ulceration, no edema Neuro: Non-responsive on sedation Discharge physical exam General Appearance: Thin Eyes / Conjunctiva: cataracts, nonresponsive pupils b/l Head, Ears, Nose, Throat: Normocephalic, Poor dentition Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : , No(t) Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present, Peg site intact Musculoskeletal: Muscle wasting Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: Admission Labs: [**2137-8-16**] 08:05AM BLOOD WBC-8.8# RBC-3.43* Hgb-9.9* Hct-29.2* MCV-85 MCH-28.9 MCHC-34.0 RDW-14.0 Plt Ct-217 [**2137-8-16**] 08:05AM BLOOD Neuts-81.1* Lymphs-12.5* Monos-5.6 Eos-0.4 Baso-0.4 [**2137-8-16**] 08:05AM BLOOD PT-13.0 PTT-25.3 INR(PT)-1.1 [**2137-8-16**] 08:05AM BLOOD Glucose-234* UreaN-19 Creat-1.1 Na-141 K-4.9 Cl-103 HCO3-31 AnGap-12 [**2137-8-16**] 08:05AM BLOOD proBNP-754 [**2137-8-16**] 08:05AM BLOOD cTropnT-0.01 [**2137-8-16**] 08:05AM BLOOD Triglyc-64 [**2137-8-16**] 09:27AM BLOOD Type-ART Temp-38.6 Rates-/28 PEEP-5 pO2-53* pCO2-67* pH-7.28* calTCO2-33* Base XS-2 Intubat-INTUBATED Vent-CONTROLLED [**2137-8-16**] 08:12AM BLOOD Lactate-1.1 . Discharge labs: [**2137-8-29**] 05:41AM BLOOD WBC-10.4 RBC-2.85* Hgb-8.2* Hct-24.7* MCV-87 MCH-28.6 MCHC-33.1 RDW-13.9 Plt Ct-462* [**2137-8-29**] 05:41AM BLOOD PT-14.0* PTT-26.7 INR(PT)-1.2* [**2137-8-29**] 05:41AM BLOOD Glucose-123* UreaN-20 Creat-1.0 Na-140 K-3.9 Cl-102 HCO3-33* AnGap-9 [**2137-8-29**] 05:41AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.5 [**2137-8-28**] 03:38AM BLOOD Vanco-15.3 [**2137-8-29**] 06:08AM BLOOD Type-ART Temp-37.2 Rates-[**10-9**] Tidal V-500 PEEP-5 FiO2-40 pO2-97 pCO2-53* pH-7.43 calTCO2-36* Base XS-8 Intubat-INTUBATED Vent-CONTROLLED [**2137-8-26**] 02:01PM BLOOD Lactate-0.7 K-3.9 [**2137-8-21**] 05:10PM OTHER BODY FLUID Polys-44* Lymphs-19* Monos-0 Mesothe-17* Macro-20* . CXR [**2137-8-16**] 1. Multifocal opacities with a more confluent opacity in the right upper lung field. These findings are worrisome for multifocal pneumonia. 2. Bilateral small pleural effusions. 3. Mild to moderate pulmonary edema. . Echo [**2137-8-16**] Normal biventricular cavity size with normal regional and low normal global left ventricular systolic function. Pulmonary artery hypertension. Mild-moderate mitral regurgitation. These findings are suggestive of a primary pulmonary process (OSA, COPD, etc.). . CT Chest [**2137-8-22**] 1. Multifocal pneumonic consolidation predominantly involving the right upper lobe. 2. Moderate loculated effusion along right minor fissure and minimal simple effusion bilaterally. 3. Borderline enlarged mediastinal lymph nodes. Prominent right hilar appearance could be due to enlarged lymph node or from enlarged vessles, however defining a cause was limited due to lack to intravenous contrast administration. 4. Bilateral pleural calcifications. Please correlate with clinical history for asbestos exposure. If a history is established, follow-up imaging surveillance is recommended. . Dishcarge Chest xray [**2137-8-29**]: In the interval from the prior examination, an endotracheal tube has been removed and tracheostomy has been placed in standard position. Right-sided PICC is unchanged with tip reaching the low SVC. There is no significant change in multifocal opacities, greatest at the right base. Trace pleural effusions may be present. No pneumothorax is seen. The cardiomediastinal silhouette is not significantly changed. . Microbiology: BAL RESPIRATORY CULTURE (Final [**2137-8-24**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. ~[**2125**]/ML. 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. _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Brief Hospital Course: 86 year old male with a history of COPD, DMII, CAD and HTN who was admitted with respiratory failure and multifocal pneumonia. . # Respiratory failure: History of COPD, found to be hypoxic at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] to 46% on 2L. CXR showed multifocal pneumonia. He was given levofloxacin in the ED and was intubated. Febrile to 101 rectally in the ED. Failed extubation due to respiratory fatigue, tachypnea, and worsening shortness of breath. He was re-intubated and underwent bronchocopy. BAL revealed MRSA. IP has was consulted for a tracheotomy tube/PEG which were performed on [**8-27**]. Pt to continue vanco for a total of 14 days to end [**9-4**]. He may continue to require Oxycodone as needed for pain related to his tracheostomy tube. His discharge chest xray showed increased opacities that were attribute to de-recruitment off the higher ventilator settings. Would recommend monitoring respiratory status, fever curve (currently afebrile) and ventilator requirements and would re-image or consider antibiotics if his clinical status changes. Plan to wean ventilator as tolerated. . # DMII: On oral hypoglycemics at home. On insulin SS in house. He was started on tube feeds which were at goal at discharge. Home metformin and glipizide were held- would restart at time of discharge to home. . # HTN: On diltiazem at home (ER). He was started on lisinopril which was at 40mg. he initially required IV hydral, which was transitioned to amlodipine 10mg daily. . # CHF/Venous stasis: On furosemide. Chronic venous stasis changes. EF 50-55% this admission, echo showed pulmonary HTN. He was diuresed, ultimately put on a standing dose of [**Hospital1 **] Lasix to remain euvolemic. Lytes were checked and K was replaced aggressively. He was on furosemide 40mg daily at discharge. Would recommend checking [**Hospital1 **] electrolytes and replete as necessary. Goal for diuresis has been 500 cc negative daily following in/outs. . # Glaucoma: Legally blind due to acute angle glaucoma, also with bilateral cataracts. Continued home eye drops. . # Anemia: Unclear baseline. MCV normal. Will monitor. No signs of bleeding, Hct stable. . Full Code Medications on Admission: ([**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Med Rec) Metformin 1000mg PO BID Dorzolemide/Timolol 2%-0.5% 1gtt both eyes, [**Hospital1 **] Erythromycin opth, 5mg/gm, apply left eye HS Lumigam 0.03% gtt, 1 gtt each eye HS glipizide 10mg PO BID [**Last Name (un) 7139**] 128; 5% gtts - 1 gtt each eye Q6H Famciclovir 500mg; 0.5 tabs PO daily Omeprazole 20mg PO daily Citalopram 10mg PO daily Diltiazem CR 180mg PO daily fluticasone nasal spray 1 spray each nostril daily furosemide 20mg PO daily Spiriva 18mcg 1 cap, daily Artificial tears [**Hospital1 **] Bromide Tartrate 0.2% 1 gtt each eye [**Hospital1 **] Calcium cab w/ D 600mg-400IU 1 tab [**Hospital1 **] Guaifenesin 100mg/5ml; 30mls PO BID Trazadone 50mg PO HS Tylenol 650mg PO prn Bisacodyl 10mg PR prn constipation milk of mag 30mls daily prn compazine 10mg TID prn nausea fleet enema daily prn albuterol nebs Q6H prn SOB Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-30**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 2. acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever: do not exceed 3 grams daily. 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (2) **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for sob/wheeze. 4. acyclovir 200 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO Q12H (every 12 hours). 5. amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO BID (2 times a day). 8. citalopram 20 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO DAILY (Daily). 9. chlorhexidine gluconate 0.12 % Mouthwash [**Month/Day (2) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day): Use only if patient is on mechanical ventilation. 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 11. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 12. dorzolamide-timolol 2-0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 13. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2 times a day). 14. erythromycin 5 mg/gram (0.5 %) Ointment [**Hospital1 **]: 0.5 gram gram Ophthalmic QHS (once a day (at bedtime)). 15. fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: One (1) Spray Nasal DAILY (Daily). 16. furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 17. 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. 18. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) injection Injection TID (3 times a day). 19. insulin regular human 100 unit/mL Solution [**Hospital1 **]: One (1) sliding scale Injection ASDIR (AS DIRECTED): following enclosed humalog sliding scale. . 20. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Six (6) Puff Inhalation QID (4 times a day). 21. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 22. latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic HS (at bedtime). 23. Lorazepam 0.5-1 mg IV Q4H:PRN aggitation 24. lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 25. lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 26. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 27. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) ml PO Q6H (every 6 hours) as needed for pain: hold for sedation. 28. vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 1250 (1250) MG Intravenous Q 24H (Every 24 Hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **] It was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted with pneumonia and required IV antibiotics. These will be continued at rehab. Due to respiratory distress, you were intubated and placed on a ventilator ("life support") until your lungs fully recovered. You continued to show improvement but will benefit from a longer weaning from the ventilator, thus a trachestomy tube was placed. This will be removed when you are fully able to breathe on your own. A peg tube (feeding tube through your stomach) was also placed to facilitate feeding until you are able to eat fully. You will need to continue the IV antibiotics for another week. The following changes were made to your medications. STARTED Albuterol inhaler 6 puffs prn SOB STARTED acyclovir 400mg Q12 STARTED amlodipine 10mg daily for hypertension STARTED Docusate sodium for constipation STARTED Heparin subcutaneous TID STARTED ipratropium bromide inhaler STARTED lansoprazole for reflux STARTED lorazepam for anxiety STARTED lisinopril for hypertension STARTED lactulose for constipation STARTED oxycodone for pain related to your tracheostomy STARTED Vancomycin (IV antibiotic) for your pneumonia, this will complete on [**9-4**] for total 14 day course. STARTED insulin coverage INCREASED furosemide/lasix dose to 40mg daily INCREASED citalopram 30mg daily STOPPED glipizide STOPPED omeprazole STOPPED diltiazem STOPPED metformin STOPPED trazodone STOPPED compazine STOPPED famciclovir Followup Instructions: You will need to follow up with your primary care doctor when you are discharged from rehab. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Admission Date: [**2187-10-23**] Discharge Date: [**2187-11-2**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3151**] Chief Complaint: syncope Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] y/o F with past med hx of DVT on coumadin, CHF, HTN, who presented [**10-23**] s/p syncopal episode with dyspnea. Pt reports she fell off of her bed this AM. Denied CP, dizziness at that time, instead stated that she just got "too close" To the edge of the bed. Found by her neighbor several hours later. Denies LOC. She denied chest pain, SOB, palpitations, n/v, dizziness, convulsive behaviour or HA. Past Medical History: DM, DVT [**5-13**] on coumadin, OSA (home CPAP, but denies using it), depression, CHF (echo [**2174**] with preserved EF), hx GI bleed and gastritis [**5-13**], HTN, angina, chronic low back pain Social History: No EtoH, Tob, IVDA Family History: Non-contributory Physical Exam: 98.4 138/78 78 14 98%2L Gen: NAD, A&O X 3, pleasant Heent: EOMI, PERRL, MMM, OP clear Neck: No JCD or LAD Heart: RRR, +S4. No murmurs. PMI laterally displaced. Lungs: Bibasilar crackles [**2-10**] way up thorax Abd: Soft, nt/nd. NABS Ext: Trace pedal edema to ankles Skin: Numerous seberrheic keratoses over neck, face and back Pertinent Results: [**2187-11-2**] 05:40AM BLOOD WBC-5.8 RBC-2.85* Hgb-9.0* Hct-27.7* MCV-97 MCH-31.6 MCHC-32.5 RDW-14.7 Plt Ct-398 [**2187-10-23**] 03:29PM BLOOD WBC-9.8 RBC-3.13* Hgb-9.7* Hct-29.5* MCV-94 MCH-31.0 MCHC-32.9 RDW-14.8 Plt Ct-235 [**2187-10-23**] 03:29PM BLOOD Neuts-86.1* Lymphs-10.5* Monos-2.6 Eos-0.6 Baso-0.2 [**2187-11-2**] 05:40AM BLOOD Plt Ct-398 [**2187-11-1**] 08:35AM BLOOD PT-15.0* PTT-31.5 INR(PT)-1.4 [**2187-11-1**] 10:00PM BLOOD LMWH-0.36 [**2187-11-2**] 05:40AM BLOOD Glucose-88 UreaN-7 Creat-0.9 Na-142 K-3.7 Cl-105 HCO3-31* AnGap-10 [**2187-10-24**] 06:16AM BLOOD ALT-14 AST-15 LD(LDH)-167 CK(CPK)-61 AlkPhos-59 Amylase-39 TotBili-0.4 [**2187-11-1**] 05:50AM BLOOD Calcium-9.8 Phos-2.5* Mg-1.9 Iron-34 [**2187-11-1**] 05:50AM BLOOD calTIBC-155* Hapto-233* Ferritn-388* TRF-119* [**2187-10-30**] 05:45AM BLOOD VitB12-305 Folate-14.6 [**2187-10-24**] 06:16AM BLOOD TSH-0.67 [**2187-10-31**] 05:30PM BLOOD PTH-163* [**2187-10-23**] 05:24PM BLOOD freeCa-1.30 Brief Hospital Course: 1. CHF exacerbation: On arrival in the ED, her O2 sats was 75% on RA, BP 128/78 (which increased to 180/68), 68, and RR 12 (increased to 24). She was placed on BiPap with increase in O2 sat to 91%. CXR indicative of pulmonary edema. Received total of 120 mg IV Lasix with good diuresis, nebs prn, ceftriaxone 1 g IV. When her BP increased to 180s, she was begun on a nitro gtt and also received hydralazine 10 mg IV x1. Her bp later dropped to 80/40, and her nitro was turned off with good BP response. She was also noted to have non specific lateral ST segment depression on EKG, with serial negative cardiac enzymes. Pt maintained on lasix 80 mg po QD with decent response (~1L net neg per day). Did require a few doses of IV lasix 80 mg to maintain this urine output. She was also placed on lopressor and her dose was titrated up to 25mg po TID. Her heart rate is in the 60's and she likely has some baseline SA dysfunction based on her age (i.e. sclerosis), but the further rate control should help her diastolic filling in addition. This CHF exac likely [**3-12**] lingular PNA, pt recieving ceftriaxone and azithromycin for community acquired pneumonia. Clinda was added to cover for possible aspiration. Will d/c for total of 10 day course of antibiotics. On the 8th hospital day, her antibiotics were changed from IV ceftriaxone and azithromycin to PO levaquin. The patient now denies SOB, orthopnea or cough. She is able to ambulate with help. She may need 1-2 L O2 by NC at [**Hospital3 **] to keep her O2 sat betwwen 90-93%. 2. ST changes: Evaluated by cards in ED. Liekly demand ischemia, with ST depressions transiently. TTE with no wall motion abnormalities. Patient was placed on BB for both decreased myocardial demand and for decreased inotropy and chronotropy with regard to diastolic dysfunction. No further risk stratification was done to the patient since no intervention would be done in the case of abdnormal result. 3. DVT: Dx'd [**5-13**]. Pt was supratherapeutic with an INR >8sec on admission. Coumadin was held until [**10-29**] when re-institued. She takes 6mg Tuesdays and Fridays, and 4mg the rest of the weekdays. Her coumadin will be managed at [**Hospital3 2558**]. The coumadin clinic was made aware of this. 4. Anemia: Pt is iron deficient. She will be discharged with oral ferrous gluconate. She recieved no blood transfusions. Her pending iron studies will be followed up by Dr.[**Last Name (STitle) 665**]. 5. Fall: The patient fell from a mechanical fall with no LOC. She had a negative head CT. 6. Pul Hypertension: The patient has a chart history of OSA. She has severe pulmonary arterial hypertension consistent either with OSA or chronic PE. She is anticoagulated for prevention of PE, and our pretest probability for PE while being anticoagulated is low such that she does not require [**Location (un) **] placement. She may need a sleep study to determine if she has OSA. Medications on Admission: lasix 80 mg po qd neurontin 300mg qHS lisinopril 20mg po QD comadin 6 mg Tu/Fr and 4 mg MWTh Protonix 40 mg po qD Timolol ophth Fluoxetine 20mg po qd Atenolol 25 mg po QD Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*2* 4. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO QD (once a day). Disp:*30 Capsule(s)* Refills:*2* 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 6. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 6 days. Disp:*48 Capsule(s)* Refills:*0* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Warfarin Sodium 4 mg Tablet Sig: One (1) Tablet PO once a day: One pill a day during the weekdays, do not take on the weekends. . Disp:*30 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 12. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): Discontinue this medication when INR >2.0. Disp:*15 * Refills:*0* 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: CHF exacerbation Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L If you have these symptoms, call your doctor or go to the ER: 1. Shortness of breath 2. Weight gain 3. Tiredeness 4. Fever 5. Chills 6. Feet swelling 7. Coughing up blood Followup Instructions: Provider: [**Name10 (NameIs) **] FERN, RNC Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-11-13**] 10:40 [**11-7**] at 11:20 AM with Dr.[**Last Name (STitle) 665**] at [**Hospital Ward Name 23**] [**Location (un) **] [**Hospital1 18**] Completed by:[**2187-11-2**]

Admission Date: [**2170-3-31**] Discharge Date: [**2170-4-4**] Date of Birth: [**2105-7-4**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11344**] Chief Complaint: status epilepticus Major Surgical or Invasive Procedure: none History of Present Illness: HPI; 64 yo LHM with hx L MCA hemorrhagic stroke in [**2158**] with subsequent seizure disorder (Status epilepticus in [**Month (only) 205**] and fall of [**2168**] with full return to baseline, but event [**12-31**] lasting 30 minutes at [**Hospital6 33**] with subsequent poor functional status), and multiple recent admissions to [**Hospital1 18**]. He was transferred from [**Hospital 38**] Rehab to [**Hospital1 18**] [**2170-2-22**] for evaluation of generally depressed mental status and concern for possible sub-clinical epileptic events vs. oversedation from his AEDs and was admitted for long-term monitoring. At time of initial presentation ([**2-22**]) his AEDs included VPA 1500 mg q12h and Carbatrol 300 mg TID. Prior AEDs include PHT, keppra, and lamictal (although full details unknown). EEG [**2-22**] showed encephalopathy without epileptiform features. EEG [**2-24**] showed a single seizure lasting 90 seconds with rhythmic epileptiform discharges in left temporal region without video correlate, presumed to be complex partial seizure. MRI brain [**2-26**] showed multiple chronic infarcts and microvascular disease, and a small right parietal subdual collection. CSF, thyroid studies, and RPR were normal. CBZ-10,11-epoxide level was elevated and depakote was subsequently discontinued and he was started on zonisamide. He was discharged [**3-9**] to rehab facility on zonisamide 300 mg qhs and carbamazepine 300 mg tid but returned the following day, [**3-10**] s/p fall at [**Hospital1 1501**]. Circumstances surrounding the fall were unclear and he was unable to provide a reliable history. CT head showed 5 mm [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and 4 mm extra-axial hematoma and R parafalcine blood. He was discharged [**3-15**] with no evidence of seizures during hospital course and returned [**3-22**] for increasing agitation, reported to be "urinating in the lobby, going into patients rooms, and difficult to re-direct" as per his most recent admission note. Today while at his nursing home, he was noted to be found unresponsive, and then had a witnessed GTC seizure lasting possibly one hour. Unfortunately, details of this event are rather limited. He initially presented to [**Hospital3 934**] hospital where he was noted to be "actively seizing with generalized shaking." VS were T 102.4, BP 185/76 RR 28 glucose 187. He received 5 ml valium, 2 mg ativan, and 1g PHT which stopped the seiuzre. He later was intubated after receiving etomidate and succynlcholine at 4:30 PM. His examination prior to transfer was notable for sluggish pupils and "unresponsive to painful stimuli." Upon arrival in ED here, T 100.8 (rectal), P 91, BP 170/76 RR 16, sat 100% on vent. He has received CTX, vanc, acyclovir, and dexamethasone. CT head showed R 4mm SDH and R subdural hygroma. ROS unobtainable. Past Medical History: 1. L. MCA territory hemorrhagic stroke in [**2158**]. Known hypertensive at the time, not on medications. Records suggest that temporal and occipital lobes were most-affected. Residual moderate aphasia and mild R. hemiparesis. 2. GTCS since this stroke, beginning 2-3y after hemorrhage. Seizures were self limited, lasting 1-2 minutes, and occurred 2-4x per year. In [**June 2169**], had an hour-long episode of status epilepticus. Two subsequent episodes of status, no self-limited seizures since that time. Refractory to multiple medications - previously on Keppra, Lamictal, and Dilantin (height of doses unknown), currently Carbatrol and Depakote. 3. Coronary artery disease, CABG x 3 vessels in [**4-29**]. Wife notes a mild cognitive hit and the change in his seizure type subsequent to this surgery. 4. HTN 5. Dyslipidemia 6. Goiter. TSH, Free T4, T3 normal at [**Hospital3 **] within the last month per transfer notes 7. TURP in [**2167**] Social History: Prior to [**2169-12-22**], the patient lived at home with his wife and is on disability. He has a 50y pack history but has not smoked in several years. No alcohol or illegal drug use. Family History: Negative for any seizure or early cognitive decline. Father deceased at 42y of "heart disease", mother deceased in 70s with "heart disease." Physical Exam: VS; T 100.8 (R) P 91 BP 170/76 RR 16 100% on vent Gen; intubated, NAD HEENT; NC/AT. Small right peri-orbital ecchymosis. Mucous membranes moist CV; RRR, no murmurs Pulm; CTA anteriorly Abd; soft, NT, ND Extr; no edema Neurological Examination; Mental status; Does not open eyes or follow commands. No grimace to noxious stimuli. Cranial Nerves; Eyes conjugate in midposition. Roving eye movements. Pupils 2.5mm --> 2mm b/l. + corneals, + VOR bilaterally. Face symmetric-appearing. Motor; Normal bulk and tone. Moves upper extremities spontaneously at the forearm and symmetrically. Moves right leg spontaneously at ankle. Withdraws all extremities equally to noxious stimuli. Sensory; intact to noxious stimuli Reflexes; 2+ at R biceps, triceps, brachioradialis, 1+ at L bicep, tricep, brachioradialis. 2+ patellars b/l. Upgoing toes b/l. Coordination; unable to assess Gait; unable to assess Pertinent Results: Admission Labs: WBC 9.1, HCT 37.0, plts 242 Na 140, K 3.5, Cl 105, CO2 23, BUN 12, Cr 1.0, gluc 121 Lactate 3.2 Troponin 0.06 ALT 38, AST 35, ALP 124, T bili 0.5, alb 4.2 lipase 70 U tox neg Serum tox neg INR 1.0, PT 12.4, PTT 22.0 UA neg Imaging: MRI [**4-1**] FINDINGS: There is a small focus of hyperintensity in the right side of the pons on diffusion images, best visualized on image 8, series 702. Subtle hypointensity is also seen on ADC map in this area. Although this could represent an acute infarct, the appearances are unusual and this could be an artifact as well. If there is a persistent clinical concern for a brain stem infarct, a repeat study could help. There is a chronic-appearing subdural hematoma seen in the right frontoparietal region with a maximum width of approximately 8 mm. There is focus of edema is seen in the right frontal lobe with a well-defined area of late subacute blood products. This area of blood products were seen on the CT of [**2170-3-11**]. No abnormal enhancement is identified in this region. Given that the edema has slightly increased compared to the prior CT, this could likely be due to post-seizure edema in this location. Moderate changes of small vessel disease and chronic left basal ganglia and left occipital lobe infarct with blood products are seen. These chronic infarcts are unchanged from prior study. Following gadolinium, no abnormal parenchymal, vascular or meningeal enhancement is seen. IMPRESSION: 1. Small area of late subacute blood products in the right frontal lobe with surrounding edema. Although the blood products were seen on the previous CT of [**2170-3-11**]. The surrounding edema is slightly more prominent accounting for differences in slice selection. This could presumably be post-seizure, edema. No abnormal enhancement is seen in this location. 2. Subtle signal abnormality within the right side of the pons on diffusion images could represent a small acute infarct but the appearance is more suggestive of an artifact. If there is continued concern, a repeat diffusion image can help. 3. Subacute chronic-appearing right-sided subdural hematoma without significant midline shift. 4. Chronic left occipital and left basal ganglia infarcts. 5. No abnormal enhancement. Brief Hospital Course: Mr. [**Known lastname 86382**] is a 64 yo LHM with hx L MCA hemorrhagic stroke in [**2158**] with subsequent seizure disorder including multiple episodes of status epilepticus in the past, presenting after status epilepticus, resolved after receiving 5 mg valium, 2 mg ativan, and 1 g PHT. He is intubated, but his examination off sedation appears nonfocal. While he has had prolonged seizures in the past, likely secondary to his known structural lesion (prior stroke), his fever (T 102.4 at arrival to OSH) may be concerning for infectious precipitant of this event. Hospital Course: #Neuro: Mr. [**Known lastname 86382**] was admitted for status epilepticus, for which he initially received 5mg Valium, 2mg Ativan and 1 gram dilantin, and was intubated for airway protection. He was febrile initially, but had a normal LP. His carbemazepine was kept at the same dose. His level on admission was 3.7, however repeat trough was 9.2 on his usual dose of medication, raising the question of whether he may have missed a dose prior to admission. His Zonegran was increased from 300mg to 400mg. He underwent an MRI with and without contrast, which showed a right frontal hemorrhage and right sided subdural hematoma, which had been observed on prior imaging. He had no new lesions to account for his increased seizure activity. #Resp: The patient was intubated for airway protection in the emergency department. He was successfully extubated on [**4-1**]. #CV: The patient was noted to have a slightly elevated troponin of 0.06 on admission, but with a normal CK-MB. This quickly decreased to 0.02, and was thought to be a slight troponin leak in the context of prolonged seizure activity. #ID: He was febrile on admission, and was initially started on empiric antibiotic coverage with vancomycin, ceftriaxone and acyclovir. He underwent a lumbar puncture which had 1WBC, 2RBCs, elevated protein of 52, and a glucose of 90. He had a negative U/A and chest x-ray. Antibiotics were discontinued. The patient did well and was brought out to the floor. He did not have any new events on EEG. He was determined to be ready for discharge. Medications on Admission: Carbamazepime 300 mg tid Zonisamide 300 mg qhs Methimazole 7.5 mg daily Cogentin PRN Haldol 2 mg qhs Trazadone 50 mg qhs Aspirin 81 mg daily Norvasc 5 mg daily Lopressor 75 mg tid Lisinopril 40 mg daily Zocor 40 mg daily Discharge Medications: 1. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 2. Zonisamide 100 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Methimazole 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: Seizures Secondary: right subdural hematoma - unchanged Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. MS: pt has transcortical aphasia, fluent speech but naming difficulty, comprehends, repetition intact, very inattentive and perseverative CN: R NLF o/w face symmetric, EOMI, and PERRLA Motor: difficult to test but appears symmetric, antigravity in all 4 extremity Sensory: withdraws at all 4 Discharge Instructions: You were admitted to the hospital for an extended seizure. It is not clear how long the seizure lasted. You had recieved a lot of anti-seizure medication and you were intubated to protect your airway. As you had a fever there was a concern that you were infected and you were started on empiric antibiotics. You had a normal infectious workup, a normal lumbar puncture, chest xray and normal urine and blood cultures. Your MRI showed the previous findings of the right frontal hemorrhage and right sided subdural hematoma. You were extubated without complication and brought to the floor where you did well with no further seizures. To prevent further seizures your Zonegran was increased to 400mg daily. You did not have any further seizures Medications were changed as follows: Zonegran increased to 400mg qhs Please make all follow up appointments. Please take all medications as prescribed. If you experience any prolonged seizures or any worsening of the symptoms listed below please call your doctor or return to the nearest emergency room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 12562**] [**Last Name (NamePattern4) 47259**], MD Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2170-5-4**] 1:30 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-6-12**] 10:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2170-6-12**] 10:30 Completed by:[**2170-4-4**]

Admission Date: [**2192-3-20**] Discharge Date: [**2192-3-23**] Date of Birth: [**2119-5-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5606**] Chief Complaint: sore throat Major Surgical or Invasive Procedure: none History of Present Illness: 72 M on C10D23 of FU/leucovorin for rectal CA presents with throat pain and fever, found to have parapharyngeal phlegmon commpressing the airway. Pt reports 4 days of right sided chest wall pain, fever that began today to 102 at home. Denies SOB/cough/abdpain/dysuria. Was seen earlier on day of admission for chest pain which was noted to be reproducible on palpation and onset while pt doing yardwork. c/o sore throat, sensation of something stuck in his throat. He has been able to drink, but it hurts. Pt thought he could palpate a lump on the left side of his neck beneath the mandible, but this area was not paniful to him on external palpation. Currently says throat when swallowing is [**8-13**] pain. No back pain. He denies trauma, previous head and neck surgery or recent dental work. He notes that he needs some dental work performed, but can not because of the chemo. He denies voice change or difficulty breathing. His last dose of chemo was on [**2192-3-12**]. No XRT currently. Of note, his prior imaging has documented diffuse spinal bone metastasis. . ED COURSE: vs on arrival: pain10 T102.2 HR114 104/53 RR20 98% exam in ED showed tenderness to palpation of left anterior cervical area, clear oropharynx without exudate or uvula deviation. Labs significant for WBC 8.3 with 78%pmns and 14%lymphs. HCT 36.9 from b.l 39, plt 158 Na 130, K 4.2, 98/21, bun/cr 21/1.0 lactate 1.3 CT neck wetread showed hypodensity left of oropharynx involving L aryepiglottic fold and compressive effect on airway. ENT was consulted. pt given steroids and zosyn in ED with plan to give vanc as well. transferred to [**Hospital Unit Name 153**] after 2L IVF. . In the [**Name (NI) 153**], pt appears comfortable, not requiring oxygen. Is able to control his own secretions. Endorses pain on swallowing and right lower ribcage/sternal sharp pains with movement. Past Medical History: peripheral neuropathy - possibly chemo induced, takes gabapentin ONCOLOGIC HISTORY: 1. [**2191-6-17**]: screening colonoscopy: rectal mass distally and multiple polyps identified. 2. Admitted with lower GI bleeding following the colonoscopy and imaging revealed multiple bone metastasis and extensive retroperitoneal and pelvic lymphadenopathy. Bone lesions were confirmed with bone scan and MRI. 3. [**2191-7-5**]: Started on FOLFOX for palliation. 4. [**2191-11-7**]: Start on 5FU/leucovorin. Stop oxaliplatin due to allergic reaction. 5. [**2-/2192**]: Torso CT: no disease progression Social History: Lives at home with his wife. His children live nearby. Smokes [**12-5**] pack cigarettes for 45 years, continues to smoke. denies alcohol, denies IVDA. Family History: One sister died of breast cancer, another of lung cancer (smoker), one brother died of MI. Physical Exam: ON ADMISSION: Tcurrent: 36.9 ??????C (98.5 ??????F) HR: 98 (97 - 98) bpm BP: 132/65(79) {132/65(79) - 132/65(79)} mmHg RR: 17 (17 - 20) insp/min SpO2: 92% RA Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric,dry mucous membranes, oropharynx not well visualized, no sores inside the mouth Neck: supple, JVP not elevated, no LAD. Unable to palpate mass in the left cervical SCM area and pt is nontender to palpation of this area Lungs: crackles at the bases bilaterally, no wheezes. 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: EKG [**2192-3-21**]: NSR @90s, unchanged from prior no signs of ischemia [**2192-3-20**] 11:52PM URINE HOURS-RANDOM UREA N-422 CREAT-63 SODIUM-45 POTASSIUM-64 CHLORIDE-61 [**2192-3-20**] 11:52PM URINE OSMOLAL-388 [**2192-3-20**] 11:10PM URINE HOURS-RANDOM [**2192-3-20**] 11:10PM URINE GR HOLD-HOLD [**2192-3-20**] 11:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2192-3-20**] 11:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2192-3-20**] 08:08PM LACTATE-1.3 [**2192-3-20**] 08:00PM GLUCOSE-113* UREA N-21* CREAT-1.0 SODIUM-130* POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-21* ANION GAP-15 [**2192-3-20**] 08:00PM estGFR-Using this [**2192-3-20**] 08:00PM WBC-8.3 RBC-3.65* HGB-12.2* HCT-36.9* MCV-101* MCH-33.5* MCHC-33.1 RDW-15.8* [**2192-3-20**] 08:00PM NEUTS-78.4* LYMPHS-14.2* MONOS-6.8 EOS-0.4 BASOS-0.3 [**2192-3-20**] 08:00PM PLT COUNT-158 . [**2192-3-20**] CXR: IMPRESSION: Streaky left base opacity, developing/early pneumonia not excluded. Bibasilar atelectasis. . [**2192-3-22**] CXR: IMPRESSION: Small bilateral pleural effusions. No evidence of focal consolidation. . [**2192-3-22**] right rib film: IMPRESSION: No evidence for rib fracture. No pneumothorax. . [**2192-3-20**] CT NECK:IMPRESSION: 1. Ill defined area of hypodensity along the left of the oropharnx extending to involve the left aryepiglottic fold with medialization of the left aryepiglottic fold and with compressive effect on the air way, appears consistent with edema/phlegmonous change. No definite rim of enhancement. No retropharyngeal edema seen. 2. Atherosclerotic calcification and thrombus involving the cervical portion the right internal carotid artery (series 2, 45) which appears asymmetrically narrowed when compared to the left. Brief Hospital Course: 72 y/o M undergoing chemo for rectal CA (not currently neutropenic) p/w throat pain and fever found with parapharyngeal phlegmon compressing airway. . #Sepsis - Patient presented with tachycardia and fever with known source (paratracheal phlegmon). Was treated with 2L IVF in ED, and started on vanc/zosyn. On arrival to [**Hospital Unit Name 153**] his tachycardia/fever had resolved. He was not hypotensive. Given desire to also provide coverage for possible ESBL, antibiotics were changed to vanc/[**Last Name (un) 2830**]. The patient remained hemodynamically stable overnight, and did not require pressors. His infection was treated as below. . #Paratracheal phlegmon- CT revealed L parapharyngeal phlegmon without a drainable collection. His airway was patent, but left AE fold edematous. Was c/f airway protection requiring ICU admission, as well as concern that at some point the inflammation could liquify. He was seen by ENT, and started on IV steroids with decadron 10mg IV Q8H x3 doses. He was covered with broad spectrum antibiotics (vanc/meropenem for ESBL coverage). He was monitored closely for evidence of stridor, and also on continuous O2 monitoring. The following morning, steroids were stopped. Plan was for 14 day course of antibiotics, with IV abx for first 48-72 hours. Can likely be transitioned to augmentin to complete antibiotics course. He was initially kept NPO, then started on regular diet on hospital day 2. Monospot was negative. Blood cultures are negative at the time of discharge. ENT did not feel patient needed repeat imaging, unless clinical course changed. He should follow-up with Dr. [**Last Name (STitle) **] in [**1-6**] weeks after abx course completed. (The patient was called and given a phone number to call as this was not done prior to discharge.) Pain was controlled with acetaminophen and oxycodone as needed initially but at discharge he did not require any pain medications. . #Hyponatremia - Na initially 130, likely secondary to hypovolemia. Hyponatremia resolved after 2L of fluid. Hypovolemia was likely secondary to decreased PO intake in setting of sore throat, and also from insensible losses in setting of sepsis. Of note, his FeNA (checked in context of initial decreased urine output) was 0.55%, c/w prerenal etiology. . #Nutrition - Patient was initially kept NPO. His diet was advanced the following morning without incident. . #Chest pain - Patient c/o 4 days of chest pain after working in the yard. Pain was reproducible with palpation, and worse with movement. It was most consistent with a musculoskeletal etiology. A cardiac etiology was unlikely; EKG was without signs of ischemia and unchanged from prior. Portable CXR showed bibasilar atelectasis and no pneumonia. Formal PA/lateral CXR showed no infiltrate. Rib films showed no signs of fracture. His pain improved with warm compresses. . #Metastatic rectal cancer - On admission, patient not neutropenic although he is immunosuppressed. Noted to have bony metastases on previous MRI to lumbar, sacral, and cervical spine. Day of admission was C10D23 of FULFOX. His oncologist was contact[**Name (NI) **] during this hospitalization. He will follow up with his oncologist as previously scheduled. Medications on Admission: pt states he is only taking neurontin 900mg [**Hospital1 **] Discharge Medications: 1. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 2. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 3. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: parapharyngeal phlegmon Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for further evaluation of sore throat and fevers. You were found to have a parapharyngeal phlegmon and were started on antibiotics. You were evaluated by ENT. There was no need for drainage. You also had some chest pain which was thought to be musculoskeletal pain and improved with warm packs. Your rib x-rays did not show any signs of fracture. Your chest x-rays showed small pleural effusions and an opacity that is likely just atelectasis. There was no evidence of pneumonia. You will have re-staging scans soon and should discuss the results with your oncologist. START: Augmentin 875 mg po BID. CONTINUE: Gabapentin Followup Instructions: Follow up with your oncologist as scheduled below. Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2192-3-26**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2192-4-9**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2192-4-9**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2123-4-26**] Discharge Date: [**2123-5-25**] Date of Birth: [**2091-8-18**] Sex: F Service: SURGERY Allergies: Codeine / Remicade / Vancomycin Attending:[**First Name3 (LF) 3376**] Chief Complaint: Admit Crohn's flare with abscess to Surgery Major Surgical or Invasive Procedure: [**4-29**] CT-guided placement of drainage catheter into pelvic abscess. Scant thick pus aspirated initially. [**5-4**] The indwelling right pelvic catheter was easily exchanged for a similar cathete [**5-12**] CT-guided placement of two pigtail drainage catheters in two residual intra-abdominal abscess collections. [**5-14**] washout/ex-lap/drain placement History of Present Illness: 31F with h/o Crohn's disease refractory to medical mgmt (remicade, etc) currently on slow steroid taper. Recently admitted [**2-25**] with microperforation. Dr. [**Last Name (STitle) 1120**] planned on ileocecectomy on [**5-5**]. The pt now presents with epigastric pain X 2 weeks in spite of being on cipro, flagyl, prednisone. Flagyl d/c'd 2 weeks ago and put on prilosec by Dr. [**Last Name (STitle) 2161**]. Over past week, pain is worse and in past 24 hrs severe [**6-28**] pain in epigastrum and RLQ. Pt reports sweating but denies fevers. This AM, following taking her PO mediacation the pt reported emesis 10-15 times. She also noted [**8-28**] abdominal pain, mostly RLQ, but also LUQ. Loose stools no melena or BRBPR. Pt reports dry mouth but denies lighheadedness, dizziness, visual changes or other presyncopal symptoms. In ED, 99,4 115/69 120 17 100%RA. While in the ED, Tm 101.4 and tachy to 130s, normotensive. WBC 5.1 with 15% bandemia, diffuse peritonitis and rigid abdomen, diffusely tender. CT abd/pelvis with likely early developing abscess with pockets of free air in pelvis. The pt received 4L of NS, Dilaudid 1mg IV x7, Morphine 4mg IV, Zofran 4gm IX x1 for pain and tylenol 1gm PO. Abx were initially continued with Cipro 400mg IV and Flagyl 500mg IV which was later switched to Vanc 1g IV and Zosyn 4.5mg was given. An NG tube was placed which the pt states relieved some of her abdominal bloating. Upon further review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Occasional chest pressure, but denies tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. The pt stated it took her 3-4 minutes to initiate urination today in the setting of increased abdominal pain. Denies dysuria. Past Medical History: Crohn's Disease Depression h/o arthritis related to medications Anorexia Nervosa/OCD Past Surgical History s/p Wisdom teeth removal in [**2103**] LEEP procedure in [**2121**] Primary Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5781**] GI: Dr. [**Last Name (STitle) 2161**] Social History: Works at [**Hospital3 328**] in PR department [**11-21**] EtOH drinks, ~3 times per week smoked [**11-20**] ppd X 3-4yrs quit 9 years ago Family History: Cousin with [**Name (NI) 4522**] Disease Father CAD Physical Exam: Vitals: T: 99.9 BP: 117/72 P: 114 R: 24-29 93-96%O2: General: Alert, oriented, NAD when lying still HEENT: Dry MMM, PERRLA, EOMI Neck: supple, JVP 6-7cm, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: firm, diffusely tender, non-distended, hypoactive bowel sounds present. + Guarding. Tenderness to palpation > Rebound. Ext: Warm. 2+ pulses, no clubbing, cyanosis or edema . at discharge: Gen: a and o x 3, nad CV: RRR no m/r/g RESP: LSCTA bilat ABD: Soft, nt, nd, + bs Incision: ota with steri strips Pertinent Results: CT Abdomen (Wet-Read) [**2123-4-26**] 1. Increased size of pelvic collection, Image 2:61, with multiple tiny pockets of extraluminal air. The collection shows early signs of organizing to an abscess. 2. Worsening of bowel wall thickening, consistent with Crohn's flare. CT Abdomen [**2123-4-28**] (wet read) Marked interval increase in intraperitoneal fluid tracking through the mesentery, around the liver, and collecting in the pelvis. Large pre-sacral pelvic collection has increased in size and demonstrates increased rim enhancement, concerning for developing abscess. Hyperemic mesentery and omental inflammatory changes, likely worsened since the prior study. Focal collection previously identified in the mid-pelvis appears largely unchanged. Redemonstration of bowel wall abnormalities c/w Crohn's flare, largely stable. . IMAGING [**3-18**] CT abd: wall thickening/inflammatory fat stranding of TI, cecum, hepatic flexure, 2.4 cm early abscess adj to cecum [**4-26**] CT abd: inc pelvic fluid collection w/ mult tiny pockets of extraluminal air, early signs of organization, worsening bowel wall thickening [**4-28**] CT abd: marked inc intraperitoneal fluid tracking thru mesentery, around liver, [**Last Name (un) **] in pelvis, lg pre-sacral pelvic [**Last Name (un) **] inc in size w/ inc rim enhancement, ? abscess, worsened hyperemic mesentery & omental inflamm changes, focal [**Last Name (un) **] in mid-pelvis largely unchanged, stable bowel wall abnl [**5-9**] CT abd: interval [**Month (only) **] pelvic fluid [**Last Name (un) **], o/w stable [**5-10**] RUE U/S: no dvt [**5-12**] CT: drains in place [**5-13**] CXR: increased L eff, atelectasis, new R eff improved on CXR [**5-16**] . [**2123-5-16**] Blood Cx2 [**2123-5-16**] urine [**2123-5-16**] cxr [**Month (only) **]. lf pleural effusion,consol or pneumo lt base is not excluded [**2123-5-14**] Tissue(OR) PMN, no growth [**2123-5-13**] CXR Increased left effusion/atelectasis and new small right effusion [**2123-5-12**] abcess x2 GRAM POSITIVE COCCI (pairs) (pairs/clusters). PMNs [**2123-5-12**] bld times 4 negative [**2123-5-11**] urine neg [**2123-5-10**] bld x2 negative [**2123-5-10**] urine neg [**2123-5-8**] bld negative [**2123-5-5**] abscess C.albicans, s. viridans AND lactobacillus [**2123-5-4**] abscess C.albicans, S.viridans, lactobacillus [**2123-4-29**] abscess >3 bacterial types Brief Hospital Course: 31F here with long-standing refractory Crohn's presenting with a severe flare and intravascular depletion. . # Abdominal Pain/Surgical Abdomen: Most likely [**12-21**] Crohn's Flare given findings on CT (Multiple Tiny Pockets of Extraluminal Air, Worsening bowel wall thickening consistent with Crohns flare). Other less likely etiologies include perforated ulcer (given chronic steroid use). Evaluated by surgery in ED and upon admission to [**Hospital Unit Name 153**]. Received IV vancomycin/zosyn. Per GI to continue hydrcortisone 100 mg qdaily. NGT placed. Foley in place. Strict NPO, serial abd exam. - NPO - Serial Abdominal Exam -Antibiotics -Hydrocortisone 100mg Daily - Morphine 2-4mg IV PRN Abdominal Pain . # Sinus Tachycardia: In the setting of intravascular depletion, crohns flare, abdominal pain. - IVF resuscitation - Pain Control with Morphine 2-4mg IV PRN - Broad Spectrum ABx . The patient was transferred to [**Hospital Ward Name 1950**] 5 she was made NPO with IVF/Foley/IVMeds/ABX. She was febrile to 102.9 with increased pain. Her pain medication was changed from morphine to dilaudid with good effect. The patient also had a repeat CT scan showing a fluid collection in her abdomen. She was taken to IR to have a drain place. Scant thick pus aspirated and cultured. . A PICC line was placed and the patient was started on TPN with bowel rest. She continued to spike temps to 103.0. Multiple fever workups were done including BCX, UCX and CXR all negative for infection. She had multiple CT scans done indicating abcesses. She was taken to IR for Drain placement, 2 drains placed for a total of 4 drains. . Despite the drain placements the patient continued to spike temps to 104.6 on HD 19 requiring a cooling blanket. She was than pre-op'd and taken to the OR for ex-lap, washout and drain placement. . She returned to the floor. She was maintained as NPO, TPN was continued along with a PCA, IVF, ABX. Infectious disease was also consulted to recommend treatment. POD 1 the patient was afebrile. However she continued to spike daily fevers there on out. ID continued to follow the patient adjust antibiotics as needed. . The patient c/o of severe pain and the pain service was consulted. She was started on a fentynal patch and PO dilaudid with good effect. At discharge the patient no longer needed the fentynal patch, her pain was well controlled with dilaudid. Her TPN was cycled and with the return of bowel function and flatus her diet was advanced from sips to regular. Her TPN was d/c'd once she tolerated regular diet. All of her drains were d/c'd prior to d/c. The patient was encouraged to have ensure with all meals. All D/C paperwork was reviewed with the patient and all questions answered. She will follow up with Dr. [**Last Name (STitle) 1120**] in [**11-20**] weeks. Medications on Admission: Ciprofloxacin 500 mg [**Hospital1 **] Celexa 20mg qday Protonix 40 mg qday Prednisone 25 mg qday Ambien 10 mg qday PRN OCP Folate MVI CITRACAL + Vit D 250 mg-200 unit PO TID Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. Disp:*60 Tablet(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain for 2 weeks. Disp:*50 Tablet(s)* Refills:*0* 4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 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:*2* 7. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO DAILY (Daily) for 8 weeks. Disp:*168 Capsule, Sust. Release 24 hr(s)* Refills:*0* 8. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Primary: Crohn's Flare Fevers Dehydration Sinus Tachycardia Fluid collection . Secondary: depression, Crohn's dz Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Followup Instructions: 1. Please call Dr.[**Name (NI) 3377**] office, [**Telephone/Fax (1) 160**], to make a follow up appointment in [**11-20**] weeks. . Scheduled Appointments : Provider: [**Name10 (NameIs) **] RM 3 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2123-5-3**] 8:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-5-18**] 8:40 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2123-6-21**] 10:00 NEITHER DICTATED NOR READ BY ME Completed by:[**2123-5-25**]

Admission Date: [**2148-5-24**] Discharge Date: [**2148-6-3**] Date of Birth: [**2088-3-6**] Sex: F Service: NEUROLOGY INTERIM DISCHARGE SUMMARY: HISTORY OF PRESENT ILLNESS: This is a 60 year old right handed woman with a past medical history of coronary artery disease, hypertension, history of aneurysm clip seven years ago at [**Hospital6 1129**], who at 4:00 p.m. on the day of admission had sudden onset vertigo, right facial weakness, and dysarthria. The week prior she had had one minute episodes of a "dizzy" sensation while she was sitting and watching television and noted some heaviness in the left leg only. Transport services [**Location (un) **] reported that the patient had had headache in the right temporal region, now resolved per the patient. Systolic blood pressure was in the 160s on arrival, heart rate in the 80s, and she is in sinus rhythm. Temperature at the outside hospital was 96.1. AccuChek was 143. Daughter-in-law and son report very severe right facial droop and dysarthria that is very difficult to understand her. It improved in the Emergency Department at the outside hospital, but she is not still at baseline. The patient also reports "dizziness". PAST MEDICAL HISTORY: 1. Hypertension, reportedly very high. 2. Coronary artery disease, status post coronary artery bypass grafting. 3. History of hypercholesterolemia. 4. History of transient ischemic attack with speech slurring one year ago and hot flashes. 5. Depression after brain aneurysm. 6. Gastrointestinal, loose stools, dark stools, incontinence of urine and feces with coughing. 7. Family also reports anemia. 8. Suspect gastrointestinal problems but she has not been scoped. There are no liver, kidney, cancer history and no history of diabetes mellitus. PAST SURGICAL HISTORY: 1. Fracture of the arm, status post pin in [**2148-2-1**], pins out three days prior to admission. 2. Aneurysm clip at [**Hospital6 1129**] in [**2141**], incidental finding. 3. History of coronary artery bypass graft, two vessel at [**Hospital6 1708**] in [**12-3**]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: (At home) 1. OxyContin. 2. Lasix. 3. Neurontin. 4. Norvasc. 5. Metoprolol. 6. Captopril. 7. Aspirin. SOCIAL HISTORY: Tobacco quit [**12-3**]. No alcohol and no drugs. She lives with roommate. Nurse comes three times per week. Son lives down the street. FAMILY HISTORY: Mother with history of myocardial infarction. Aneurysms run in the family. Father with myocardial infarction. PHYSICAL EXAMINATION: On admission, vital signs revealed temperature 96.1, heart rate 92, blood pressure 140/110, respiratory rate 18, oxygen saturation 92% in room air. Head, eyes, ears, nose and throat examination - sclera clear. Mucous membranes are moist although dry around the mouth. Neck - no bruits. The heart is regular rate and rhythm. Chest - Lungs clear to auscultation bilaterally anteriorly. The abdomen is obese, soft. Extremities no edema bilaterally. Neurologic examination - mental status - alert and oriented. There is dysarthria although she follows commands and speech is fluent. Extraocular movements are impaired. Upgaze, right more than left. She looks to the right and left. Right eye did not look laterally. Adduction impaired. Right pupil 4.0 millimeters, left pupil is 6.0 millimeters. Ptosis in the right eye, torsional upbeating nystagmus in primary gaze. Right facial weakness. Head turning intact bilaterally. Shoulder shrug intact bilaterally. Decreased sensation in right V1 through V3. There is tongue midline but slightly deviated to the left. Hearing is intact bilaterally to finger rub. Over the course of hospitalization, the nystagmus has improved significantly as well as the facial droop although she does continue to have somewhat of a facial droop. Motor - bilateral grasp is [**6-5**]. Biceps [**6-5**]. Tibialis anterior and gastrocnemius [**6-5**]. The patient did continue to have full strength throughout. Sensation intact bilaterally to light touch throughout. Coordination - fine finger movements intact bilaterally in hands. She moves very ataxic on initial examination, however, this improved significantly and she has much less ataxia on [**2148-6-3**]. Reflexes are symmetric. Both toes are upgoing. LABORATORY DATA: On [**2148-6-3**], white blood count 10.3, hematocrit 30.7, and she was transfused throughout the hospital course to attempt to keep the hematocrit above 30.0. However, stool guaiac was negative. Platelet count was 269,000. INR on [**2148-6-3**], was 1.4. Partial thromboplastin time was 63.8. Prothrombin time was 14.5. Fibrinogen was 294. Reticulocyte count 1.9. Protein B 121 which is normal. Urinalysis on [**2148-5-28**], was positive. Repeat urinalysis after treatment on [**2148-6-3**], is now negative. Glucose 120, blood urea nitrogen 10, creatinine 0.7, sodium 140, potassium 4.4, chloride 107, bicarbonate 27 on [**2148-6-3**]. ALT 19, AST 15, LDH 154, alkaline phosphatase 58, amylase 11, total bilirubin 0.5. She ruled out for myocardial infarction by enzymes twice. Lipase 17. Calcium 8.9, phosphate 4.3, magnesium 2.4. Iron 34, total cholesterol 178, TIBC 224, Vitamin B12 315, folate 12.7, haptoglobin 238, ferritin 41, transferrin 172. Hemoglobin A1C 6.1. Triglycerides 103, HDL 54, LDL 103, homocysteine 5.9. TSH 0.77. Urine culture was growing Klebsiella oxytoca and Enterococcus species, both of which are pansensitive. Sputum culture was no growth. Factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5244**] is pending. Protein S 68 which is within normal range. Angiocardiolipin antibodies IgG and IgM normal at 3.0 and 3.1, respectively. Lipoprotein A is high at 60 on [**2148-5-24**]. Initial magnetic resonance scan of the head showed bilateral pica infarcts, also an aneurysm clip causing loss of signal, inability to evaluate in distal right internal carotid artery M1 and A1 segments. Angiogram on [**2148-5-23**], showed multiple areas of thrombosis including right vertebral artery thrombosis, left pica thrombosis, stenosis at the origin of the right anterior inferior cerebellar artery as well as stenosis of the left vertebral artery in both its proximal segment above the level of C5 vertebral body as well as the level of C1 vertebral body, approximately 50%, as well as distal intracranial left vertebral artery stenosis greater than 60% but with a patent basilar artery and collateral flow as described in the results. Serial head CT proved stable. There is hypoattenuation in the cerebellar cortex consistent with pica infarction bilaterally. There is some surrounding edema, however, no midline shift or evidence of tonsillar herniation. There was some distortion of the fourth ventricle and flattening of the quadrigeminal plate cistern which was unchanged as well as a hypodensity in the left basal ganglia consistent with an old infarct. There was never any herniation or change in the CT. CT of the abdomen and pelvis on [**2148-6-1**], showed no evidence of retroperitoneal hemorrhage. This was obtained because of the patient's hematocrit, however, there was no retroperitoneal hemorrhage. There was bilateral mild to moderate atelectasis in the lungs. There was no free air and no lymphadenopathy. There was a large left sided paraesophageal hernia. This hernia required placement of nasogastric tube with the help of interventional radiology initially. Transthoracic echocardiogram revealed ejection fraction of 40%, left and right atrium normal in size, left ventricular wall thickness normal with mild regional left ventricular systolic dysfunction. There is a moderate size thrombus in the left ventricle. Left ventricular wall motion abnormalities show at the anterior apex akinetic, septal apex akinetic, lateral apex akinetic and the apex akinetic. Right ventricle and right ventricular chamber size and free wall motion normal. Aortic root normal in diameter. Aortic valve leaflets mildly thickened, no aortic regurgitation. Mitral valve showed trivial mitral regurgitation seen. There is no pericardial effusion. HOSPITAL COURSE: The patient was admitted, initially transferred, and underwent angiogram revealing occluded right vertebral artery and stenosis in the left vertebral artery in addition to her pica infarcts bilaterally. Transthoracic echocardiogram showed incidental clot in the heart although the infarcts were thought to be due to artery-artery emboli from the vertebrals. Hypercoagulable workup was originally sent because initially the clot in the heart was found, though likely this clot formed because of the akinetic apex. The hypercoagulable workup revealed elevated lipoprotein A. This will be repeated this week and will be treated with Niacin should it still be high. The patient was started on Heparin on the day of admission especially given this clot in the heart and she was continued on Labetalol drip to control her blood pressure to keep it in the systolic range of 120 to 160. On [**2148-5-26**], the day after admission, the patient was transiently transferred to the floor, however, she became agitated. She self discontinued her femoral line which was her only access and later had some episode of desaturating to the mid 80s. The repeat head CT showed signs of cerebellar edema, but no herniation. She was transferred back to the Intensive Care Unit. She did remain stable in the Intensive Care Unit and was started on Coumadin initially, however, was requiring frequent suctioning for her sputum. Feeding tube was placed and she was started on tube feeds. She did become somnolent around the date of [**2148-5-29**], however, she was found at that time to have a urinary tract infection and was started on Levaquin. On [**2148-6-3**], was day six of the Levaquin. The patient was transfused for her anemia. Anemia workup was sent and her stool guaiac was negative. Later on that evening, she desaturated while being suctioned. She had transient respiratory arrest and became very bradycardic. Code Blue was called. Chest compressions were given for about one minute when the patient became asystolic and the patient was intubated. At the time of the code, the patient was at her baseline neurologic status and then after intubation she was moving all four extremities. Head CT at that time was unchanged. Heparin drip was temporarily stopped and a central line was placed. The patient was placed on Propofol at that time. The following day the patient was taken off the Propofol and she did awaken and was able to follow commands well. She was intubated for the next couple of days for stabilization of her respiratory status and was extubated on [**2148-6-1**], and did well after that. By [**2148-6-3**], the frequency of suctioning decreased and the patient was on nasal cannula. Her issues neurologically, the patient suffered bilateral pica strokes. She is on Lipitor for future stroke prevention and also continues on Heparin drip until she has a therapeutic INR on her Coumadin. As for the elevated lipoprotein A, that will be repeated and then Niacin will be started if it does indeed remain elevated. Respiratory wise, she has been extubated and is stable, status post extubation. It is unclear as to whether some of her somnolence may have been due to CO2 narcosis and so today she has been maintaining oxygen saturation in the low to mid 90s and has become more awake, is doing well on oxygen by nasal cannula. Cardiovascularly, she is now on Metoprolol, Enalapril and p.r.n. Hydralazine for her blood pressure and is off the Labetalol drip. Gastrointestinal - She has a large hiatal hernia and nasogastric tubes are very difficult to place. She will receive a percutaneous endoscopic gastrostomy tube tomorrow [**2148-6-4**], as she cannot swallow, has failed her swallowing evaluation and likely will not be able to swallow for some time. Infectious disease - She ahs remained afebrile throughout her hospital course. She was found to have a urinary tract infection on [**2148-5-29**], and is now on day six of the Levaquin. This will likely be continued for seven days and stopped. Hematologically, her hematocrit remained stable. Currently she is being transfused for hematocrit less than 30.0. She has not had any retroperitoneal bleed and no guaiac positive stools. Renally, she is stable and there are no issues. Endocrine wise, she does have evidence of diabetes mellitus with a hemoglobin A1C of 6.0. She is on four times a day fingerstick and her regular insulin sliding scale. She will need outpatient follow-up for this. Code Status - Her code status has been full code. She has improved as far as having no further double vision, less vertigo and less dysarthria at this point than on admission. She is being currently stabilized for transfer to the floor at some point in the very near future. The oncoming [**Male First Name (un) 1573**] resident will dictate the rest of the hospital course, discharge instructions, medications and follow-up. [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Last Name (NamePattern1) 4525**] MEDQUIST36 D: [**2148-6-3**] 20:04 T: [**2148-6-3**] 20:12 JOB#: [**Job Number 55561**]

Admission Date: [**2108-1-25**] Discharge Date: [**2108-1-25**] Date of Birth: [**2024-10-13**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2712**] Chief Complaint: N/V/D, abdominal pain Major Surgical or Invasive Procedure: -central venous line, intubation -CPR times 2 History of Present Illness: This is an 83 year old female with PMH of HTN, chronic kidney injury with baseline Cr=1.7-2, hyperlipidemia, hypothyroidism, and osteoporosis presenting with 3-4 days of N/V/D and abdominal pain. She was reportedly caring for her disabled brother in his 70s who also has gastroenteritis. She was found by EMS earlier today with SBP in the 70s and was reportedly very dry and unable to take POs. She reported no fevers or chills, but did endorse non-bloody emesis and diarrhea. . In the ED, initial VS were not recorded, but she was reportedly hypotensive to the 70s which responded to systolic in the 100s after 4L of IVFs. Her WBC count was 14.1 and her initial lactate was 5 which trended down to 2.1 after fluid resuscitation. She was empirically treated with Cipro and Flagyl. A right IJ central line was placed for the initial resuscitation. CXR showed mild pulmonary vascular congestion. SVO2=48 and her CVP was [**10-2**] after 3L of IVFs. Given the concern for cardiogenic shock, a bedside ECHO was attempted by the ED which showed a dilated right ventricle. She was guaiac negative and the concern for PE was high given these findings so she was empirically started on a heparin drip since her Cr=1.7 and the goal was to avoid a dye load for a CTA. Cardiology fellow was consulted for bedside ECHO, but had poor windows and during ECHO at around 12:30AM the patient had an acute change in mental status complaining of sudden onset abdominal pain and reported feeling as though she was going to die. She then vagaled down to a HR in the 30s and dropped her blood pressures, but reportedly did not lose consciousness. She was started on dopamine which was soon maxed out and Levophed was added as well. She was then intubated, given 4.5 grams of Zosyn, and a CTA torso was obtained. No PE was seen, but diffuse bowel wall edema was noted and surgery was consulted for this. Of note, she had several failed attempts at a right femoral and left radial A-lines on heparin with a lot of bleeding at the leg site. Protamine was given to reverse the heparin. Transfer VS: BP=155/120, HR=137, RR=22, 100% on vent of FiO2 95%, PEEP 5 on dopa of 10 and levophed alone at 0.3 mcg. . On arrival to the MICU, patient was intubated/sedated. Social work was consulted in the ED. She is the sole caretaker for her younger 73 year old disabled brother who also has gastroenteritis and is also in the ED. She has no other family. Past Medical History: Past Medical History: -HTN -Chronic kidney injury with baseline Cr=1.7-2 -Hypothyroidism -Hyperlipidemia -Osteoporosis -h/o Non Hodgkins lymphoma in remission since [**2096**] -h/o NSVT -Remote history of endometrial cancer s/p chemo and radiation -Severe scoliosis . Past Surgical History: -s/p left radius/right humerus fractures in [**2070**] -s/p TAHBSO and radiation for endometrial CA in [**2072**] -s/p hip surgery [**2106**] Social History: She has been living with her stepbrother in a historic brownstone on [**Doctor First Name **] street, which is the home she grew up in. Occupation: worked as a researcher in radiation therapy at the VA before she retired at 48 after she was diagnosed with endometrial cancer. No smoking. No alcohol. Family History: Non-contributory Physical Exam: General: Intubated, sedated HEENT: Sclera anicteric, dry MM, PERRL but sluggish Neck: supple CV: Tachycardic Lungs: Clear to auscultation anteriorly Abdomen: soft, non-distended, bowel sounds present GU: Foley Ext: warm, no clubbing or edema, massive right thigh hematoma Neuro: intubated/sedated Pertinent Results: CTA abdomen/pelvis: 1. Active arterial extravasation in the right proximal medial thigh, likely related to recent arterial puncture. 2. Right portal vein thrombus with hypoenhancement of the right lobe of the liver. Differential diagnosis includes low-flow state, hypercoagulability, and tumor. 3. Pericholecystic fluid, which could be secondary to recent volume resuscitation, but cholecystitis is also a possibility. Further evaluation is recommended with ultrasound. 4. Heterogeneous enhancement of the right kidney, which could be secondary to infection or low-flow state. 5. Bowel wall edema and mucosal hyperenhancement suggestive of recent hypoperfusion. 6. Non-acute findings: chronic-appearing severe left hydroureteronephrosis, ascending aortic dilation, colonic diverticulosis, mid-thoracic vertebra plana. Brief Hospital Course: This is an 83 year old female with PMH of HTN, chronic kidney injury with baseline Cr=1.7-2, hyperlipidemia, hypothyroidism, osteoporosis, and remote history of endometrial cancer and Non-Hodgkin's lymphoma presenting with 3-4 days of N/V/D and abdominal pain with ED course complicated by PEA arrest requiring a round of CPR. . She was brought to the ED for further evaluation of N/V/D and abdominal pain. She was markedly hypovolemic and hypotensive to the 70s which initially responded to 4L IVFs. She was given empiric abx and thought to be in cardiogenic shock. She then developed severe abdominal pain and change in mental status. Shortly thereafter, she vagaled down to the 30s and dropped her blood pressures. She was intubated and central line was place. Two pressors were started. She received one round of CPR in the ED with return of spontaneous circulation. Unfortunately, she passed away after 10 minutes of CPR upon admission to the ICU for PEA arrest. Medications on Admission: -Atenolol 12.5mg daily -Levothyroxine 88mcg daily -Pravastatin 40mg at bedtime -Calcium/vitamin D Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

Admission Date: [**2171-2-27**] Discharge Date: [**2171-3-29**] Date of Birth: [**2093-12-30**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Heparin Agents Attending:[**First Name3 (LF) 613**] Chief Complaint: transferred from [**Hospital3 **] with abnormal labs--worsening renal failure and metabolic acidosis Major Surgical or Invasive Procedure: placement and removal of central venous access swan-ganz catheter History of Present Illness: Mr. [**Known lastname 74377**] is a 77 year-old man with multiple medical problems including CAD, left ventricular systolic dysfunction with EF of 20%, diabetes mellitus, chronic renal insufficiency with baseline creatinine of 2.2-2.4, hypertension, admitted now from [**Hospital3 **] after labs there demonstrated worsening renal failure and metabolic acidosis. ABG there was 7.25/64/37. The patient reports being bored there. He also reports non-productive cough. Denies chest pain, shortness of breath, pnd, orthopnea, palpitations. He says he was brought to [**Hospital1 18**] because he has a urinary tract infection. As per notes, patient has had recent fevers, which he denies. Additionally at [**Hospital1 **], the was patient being treated for c. diff infection, although no definitive C. diff positivity as per records from [**Hospital1 1319**]. Patient was discharged from [**Hospital1 18**] on [**2-1**]. At that time, lisinopril and lasix had been added to medication regimen. Unclear when these meds were stopped, but at least on day of admission, patient did not receive these. He denies uremic complaints. No dysuria, hesitancy, increased frequency as per patient. Past Medical History: 1. Type 2 DM c/b neuropathy, 2. CAD s/p cath [**4-24**] and [**12-26**]: PTCA LAD and LCX, course complicated by ischemic CM with EF 20%, hemothorax secondary to chest compression 3. CHF: [**1-23**] ischemic CM w/ EF 20% 4. CRI: [**1-23**] diabetic nephropathy, baseline CR 2.2-2.4 5. Anemia of chronic disease, baseline HCT 30 6. h/o VTach s/p DCCV 7. Hypertension 8. stroke: Left posterior deep white matter CVA [**7-25**] 9. Seizures: [**4-24**] on dilantin 10. Urinary retention 11. s/p OS catract, s/p OD catract [**2166**] 12. s/p thoroscopic, parietal decrotication for hemo thorax [**4-24**] 13. s/p tracheostomy [**4-24**] 14. s/p EGD with percutaneous gastrostomy [**4-24**] 15. s/p CCY [**7-25**] 16. s/p appendectomy Social History: Patient is married. He has been between hospital and [**Hospital1 **] since [**4-24**]. He is a retired court officer and state representative. Denies any history of tobacco, alcohol, or illicit drug use. Family History: mother died at 92, had diabetes and breast cancer sisters ages 70 and 80 - one has CAD and had MI, other with MR, thyroid problems brother died at 52 of cancer of unknown type Physical Exam: VS: temp: 97.9 hr: 83 bp: 101/42 rr: 22 95% room air general: somewhat lethargic, elderly appearing gentleman in no apparent distress, "bored" HEENT: PERLLA, EOMI, MMM, op without lesions, no jvd, no carotid bruits, no cervical or supraclavicular lymphadenopathy lung: scattered rhonchi heart: RR, S1 and S2 wnl, no murmurs rubs, gallops abd: +b/s, soft, nt, nd extr: no cyanosis, clubbing or edema, has b/l boots, left heel ulcer with erythema and tenderness neuro: AAOx3, somewhat lethargic, 5/5 strength throughout, good sensation throughout, cn ii-xii intact, no pass pointing, [**1-25**] patellar reflex, gait not assessed Pertinent Results: Admit labs: [**2171-2-27**] 12:00PM WBC-7.8 RBC-2.91* HGB-8.9* HCT-27.9* MCV-96 MCH-30.7 MCHC-32.0 RDW-15.7* [**2171-2-27**] 12:00PM NEUTS-85.8* LYMPHS-10.7* MONOS-2.2 EOS-1.2 BASOS-0.1 [**2171-2-27**] 12:00PM PLT COUNT-160 [**2171-2-27**] 12:00PM PT-18.8* PTT-35.7* INR(PT)-2.2 [**2171-2-27**] 12:00PM GLUCOSE-135* UREA N-81* CREAT-3.2*# SODIUM-137 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-20* ANION GAP-14 Urinalysis: [**2171-2-27**] 12:35PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2171-2-27**] 12:35PM URINE RBC-0-2 WBC->50 BACTERIA-NONE YEAST-NONE EPI-0 Cardiac Enzymes: [**2171-2-27**] 07:40PM CK(CPK)-63 [**2171-2-27**] 07:40PM cTropnT-0.12* [**2171-2-27**] 07:40PM CK-MB-NotDone EKG: NSR, LBBB, no changes [**2171-3-14**] renal U/S: IMPRESSION: Left-sided simple renal cysts. No evidence of hydronephrosis. Chest x-ray: PA and lateral views of the chest: There is stable cardiomegaly. The aorta is tortuous. There is perihilar haziness, upper zone vascular redistribution, and vascular indistinctness, findings all consistent with mild congestive heart failure, which is improved since the prior examination. There is persistent retrocardiac opacity present, which may represent a collapsed/consolidation. Additionally, there is a small bilateral pleural effusions, which appears slightly improved since the prior examination. Degenerative changes are noted within the thoracic spine. IMPRESSION: 1. Mild congestive heart failure, improved since the prior examination. 2. Persistent retrocardiac opacity, which may represent collapse/consolidation. 3. Small bilateral pleural effusions, decreased since the prior examination. Head CT [**2171-3-14**]: IMPRESSION: No evidence of intracranial hemorrhage or edema. Of note, an MRI with diffusion-weighted imaging is most sensitive for acute infarction. Left heel [**2171-3-14**]: IMPRESSION: No focal bone destruction to confirm the presence of osteomyelitis. CT Chest/Abd/Pelvis [**2171-3-27**]: IMPRESSION: 1. Unchanged appearance of the abdomen compared to [**Month (only) 956**] [**2170**]. There is persistence of the nonspecific [**Doctor First Name 9189**] mesentery, without associated lymphadenopathy or bowel abnormalities. There is no evidence of abscess or ascites. There is no CT evidence of pancreatitis. 2. Bilateral pleural effusions have slightly improved but persist. 3. Marked vascular calcifications. Right knee x-ray [**2171-3-26**]: degenerative changes. no fracture or dislocation On discharge: [**2171-3-28**] 06:08AM BLOOD WBC-8.2 RBC-3.04* Hgb-9.4* Hct-28.1* MCV-92 MCH-30.9 MCHC-33.5 RDW-16.6* Plt Ct-163 [**2171-3-29**] 09:00AM BLOOD PT-18.4* PTT-33.8 INR(PT)-2.1 [**2171-3-29**] 05:29AM BLOOD Glucose-78 UreaN-103* Creat-4.4* Na-133 K-4.9 Cl-102 HCO3-18* AnGap-18 Brief Hospital Course: 77 year-old man with history of CAD, left ventriuclar systolic dysfunction with EF 20-25%, type II diabetes mellitus, hypertension, anemia, history of v-tach, chronic renal insufficiency admitted with worsening renal failure, metabolic acidosis, undocumented fevers, and concern for UTI or pneumonia. During his hospitalization the following problems were addressed: 1. Worsening renal failure: the patient's baseline creatinine was 2.2-2.4, and he presented with creatinine of 3.2. Previously he had been discharged to rehab on n lisinopril and lasix, and his creatinine worsened since that time. Renal failure was likely multifactorial related to his poor cardiac function, prerenal azotemia leading to ATN, and complicated by ACE inbitor and lasix use, obstruction due to prostatic hypertrophy as he was noted to have urine residuals of 350cc when catheter was inserted, and continued periods of hypotension. Renal service consulted. Despite efforts to closely monitor his fluid status, to increase his blood pressure to SBP >120 to maintain renal perfusion, to relieve obstruction by placing a foley, and to treat his funguria aggressively, his creatinine continued to rise. Hemodialysis was discussed at length with the patient by both the primary medical and renal teams. He fluctuated in his willingness to start dialysis, but would not commit to it. He developed subtle metabolic acidosis, K+ rose but not above the normal level, and he continued to make urine and maintain a euvolemic fluid balance. There was no an indication for acute initiation of hemodialysis. Creatinine stabilized at around 4.2 by the time of discharge. 2. Funguria: the patient had a fever and a delirium. The only source of infection identified was yeast in his urine, and it was felt this warrented treatment. Two species of yeast were identified; [**Female First Name (un) **] albicans and galabrate. He was treated with a two week course of fluconazole 200mg daily. Infectious disease service was consulted and saw no indication for amphotericin bladder washes. They recommended continuing the two week course of fluconazole. 3. Conjestive heart failure: With treatment for his renal failure the patient developed acute worsening of his conjestive heart failure. He became hypoxic and was admitted to the CCU. There a Swan-Ganz catheter was placed for tailored diuresis. He was diuresed and placed on afterload reduction with hydralazine. He was transferred back to the floor on metoprolol, hydralazine, and lasix. His renal failure continued to worsen on this regimen, and he became hypotensive with SBP 80-90. The metoprolol dose was reduced, the hydralazine initially held, then restarted at a reduced dose, and lasix discontinued. His respiratory status remained stable. He did not complain of shortness of breath. He continued to saturate well on room air. He did have elevated JVP suggestive of fluid overload. This improved but did not resolve entirely by the time of discharge. He was discharged on continued metoprolol, hydralazine, and statin, for secondary prevention of CHF exacerbation. 4. Fevers: The patient presented initially with fevers, with concern for UTI and pneumonia. CXR here showed a possible pneumonia, and he was treated with levofloxacin. Additionally he was treated with flagyl for c.diff infection. He completed both courses. He also ruled out for influenza by nasal aspirate. Additionally, there was concern for osteomyelitis given his chronic left heal ulcer. X-ray; however, did not show any signs of osteomyelitis. 5. h/o DVT: pt had a DVT diagnosed in [**12-26**]. He was continued on anticoagulation. INR became surpratherapeutic while on concurrent antibiotics, and coumadin was held. It remained elevated, thought to be due to nutritional Vit K deficiency, but eventually trended down. He should be treated for an additional 3months. Coumadin should be resumed at 2mg qHS, and held for INR >2 (goal INR [**1-24**]). 6. Anemia: the patient has a history of anemia and guiaic positive stools. He continued to have guiaic positive stools, but his Hct remained stable. He had a colonoscopy in [**12-26**] that showed benign adenomatous polyps. He should likely consider repeat colonoscopy as part of his outpatient. He was treated with Epogen injections, and Hct remained stable. 7. Type II diabetes mellitus: [**Last Name (un) **] services were consulted. The patient was initially treated with a regular insulin sliding scale. He was then on tubefeeds for about three weeks, and lantus was added. When the tubefeeds were discontinued, hte lantus dose was reduced. He was discharged to rehab on 26units Lantus in the mornings, and a regular insulin sliding scale. 8. Dispo: he was discharged back to [**Hospital3 **]. His renal failure may progress, and he may require hemodialysis at some time in the future. For now, he continues to be euvolemic and stable. He should be encouraged to improve his po diet to sustain nutrition for healing of his pressure ulcers. He will follow up with Drs. [**Last Name (STitle) **] in the primary care clinic, Dr. [**Last Name (STitle) 1366**] in nephrology, and Dr. [**Last Name (STitle) 284**] in cardiology. Medications on Admission: plavix 75mg daily aspirin 325mg daily toprol 50mg daily imdur 30mg daily hydral 10 q6hrs glargine 20 qhs zinc vit c vit d vit a calcitriol zocor 40mg daily coumadin 5mg daily protonix 40mg daily tamsulosin 0.4mg daily Discharge Medications: 1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-23**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily): hold for loose stool. 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Hydralazine HCl 10 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for gas. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 17. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleeplessness. 18. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Thirty (30) ML PO QD (). 19. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Four (24) units Subcutaneous QAM. 20. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 21. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours). 22. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 23. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold for INR >2. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: renal failure conjestive heart failure (EF 20%) deep venous thrombosis funguria type II diabetes mellitus anemia s/p stroke coronary artery disease pressure ulcers Discharge Condition: stable Discharge Instructions: If you develop fever >101.3, chest pain, shortness of breath, or decreased urine output, please contact your primary care physician [**Name Initial (PRE) **]/or return to the emergency department. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 33346**], MD Where: [**Hospital6 29**] [**Hospital6 **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2171-4-8**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-4-15**] 3:00 Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2171-4-11**] 2:30 You also have an appointment with Dr. [**First Name4 (NamePattern1) 105334**] [**Last Name (NamePattern1) 284**], your cardiologist, for [**2171-4-29**]. Please call [**Telephone/Fax (1) 285**] for the time. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Admission Date: [**2109-7-29**] Discharge Date: [**2109-7-31**] Date of Birth: [**2045-11-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 11220**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation and extubation History of Present Illness: [**Hospital Unit Name 153**] Admission Note Primary Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1437**] ([**Location (un) **]) Neurologist: Dr. [**Last Name (STitle) **] ([**Location (un) **]) Chief Complaint: respiratory failure and altered mental status Reason for MICU transfer: intubated History of Present Illness: 63 yo F (real name [**First Name5 (NamePattern1) **] [**Known lastname 11135**]) with PMHx of alcohol abuse with withdrawal seizures, a SDH s/p R craniotomy, HTN and HL who presents intubated from [**Hospital1 2519**] for confusion. Per OSH records, patient fell the night prior to arrival on cousin's floor and struck her head; denied LOC, but c/o left brow pain, heaache, chipped tooth and sore R shoulder. A preliminary head CT showed no acute intracranial abnormality with chronic findings (old R parietal craniotomy, old R burr hole). Labs were notable for lactate 1.2, normal chem 7, normal CBC, normal UA, ammonia 32 (WNL). Tox negative for ethanol, salicylates, acetominophen. The patient was intubated for failure to oxygenate/ventilate and inability to protect airway (sedation and confusion). CXR showed R mainstem intubation--> pulled back 1 cm and improved L lung aeration. In the ED, initial VS were: 98.7, 91, 137/78, 21, 99%. Labs notable for UA with small WBC, Pos nitrite, few bact. ABG 7.33/41/421 on 450/100%. Initially in the ED, she was "fighting the vent" and was making purposeful movements of all 4 extremities to attempt to remove the ETT, she was then heavily sedated in the ED with fentanyl and midazolam. She received 500mg azithromycin and 1g of ceftriaxone. Neurology was consulted who recommended EEG. On arrival to the MICU, patient's VS. 94.5, 73, 97/64. Patient was intubated and sedated. Vent 450/12/40%/5. Review of systems: unable to perform, patient intubated and sedated Past Medical History: SDH with coma for 3 mo about 5 years ago s/p Burr hole Seizures Alcoholism HTN HLD chronic cough of unclear etiology (sig second-hand smoke exposure) h/o colostomy for unclear reasons 8 pregnancies (G8) h/o breast bx x 2 foot and ankle fractures Social History: Patient lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in [**Hospital1 **]. She has a brother in law in the area but often spends time with her cousin, [**Name (NI) 553**], who is local. She is currently disabled. Denies having any problems with alcohol currently, but did before her stroke. Drinks 3 glasses of wine a night, no significant beer or liquor, CAGE negative, denies illicits or tobacco but her ex-husband (married for 25 years) smoked a lot Family History: Mother died of congenital heart condition in her 40s. Brother died of an MI in his 60s. Otherwise, denies. Physical Exam: ADMISSION EXAM 94.5, 73, 97/64. Vent 450/12/40%/5. General: sedated, non-responsive HEENT: Sclera anicteric, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anterior lung fields, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: sedated, non-responsive Pertinent Results: ADMISSION LABS [**2109-7-29**] 05:44AM BLOOD WBC-4.7 RBC-3.51* Hgb-11.8* Hct-35.4* MCV-101* MCH-33.5* MCHC-33.2 RDW-13.7 Plt Ct-104* [**2109-7-29**] 05:44AM BLOOD PT-11.1 PTT-26.3 INR(PT)-1.0 [**2109-7-29**] 05:44AM BLOOD UreaN-17 Creat-0.6 [**2109-7-30**] 05:20AM BLOOD Glucose-100 UreaN-7 Creat-0.3* Na-139 K-3.1* Cl-110* HCO3-22 AnGap-10 [**2109-7-29**] 05:44AM BLOOD ALT-20 AST-24 LD(LDH)-275* CK(CPK)-138 AlkPhos-81 TotBili-0.4 [**2109-7-30**] 05:20AM BLOOD Calcium-7.0* Phos-2.2* Mg-1.9 [**2109-7-29**] 05:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2109-7-29**] 05:57AM BLOOD Type-ART Tidal V-450 FiO2-100 pO2-421* pCO2-41 pH-7.33* calTCO2-23 Base XS--4 AADO2-252 REQ O2-49 -ASSIST/CON [**2109-7-29**] 06:30PM BLOOD Type-ART pO2-83* pCO2-36 pH-7.39 calTCO2-23 Base XS--2 Intubat-NOT INTUBARED MICRO IMAGING CXR 8.20 A feeding tube is noted with tip at the level of the gastric antrum. ET tube is at the carina and should be repositioned. Bilateral low lung volumes are noted with crowding of bronchovascular markings. Cardiac silhouette is accentuated by low lung volumes. Additionally, opacification at the left lung base and in the retrocardiac region appears concerning for either pleural effusion versus atelectasis, infectious process such as pneumonia cannot be completely excluded in the correct clinical setting. CXR 8.21 In comparison with the study of [**7-29**], there again are lower lung volumes. Cardiac silhouette is within upper limits of normal or slightly enlarged. Minimal poor definition of pulmonary vessels could reflect slight elevation of pulmonary venous pressure. Blunting of costophrenic angles could reflect small effusions or pleural thickening. No definite pneumonia is appreciated, though in the appropriate clinical setting a supervening consolidation would be difficult to exclude in lower zones. Brief Hospital Course: 63 yo F with PMH alcohol abuse with seizures, SDH s/p burr hole 5 years ago admitted with acute change in mental status. # Acute Respiratory Failure: Patient arrived to the ICU intubated for respiratory failure in settting of acute confusional state. The patient's initial ABG was reassuring and she was deemed able to extubate. She was extubated on the day of arrival to the ICU and tolerated it well. Her oxygen saturation remained in the mid to high 90s on room air. The etiology of her respiratory was felt to be her toxic-metabolic encephalopathy as noted below. # Toxic-metabolic encephalopathy: The patient presented with acute altered mental status with history of alcohol abuse and seizures, also with history of SDH s/p craniotomy 5 years ago. The etiology was unclear, but the differential included alcohol withdrawal/seizure, toxic metabolic (hepatic encephalopathy), CVA/ICH, sepsis, wernicke's encephalopathy. UA unremarkable. Ammonia level normal. Lactic acid WNL. Drug induced possible, home medications were difficult to clarify (the patient and her family were poor historians). The patient showed no signs of alcohol withdrawl and required only one dose of diazepam on the CIWA protocol, which was mostly given for insomnia. She was given thiamine. Neurology was consulted and they performed an EEG, which showed no epileptiform activity. The day of discharge, she developed a headache, but a repeat head CT was normal, and she felt better after Tylenol and ibuprofen so was discharged to follow-up as an outpatient. # Chronic cough: the pt had a non-productive cough during your admission, which has been present for several years, according to the patient. She had no fevers, chills, oxygen requirement or leukocytosis, so she was not treated for a pneumonia, and she felt this was at her baseline. I suspect she may have COPD due to second hand smoke exposure (ex-husband smoked for 25 years with her). She should have outpatient PFTs done to further evaluate this. # Coordination of care: I attempted to speak with the patient's PCP and Neurologist, but neither were available by phone on the day of discharge. They will be sent a copy of this summary. # Inactive issues: The patient was continued on her home amitriptyline, fluoxetine, furosemide, gabapentin, topiramate, and methocarbamol. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/CaregiverPharmacy. 1. risedronate *NF* 35 mg Oral WEEKLY 2. Amitriptyline 100 mg PO HS 3. Klor-Con *NF* (potassium chloride) 40 mg Oral [**Hospital1 **] 4. Furosemide 40 mg PO DAILY 5. Methocarbamol [**Telephone/Fax (1) 22024**] mg PO Q6H:PRN muscle pain 6. Gabapentin 1200 mg PO TID 7. Fluoxetine 60 mg PO DAILY 8. Topiramate (Topamax) 100 mg PO QAM 9. Topiramate (Topamax) 200 mg PO HS Discharge Medications: 1. Amitriptyline 100 mg PO HS 2. Fluoxetine 60 mg PO DAILY 3. Gabapentin 1200 mg PO TID 4. Methocarbamol [**Telephone/Fax (1) 22024**] mg PO Q6H:PRN muscle pain 5. Topiramate (Topamax) 100 mg PO QAM 6. Topiramate (Topamax) 200 mg PO HS 7. Furosemide 40 mg PO DAILY 8. Klor-Con *NF* (potassium chloride) 40 mg Oral [**Hospital1 **] 9. risedronate *NF* 35 mg Oral WEEKLY Discharge Disposition: Home Discharge Diagnosis: Toxic-metabolic encephalopathy of unclear etiology -- resolved spontaneously Acute respiratory failure related to above -- resolved spontaneously Subdural hematomat with coma for 3 months about 5 years ago status post Burr hole Seizures, possibly related to alcoholism in the past Hypertension Hyperlipidemia Chronic cough of unclear etiology (significant second-hand smoke exposure) History of colostomy for unclear reasons 8 pregnancies (G8) History of breast biopsy x 2 Foot and ankle fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You developed confusion at home, fell and struck your head, suffering a headache, chipped tooth and sore R shoulder. You became progressively more confused until you were taken to [**Hospital1 18**]-[**Hospital1 **] where your evaluation included a head CT, which was unchanged from your prior (not normal due to your history of subdural hemorrhage ~5 yrs ago with old R parietal craniotomy, old R burr hole). Lab testing was unremarkable. You were intubated (placed on a breathing machine) because your mental status was so poor and you could not protect your airway and you were transferred to [**Hospital1 18**]-[**Location (un) 86**]. Here you were quickly extubated (taken off the breathing machine) and you spontaneously improved. The Neurology consult team saw you and could not explain what had happened. You developed a headache on the day of discharge, but a repeat head CT was normal, and you felt better after Tylenol and ibuprofen so were discharged to follow-up as an outpatient. Followup Instructions: Primary Care Please follow-up with your primary care doctor within the next few weeks. Dr. [**Last Name (un) **] (your [**Hospital1 18**]-[**Location (un) 86**] discharging physician) called Dr. [**Last Name (STitle) 1437**], but he was unavailable. After reviewing your discharge summary, his office will call you with an appointment. Please be sure to discuss your medications and possible pulmonary function testing at this appointment. Neurology Please follow-up with Dr. [**Last Name (STitle) **] as you had previously planned. [**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**] Completed by:[**2109-7-31**]

Admission Date: [**2111-4-16**] Discharge Date: [**2111-5-15**] Date of Birth: [**2068-11-7**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7591**] Chief Complaint: Pneumonia, New Leukemia Major Surgical or Invasive Procedure: Central Line Placement History of Present Illness: Ms. [**Known lastname **] is 42 yo woman with PMH significant for morbid obesity with gastric bypass 3 years ago as well as HTN and hyperlipidemia, who presents with acute leukemia. . Ms. [**Known lastname **] describes that she has been feeling unwell for the past four weeks; she describes being in her normal state of health before this. Four weeks ago she started developing pain in her thighs that she describes as an achy, bony pain, with no associated trauma or swelling. She saw her PCP who [**Name9 (PRE) 78036**] increased ESR, decreased platelets and abnormal electrolytes and recommended followup with Rheumatology. She was seen by a Rheumatologist who put her on a 10 day taper of Prednisone, starting at 40 mg daily. Her pain did not improve with this regimen and instead spread to her arms and lower back. She visited the [**Hospital1 1474**] ED where she was discharged with Percocet and instructions to followup with her rheumatologist. At a subsequent Rheumatology visit her platelets were further decreased. She was sent back to her PCP who referred her to hematology for thrombocytopenia. Around this time (5 days prior to admission) she also started to notice a L sided chest pain, worse with taking deep breaths. She was unable to make an appointment with hematology and so yesterday morning went to the [**Hospital6 33**] ED. She denies fever, chills, difficulty breathing, diarrhea or any other symptoms over the past few weeks. . In the ED at [**Hospital3 **], she was found to have a CBC significant for WBC 15.0 with 7% bands, 2% atypical lymphocytes. Also ESR 113, LDH of 1600, indicating acute leukemia; she was treated with allopurinol. . Chest CT showed multiple bilateral prominent axillary lymph nodes and air trapping, ground glass opacities and consolidations in the L lung. with largest in L axilla measuring 1.1 cm. She was evaluated by Infectious Disease who were concerned for atypical PNA v. viral illness and gave her Levaquin. She transiently desated to 86% on RA while walking to the bathroom and was placed on nasal cannula. She was given Percocet and Toradol for her leg pain. Vitals on transfer were 98.5 103 90/58 98% 2L. . On the floor, she is comfortable and not in pain. She is anxious to initate diagnosis and possible treatment. Past Medical History: Gastric bypass 3 years ago Hypertension Gestational diabetes Hypercholesterolemia History of C-section s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8509**] Social History: [**Known firstname **] is married with 2 children, age 13 and 15. She works as an ophthalmic technician [**1-30**] mornings a week, 3-4 hours. She drinks occasionally on the weekend but not in the last month, has never smoked, does not use illicit drugs. Mother has ALL, Breast Cancer, Lung Cancer. Family History: See Above Physical Exam: Admission Exam: Genera: Diaphoretic, young woman in NAD HEENT: Anicteric, EOMI, Atraumatic CV: RRR, no murmurs, no rub Pulmonary: Decreased breath sounds in bases bilaterally with mild rhonchi in L lung base. Ab: Normoactive BS, Soft, NT, ND Extremities: No rashs, no LE edema Neuro: CNII-XII intact. Strength intact in all four exteremities. Cerebellar testing (finger to nose and heel to shin testing) intact. Pertinent Results: ADMISSION LABS: ============== [**2111-4-16**] 09:47AM BONE MARROW IPT-DONE [**2111-4-16**] 09:47AM BONE MARROW CD34-DONE CD3-DONE CD4-DONE CD8-DONE [**2111-4-16**] 09:47AM BONE MARROW CD33-DONE CD41-DONE CD56-DONE CD64-DONE CD71-DONE CD117-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 31151**] A-DONE KAPPA-DONE CD2-DONE CD7-DONE CD10-DONE CD11C-DONE CD13-DONE CD14-DONE CD15-DONE CD19-DONE CD20-DONE LAMBDA-DONE CD5-DONE [**2111-4-16**] 05:05PM FIBRINOGE-904* [**2111-4-16**] 05:05PM PT-15.0* PTT-26.0 INR(PT)-1.3* [**2111-4-16**] 05:05PM PLT SMR-LOW PLT COUNT-83*# [**2111-4-16**] 05:05PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL [**2111-4-16**] 05:05PM I-HOS-AVAILABLE [**2111-4-16**] 05:05PM NEUTS-55 BANDS-0 LYMPHS-30 MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* OTHER-15* [**2111-4-16**] 05:05PM WBC-10.1 RBC-2.67*# HGB-8.4*# HCT-24.5*# MCV-92 MCH-31.3 MCHC-34.0 RDW-14.3 [**2111-4-16**] 05:05PM calTIBC-169* VIT B12-211* FERRITIN-[**Numeric Identifier **]* TRF-130* [**2111-4-16**] 05:05PM ALBUMIN-3.0* CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-2.1 URIC ACID-4.4 IRON-60 [**2111-4-16**] 05:05PM ALT(SGPT)-58* AST(SGOT)-72* LD(LDH)-1681* ALK PHOS-169* TOT BILI-0.5 [**2111-4-16**] 05:05PM GLUCOSE-96 UREA N-18 CREAT-1.2* SODIUM-133 POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-29 ANION GAP-13 . ANC Trend ========== [**2111-4-18**] 12:01AM BLOOD Gran Ct-2432 [**2111-4-19**] 03:15AM BLOOD Gran Ct-3274 [**2111-4-21**] 12:00AM BLOOD Gran Ct-1748* [**2111-4-22**] 12:00AM BLOOD Gran Ct-870* [**2111-4-23**] 12:00AM BLOOD Gran Ct-152* [**2111-4-25**] 06:00AM BLOOD Gran Ct-0* [**2111-4-26**] 12:00AM BLOOD Gran Ct-0* [**2111-4-27**] 12:00AM BLOOD Gran Ct-0* [**2111-4-28**] 06:00AM BLOOD Gran Ct-40* [**2111-4-29**] 08:50AM BLOOD Gran Ct-30* [**2111-4-30**] 05:50AM BLOOD Gran Ct-0* [**2111-5-1**] 12:30AM BLOOD Gran Ct-0* [**2111-5-2**] 03:56AM BLOOD Gran Ct-0* [**2111-5-4**] 12:50AM BLOOD Gran Ct-0* [**2111-5-5**] 06:00AM BLOOD Gran Ct-0* [**2111-5-6**] 06:15AM BLOOD Gran Ct-0* [**2111-5-7**] 06:15AM BLOOD Gran Ct-0* [**2111-5-6**] 06:15AM BLOOD Gran Ct-0* [**2111-5-7**] 06:15AM BLOOD Gran Ct-0* [**2111-5-8**] 06:00AM BLOOD Gran Ct-0* [**2111-5-9**] 06:30AM BLOOD Gran Ct-9* [**2111-5-10**] 06:00AM BLOOD Gran Ct-11* [**2111-5-11**] 05:27AM BLOOD Gran Ct-39* [**2111-5-12**] 06:20AM BLOOD Gran Ct-195* [**2111-5-13**] 12:45AM BLOOD Gran Ct-209* [**2111-5-13**] 02:30PM BLOOD Gran Ct-524* [**2111-5-14**] 12:00AM BLOOD Gran Ct-503* [**2111-5-14**] 01:45PM BLOOD Gran Ct-1180* [**2111-5-15**] 12:00AM BLOOD Gran Ct-792* . DISCHARGE LABS: ================== [**2111-5-15**] 12:00AM BLOOD WBC-2.7* RBC-3.25* Hgb-9.5* Hct-28.6* MCV-88 MCH-29.1 MCHC-33.1 RDW-13.9 Plt Ct-823* [**2111-5-15**] 12:00AM BLOOD Neuts-26* Bands-0 Lymphs-31 Monos-37* Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-2* Blasts-3* [**2111-5-15**] 12:00AM BLOOD Glucose-131* UreaN-4* Creat-0.6 Na-136 K-3.5 Cl-98 HCO3-25 AnGap-17 [**2111-5-15**] 12:00AM BLOOD ALT-63* AST-46* LD(LDH)-315* AlkPhos-235* TotBili-0.4 [**2111-5-15**] 12:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8 BONE MARROW [**2111-4-16**]: PATHOLOGY: BONE MARROW WITH EXTENSIVE INVOLVEMENT BY ACUTE MONOCYTIC LEUKEMIA (FAB M5). CYTOGENETICS Karyotype: 54,XX,+X,+1,[**Doctor Last Name **](1)t(1;16)(q11;p11),+3,+4,+8,+14,+20,+21[20] 20/20 cells show the hyperdiploid karyotype described . BONE MARROW [**2111-5-3**]: Markedly hypocellular marrow with features consistent with myeloablative chemotherapy effect . BONE MARROW [**2111-5-8**] PATHOLOGY Variably cellular, overall hypocellular bone marrow with megakaryocytic clustering, left-shifted myelopoiesis and increased blasts (see note). . Note: Circulating blasts are seen in the peripheral blood (7%). The aspirate is paucispicular, however increased blasts and monocytic precursors are noted. The core biopsy is variably cellular with trilineage hematopoiesis, megakaryocytic clustering and left shifted myelopoiesis. By immunostaining CD34 immunoreactive blasts are increased (~10% of cellularity), however are present singly without clusters. CD117 highlights early myeloid precursors in clusters comprising 30% of marrow cellularity. Overall, the morphologic differential includes regenerating marrow versus residual disease and correlation with cytogenetic findings is recommended . CYTOGENETICS KARYOTYPE: 46,XX[20] . INTERPRETATION: This karyotype is characteristic of a chromosomally normal female. . BRONCHIAL LAVAGE [**4-18**]: Bronchial lavage: NEGATIVE FOR CARCINOMA, (see note.) Bronchial cells, macrophages and small lymphocytes. . Pericardial fluid [**5-4**]: . ATYPICAL. . Numerous mature lymphocytes with occasional atypical cells (see note). . Note: Occasional larger cells are identified; the differential diagnosis includes reactive lymphocyte vs. leukemic blast. A definitive distinction is difficult with this preparation, although reactive lymphocyte is favored. . . MICROBIOLOGY: ============== - Parvovirus IgG and IgM negative - Mycoplasma IgG and IgM negative - Anaplasma IgG and IgM negative - Beta glucan/galactomanin negative - EBV PCR negative - HHV8, HHV6, HSV1, HSV2, DNA PCR negative - Adenovirus PCR negative . [**2111-5-14**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL NEGATIVE [**2111-5-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL NEGATIVE [**2111-5-12**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL NEGATIVE [**2111-5-10**] BLOOD CULTURE Blood Culture, Routine-PENDING NEGATIVE [**2111-5-10**] BLOOD CULTURE Blood Culture, Routine-PENDING NEGATIVE [**2111-5-10**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-5-9**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-5-9**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-5-8**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-5-8**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-5-8**] Immunology (CMV) CMV Viral Load-FINAL NEGATIVE [**2111-5-7**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-5-5**] STOOL ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE-PRELIMINARY [**2111-5-4**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-5-4**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-5-2**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-5-2**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-5-2**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-5-2**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY INPATIENT [**2111-5-1**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL NEGATIVE [**2111-5-1**] MRSA SCREEN MRSA SCREEN-FINAL NEGATIVE [**2111-5-1**] FLUID,OTHER GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE-PRELIMINARY [**2111-5-1**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-5-1**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-30**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-28**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-28**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-4-27**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-27**] CATHETER TIP-IV WOUND CULTURE-FINAL NEGATIVE [**2111-4-26**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-4-26**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-25**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-25**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-23**] SWAB WOUND CULTURE-FINAL NEGATIVE [**2111-4-23**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-4-23**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-23**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-18**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-18**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-18**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL NEGATIVE [**2111-4-18**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL NEGATIVE; POTASSIUM HYDROXIDE PREPARATION-FINAL NEGATIVE; Immunoflourescent test for Pneumocystis jirovecii (carinii)-FINAL NEGATIVE; FUNGAL CULTURE-FINAL NEGATIVE; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY INPATIENT [**2111-4-18**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-17**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2111-4-17**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-4-17**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM ANTIBODY-FINAL NEGATIVE [**2111-4-17**] SEROLOGY/BLOOD MONOSPOT-FINAL NEGATIVE [**2111-4-17**] URINE URINE CULTURE-FINAL NEGATIVE [**2111-4-16**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE IMAGING: ================= [**4-16**] ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Normal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. . [**5-1**] ECHO The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. The right ventricular free wall appears thickened with depressed/paradoxical free wall contractility. There is markedly abnormal/paradoxical septal motion/position. The aortic valve is not well seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Tricuspid regurgitation is present but cannot be quantified. There is a large pericardial effusion subtending primarily the right atrial and right ventricular free walls. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . The right atrial free wall and right ventricular free wall appear markedly thickened with marked acoustic enhancement and impaired contractile function, suggestive of an inflammatory or infiltrative process. . Compared with the findings of the prior study (images reviewed) of [**2111-4-20**], a large pericardial effusion and cardiac tamponade are now present. . IMPRESSION: large pericardial effusion subtending the right atrial and right ventricular free walls; cardiac tamponade is present . [**5-8**] ECHO Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is abnormal septal motion/position. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Pericardial constriction cannot be excluded. . Compared with the prior study (images reviewed) of [**2111-5-4**], the findings are similar. The presence of abnormal septal motion can be seen shortly after an effusion is drained ("effusive-constrictive" physiology). This often resolves over time (several months). Brief Hospital Course: Ms. [**Known lastname **] is a 42 yo woman with PMH significant for morbid obesity with gastric bypass who presented from OSH ED with acute monocytic leukemia, she was treated with 7+3 and her course was complicated by pericardial tamponade and febrile neutropenia. . # Acute Leukemia: Ms. [**Known lastname **] was diagnosed with acute monocytic leukemia and initiated 7+3 induction chemotherapy with daunorubicin and cytarabine which she tolerated well. Cytogenetics on initial bone marrow biopsy showed 54,XX,+X,+1,[**Doctor Last Name **](1)t(1;16)(q11;p11),+3,+4,+8,+14,+20,+21[20]. Day 14 bone marrow biopsy was delayed due to pericardial tamponade. Day 16 bone marrow biopsy showed hypocellular marrow by report however on review of the slides, few early forms were seen. Patient continued to have nightly fevers and blasts were seen on pheripheral smear. Bone marrow bx was performed early on day 21 and showed early forms, cytogenetics showed normal karyotype in 20/20 cells. Bone marrow biopsy was again repeated [**5-14**], results were pending at the time of discharge. ANC began to rise on day 21, recovery was sluggish and reached 792 on the day of discharge. Given complex the cytogenetics of her AML, the plan will be for her to undergo transplant. . # Pulmonary Infiltrates: CT scan obtained on admission showed bilateral pulmonary opacitities in an interestitial pattern which were concerning for infection vs. leukemic involvement. Pulmonology was consulted and bronchoscopy was performed which was culture negative and did not reveal malignant cells. The patient's hypoxia resolved with simultaneous treatment with antibiotics (see below) and chemotherapy. Repeat CT scan showed resolution of pulmonary opacities. . # Pericardial Effusion: The patient developed a dramatic friction rub on the day after admission that was concern for effusion. An initial ECHO showed a small perical cardial effusion and subsequent ECHO described the effusion as trivial. The patient was hemodynamically stable. On [**2111-5-1**] the friction rub was absent, EKG showed low voltage across the precordium. Pulsus was 8mmHg repeat ECHO demonstrated tamponade physiology. She was hemodynamically stable. Cardiology performed pericardiocentesis which dropped right atrial pressure from 15 to 1 by draining 85 cc of pericardial fluid which was sent for viral, bacterial, mycobacterial and fungal culture. A pericardial drain was placed and removed the next day as little drainage was noted overnight. Repeat TTE on [**2111-5-2**] showed resolution of tamponade physiology and normal systolic function. The study also showed possible thickening of the posterior parietal pericardium, with tethering of visceral and parietal surfaces consistent with constrictive pericarditis. She had a cardiac MRI showing constrictive pericarditis, with a small circumfrential effusion, normal RV function though RV hypertrophy was noted. Repeat ECHO showed no evidence of pericardial tamponade and findings consistent with constrictive pericarditis. Constrictive pericarditis is expected to resolve without intervention in the coming months, no specific cause of the effusion was identified however malignancy vs viral etiology were considered most likely. . # Febrile Neutropenia: The patient developed a fever on day+5 of chemotherapy. She was initially treated with Vancomycin and developed a rash she was then pre-medicated for subsequent doses which were tolerated without issue. She was treated with Vancomycin and cefepime and continued to have low grade fevers. Micafungin was added and low grade fevers continued. Antibiotics were again broadened to include vancomycin, cefepime, voriconazole, and metronidazole. Potential sources included central line (removed and tip culture negative) pulmonary, pericaridal fluid or malignancy. ID was consulted who recommended sending pericardial fluid for fungal, bacterial and viral (EBV, Coxackie, Enterovirus, adenovirus) culture and Acid fast (TB) culture & smear; Cytologic exam; Cell Count and Differential; Enterovirus RNA, Qualitative, RT-PCR; EBV PCR, Coxackie PCR, Adenovirus PCR, all of which were negative. CT Abd/Pelvis on [**5-2**] was performed for further infectious workup and showed bilateral pleural effusions and presacral soft tissue thickening without fluid collection which was of unclear significance. Antibiotics were changed again to Voriconazole, meropenem, and vancomycin nad metronidazole. She continued to have fevers to 101 and repeat CT scan showed resolution of soft tissue thickening and no other fluid collections or pulmonary findings. Antibiotics were held and fevers resolved. Given previous reaction to vancomycin, this medication may have been the source of prolonged fevers. At the time of discharge, she as afebrile >36 hours. . # Menses: Patient was treated with Provera during her chemotherapy to prevent menses. This failed to prevent menstrual cycle and was discontinued to lower thrombotic risk. . # HTN: Held HCTZ during admission. . # Hyperlipidemia: Held statin during admission. . . Medications on Admission: ATORVASTATIN 10 mg once daily (STOPPED PRIOR TO ADMISSON by PCP) HYDROCHLOROTHIAZIDE 12.5 mg once daily (STOPPED PRIOR TO ADMISSON by PCP) Multivitamin and Vitamin D Discharge Medications: 1. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0* 2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* 3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours for 10 days: Do not drive while taking this medication. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute monocytic leukemia . Constrictive pericarditis Febrile neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], It was a pleasure taking care of you in the hospital. You were admitted with leg pain, pneumonia and abnormal blood counts. You were found to have acute myelogenous leukemia and were treated with chemotherapy you had a repeat bone marrow biopsy prior to being discharged and the results are pending. . Your course was complicated by a fluid accumulation around the heart (pericardial tamponade) and you were admitted to the intensive care unit where the fluid was removed. A repeat ultrasound and a cardiac MRI of your heart which showed that the fluid had not reaccumulated. While your white blood cell count was low, you developed fevers and were treated with antibiotics, no source of fever was identified and the antibiotics were stopped. . It is important that you eat a balanced diet following your chemotherapy. It will be important for you to increase your intake of red meat and foods high in protein and phosphorous (meat, grains, nuts) while your body makes new cells to replace the cells destroyed by chemotherapy. . Your medication list has changed substantially since your admission. Please see the attached list for the medications that you should be taking. . Please see below for follow up appointments. Followup Instructions: Department: BMT/ONCOLOGY UNIT When: MONDAY [**2111-5-18**] at 3:00 PM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage

Admission Date: [**2197-1-4**] Discharge Date: [**2197-1-6**] Date of Birth: [**2148-7-18**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Brain mass Major Surgical or Invasive Procedure: Right craniotomy and recurrent glioma resection History of Present Illness: The patient is a 48-year-old woman who had resection of the right temporal low-grade astrocytoma in [**2188**]. She was followed with series of scans, seen in Brain [**Hospital 341**] clinic for recurrent astrocytoma. Past Medical History: Brain tumor. Thyroid disease. Gastroesophageal reflux disease. Hypertension Depression. Social History: She does smoke 1 to 1-1/2 pack of cigarettes per day. She does not drink. Pertinent Results: [**2197-1-4**] 04:27PM GLUCOSE-175* UREA N-11 CREAT-1.0 SODIUM-142 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-18 [**2197-1-4**] 04:27PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.8 [**2197-1-4**] 04:27PM WBC-10.3# RBC-4.23 HGB-11.4* HCT-34.4* MCV-81* MCH-26.9* MCHC-33.2 RDW-15.7* [**2197-1-4**] 04:27PM PLT COUNT-313 [**2197-1-4**] 12:52PM TYPE-ART PO2-99 PCO2-33* PH-7.45 TOTAL CO2-24 BASE XS-0 [**2197-1-4**] 12:52PM GLUCOSE-112* LACTATE-2.7* NA+-136 K+-4.4 CL--103 [**2197-1-4**] 12:52PM HGB-11.6* calcHCT-35 [**2197-1-4**] 12:52PM freeCa-1.25 [**2197-1-4**] 10:31AM TYPE-ART PO2-98 PCO2-32* PH-7.43 TOTAL CO2-22 BASE XS--1 [**2197-1-4**] 10:31AM GLUCOSE-87 LACTATE-0.7 NA+-136 K+-3.3* [**2197-1-4**] 10:31AM HGB-8.9* calcHCT-27 [**2197-1-4**] 10:31AM freeCa-1.02* RADIOLOGY Preliminary Report MR HEAD W & W/O CONTRAST [**2197-1-5**] 9:04 AM IMPRESSION: Multiple right-sided enhancing masses as shown on the pre- procedure examination, which have grown since [**2196-12-19**]. Many of these now show increased central susceptibility, which was not present on the prior examinations, consistent with interval hemorrhage into lesions. At least one enhancing lesion in the right anterior cranial fossa which was shown on the prior examination is no longer seen, presumably post resection. Brief Hospital Course: She was brought to the operating room on [**2197-1-4**], where under general anesthesia, she underwent a right frontal craniotomy for resection of recurrent astrocytoma. Postoperatively, she was transferred to the PACU, where she was monitored overnight for close neurosurgical checks. Postoperatively, her vital signs were stable. She was afebrile. She was alert and oriented times 3. She had no complaints. Her face was symmetric. Her extraocular movements were intact. Tongue was midline. Pupils were brisk and reactive bilaterally. She was strong in all 4 extremities. She continued to do well. Her diet and activity were increased. She was on steroids, which was started to be tapered. She continued to do well and she was discharged to home on [**1-6**]/6. She was discharged on the same medications that she was taking preoperatively with the addition of Percocet and Decadron, which was to be tapered over 2 days to 2 mg b.i.d. Medications on Admission: 1. Prilosec 40 mg per day. 2. Trileptal 600 mg. 3. [**Doctor First Name **] 180 mg. 4. Klonopin 1 mg. 5. Ditropan 15 mg. 6. Levoxyl 137 mcg. 7. Plendil 5 mg. Discharge Medications: 1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* 2. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 3. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Recurrent Glioma Discharge Condition: Good Discharge Instructions: -Please call to make an appointment with the Brain [**Hospital 341**] Clinic. -Please call to make an appointment with Dr [**Last Name (STitle) **] Clinic at [**Telephone/Fax (1) 2992**]. -If you have any wound readness, swollen or increasing pain, please call Dr[**Name (NI) 9034**] office Followup Instructions: With the Brain [**Hospital 341**] Clinic and Dr [**Last Name (STitle) **]. Completed by:[**2197-1-6**]

Admission Date: [**2147-7-6**] Discharge Date: [**2147-7-17**] Date of Birth: [**2090-10-5**] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Ascites, need for transplant workup Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 56 yo female with HepC cirrhosis, esophageal varices, h/o SBP, HTN, presented to [**Hospital 792**]Hospital on [**6-25**] with abdominal pain, nausea, and vomiting. While there, she underwent a CT abd/pelvis with contrast which showed choledocholithiasis and CBD dilation. She then underwent ERCP, the first one was unsuccesful, second one monday with papillotomoy and drainage of stones/bile. During her hospitalization there, her T.bili continued to rise and last was 22 (up from 16). Also, during that hospitalization, her creatinine bumped from baseline of 1.0 to to 2.6 (lab results unavailable currently). Renal had seen her there, felt this was likely ATN, and she was oliguric with daily UOP 450-650. She had muddy brown casts on the urine microscopy. After her ERCP, she had FFP, and then developed hypoxia, tachypnea, and bilateral infiltrate. This was thought to potentially be pulmonary edema, but TRALI was also possible. Also, she had urine/blood cultures which were negative, and 2 paracenteses that were negative for SBP. She was transferred here to [**Hospital1 18**] for further transplant eval. Prior to transfer, she was hemodynamically stable, and was on 4L O2 with high 90s sats. . Here, the patient states that she has abdominal bloating. She denies fevers, chills. Denies headache. She does report some mild nausea. She has no other complaints. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea. She does report significant constipation. Past Medical History: HCV cirrhosis Esophageal varices (grade unknown) HTN h/o SBP Social History: Lives in RI with husband. [**Name (NI) **] 2 grown children. Daughter listed as POA in RI. She denies history of alcohol, tobacco, or drug use. Currently unemployed. Family History: No history of liver disease. Mother deceased- had DM2 Physical Exam: On admission: General: Alert, oriented. somnolent but wakes up easily and answers questions appropriately HEENT: Sclera icteric, MM slightly dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: bibasilar crackles, no rhonci, no wheezes CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur at base Abdomen: soft, distended, bowel sounds hypoactive, no rebound tenderness or guarding. + fluid wave Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: jaundiced, no rash, no spider angiomas, no palmar erythema Neuro: A/O x 3; asterexis present Pertinent Results: On admission [**2147-7-7**]: WBC-5.9 RBC-2.66* Hgb-9.5* Hct-27.5* MCV-103* MCH-35.8* MCHC-34.6 RDW-17.8* Plt Ct-100* PT-23.6* PTT-44.5* INR(PT)-2.2* Glucose-74 UreaN-43* Creat-1.8* Na-135 K-5.0 Cl-104 HCO3-25 AnGap-11 ALT-45* AST-131* LD(LDH)-260* AlkPhos-95 TotBili-21.8* transplant labs: HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HCV Ab-POSITIVE* AMA-NEGATIVE [**Doctor First Name **]-POSITIVE * Titer-1:40 [**Last Name (un) **] CEA-4.7* CA [**57**]-9 -64 IgG-2251* IgA-1000* IgM-213 HIV Ab-NEGATIVE EBV IgG-POSITIVE CMV IgG-POSITIVE VZV IgG- POSITIVE Rubella- Positive RPR- Negative ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG VITAMIN D 25 HYDROXY-7 Hct trends prior to MICU transfer ([**Date range (1) 9458**]): 24.4 -> 22.2 -> 23.5 -> 23.3 -> 21.8 -> 25.5 -> 21.7 -> 31.3 plt trends: 44 -> 90 -> 126 -> 46 Studies: [**7-6**] CXR: Lung volumes are somewhat low, but interstitial markings appear prominent and the pulmonary vasculature is indistinct. The cardiac silhouette appears large, although cardiac size may be exaggerated by AP technique. Mediastinal structures are otherwise unremarkable. The bony thorax is grossly intact. IMPRESSION: Increased interstitial markings which may represent mild edema. [**7-7**] Doppler abdominal ultrasound: The nodular liver is seen without focal lesion. There is a moderate amount of ascites. There are also bilateral pleural effusions. The hepatic vasculature is patent without evidence of thrombosis. The gallbladder is contracted, without stones. No evidence of intrahepatic or extrahepatic biliary ductal dilatation. The right kidney measures 10 cm, and the left kidney measures 9.3 cm. There is no evidence of hydronephrosis or renal calculi. In the left upper pole, there is a 5mm echogenic focus, without posterior shadowing, most likely representing a congenital AML. IMPRESSION: 1. Patent hepatic vasculature without evidence of thrombosis. 2. Moderate ascites. 3. Bilateral pleural effusions. 4. Nodular liver without focal lesions. [**7-8**] EKG: Sinus rhythm with sinus arrhythmia. Left axis deviation. Possible anteroseptal anterior and lateral myocardial infarction, age undetermined. Possible inferior myocardial infarction, age undetermined. Possible left ventricular hypertrophy [**7-9**] EKG: Sinus rhythm. Left axis deviation. Probable left ventricular hypertrophy. [**7-9**] CXR: Single portable upright chest radiograph is compared to the prior study from [**2147-7-6**]. Since prior study, interstitial edema has diminished and appears resolved. Heart and mediastinum are within normal limits. Lungs are clear. [**7-13**] MRCP: There is a cirrhotic, nodular liver. No focal liver lesions are identified. The umbilical vein is recanalized. No filling detects are visualized within the hepatic vasculature; the portal vein is patent. No evidence of gastroesophageal varices. Assessment of the MRCP is severely limited due to technical factors related to 3T artifacts from the patient's ascites. There is, however, no biliary ductal dilatation and no definite evidence of retained stones. Spleen, pancreas, kidneys, and adrenal glands show no abnormalities. No significant lymphadenopathy. Visualized bowel shows no abnormalities. No abnormal marrow signal is evident. IMPRESSION: 1. Cirrhotic liver with severe ascites. 2. MRCP limited by 3T artifact due to degree of patient's ascites. However, no definite evidence of retained stones or biliary ductal abnormalities. For subsequent examinations for this patient, suggest that studies be performed on a 1.5 Tesla magnet. [**7-14**] ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No diastolic LV dysfunction, pulmonary hypertension, or clinically-significant valvular disease seen. Multiplanar 2D and 3D reformations provided multiple perspectives for the dynamic series. [**7-16**] CT abdomen and pelvis: There is gross ascites. The majority of the fluid in the abdomen and pelvis measures in the region of 10 Hounsfield units, compatible with simple fluid. There is, however, some minimal amount of dependent higher attenuation material in the free fluid in the pelvis (series 2, image 75), raising the possibility of a small amount of intraperitoneal hemorrhage or debris. The liver is small and nodular in contour, compatible with given history of cirrhosis. The spleen is normal in size. The pancreas is normal in morphology and attenuation. The adrenal glands are normal. There is a small calculus in the interpolar region of the left kidney measuring 5 mm in diameter. There is a tiny [**Doctor Last Name **] of calcification measuring approximately 1 mm in the lower pole of the right kidney (series 2, image 41). There is no significant retroperitoneal lymphadenopathy. The bowel caliber is normal in appearance. There is no evidence of free air in the abdomen or pelvis. There is patchy atelectasis in the lower lobes bilaterally. No focal bone lesion or fracture is seen. IMPRESSION: 1. Gross ascites, predominantly with simple-appearing fluid, but some dense material in the dependent portion of the fluid in the pelvis raises the possibility of a small amount of intraperitoneal hemorrhage or debris. 2. Nodular low volume liver compatible with cirrhosis. 3. Small interpolar region of left kidney calculus. 4. Bibasilar atelectasis. Brief Hospital Course: # HCV Cirrhosis: Decompensated liver failure with encephalopathy on admission; likely after ERCP and cholelithiasis. INR elevated, T.bili elevated from baseline in the 3s. Abdominal ultrasound on admission to [**Hospital1 18**] showed no thrombosis, macronodular liver contour without focal lesion, contracted gallbladder, ascites and pleural effusion. MRCP also found no retained stones or biliary distention. No SBP. She received aldactone, lactulose, rifaxamin and nadalol. Transplant workup was initiated but on hold pending insurance activation. #. Coagulopathy: She had low platelet count and elevated INR secondary to her liver disease which was the likely cause of her previous limited episode of bright red blood per rectum, mild hemoptyosis and hematuria. Throughout these previous episodes, she remained hemodynamically stable and asymptomatic. She received blood products, PPI and octreotide. Did not attribute this bleeding to variceal bleeds although she had a history of this with subsequent banding back in [**Month (only) **]. On the day of transfer to the MICU, she was hypotensive in the morning and had a bloody paracentesis. She was given more blood products and albumin, and had a CT that was negative for bleeding source. However, she had another lower GI bleed overnight and was transferred to the MICU where she was resuscitated with pRBC, FFP, Platlets, Cryo and taken to IR to attempt to find a source of the bleeding which was unsucessful. After returing to the MICU from IR Ms. [**Known lastname 4186**] continued to have copious bright red blood per rectum. She became bradycardic and then became pulseless and was found to be in asystole. Despite continued resuscitation efforts with blood product and following ACLS attempts at resuscitation were unsucessful and Ms. [**Known lastname 4186**] died at 0822hrs. # Cholelithiasis: Had two ERCPs at [**Hospital 792**]Hospital with improvement of pain, though elevating t.bili which may be secondary to worsening hepatic failure. Her baseline t bili in the 3s. Resolving ascending cholangitis. MRCP shows no further stones or duct dilation. Covered with Zosyn as she had been on ppx Cipro. She was also on ursodiol. # Acute Kidney Injury: Thought to be ATN secondary to relative hypotension. [**Name2 (NI) **] baseline creatinine is 1.0 but was elevated up to 2.7 in [**Doctor Last Name **]. Her Cr improved over time with maintaining equal, normal volume status. # Hypoxia: Mild hypoxia on admission that resolved over her hospital stay. Unclear etiology- could have been fluid overload from blood products or possible TRALI. Unlikely infectious given negative workup thus far and afebrile. # Blood pressure: Had some hypotensive episodes attritubuted to low intravascular volume. Her pressure responded to IVFs and albumin. Her diuretics were held during hypotensive periods. Medications on Admission: Medications on Transfer from RIH: Ciprofloxacin 400 mg daily Propranolol 20 mg TID Lactulose TID Spironolactone 25 mg daily Furosemide 40 mg [**Hospital1 **] MVI Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Hepatitis C Cirrhosis Gastrointestinal Bleed Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Admission Date: [**2115-2-12**] Discharge Date: [**2115-2-28**] Date of Birth: [**2050-4-3**] Sex: M Service: MEDICINE Allergies: Neupogen Attending:[**First Name3 (LF) 3624**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2115-2-14**] Non-tunneled hemodialysis line placement [**2115-2-22**] Tunneled hemodialysis line placement History of Present Illness: 64 year old man with history of cadaveric kidney transplant in [**2109**] after acute tubular necrosis from a viral gastroenteritis whose kidney function has been slowly worsening of the past year who presents with shortness of breath for 1 week. Patient reports cough and shortness of breath, mainly with extertion for the past week. The symptoms started with runny noise and the patient thought he had a cold. He notice dyspnea on extertion when he was walking from his car to his house, a distance he is normally able to do without difficulty. He also has noted this dry cough, worse at night that makes him sit up off the side of the bed. He denies any chest pain or history of chest pain with extertion. He also denies recent fevers, chills, nausea, vomiting, abdominal pain, diarrhea, or constipation. He has noticed a progressive decrease in his urine output over the past year but no acute change recently. He does not occasional intermittent dysuria. He denies any recent medication non-compliance or change in his diet. Patient does feel like he has been gaining weight over the past few months. . The patient was also recently admitted at [**Hospital3 2568**] for a similar progressive shortness of breath. It was thought due to his worsening renal function. He was diuresed and he improved. . The patient also reports a fall two weeks prior to admission. Patient tripped on stairs at his home and fell. He did hit his head but denies any LOC. He denies any associated chest pain, weakness, dizziness, or palpitations. Past Medical History: #Atrial Fibrillation - s/p cardioversion in [**10-14**]. Was maintained on coumadin for 6 months. currently not anticoagulated . #Pericardial Effusion - s/p drainage, unclear etiology . #Kidney Disease - ESRD from ATN in setting of acute gastroenteritis, s/p cadaveric kidney transplant in [**2109**], worsening renal function over the last year. Has appointment in [**Month (only) **]. for AV fistula placement in anticipation of future dialysis . #Abdominal Wall Hernia - s/p repair after transplant . Multiple Knee surgeries 20 years ago Social History: Denies any history of Tob use, no EtOh use for 15 years, no drug use. Lives with his wife, now on disability. Used to work as a spray painter Family History: History of CAD, cancer, MS Physical Exam: Vitals: 96.9, 132/80, 92, 20, 97% on 4L GEN: Coughing repeatedly during interview with moderate distress, some difficulty completing sentences because of coughing HEENT: PERRL, EOMI, Clear OP with MMM Neck: no LAD, JVP difficutly to assess because of girth CV: [**Last Name (un) 3526**] [**Last Name (un) 3526**], otherwise heart sounds difficutly to interpret because of loud ronchi Lungs: diffuse ronchi throughout lung fields, few crackles apparent at bases ABD: +BS nt nd, soft, obese, large irregular ventral hernia appreciated Ext: [**1-9**]+ peripheral edema, r>l, erythema of right leg but without significant warmth or tenderness, some bruising at right ankle. 2+ DP pulses, ROM at right ankles seems full Neuro: CN 2-12 intact, 5/5 strength upper and lower extremities, sensation grossly intact throughout Pertinent Results: ============ LABORATORIES ============ LABORATORIES ON ADMISSION: [**2115-2-12**] WBC-3.7 (NEUTS-78 BANDS-0 LYMPHS-9 MONOS-9 EOS-3 BASOS-1 ATYPS-0 METAS-0 MYELOS-0) HGB-9.4 HCT-29.0 MCV-88 PLT COUNT-151 [**2115-2-12**] SODIUM-126 POTASSIUM-6.7* (hemolyzed)-->repeat K=4.1 CHLORIDE-93 TOTAL CO2-17 UREA N-103 CREAT-4.8 GLUCOSE-69 [**2115-2-12**] ALT(SGPT)-9 AST(SGOT)-46 CK(CPK)-233 ALK PHOS-24 TOT BILI-0.4 [**2115-2-12**] CK-MB-10 MB INDX-4.3 cTropnT-0.07 proBNP-[**Numeric Identifier **] [**2115-2-12**] ALBUMIN-3.6 [**2115-2-12**] LACTATE-0.7 . CARDIAC ENZYMES: [**2115-2-12**] 11:30AM BLOOD CK(CPK)-233 CK-MB-10 MB Indx-4.3 cTropnT-0.07 [**2115-2-12**] 07:30PM BLOOD CK(CPK)-187 CK-MB-12 MB Indx-6.4 cTropnT-0.09 [**2115-2-13**] 05:26AM BLOOD CK(CPK)-166 CK-MB-9 cTropnT-0.06 . OTHER LABORATORIES [**2115-2-15**] calTIBC-276 Ferritn-114 TRF-212 [**2115-2-15**] TSH-0.90 [**2115-2-15**] PTH-106 [**2115-2-14**] BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HCV Ab-NEGATIVE [**2115-2-25**] Cyclspr-69 . LABORATORIES UPON DISCHARGE: [**2115-2-27**] WBC-3.7 HGB=8.7 HCT-29.1 MCV-94 PLT COUNT-141 [**2115-2-28**] SODIUM-141 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-17 UREA N-26 CREAT-3.7 GLUCOSE-97 . ======= STUDIES ======= UNILAT LOWER EXT VEINS RIGHT [**2115-2-12**] RIGHT LOWER EXTREMITY ULTRASOUND: The exam is technically limited, because pain limited the patient's ability to tolerate compression of the superficial femoral vein at its mid and distal portions. Grayscale and Doppler [**Year/Month/Day 108683**] were obtained of the right common femoral, proximal superficial femoral, and popliteal veins. Normal compressibility, color flow and waveforms are seen. Color flow and Doppler [**Name (NI) 108683**], without compression, were obtained for the mid and distal right superficial femoral vein. Normal color flow and waveforms are seen. The left common femoral vein demonstrates normal color flow and waveforms. IMPRESSION: DVT highly unlikely. However, cannot be completely ruled out due to technical limitations resulting from patient discomfort. If clinical concern persists, followup exam can be performed following appropriate pain control. . AP PORTABLE CHEST [**2115-2-12**] The study is limited secondary to AP portable technique and body habitus. The cardiomediastinal configuration remains markedly enlarged but stable. The cardiac silhouette is globular in morphology. There is no superimposed edema or consolidation evident. No effusion or pneumothorax is seen. Again noted and slightly exaggerated is a dextroconcave curvature of the thoracic spine likely at least in part positional. IMPRESSION: Low lung volumes; however, no focal consolidation seen. Stable marked cardiomegaly. . ECG Study Date of [**2115-2-12**] Atrial fibrillation with moderate ventricular response. Diffuse low voltage. Delayed precordial R wave transition. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [**2110-10-14**] atrial fibrillation has appeared. Rate 85, PR 0, QRS 88, QT/QTc 392/435, P 0, QRS 15, T 89 . Portable TTE (Complete) Done [**2115-2-14**] The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-15mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [**2109-10-22**], cardiac rhythm now atrial fibrillation; no pericardial effusion seen; otherwise findings similar. . CHEST (PORTABLE AP) [**2115-2-18**] The right supraclavicular catheter remains in place with tip in the right atrium. Bibasilar atelectasis are again seen, slightly worsened on today's examination with a lower lung volume than before. Small bilateral pleural effusion have not changed. There is cardiomegaly along with minimal vascular congestion. The abdomen is gasless. IMPRESSION: 1. Lower lung volume with more prominent bibasilar atelectasis. 2. Right central catheter still terminates in the right atrium, for which repositioning is required. . CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/O CONTRAST, [**2115-2-20**] 1. No pulmonary embolism. There is CT evidence of pulmonary hypertension. 2. The lung parenchyma is not well evaluated given that the amount of respiratory motion present. There appear to be centrilobular nodules, ground- glass opacity and atelectasis. There are small bilateral pleural effusions. 3. Cardiomegaly and coronary artery calcifications. 4. Rounded hypodense liver lesions are not fully characterized on this study but not appear greatly changed from [**2109-12-2**]. 5. The spleen is generous in size. 6. Right lower quadrant renal transplant. 7. Right flank ecchymosis and focal right abdominal wall muscular enlargement, possibly representing a hematoma. This muscle enlarged should be followed to complete resolution to exclude an underlying mass. Consider targeted ultrasound for followup. . VENOUS DUP EXT UNI (MAP/DVT) LEFT [**2115-2-21**] The left basilic vein was not identified, presumably thrombosed. The left cephalic vein is patent and measures 0.23 cm in diameter superiorly and 0.37 cm in diameter in the forearm distally. In between, measurements range from 0.21-0.33, as charted on the vasculat lab diagram. The left brachial artery is patent with triphasic waveforms. There is respiratory phasicity of the left subclavian venous waveform. . [**2114-2-26**] EKG Atrial fibrillation, average ventricular rate 80-85. Generalized low voltage. Delayed precordial R wave progression - cannot exclude anterior myocardial infarction. Generalized non-specific repolarization changes most marked anteroseptally and laterally consistent with ischemia. Compared to the previous tracing of [**2115-2-13**] anteroseptal T wave inversions are new. Rate 83 PR 0, QRS 76, QT/QTc 386/426, P 0, QRS 18, T 109 . MICROBIOLOGY . [**2115-2-18**] Blood Culture (4 BOTTLES): NO GROWTH FINAL. [**2115-2-21**] NASOPHARYNGEAL ASPIRATE. Positive for Respiratory Syncytial viral antigen. CULTURE CONFIRMATION PENDING. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. VIRAL CULTURE (Final [**2115-2-27**]): HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY Brief Hospital Course: #. RESPIRATORY DISTRESS The patient's respiratory distress was likely multifactorial due to volume overload and RSV infection (by nasopharyngeal aspirate). In the MICU, the patient was also determined to have chronic CO2 retention likely secondary to obstructive sleep apnea given his habitus. Of note, pt did not tolerate BiPap trial in unit. Pt received 3 days of burst steroids for ? COPD exacerbation, was discontinued given lack of improvement and no known COPD (not a smoker). In addition, Mr. [**Known lastname 108684**] beta blocker was discontinued as uptitration of it was thought to exacerbate his wheezing. CT chest was negative for pulmonary embolism. Hemodialysis was initiated. The patient was diuresed to a net negative fluid balance of ~10 L on HD with significant improvement in wheezing/decreased O2 saturations/rhonchi after dialysis. However, wheezing persisted and low O2 saturations (~91% room air) persisted after significant volume removal. Nasopharyngeal aspirate showed patient had an RSV infection. Pulmonary was consulted and there was no indication for an antiviral medication for RSV. Supportive care was provided for viral pulmonary infection. Of note, viral cultures of the nasopharyngeal aspirate grew HSV 1, which was felt to be a normal colonizer of the patient's respiratory tract. By the time the HSV culture returned ([**2-27**]), the patient's respiratory status was at baseline; no antiviral for HSV was felt to be indicated. Upon discharge, the patient had clear lungs to auscultation bilaterally and had an normal O2 saturation on room air. Bactrim was continued for prophylaxis. Sleep study was recommended as an outpatient to evaluate the need for home BiPAP. . #. END-STAGE RENAL DISEASE ON HEMODIALYSIS See above. Failed cadaveric renal transplant in [**2109**], initiated on hemodialysis on this admission with successful placement of tunneled line on this admission. For renal transplant, continued low dose prednisone, and cyclosporine was decreased to 25 mg daily. He was maintained on a fluid restricted diet. Venogram was performed in anticipation of outpatient fistula placement. He was scheduled for a vascular surgery appointment as an outpatient for fistula placement. . #. ATRIAL FIBRILLATION The patient has a history of atrial fibrillation s/p cardioversion and re-presented in atrial fibrillation in the setting of metabolic derangements and fluid overload. Home betablocker was discontined (due to persistent wheezing), and diltiazem was provided for rate control. Of note, diltiazem elevates cyclosporin which could be problem[**Name (NI) 115**] in this patient. In the future if respiratory distress deemed not to be related, beta blocker may provide more cardiac benefit and also does not have cross reaction with cyclosporin; defer to outpatient PCP. [**Name10 (NameIs) **] cards, no cardioversion was indicated during this admission as the patient could not lie flat for procedure, which would require TEE. Per ther recs: outpatient cardiology f/u in [**2-11**] weeks with Dr. [**Last Name (STitle) 73**] for outpatient cardioversion once respiratory status improves. Coumadin was provided after HD line placed; he was bridged with heparin drip until then. Upon discharge, he was off the heparin drip and therapeutic on coumadin. He was in atrial fibrillation through admission with adequate rate control upon discharge. . #. ACIDEMIA The patien presented with mixed metabolic and respiratory acidosis. Respiratory component possibly due to CO2 retention (OSA vs obesity hypoventilation syndrome vs COPD); AG metabolic acidosis due to his renal failure. His acidemia improved with dialysis and adjustment of diasylate bath. . # F/E/N: Replete lytes PRN. Fluid restricted renal diet. . # PPx: Bowel regimen, PPI (on steroids) . # Access: PIV 22 X 2, temporary HD line. . # Dispo: pending further improvement in respiratory status. . # Code Status: Full Medications on Admission: Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO PredniSONE 5 mg PO QPM Furosemide 80mg PO daily Gengraf *NF* 100 mg Oral [**Hospital1 **] Mycophenolate Mofetil 250 mg PO TID Sulfameth/Trimethoprim SS 1 TAB PO MWF Amlodipine 10 mg PO DAILY Iron TID Calcium + Vitamin D Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO Q MWF (). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center for Rehab Discharge Diagnosis: Primary: End-stage renal disease Respiratory Syncytial Virus . Secondary: Atrial Fibrillation Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to the hospital with shortness of breath. Hemodialysis was initiated. Your shortness of breath improved with excess volume removal with hemodialysis. You were also found to have respiratory syncytial virus, and you were treated with supportive care. . Please keep all followup appointments. . Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. . Medication changes: 1. Cyclosporin dosage was decreased to 25 mg daily. 2. Toprol XL was discontinued as it was thought to contribute to your shortness of breath. . New medications: 1. Warfarin (coumadin) 2.5 mg by mouth daily. The dosage of your coumadin should be adjusted as an outpatient to maintain a therapeutic level. 2. Diltiazem 180 mg daily was added to control your heart rate. Followup Instructions: 1. For fistula placement for dialysis: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 40164**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-3-14**] 2:30 PM. . 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2115-4-18**] 1:30 PM. . 3. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-5-7**] 11:10 AM. . 4. Please followup with you PCP: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 108685**], MD within 1 week of discharge from rehabilitation. Phone: [**Telephone/Fax (1) 100430**]. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

Admission Date: [**2161-2-9**] Discharge Date: [**2161-2-19**] Date of Birth: [**2077-11-3**] Sex: F Service: CARDIOTHORACIC Allergies: pyriduim / macrobid / bactrim Attending:[**First Name3 (LF) 1505**] Chief Complaint: mitral/aortic regurgitation, coronary artery disease Major Surgical or Invasive Procedure: Mitral valve replacement(27mm St.[**Male First Name (un) 923**] tissue),aortic valve replacement(21mm St.[**Male First Name (un) 923**] tissue),coronary artery bypass graft (SVG-PDA) [**2161-2-10**] History of Present Illness: This 83 year old female with a history of rheumatic heart disease has been followed by serial echocardiograms for both mitral and aortic valvular disease. She was hospitalized for CHF 4 years ago when the diagnosis was revealed. Interestingly her last echocardiogram in [**2160-11-13**] showed moderate to severe aortic stenosis with mild to moderate aortic insufficiency and mild to moderate mitral regurgitation, however, her cardiac catheterization revealed mild aortic stenosis and severe mitral regurgitation. She is symptomatic with significant fatigue. She was seen previously and admitted this time for Heparin bridge and surgery. Past Medical History: Mitral regurgitation Rheumatic heart disease Hypertension Chronic atrial fibrillation non-insulin dependent diabetes mellitus glaucoma diastolic heart failure s/p tonsillectomy s/p thyroidectomy s/p cataract surgeries Social History: Race: Caucasian Last Dental Exam:full dentures Lives with:husband Contact: husband Phone #cell [**Telephone/Fax (1) 91878**] Occupation:retired Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use:none ETOH: < 1 drink/week [x] [**1-20**] drinks/week [] >8 drinks/week []rare Illicit drug use-none Family History: Family History:Premature coronary artery disease-none Physical Exam: Physical Exam Pulse:76 Resp: 16 O2 sat: 100% RA B/P Right: 176/88 Left: 158/77 Height: 62" Weight: 120 # General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM []; no JVD appreciated Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [x] grade 4/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema [x] trace Varicosities: + significant BLE spider veins Neuro: Grossly intact, nonfocal exam; MAE [**4-18**] strengths Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: NP Left:NP Radial Right: 2+ Left:1+ Carotid Bruit: murmur radiates to B carotids Pertinent Results: [**2161-2-19**] 07:30AM BLOOD WBC-18.2* RBC-3.36* Hgb-10.4* Hct-30.4* MCV-91 MCH-30.9 MCHC-34.1 RDW-13.7 Plt Ct-245 [**2161-2-19**] 07:30AM BLOOD PT-21.2* INR(PT)-2.0* [**2161-2-18**] 03:24AM BLOOD PT-17.0* INR(PT)-1.6* [**2161-2-17**] 06:04AM BLOOD PT-15.5* INR(PT)-1.5* [**2161-2-15**] 03:15AM BLOOD PT-16.5* INR(PT)-1.6* [**2161-2-14**] 02:41AM BLOOD PT-20.6* PTT-31.1 INR(PT)-2.0* [**2161-2-11**] 01:12AM BLOOD Glucose-126* UreaN-13 Creat-0.8 Na-136 K-4.2 Cl-110* HCO3-16* AnGap-14 [**2161-2-9**] 04:55PM BLOOD Glucose-185* UreaN-16 Creat-0.9 Na-137 K-4.0 Cl-97 HCO3-32 AnGap-12 [**2161-2-9**] 04:55PM BLOOD ALT-14 AST-17 AlkPhos-94 TotBili-1.1 [**2161-2-9**] 04:55PM BLOOD %HbA1c-8.6* eAG-200* Findings LEFT ATRIUM: Mild spontaneous echo contrast in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS (area 0.8-1.0cm2). Moderate (2+) AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Moderate valvular MS (MVA 1.0-1.5cm2) Mild to moderate ([**12-15**]+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions Pre-CPB: The patient is in A.Fib. Mild spontaneous echo contrast is present in the left atrial appendage. The LV is mildly depressed with inferior basal HK. EF is 45 - 50%. There is mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Mild to moderate ([**12-15**]+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on no inotropes. There is a prosthetic tissue valve in the mitral position with no leak, no MR and a residual mean gradient of 5 mmHg. There is a prosthetic tissue valve in the aortic position with no leak and no AI. Residual mean gradient is 5 mmHg. Unchanged biventricular systolic fxn. Brief Hospital Course: Heparin was begun after admission and on [**2-10**] she went to the Operating Room where surgery was performed. See operative note for details. She weaned from bypass on NeoSynephrine and Propofol infusions. She remained stable, was awakened and extubated the evening of surgery and came off pressor quickly. She then was hypertensive, requiring Nitroglycerin intravenously for control. She was diuresed and was weak and confused. She remained in the ICU for several days, transferring to the floor on [**2-16**]. She had a very poor appetite, as at home according to family and was very slow to participate in her care (also as at home). A feeding tube remained in (stoach ) and tube feeding were given. Speech and swallow studiesd were done several times and she was advance to a ground solids/nectar thick liquid diet with crushed pills in puree. She had urinary retension and the Foley was replaced on [**2-19**] for 700cc. Hopefully as she becomes mobile this will resolve. She was changed to nocturnal tube feeds(1900-0400) with full strength Glucerna 1.0 at 55cc/hour. This was in a effort to get her to eat during the day. She requires much encouragement and prompting to eat, use the incentive spirometer and help with her care. Coumadin was resumed for her chronic atrial fibrillation, with a target INR of [**1-15**].5. She was discharged to [**Hospital3 7665**] Hospital in [**Hospital1 3597**], NH for further recovery on [**2-19**]. All follow up appointments were given. Medications on Admission: Digoxin 0.125mg daily,Lasix 40mg daily,Glimepiride 1mg TID,metoprolol50mg [**Hospital1 **],KCl8mEq daily,Aldactone 25mg daily,Coumadin 2.5mg daily,Tums 1 daily,VitD daily Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day as needed for constipation. 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. glimepiride 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): INR goal 2-2.5. 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 16. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO once a day for 2 weeks. 17. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous once a day. 18. Humulin R 100 unit/mL Solution Sig: per scale Injection four times a day: 120-160:2units ac SQ/0units HS; 16-200:4units ac/2units HS;201-240:6units ac/4units HS;241-280:8units ac/6units HS. 19. Outpatient Lab Work INR/PT [**2-20**], then M-W-F for two weeks, then prn. Coumadin dosing based upon results Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Mitral stenosis/regurgitation aortic stenosis coronary artery disease s/p aortic/mitral replacements,coronary artery bypass graft rheumatic heart disease chronic atrial fibrillation glaucoma hypertension diastolic heart failure noninsulin dependent diabetes mellitus s/p thyroidectomy s/p tonsillectomy s/p cataract extractions Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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.[**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2161-3-25**] at 1pm Cardiologist:Dr.[**Last Name (STitle) **] on [**2161-3-4**] at 1pm Please call to schedule appointments with: Primary Care: Dr.[**Last Name (STitle) 91879**] [**Name (STitle) 72824**] in [**3-19**] 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 Goal INR 2-2.5 First draw [**2-20**] then M-W-F for two weeks, then prn *** Needs Coumadin management arranged after rehab discharge*** Completed by:[**2161-2-19**]

Unit No: [**Numeric Identifier 69294**] Admission Date: [**2112-9-23**] Discharge Date: [**2112-10-12**] Date of Birth: [**2112-9-23**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 2816**] is the former 1.66 kg product of a 34-2/7 week gestation pregnancy born to a 39-year-old G3, P1 now 2 woman. PRENATAL SCREENS: [**Known lastname **] type O-, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta strep status unknown. PREGNANCY COMPLICATIONS: Gestational diabetes, diet controlled. Amniocentesis was performed secondary to the advanced maternal age and was normal. There were uterine fibroids seen on prenatal ultrasound. On the day of delivery the baby had a biophysical profile of [**3-16**] and a nonreactive fetal heart rate tracing. This prompted a cesarean section under spinal anesthesia. The large fibroids required a classical incision for the cesarean section. The fibroids were removed prior to delivery of the infant. Rupture of membranes occurred at the time of delivery with clear fluid. Apgars were 7 at 1 minutes and 8 at 5 minutes. The infant was admitted to the neonatal intensive care unit for treatment of prematurity. PHYSICAL EXAMINATION UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 1.66 kg at the 10th percentile, length 44.5 cm, head circumference 29.5 cm. General: Small preterm male infant. Pink and comfortable in room air. HEENT: Anterior fontanel soft and flat. Nondysmorphic facies. Intact palate. Chest: Breath sounds clear. Good aeration. Cardiovascular: No murmur. Normal pulses. Abdomen: Soft. No hepatosplenomegaly. A 3-vessel cord. GU: Hypospadias noted. Testes descended into scrotum. Extremities: Hips stable. Moving all spine straight. Normal sacrum. Skin: Mongolian spot over buttocks, a 2 cm x 1.5 cm nevus on the back of the left thigh. Neurologic: Normal tone. Moving all extremities. Appropriate reflexes. HOSPITAL COURSE BY SYSTEMS: Respiratory: This baby boy developed respiratory distress over the 1st few hours after admission to the neonatal intensive care unit. He was initially on nasal cannula O2 that was later changed to continuous positive airway pressure. A chest x-ray was concerning for haziness, especially of the left lung field. By day of life #2 the baby had transitioned to room air. A repeat chest x-ray on day of life #3 was within normal limits. Due to the unknown etiology of the respiratory distress, the baby was treated empirically with antibiotics. Cardiovascular: This baby has maintained normal heart rates and [**Date Range **] pressures. No murmurs have been noted. Fluids, electrolytes, nutrition: Initial whole [**Date Range **] glucose was 41. Infant was treated with intravenous 10% glucose in water. Enteral feeds were started on day of life #2 and were gradually advanced and were well tolerated. At discharge he weighed 1895 grams and was taking > 160 cc/kg of Neosure 24. Infectious disease: As previously noted, the infant was treated empirically with antibiotics. A complete [**Date Range **] count was within normal limits. A [**Date Range **] culture obtained prior to starting intravenous antibiotics was no growth at 48 hours, and the antibiotics were discontinued. Hematological: This baby and mother are [**Name2 (NI) **] type [**Name (NI) **] and direct antibody test negative. Hematocrit at birth was 43%. Gastrointestinal: Peak serum bilirubin occurred on day of life #4. Phototherapy was started on day of life #3. at peak with a total of 8.3 mg/dl. On day of life 6 it was 6.5/0.3, phototherapy was d'c d and 48 hour rebound level was 6.1/0.4. Neurology: This infant has maintained a normal neurological exam during admission. There are no neurological concerns at this time. Urology: As noted in the admission physical exam, this baby has a hypospadias. It was explained to mother why we woulld not have him circumcized. He will be seen as outpatient by urology. Sensory: Audiology: Hearing screening passed on [**2112-10-11**]. Immunizations: Hepatitis B given on [**2112-10-11**]. Medications: Ferrous Sulfate 0.2 cc's PO daily. Primary pediatrician will be [**Hospital1 **] at [**Location (un) **]/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**10-18**]. VNA to come to home day post discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 34-2/7 weeks gestation. 2. Transitional respiratory distress. 3. Suspicion for sepsis ruled out. 4. Unconjugated hyperbilirubinemia. 5. Hypospadias. Will have Dr. [**Last Name (STitle) **] recheck for red reflex as am currently unable to visualize. No cataracts seen, eyes deeply pigmented. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2112-9-27**] 20:25:50 T: [**2112-9-27**] 20:48:24 Job#: [**Job Number 69295**]

Admission Date: [**2156-7-5**] Discharge Date: [**2156-7-6**] Date of Birth: [**2124-1-11**] Sex: F Service: MEDICAL IC CHIEF COMPLAINT: Narcotic overdose. HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname 13474**] is a 32-year-old woman with a history of suicidal ideation, pseudoseizures, endometriosis status post right oophorectomy, chronic abdominal pain, gastroparesis, and positional orthostatic tachycardiac syndrome. The patient presented to the emergency department on the day of admission when he was brought in by the EMS after an overdose of narcotics including several pills of MSIR. More precisely, on counting the pills, there were three bottles provided by EMS. The first, MS Contin was prescribed on [**2155-5-28**], filled for 60 pills and had one pill left in the bottle. The second, MSIR was prescribed on [**2155-5-2**] with a prescription for 30 pills and had one left in the bottle. The third, MSIR, was prescribed on [**2155-6-18**] and it was for 120 pills with 20 pills left in the bottle. Apparently, the patient took the pills to "go to sleep." She then called her PCP to tell her about what she had done and the PCP immediately [**Name (NI) 653**] the EMS. When the EMS arrived, the patient was lucid and ambulatory. She then quickly became unresponsive. She was brought to [**Hospital1 346**]. En route, they were unable to obtain IV access and they gave her a total of 6 mg IM Narcan with no response. In the emergency department, the patient was intubated for respiratory depression and received a total of 4 mg IV Narcan. She was eventually placed on a 0.4 mg per hour Narcan drip. She was given p.o. charcoal and required 8 mg Ativan, while the charcoal was being administered. She was subsequently extubated after waking up. The patient was admitted to the Medical Intensive Care Unit for close monitoring of her respiratory status, Narcan drip and suicidal ideation. PAST MEDICAL HISTORY: 1. Suicidal ideation. The patient was seen in the [**Hospital1 1444**] Emergency Department [**2156-7-4**] for suicidal ideation. She was discharged after evaluation. 2. Postural orthostatic and tachycardiac syndrome, followed by the neurologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**]. On [**2156-6-14**] the patient underwent tilt-table testing in the autonomic laboratory. This study revealed postural tachycardia followed by a hypertensive bradycardiac syncope. 3. History of pseudoseizures. 4. Endometriosis status post right oophorectomy. 5. Chronic abdominal pain. 6. Gastroparesis. 7. PPD positive. 8. CT angiogram on [**2156-2-21**] negative for pulmonary embolism. 9. Abdominal ultrasound [**2156-2-27**], negative for gallstones. 10. CT of the head from [**2156-2-21**] negative for hemorrhage. MEDICATIONS ON ADMISSION: 1. Reglan 10 mg p.o.q.i.d. 2. Zofran p.r.n. 3. Florinef 0.1 mg p.o.q.d. 4. Motilium (motility [**Doctor Last Name 360**] available only from [**Country 26467**]). ALLERGIES: The patient is allergic to DEMEROL, PERCOCET, VICODIN, BACTRIM, COMPAZINE, AND LIDOCAINE. SOCIAL HISTORY: The patient lives with her roommate. She was born in [**Country 26467**], which is where her family resides. She is a research scientist with a PhD working at the [**Hospital1 1444**]. She denies the use of alcohol or tobacco. FAMILY HISTORY: History is positive for coronary artery disease and cerebrovascular accident; negative for neurological disease. Examination in the emergency room revealed the following: The patient was afebrile, heart rate 95, blood pressure 135/80, respiratory rate 11, oxygen saturation 99% on room air. GENERAL: The patient was depressed and tired, in no acute distress. HEENT: Examination showed no jugulovenous distention or lymphadenopathy. Pupils equal, round, and reactive to light and accommodation. Pupil size was approximately 4 mm. Extraocular movements were intact. LUNGS: Lungs were clear to auscultation bilaterally. HEART: regular rate and rhythm with normal S1 and S2, no extra heart sounds. ABDOMEN: Abdomen was soft, nontender, and nondistended with positive bowel sounds. EXTREMITIES: Extremities showed no edema, 2+ distal pulses. NEUROLOGICAL: Examination revealed that the patient was alert and oriented times three, answering questions appropriately, moving all four extremities. LABORATORY DATA: Labs at the time of admission revealed the following: The patient had a white count of 7.1, hematocrit 13.7, hematocrit 38.3, and platelet count of 364,000. She had a sodium of 144, potassium 3.8, chloride 105, bicarbonate 26, BUN 8, creatinine 0.9, and glucose of 129. Urinalysis was negative. Coagulations were within normal limits. Urine toxicology screen was positive for benzodiazepines (probably received in the emergency room) and opiates. Urine toxicology screen was negative. EKG was sinus rhythm at 93 with a normal axis and normal intervals. There were no acute ST or T-wave changes. Chest x-ray was clear. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit on a Narcan drip at 0.4 mg per hour. She was alert and cooperative at the time and remained so throughout her admission. On the morning of [**2156-7-6**], the Narcan drip was slowly titrated to off. The patient remained alert and oriented, answering questions appropriately without signs of respiratory distress or depression. She was seen by the Psychiatry Department, who felt that the patient required inpatient [**Year (4 digits) **] admission for a serious and almost successful suicide attempt. The patient was medically cleared on [**2156-7-6**] and transferred to the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 7637**] Facility. During the entire course of her hospital stay at [**Hospital1 69**], she was observed by a 1:1 sitter for safety. DISCHARGE MEDICATIONS: 1. Reglan 10 mg p.o.q.d. 2. Florinef 0.1 mg p.o.q.d. 3. Tylenol 650 mg p.o.q.4h. to 6h.p.r.n. 4. Maalox 15 ml to 30 ml p.o.q.i.d.p.r.n. DISCHARGE DIAGNOSES: 1. Narcotic overdose with respiratory depression-resolved. 2. Suicidal ideation. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Name8 (MD) 30425**] MEDQUIST36 D: [**2156-7-6**] 13:40 T: [**2156-7-6**] 12:36 JOB#: [**Job Number **]

Admission Date: [**2171-7-22**] Discharge Date: [**2171-7-26**] Date of Birth: [**2109-2-28**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Percocet / Tetanus / Latex Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: [**2171-7-22**] s/p Coronary artery bypass graft surgery (left internal mammary artery > left anterior descending, saphenous vein graft > obtuse marginal 1, saphenous vein graft > obtuse marginal 2) History of Present Illness: 62 year old female being scheduled for distal SFA to below knee popliteal artery bypass to relieve her symptoms with Dr [**Last Name (STitle) 3407**] and developed episode of chest heaviness approximately 2-1/2 weeks ago. This occurred while sleeping and lasted for a couple of days and resolved spontaneously. Past Medical History: Diabetes Mellitus type 2 Hypertension Hyperlipidemia, Hypothyroidism Depression Osteopenia Squampous cell cancer s/p excision Renal tumor with renal calculi Bronchitis Anxiety s/p Cholecystectomy s/p appendectomy s/p polypectomy. Social History: Occupation: Retired hairstylist Lives with her husband, daughter and grandson. Tobacco: 1 pack per day ETOH Only rare alcohol use, no recreational drug use. Family History: noncontributory Physical Exam: Pulse: 85 Resp: 22 O2 sat: 95 RA B/P Right: 127/68 Height:5'3" Weight:149 lbs/68 kgs General: Skin: Dry [x] intact [x], 3 inch long well-healed incision along midline of anterior chest wall from skin cancer removal HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally anteriorly[x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2171-7-22**] 07:47AM HGB-14.2 calcHCT-43 [**2171-7-22**] 07:47AM GLUCOSE-204* LACTATE-2.4* NA+-138 K+-4.2 CL--108 [**2171-7-22**] 11:24AM PT-14.0* PTT-33.9 INR(PT)-1.2* [**2171-7-22**] 11:24AM WBC-5.6 RBC-2.76*# HGB-8.8*# HCT-24.1*# MCV-87 MCH-31.9 MCHC-36.6* RDW-13.4 [**2171-7-22**] 11:24AM GLUCOSE-175* LACTATE-2.6* NA+-137 K+-4.1 CL--110 [**2171-7-25**] 04:49AM BLOOD WBC-10.8 RBC-3.24* Hgb-9.4* Hct-28.3* MCV-87 MCH-28.9 MCHC-33.1 RDW-13.6 Plt Ct-183 [**2171-7-25**] 04:49AM BLOOD Glucose-174* UreaN-16 Creat-0.6 Na-135 K-3.7 Cl-101 HCO3-26 AnGap-12 Intra-operative Echo [**2171-7-22**] PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions includingphenylephrine and is in sinus rhythm. 1. Biventricular function is unchanged. 2. Aortic contours appear intact post decannulation 3. Other findings are unchanged [**Known lastname **],[**Known firstname **] [**Medical Record Number 26365**] F 62 [**2109-2-28**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2171-7-24**] 7:45 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2171-7-24**] 7:45 AM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 26366**] Reason: s/p ct removal ? ptx Final Report FINDINGS: In comparison with study of [**7-22**], there has been removal of all the monitoring and supportive devices except for the left subclavian catheter. Specifically, no evidence of pneumothorax. Mild bibasilar atelectatic changes persist. DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Approved: WED [**2171-7-24**] 11:40 AM Brief Hospital Course: Admitted same day surgery and was brought to the operating room and underwent coronary artery bypass graft surgery. See operative report for further details. In summary she had CABG x3 with LIMA-LAD,SVG-OM1, SVG-OM2. Her bypass time was 73 minutes with a crossclamp of 58 minutes. She tolerated the operation well and was transferred to the CVICU in stable condition. She received vancomycin for perioperative antibiotics. In the intensive care unit she was weaned from sedation, awoke neurologically intact and extubated without complications. On post operative day one she was started on beta blockers and diuretics and transferred to the floor. Physical therapy worked with her on strength and mobility. On post operative day two her chest tubes were removed. Her epicardial wires were removed the following day. She was gently diuresed toward her pre-operative weight. Her activity level gradually advanced and by post-operative day four she was discharged to home with the approval Dr. [**Last Name (STitle) 914**]. All follow-up appointments were advised per cardiac surgery protocol. Medications on Admission: metformin 1000 mg twice a day glipizide 5 mg twice a day simvastatin 80 mg daily Synthroid 125 mcg daily Ativan p.r.n. Bupropion 150 mg daily clotrimazole 0.05 mg apply to the foot aspirin 81 mg daily Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for to foot . 6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease s/p CABG Diabetes Mellitus type 2 Hypertension Hyperlipidemia, Hypothyroidism Depression Osteopenia Squampous cell cancer s/p excision Renal tumor with renal calculi Bronchitis Anxiety s/p Cholecystectomy s/p appendectomy s/p polypectomy. Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Last Name (STitle) 914**] (cardiac surgeon) in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) in 1 week - please call for appointment Dr [**Last Name (STitle) **] (cardiology) in [**1-8**] weeks - please call for appointment Wound check [**Hospital Ward Name 121**] 6 in 2 weeks as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2171-7-26**]

Admission Date: [**2199-12-6**] Discharge Date: [**2199-12-13**] Date of Birth: [**2120-4-15**] Sex: M Service: MEDICINE Allergies: Pneumococcal Vaccine Attending:[**First Name3 (LF) 338**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: s/p bronchial artery embolization History of Present Illness: 79-year-old male with history of NSCLC s/p chemotherapy and radiation in [**2191**] with local recurrence diagnosed [**4-10**] who developed hemoptysis and was transferred for bronchial artery embolization. . The patient was doing well until a couple months ago. At that time he developed intermittent hemoptysis. This was scant and intermittent until [**5-6**] day ago. At that time he noted increased hemoptysis totaling a couple teaspoons and he presented to [**Hospital3 3765**] on [**2199-12-4**]. He was noted to have Hct of 28, had bronchoscopy with 90% obstructing mass in proximal right bronchus at the orifice of RML and RLL. Per note, the mass was fungating and polypoid. Electrocautery coagulation was done with reduction of the amount of bleeding. He has evidence of mets to RML and RLL. He was transferred to [**Hospital1 18**] for bronchial artery embolization. . At [**Hospital1 18**] his hct was noted to be 28.2. He was breathing comfortably with 4L NC. He was monitored on floor until procedure. He underwent a right bronchial artery embolization (330-550 microns) which was uncomplicated. After the procedure the patient was transferred from angio table to stretcher and developed tachypnea to 40s, desaturation to low 80s on 2L NC and significant work of breathing. He was switched to 8L simple face mask with saturation to 90. 15L NRB with saturation to 95. He was given 1mg morphine and albuterol treatment with some ease in breathing. CXR was done with no apparent change from prior description (although no comparison CXR). ABG of 7.42/47/23 with SaO2 of 95%. Over the next 5-10 minutes the patient became more comfortable and patient no longer in respiratory distress. NRB was weaned to simple face mask. Request was made to have patient observed in MICU overnight. . Upon transfer, initial vitals were: BP 154/65, HR 115, RR 35, SaO2 94% on 50% FM. The patient denies pain, fevers, chills, nausea, vomiting, diaphoresis, diarrhea, constipation. He endorses intermittent shortness of breath and notes he occassionally has productive cough, sometimes with blood clots. Past Medical History: 1. Stage IIIB NSCLC, s/p radiation and chemotherapy in [**2191**]. Cancer was originally in distal trachea near right bronchus. Patient in [**4-10**] was noted to have local recurrence during an admission for pneumonia. Patient was started late [**2199-10-2**] on palliative chemo with Gemcitabine and has had five cycles. 2. COPD 3. h/o Seizures secondary to brain injury 4. Hyperlipidemia 5. h/o pseudomonas pneumonia Social History: Widower, quit smoking in [**2199-4-1**], denies EtOH. Family History: Noncontributory. Physical Exam: Vitals: T 99.5, BP 135/61, HR 108, RR 26, SaO2 97% 40% FM General: Alert, oriented, cachectic, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Decreased breath sounds throughout, more decreased in RLL and RML. Anterior exam only. No crackles or wheezes appreciated. Cardiovascular: Decreased heart sounds, difficult to assess. RR, tachycardia. No murmurs or rubs. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, cyanosis or edema, mild clubbing, no hematoma/bruit at groin. Pertinent Results: Labs: [**2199-12-6**] 04:53PM BLOOD WBC-7.4 RBC-3.34* Hgb-10.0* Hct-29.1* MCV-87 MCH-29.8 MCHC-34.2 RDW-20.0* Plt Ct-209 [**2199-12-7**] 05:11PM BLOOD WBC-15.5*# RBC-3.20* Hgb-9.3* Hct-28.0* MCV-88 MCH-29.1 MCHC-33.3 RDW-20.4* Plt Ct-341 [**2199-12-10**] 04:15AM BLOOD WBC-13.3* RBC-2.98* Hgb-8.9* Hct-26.1* MCV-88 MCH-29.7 MCHC-33.9 RDW-20.0* Plt Ct-669* [**2199-12-11**] 04:00AM BLOOD WBC-11.0 RBC-2.84* Hgb-8.2* Hct-24.7* MCV-87 MCH-28.9 MCHC-33.3 RDW-19.6* Plt Ct-890* [**2199-12-12**] 04:32AM BLOOD WBC-10.3 RBC-2.68* Hgb-8.0* Hct-23.0* MCV-86 MCH-29.9 MCHC-34.8 RDW-19.9* Plt Ct-901* [**2199-12-13**] 03:59AM BLOOD WBC-11.5* RBC-3.15* Hgb-9.0* Hct-27.1* MCV-86 MCH-28.7 MCHC-33.2 RDW-19.5* Plt Ct-1208* [**2199-12-6**] 04:53PM BLOOD Glucose-105* UreaN-15 Creat-0.6 Na-136 K-3.5 Cl-99 HCO3-29 AnGap-12 [**2199-12-8**] 04:46AM BLOOD Glucose-127* UreaN-21* Creat-0.9 Na-132* K-4.0 Cl-99 HCO3-25 AnGap-12 [**2199-12-11**] 04:00AM BLOOD Glucose-147* UreaN-12 Creat-0.7 Na-129* K-4.1 Cl-95* HCO3-31 AnGap-7* [**2199-12-12**] 04:32AM BLOOD Glucose-159* UreaN-11 Creat-0.6 Na-132* K-4.2 Cl-96 HCO3-31 AnGap-9 [**2199-12-13**] 03:59AM BLOOD Glucose-132* UreaN-9 Creat-0.7 Na-127* K-4.6 Cl-91* HCO3-32 AnGap-9 [**2199-12-6**] 04:54PM BLOOD PT-13.7* PTT-26.4 INR(PT)-1.2* [**2199-12-12**] 04:32AM BLOOD PT-16.2* PTT-37.9* INR(PT)-1.4* [**2199-12-6**] 04:53PM BLOOD Calcium-8.2* Phos-2.5* Mg-2.2 [**2199-12-13**] 03:59AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.1 [**2199-12-6**] 11:16PM BLOOD Type-ART pO2-23* pCO2-47* pH-7.42 calTCO2-32* Base XS-3 [**2199-12-7**] 12:45AM BLOOD Type-[**Last Name (un) **] Temp-37.8 pO2-43* pCO2-46* pH-7.39 calTCO2-29 Base XS-1 Intubat-NOT INTUBA [**2199-12-10**] 04:15AM BLOOD Vanco-17.0 . Blood cx [**2198-12-9**] pending, blood cx earlier in admission negative Urine cx: negative . [**2199-12-9**] 8:31 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [**2199-12-9**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2199-12-9**]): TEST CANCELLED, PATIENT CREDITED. . CXR [**2199-12-11**]: FINDINGS: Right middle and lower lobe post-obstructive combination of collapse and consolidation with volume loss and rightward shift of midline structures is unchanged. Increased opacity within the right upper lobe and the entire left lung reflects vascular congestion and mild-to-moderate pulmonary edema. Cardiac silhouette is significantly obscured. There is no pneumothorax or left effusion. IMPRESSION: Mild-to-moderate pulmonary edema within the left lung and right upper lobe with unchanged right pleural effusion and post-obstructive atelectasis and consolidation of the right middle and lower lobes. . LENIs [**2199-12-9**]: FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, superficial femoral, popliteal and tibial veins. There is normal flow, compression and augmentation seen in all the vessels. IMPRESSION: No evidence of deep vein thrombosis in either leg. . CT chest with contrast [**2199-12-8**]: CT OF THE CHEST WITH CONTRAST: No pathologically enlarged supraclavicular, or axillary lymph nodes are present. A small 8-mm left hilar node seen. There is loss of the normal fat plane along the right mediastinal surface with 2 inferior paraesophageal nodes measuring 6 and 10 mm in short axis (2:29). Volume loss is noted involving the right lung with paramediastinal fibrosis seen bilaterally, but predominantly on the right in the upper lobe which is poorly enhancing. Some aerosolized secretions are noted within the distal trachea extending into the proximal main stem bronchi on the right with complete occlusion of the bronchus intermedius and proximal segmental branches of the right middle and right lower lobe by soft tissue mass. The right upper lobe bronchus has some secretions within its origin but is patent distally. The overall size of the right hilar mass is difficult to delineate in conjunction with the surrounding post-obstructive collapse of a large portion of the right lower lobe with the vasculature remaining patent and coursing through the atelectatic lung. Some scattered centrilobular nodules are noted within the right upper lobe in conjunction with regions of bronchiolectasis and bronchial/bronchiole wall thickening (4:64). The aerated portions of the right middle and right lower lobe display bronchiectasis, interstitial septal thickening and surrounding ground-glass opacities. Mild thickening is noted along the pleural surface of the right major and minor fissures. Mild enhancement is noted along the right pleural surface in conjunction with a moderate-sized pleural effusion with fissural components. The left lung displays some apical scarring and paramediastinal fibrotic changes as well as a tubular 4 x 6-mm nodule within the lingula (4:95), without any other suspicious pulmonary nodules. Underlying traction bronchiectasis is noted adjacent to the post-radiation changes with the remaining airways appearing otherwise unremarkable. Moderate background centrilobular emphysema is better appreciated within the more normal-appearing left lung. Mild-to-moderate atherosclerotic calcification is noted involving the aortic arch, ascending/descending aorta, and coronary arteries. Atherosclerotic calcification is also noted involving the aortic valve. Incidentally noted is independent takeoff of the left vertebral artery from the aortic arch. Included portions of the upper abdomen display a few scattered small cardiophrenic lymph nodes. No suspicious masses within the liver, spleen, kidneys, pancreas, or visualized bowel. Both adrenal glands appear hypertrophied more prominent on the left side. BONE WINDOWS: No malignant-appearing osseous lesions are noted. IMPRESSION: 1. Poorly defined mass in the region of the right hilum with complete opacification of the bronchus intermedius and proximal segmental branches of the right middle and right lower lobe bronchi. The right upper lobe bronchus is opacified at its orifice but likely with fluid which is present within the distal right mainstem bronchus. There are extensive post-obstructive and post radiation changes involving the right lung with resultant volume loss. Lymphangitic spread of disease is not excluded. 2. Moderate-sized right pleural effusion with pleural enhancement suggesting complex fluid. Effusion surrounds the large portion of the right lower lobe with fissural components. Left lobe contains single lingular nodule and mild post-radiation changes Note: Please note assessment for superimposed pneumonia, pulmonary hemorrhage, or worsening post-obstructive changes is not possible in the absence of any prior exams available for our review. [**2199-12-6**] s/p embolization: PROCEDURE: 1. Right common femoral arterial access. 2. Aortogram. 3. Bronchial artery embolization. DETAILS: After explaining the risks, benefits, and alternatives to the procedure, a written informed consent was obtained. The patient was brought to the angiographic suite and placed supine on the table. A timeout and huddle was performed per [**Hospital1 18**] protocol. The right groin was prepped and draped in a sterile fashion. Under continuous fluoroscopic and palpatory guidance, the right common femoral artery access was obtained using a micropuncture system, which was then exchanged for a 5 French vascular sheath, the sidearm of which was connected to a continuous heparin flush. A 5 French pigtail catheter was then advanced into the aorta over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire and aortogram was performed. Next, multiple different catheters over the wire were tried to cannulate the common bronchial trunk arising from the aorta. Due to the tortuous and acute orientation of the origin of the common bronchial trunk, the cannulation and advancement of the catheter was difficult. However, with extreme care, a Renegade catheter over an angled Glidewire was advanced further into the common bronchial trunk. Arteriograms were performed to confirm the location. Further advancement of the catheter over the Glidewire was not possible due to the extreme tortuous anatomy of the vessels. Hence, it was decided to perform embolization from this location. 300-500 micron Embospheres were then used to embolize with intermittent saline flushes. Care was taken to avoid anyreflux. Intermittent hand angiograms were performed to rule out filling of the anterior spinal artery. Further embolization was stopped when stagnancy in antegrade flow was noted. The catheter and the wires were then removed followed by the vascular sheath and manual pressure held over the arterial puncture site for about 15 minutes until good hemostasis was achieved. FINDINGS: 1. Aortogram performed demonstrating common bronchial trunk. The right bronchial artery is relatively hypertrophied as compared to the left. No active extravasation is noted. 2. No contribution to the anterior spinal artery from the bronchial arteries is noted. IMPRESSION: Successful Embosphere embolization of the common bronchial trunk with preferential flow into the right bronchial artery. Far distal embolization selectively into the right bronchial artery was not possible at this stage due to the difficult angle of origin and tortuousity. Brief Hospital Course: This is a 79-year-old male with history of NSCLC s/p chemo and XRT in [**2191**] now with local recurrence who developed hemoptysis and s/p right bronchial artery embolization who developed hypoxic respiratory distress. . # Hypoxic respiratory distress: The patient developed hypoxemic respiratory distress after being turned on right side after procedure. The differential is broad and includes airway obstruction from tumor, mucous plugging, intermittent bronchospasm, and pulmonary embolus. The most likely etiology of the original hypoxia was secondary to airway obstruction from tumor or from mucous plugging causing temporary shunt physiology. This is likely because it occurred after patient was turned on right side, was temporary, and relieved by coughing. Interval CXRs showed worsening opacifiation of his right lung suggesting complete tumor or mucous occlusion of his bronchus versus a post obstructive pneumonia process. He was started and continued on IV vanocmycin (day 1 was [**12-7**]) and cefepime (day 1 was [**12-7**]) as all cultures remained negative. He then spiked a fever and flagyl was started on [**12-9**]. The plan is for a total of a 14 day course of all antibiotics. The patient was given nebulizations to ease any possible bronchospastic response. No peripheral signs of DVT, including negative LENIs although pt is mildly tachycardic and PE was not entirely excluded as CTA was not done with PE protocal. However, cancer and PNA can explain his oxygen requirement and anticoagulation treatment would be risky given recent arterial access, embolization, and hemoptysis. He generally requires 4-5L of oxygen to maintain sats in the low 90s (has h/o hypercarbia and COPD) with intermittent needs for facemask ventilation in the setting of coughing fits. He was started on morphine 5mg po prn SOB. He regularly self suctions. He also has a lot of anxiety which he receives lorazepam 0.5mg po as needed. He is also on standing tylenol to suppress fever. . # Goals of care: The patient wanted a second opinion from oncology here at [**Hospital1 18**]. Oncology consult was called and his previous oncology records were obtained from Dr. [**Last Name (STitle) 87663**] and Dr. [**Name (NI) 88182**]. Oncology suggested a possible 3rd line of chemotherapy, but the patient said that he would want to "get better" before trying it. Palliative care was also consulted and his code status was changed to DNR/DNI. The patient expressed his wishes to die at home, but the family was not able to organize 24 hour home care and preferred that the patient be discharged to a [**Hospital1 1501**] to complete his IV antibiotics course before making a decision about how to approach his care at home. He has a follow up appointment with thoracic oncology on [**12-31**] at 10:30 to discuss further chemo options. There were discussions abbout home with hospice but that is not being implemented at this time. . # Hemoptysis: The patient has stable hematocrit and is s/p bronchial artery embolization. The procedure went very well, but he desatted to the 80s after the procedure when he layed on his right side as he was being transferred to the stretcher. His desaturation improved on nonrebreather, resolved within hours with weaning to nasal cannula, and was likely ssecondary to mucous plugging. LENIs were checked and were negative for any DVT. He only had minimal hemoptysis after the procedure and once or twice in the week following. His heparin sc was stopped and should remain off given risk of bleeding. HIS HCT did trend down to 23 from 29 on admission and was 27 on discharged without transfusion. . # Metastatic NSCLC: The patient is undergoing palliative chemotherapy with Gemcitabine. Will hold on further chemo for now pending oncology input. See goals of care section above. . # Hypothyroidism: Continued levothyroxine . # Hyperlipidemia: Continued statin . #. Constipation: Pt had constipation while here that he did not report to us initially. He moved his bowels on senna, colace, and miralax. He should be monitored for constipation. . # h/o Seizures secondary to brain injury: Continue home phenytoin. . # Hypophosphatemia: He repeatedly had a low phos while in hospital. He should have his phos monitored regularly. . #.Hyponatremia: Is SIADH also likely a hypovolemic component given decreased pos. Trend hyponatremia. . # Thrombocytosis: Likely secondary to suboptimally tx post obstructive pneumonia . # Insomnia in setting of respiratory issues: Pt does well on trazodone 25mg qhs. . # Code: DNR/DNI as outlined above Medications on Admission: Simvastatin 20mg daily Levothyroixine 75mcg daily Dilantin 100mg QID Phenobarb 60mg daily Albuterol neb q4hrs prn Spiriva 18mcg daily Temazapam 30mg qHS Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. levothyroxine 75 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 4. phenobarbital 60 mg Tablet Sig: One (1) Tablet PO once a day. 5. phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO twice a day. 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): day 1 was [**12-9**] for total of 14 day course last day [**12-23**]. 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety, discomfort: hold for sedation. 9. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous membrane TID (3 times a day) as needed for sore throat. 10. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 13. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q4H (every 4 hours) as needed for shortness of breath. 14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 15. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal QID (4 times a day) as needed for dry nose. 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stool. 18. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 20. 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. 21. CefePIME 2 g IV Q12H day 1=[**12-7**] 22. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): day 1 [**12-7**] total 14 day course last day [**12-21**]. 23. Outpatient Lab Work Chem 10, CBC daily for 1st 3 days and then at discretion of MD at facility 24. Pneumoboots Discharge Disposition: Extended Care Facility: the highlands Discharge Diagnosis: Primary diagnosis: 1. Stage IIIB NSCLC, s/p radiation and chemotherapy in [**2191**]. Cancer was originally in distal trachea near right bronchus. Patient in [**4-10**] was noted to have local recurrence during an admission for pneumonia. Patient was started late [**2199-10-2**] on palliative chemo with Gemcitabine and has had five cycles. 2. s/p bronchial artery embolization 3. Post obstructive PNA 4. COPD . Seondary diagnosis: 1. h/o Seizures secondary to brain injury 2. Hyperlipidemia 3. h/o pseudomonas pneumonia Discharge Condition: A & O x3, able to get up to chair with assistance but does not have oxygen reserve to do more, on 4-5L of oxygen to maintain o2 sats 89-92% occasionally needs fase mask for short periods Discharge Instructions: You were admitted for bronchial artery embolization and then had an increased oxygen requirement. Your lung cancer is worse and has taken over almost the entire part of your right lung. In addition you developed fever and have a post obstructive PNA and you are on cefepime, flagyl, and vancomycin which you will take for 14 days. You also were started on morphine and you are on ipratropium and albuterol nebs. You saw oncology here and you have a follow up appointment with Dr. [**Last Name (STitle) **] on [**12-31**]. Followup Instructions: Thoracic oncology is working on an appointment for you later this month. please call ([**2199**] 1-2 days after discharge to find out the time appointment. Completed by:[**2199-12-13**]

Unit No: [**Numeric Identifier 67907**] Admission Date: [**2194-4-20**] Discharge Date: [**2194-5-28**] Date of Birth: [**2194-4-20**] Sex: M Service: NEONATOLOGY HISTORY: Baby [**Name (NI) **] [**Known lastname **]-[**Known lastname **] was a [**2217**] grams, product of a 33-0/7 week gestation, EDC [**2194-6-8**]. Mother is a 34 year old, gravida 4, para 5 woman with the following prenatal screens: blood type O-positive, antibody negative, RPR nonreactive, rubella immune, Hep-B negative, and GBS unknown. Maternal OB history notable for a now 6-year-old former 28-week infant that was cared for at [**Hospital1 18**]. This pregnancy was complicated by IDDM and hypertension. The mother was treated with insulin, labetalol and Procardia. The infant was born by C- section because of decreased fetal movement. Apgar scores 8 at 1 minute and 9 at 5 minutes. INITIAL EXAMINATION AT ADMISSION: Generally active, alert infant in no obvious distress, weight [**2217**] grams (50-75%), head circumference 30-cm (25-50%), length 42-cm(25%). Vital signs on admission to NICU: Temp 98.8, heart rate 160, blood pressure 64/18, mean 33, respiratory rate 60, and O2 sat 93% room air. Dextro stick was 11. HEENT: Normocephalic, atraumatic, anterior fontanel open and flat, red reflex present bilaterally, palate intact, and normal facies. SKIN: Mongolian spot on the buttock, no rash. Neck supple. Lungs clear bilaterally, no grunting, flaring or retractions. Cardiovascular regular rate and rhythm, no murmur. Femoral pulses 2+ bilaterally. Abdomen soft with active bowel sounds, no masses, no distention. Genitourinary: Normal males testes bilaterally in the canal. Anus patent. Hips stable. Clavicles intact. Spine midline with no sacral dimple. Neuro: Normal tone and moved all extremities equally. HOSPITAL COURSE BY SYSTEM: RESPIRATORY: He was initially placed on nasal cannula with oxygen for the first 2 days, and then was gradually weaned to room air after third day of life. He had mild apnea of prematurity with hs last event noted on [**2194-4-22**]. CARDIOVASCULAR: He did not require any cardiac intervention. He did develop an intermittent soft murmur heard best over axilla and back consistent with peripheral pulmonic stenosis (PPS). FEEDING: Initially, he was kept n.p.o. and given IV fluids starting at 60 mL/kg/D. He exhibited early hypoglycemia requiring three dextrose boluses and infusion of 12.5% dextrose in his maintenance IV fluids. On the second day of life he was started gradually with p.o. feedings. Currently he is taking Similac 24 po ad lib. His discharge weight is 3225 grams, length 45-cm, and head circumference is 32-cm. GI: He has a soft, nondistended abdomen with a tiny umbilical hernia. His maximum bilirubin was 10.6/0.4 on day of life 3. He did not require any phototherapy. HEMATOLOGY: The last hematocrit which was done was on the 19 day of life, was 43.9. He did not require any blood transfusions. ID: He received ampicillin and gentamicin for 48 hours and after the a negative sepsis evaluation and blood culture, the antibiotics were stopped. NEUROLOGY: Head ulsrasound screening nor ophthalmology screening were indicated. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Patient is being discharged home with mother. PRIMARY CARE PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 51097**] [**Name (STitle) 12332**] of [**Hospital **] Pediatrics, (p) [**Telephone/Fax (1) 3581**] (f) [**Telephone/Fax (1) 61285**]. HEALTH CARE MAINTENANCE/ DISCHARGE INSTRUCTIONS: 1. Feeding: Similac 24 ad lib. 2. Medications: None. 3. Car seat position screening test passed. 4. State newborn screen sent [**4-23**] and [**5-4**] - no abnormal results have been reported. 5. The patient received hepatitis B vaccine on [**2194-5-20**]. 6. Circumcision was done on [**2194-5-21**]. 7. The following immunizations have been recommended: 1) Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: A) Born at less than 32 weeks, B) Born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school- aged siblings, or C) With chronic lung disease. 2) Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. 8. FOLLOW_UP [**Name2 (NI) **]NTMENTS: Pediatrician within 2 days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 33 weeks of gestation. 2. Infant of a diabetic mother. 3. Transitional respiratory distress. 4. Sepsis, ruled out. 5. Hypoglycemia. 6. Peripheral pulmonic stenosis. 7. Small umbilical hernia. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Name (STitle) 67908**] MEDQUIST36 D: [**2194-5-26**] 13:58:50 T: [**2194-5-26**] 14:37:09 Job#: [**Job Number 67909**]

Admission Date: [**2147-4-25**] Discharge Date: [**2147-5-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: guaiac positive stool Major Surgical or Invasive Procedure: colonoscopy EGD with cauterization of AVM capsule endoscopy History of Present Illness: 88M with CAD, atrial fibrillation on coumadin, CHF with EF of 35% (end-stage per prior notes), s/p placement of VVI pacer who presents after PCP found him to be guaiac positive on DRE. Patient has not noted bleeding himself, although he has previously noted some small red spots on the toilet paper. He has not seen streaks of blood in his stool of blood in the toilet. He also denies melanotic stool. He denies previous issues with GI bleeding (although previous discharge summaries document this history). His last full colonoscopy was in [**2141**] where he was found to have a rectal polyp (adenoma) which was removed. He denies recent history of worsening fatigue (patient reports chronic fatigue), lightheadedness, tachycardia. Of note he was recently discharged from [**Hospital1 18**] after a fall. Past Medical History: 1. Coronary artery disease, status post coronary artery bypass graft in [**2136**] 4 VD. 2. Congestive heart failure with an ejection fraction of 35% with diastolic and systolic dysfunction. ([**5-17**] ECHO) 3. Hyperlipidemia. 4. Paroxysmal atrial fibrillation, on Coumadin. 5. Status post appendectomy. 6. History of lower gastrointestinal bleed. 7. Glucose intolerance. 8. Right carotid stenosis of 60% to 69%. 9. History of Escherichia coli urosepsis. 10. History of low blood pressure 11. melanoma removed from arm 12. basal cell ca. 13. gout 14. hypothyroidism 15. VVI Pacemaker Placed [**8-17**] Social History: Single. He lives with his sister who is in her 90's. He and his sister have services at home and receive help from other relatives. [**Name (NI) 1094**] HCP is his [**First Name9 (NamePattern2) 21457**] [**Name (NI) **]. [**Name2 (NI) **] uses a walker to get around. He does not drive. He denies any tobacco history. Rare glass of wine. Family History: Positive for coronary artery disease and breast cancer. Physical Exam: 98.6 102/62 68 22 99%RA Gen: well-appearing elderly male, NAD HEENT: mucous membranes moist Chest: bibasilar crackles CV: RRR nl s1 and s2 no murmurs Abd: BS+ nontender nondistended Extrem: 1+ pedal edema to mid-shin. left shin with healing ulcer anteriorly Neuro: A+Ox3 Pertinent Results: [**2147-4-25**] 03:10PM BLOOD WBC-7.3 RBC-3.97* Hgb-11.2* Hct-34.1* MCV-86 MCH-28.3 MCHC-32.9 RDW-17.6* Plt Ct-184 [**2147-4-25**] 03:10PM BLOOD Neuts-67.9 Lymphs-22.7 Monos-5.9 Eos-3.0 Baso-0.5 [**2147-4-25**] 03:10PM BLOOD PT-29.4* PTT-34.7 INR(PT)-3.0* [**2147-4-25**] 03:10PM BLOOD Glucose-113* UreaN-40* Creat-1.3* Na-136 K-4.9 Cl-99 HCO3-25 AnGap-17 [**2147-4-25**] 03:19PM BLOOD Hgb-11.8* calcHCT-35 Brief Hospital Course: Hospital Course: 88 yo M with CAD, AF on coumadin, CHF, presenting with guaiac-positive stool, treated for GI bleed, with 2 MICU admission for hypotension, now stable. . # GI bleed: After reversal of her INR with vitamin K the patient underwent EGD, colonoscopy and capsule study. EGD showed an AVM which was cauterized. The colonoscopy showed polyps which were not removed. Capsule study showed nonbleeding red spots. The decision was made for the patient not to restart anticoagulation. He should have repeat colonoscopy and enteroscopy as an out-patient. The patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] will help arrange for this. . #AFib: The patient was continued on digoxin. Metoprolol was held during episodes of hypotesion but was restarted and tolerated well. Anti-coagulation was defered to the out-patient setting. . #chronic systolic CHF: Initially the patient was slightly volume overloaded (with crackles and pedal edema on exam). While NPO the patient was diuresed and exam was euvolemic. As his creatinine was then elevated, diuretics then stopped prior to colonoscopy. After colonoscopy patient became septic so patient was given fluids and became further volume overloaded. On transfer to ICU, bumetanide, spironolactone, metoprolol, lisinopril held. Digoxin was continued. On discharge the patient was breathing comfotably and satting well on room air. . #Septic Shock: After colonoscopy/EGD/capsule study the patient was febrile and hypotensive. This prompted an ICU transfer. Blood cultures grew MRSA in [**4-14**] bottles in 12hrs. The source felt to possibly be left lower extremity ulcer and/or right wrist abscess. A TTE did not show valvular lesions to suggest endocarditis. The patient was discharged to the floor without the need for pressors in the ICU. The patient again had an episode of low-grade hypotension prompting an ICU transfer. However, the patient remained stable off pressors and was transfered back to the floor. The patient was restarted on his metoprolol and continued on his ACE-inhibitor without further episodes of hypotension. The patient is to be continued on a 14 day course of vancomycin (day 1=[**4-29**]) for the bacteremia. . #CAD: The patient was continued on his statin. His aspirin was held given the GI bleed. Re-addition of aspirin was deferred to the out-patient setting. The patient's beta-blocker and ACE were added back as his pressure tolerated, as above. . # Aspiration pneumonia: On the patient's second transfer to the ICU as above an chest X-ray demonstrated a possible right sided infiltrate. There was some question of aspiration at the time. The patient was started on a ten day course of levofloxacin/flagyl (day 1=[**5-4**]). . # rash: The patient was seen by derm and diagnosed with likely miliaria rubra. He was started on a one week course of triamcinolone. He was also found to have several actinic keratoses on skin exam and was recommended to follow-up with dermatology as an out-patient. . # BPH: The patient's flomax was held in the setting of hypotension. Re-starting of the medication will be deferred to the out-patient setting. . #Depression: The patient was continued on his home celexa. . #Hypothyroidism: The patient was continued on levothyroxine. . #Code: Full code, discussed with patient and family Medications on Admission: per recent d/c summary: atorvastatin 40mg daily flomax 0.4mg citalopram combivent inhaler 1-2 puffs q6:prn asa 81mg allopurinol 50mg daily bumetanide 2mg [**Hospital1 **] lisinopril 2.5mg daily digoxin 0.125mg daily aldactone 25mg daily levothyroxine 25mcg daily warfarin 5mg daily metoprolol SR 25mg daily Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 13. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 1 weeks: Start date [**2147-5-4**]. End date [**2147-5-10**]. 14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 2 weeks: Start date: [**2147-4-29**] End date: [**2147-5-12**]. 17. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 10 days: Start date: [**2147-5-4**] End date: [**2147-5-13**]. 18. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 10 days: Start date: [**2147-5-4**] End date: [**2147-5-13**]. 19. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING SCALE units Injection ASDIR (AS DIRECTED): PER SLIDING SCALE. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: MRSA bacteremia suspected pneumonia gastrointestinal bleed acute renal failure Congestive Heart Failure--Systolic and Diastolic dysfunction Discharge Condition: Stable. The patient is asymptomatic and his vitals are stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Take all medications as prescribed. Follow-up with your appointments as below. Call your doctor or return to the emergency room if you experience: --chest pain --shortness of breath --fever or chills --nausea or vomiting --abdominal pain --any other symptom that concerns you Followup Instructions: You should follow-up with the appointments below: . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Phone:[**Telephone/Fax (1) 142**] Date/Time:[**2147-5-9**] 9:30 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2147-5-29**] 3:00 . Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2147-6-6**] 8:30 . You were noted to have several actinic keratoses and a lesion concerning for NMSC along the right wrist. These lesions will need to be followed up as an outpatient. You should follow up with Dr. [**Last Name (STitle) **] in dermatology. His phone number is [**Telephone/Fax (1) 3965**]. Your caregivers at [**Hospital 100**] Rehab can help you set up an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

Admission Date: [**2164-1-23**] Discharge Date: [**2164-2-20**] Date of Birth: [**2102-3-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: multiple bronchoscopies [**1-30**]: CT guided lung biopsy [**1-31**]: Chest tube (left) placed; removed [**2-10**] [**2-7**]: started chemoradiation (stopped [**2-13**]) after d/w family [**2-8**]: PEG placement, Trach placement, VATS, pleurodesis History of Present Illness: 61 M Cantonese-speaking only, former smoker who quit 10 yrs ago, admitted on Mon to [**Location **] service for workup of L lung mass which is likely malignant, here with dysphagia x 2 months, hemoptysis x 2 months, weight loss of [**5-10**] lbs, reduced PO intake, became acutely SOB today at 2 pm. He was doing very well yesterday, was not SOB at all, RR 14, was very comfortable. He has been in isolation getting r/o for TB (due to hemoptysis), and bronch was planned for tomorrow PM. Throughout today, he developed worsening SOB, with O2 sats ranging from 95-98% RA at 2 pm, 92% RA at 5 pm, 87% 2L nc at 9 pm, 85% 100% FM at 11 pm. . He became severely SOB, with no rales, no wheezing, first ABG 7.35/60/68, O2 sat 95-98% RA. ENT was consulted for SOB, and found normal vocal cords, normal posterior pharynx, no lesions on vocal cords, +mediastinal lymph nodes. CXR shows no cardiomegaly, no pleural effusions, no infiltrate. Earlier today, patient was sitting straight up on the side of bed drooling, with severe SOB, RR 30. EKG showed mild STD in lateral leads, no previous for comparison. Patient failed bedside video swallow study. . Patient has one AFB negative, one AFB pend. Bronch was planned by IP for tomorrow after r/o TB. Past Medical History: stomach ulcer- ?of partial gastrectomy (30 years ago) . Social History: Previous smoker, quit 10 yrs ago. Lives with son at home, worked as a dishwasher in restaurant. Family History: noncontributory Physical Exam: VS: 95.5 / 154/81 / 30 / 87% 5L nc GEN: Cachectic, too SOB to speak, akathisic, fatigued HEENT: JVD flat, no LAD, OP clear, anicteric sclerae LUNGS: CTA B HEART: RRR, no m/r/g ABD: Soft, thin, +BS, ND NT EXTR: No c/c/e NEURO: No exam performed SKIN: No rash Pertinent Results: Admission labs: 136 99 14 -------------< 99 4.9 28 0.8 . 14.5 7.3 >---< 551 42 N:79.6 L:15.4 M:2.9 E:1.5 Bas:0.5 . Trends: Discharge CBC: [**2164-2-16**] 04:33AM BLOOD WBC-15.2* RBC-3.37* Hgb-10.1* Hct-29.7* MCV-88 MCH-29.9 MCHC-33.9 RDW-14.5 Plt Ct-386 Discharge coags: [**2164-2-15**] 05:56AM BLOOD PT-12.2 PTT-40.9* INR(PT)-1.1 Discharge Chem panel: [**2164-2-17**] 02:50AM BLOOD Glucose-127* UreaN-32* Creat-0.6 Na-142 K-3.6 Cl-103 HCO3-36* AnGap-7* [**2164-2-17**] 02:50AM BLOOD ALT-27 AST-30 LD(LDH)-207 AlkPhos-76 Amylase-92 TotBili-0.2 . CE: [**2164-1-25**] 03:45PM BLOOD CK-MB-5 cTropnT-<0.01 [**2164-1-26**] 12:25AM BLOOD CK-MB-11* MB Indx-4.4 cTropnT-0.9* [**2164-1-26**] 06:13AM BLOOD CK-MB-10 MB Indx-5.5 cTropnT-0.23* [**2164-1-28**] 09:54AM BLOOD CK-MB-3 cTropnT-0.09* [**2164-1-31**] 02:43AM BLOOD CK-MB-2 cTropnT-0.01 . [**2164-1-29**] 05:27AM BLOOD calTIBC-170* VitB12-449 Folate-9.8 Ferritn-55 TRF-131* [**2164-1-25**] 03:32PM BLOOD Lactate-1.3 [**2164-2-4**] 03:34PM BLOOD Lactate-0.8 . Micro: Multiple blood, sputum, urine, and BAL cultures negative. BAL from [**1-25**]: RESPIRATORY CULTURE (Final [**2164-2-2**]): >100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. BETA STREPTOCOCCI, NOT GROUP A. 10,000-100,000 ORGANISMS/ML.. SENSITIVITY PER DR [**First Name (STitle) **] #[**Numeric Identifier 70374**]. UNABLE TO ISOLATE FOR FURTHER WORK UP. Thought to be contaminant. . Cytology: Pleural fluid negative x3 for malignancy CT guided bx positive for adenoca of lung . Imaging: [**1-24**]: CT Abd: 1. Focal liver lesions with peripheral enhancement, most likely representing hemangiomas. 2. 2 cm left adrenal nodule with enhancement, worrisome for metastasis in this patient with lung mass. PET CT may help for further staging. 3. Small free fluid in the lower pelvis. . [**1-23**]: CT chest: Chest CT [**2164-1-23**]: (1) Mass or mass-like consolidation in two segments of the left upper lobe. (2) Small left adrenal mass. Extensive heterogeneity in liver texture. (3) Esophageal distention, probably functional. . [**1-26**]: ECHO: 1.The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mid septal hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. . CXR upon admission: 1. New left upper lobe consolidation occupying predominantly the upper portion of the lobe in addition to known left upper lobe/lingular consolidation/mass. These finding may represent massive aspiration or hemorrhage 2. New retrocardiac left lower lobe atelectasis. . CXR upon discharge: Tracheostomy tube and G-tube seen in relatively stable position. Cardiac and mediastinal contours appear stable. There is improved aeration of the left lung with persistent atelectasis and consolidation with air bronchograms noted. Left-sided PICC seen with the tip in the region of the cavoatrial junction. IMPRESSION: Improved aeration in the left lung with persistent atelectasis and consolidation Brief Hospital Course: 61 yo former smoker admitted for workup of L lung mass after presenting w/ c/o dysphagia, hemoptysis, and weight loss x 2 months, admitted to the ICU for acute SOB. Hospital course by problem: . # Hypoxemic respiratory failure: Likely [**2-3**] mucus plugging of L upper lung field complicated by ? postobstructive pneumonia. Bronchoscopy was performed x4 each time with evidence of mucus plugging and thick secretions. Sputum cultures did not, however, yield growth in order to guide antibiotic coverage. He was continued on zosyn and vancomycin x14 days then switched to meropenem for 1 week to treat possible ESBLs. Following his 4th bronchoscopy, he was tolerating trials of PS. Thereafter, we placed a trach on [**2-8**] which he tolerated well. We aggressively diuresed. On [**2-16**] he did very well on a trach collar and remained off the vent for >24 consecutive hours. We recommend continued lasix 40mg PO daily for approx 1-2 weeks as he was quite volume overloaded during this admission. . # Adenoca of the lung: CT guided biopsy showed adenoca of the lung. He had a negative head CT for mets but did have an adrenal met noted on abdominal CT scan. He had pleural fluid neg x3 for malignancy. We were unable to accurately stage him without a PET scan. Given his poor respiratory status and extensive disease burden, the heme/onc service did not feel that he would benefit from surgical resection or high dose chemo. We did however treat him for a 5 day course of chemoradiation to help decrease the size of the mass in an attempt to assist with weaning off the vent. This may have helped as he was subsequently off the vent several days after therapy. The family and patient are no longer interested in treating this malignancy. . # Cards Vasc: In the setting of hypoxia and hemoptysis, the patient had a troponin peak to 0.9. His CKs were negative. An echo showed some mid-septal hypokinesis. It was thought that this was a demand ischemic event and there were no further issues during his hospitalization. .. # Left pneumothorax: Patient had a PTX s/p CT guided biopsy. He had a chest tube placed on the left. It remained in place for approx one week. Thereafter the PTX resolved. He did undergo VATS with pleurodesis on [**2-8**] given his signifant pleural effusion. . # A fib: on [**2-10**], went into afib with rvr to 160s. BP stable. - lopressor 37.5 tid achieved good rate control . # HTN- Consistently elevated BP, especially when he becomes agitated. -continue lopressor 37.5 tid, -lorazepam 0.5 prn . # Hemodynamic instability: Originally he was hypotensive. This appeared to be combination of sedation for intubation and hypovolemia. He did, however, remain largely levophed dependent. His BP would rise to >170s systolic with agitation. However, for at least 10 days prior to discharge, his blood pressure was well controlled on metoprolol 37.5 tid. . # FEN: A peg was placed on [**2-8**]. Tube feeds were started. He tolerated these well. . # Anxiety: ambien and/or ativan prn . # Code: DNR per discussion with family. final discussion revealed that patient is DNR but would be hooked up to ventilator if in respiratory distress. . # Communication: Son = [**Name (NI) **] [**Name (NI) 3443**]: speaks English. [**Telephone/Fax (1) 70375**] Medications on Admission: unknown, ? antihypertensives Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1) Injection TID (3 times a day). 2. Albuterol 90 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: 6-8 Puffs Inhalation Q4H (every 4 hours). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: 6-8 Puffs Inhalation Q4H (every 4 hours). 4. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Chlorhexidine Gluconate 0.12 % Mouthwash [**Telephone/Fax (1) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 8. Zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO TID (3 times a day). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): we recommend continuing this for another 5-7 days to correct his positive fluid balance. 12. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO HS (at bedtime). 13. Morphine 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) mg Injection Q4H (every 4 hours) as needed. 14. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) treatment Inhalation Q4H (every 4 hours) as needed. treatment 15. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) treatment Inhalation Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: - Adenocarcinoma of the lung - hypoxic respiratory failure - postobstructive pneumonia - atrial fibrilation - hypertension - left pneumothorax (now resolved) - prolonged intubation requiring trach placement - s/p VATS, pleurodesis - s/p PEG placement Discharge Condition: fair, breathing on trach collar. Discharge Instructions: You were admitted with shortness of breath and coughing up blood. You had a mass in your lung which is consistent with adenocarcinoma of the lung. We treated you for a prolonged course on the ventilator and ultimately you were extubated and did well with a trach. You briefly received chemotherapy and radiation. However, given the severity of your disease, we did not continue these measures. . Please contact your PCP with any questions. Please take your medications as instructed. Followup Instructions: please followup with your PCP within the next month

Admission Date: [**2133-3-4**] Discharge Date: [**2133-3-12**] Date of Birth: [**2055-2-8**] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 297**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: NGT placement, PICC line placement. s/p intubation History of Present Illness: 78 y.o. female with h/o CHF EF = 15-20%, active tobacco use, 0.5-1.5 ppd who presents with acute onset of shortness of breath and black stool one day prior to admission. She was in her general state of chronic health, sleeping on 3 pillows and sob with walking short distances until the night prior to admission when she experienced bilateral lower quadrant cramping and then had a moderate amount of black stool. She then awoke later with shortness of breath. She denies cp, diphoresis, nausea or vomiting, or palpitations. Denies NSAID use. She called her PCP's office who checked labs and then advised her to go to the [**Hospital1 18**] emergency room. In the ED an NGT was placed which did not clear after 500 cc. It was on intermittent suction until d/c'ed at the rest of GI. She was given 150 cc NS. . On review of systems, the pt. denied recent fever or chills. Reported a 3 pound wt loss. No change in chronic cough productive of white sputum. Increased lower extremity swelling. C/o chronic aches and pains including back pain. . In MICU pt received FFP to reverse INR until bleeding resolved. Received 4 units PRBC with HCT 20-->31. Past Medical History: 1. anemia with hx GI bleed, baseline Hct 30-35, Hct 35 last week - last EGD [**2131-1-29**] with 1 cm angioectasia cauterized, no major GIB since - last C-scope [**8-18**] with diverticulosis, int hemorrhoids 2. type II DM 3. CHF ef 15-20%, last echo [**8-19**] with severely depressed EF 15-20%, severe global LV HK, mod 2+MR 4. MVR -St. [**Male First Name (un) 1525**] mechanical valve placed [**2122**] secondary to rheumatic heart dz, on coumadin 5. hyperparathyroid 6. h/o PUD 7. HTN 8. hx NSVT 9. afib s/p cardioversion [**2130**], on amiodarone 10. hx TIA 11. high cholesterol Social History: Widowed [**2110**], independent in all her ADLs and IADLs. Lives alone in [**Location (un) **] Corner. Children live in the area. no EtOH and +tob (1 ppd x 60 yrs, still smoking),no IVDA. Family History: non-contributory Physical Exam: VS T 97.2, P 82 BP 86/44 RR 22 O2Sat 96% GENERAL: Elderly female sitting upright in chair, able to speak in full sentence. HEENT: NC/AT, PERRL, no scleral icterus noted, dry MMM, no lesions noted in OP Neck: supple, JVD elevated to the mandible Pulmonary: Lungs with difuse wheeze and rhonchi. Cardiac:irreg, irreg, no murmur appreciated. Abdomen: soft, NT/ND, normoactive bowel sounds, mild diffuse tenderness, RECTAL: black stool on guiac in ED Extremities: 2+ pitting edema to the shin with 1+ DPP bilaterally Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. Pertinent Results: [**2133-3-4**] 10:51PM HCT-20.4* [**2133-3-4**] 06:58PM HGB-6.5* calcHCT-20 [**2133-3-4**] 06:47PM HGB-7.1* calcHCT-21 [**2133-3-4**] 06:30PM GLUCOSE-61* UREA N-117* CREAT-4.0*# SODIUM-136 POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-23 ANION GAP-25* [**2133-3-4**] 06:30PM ALT(SGPT)-7 AST(SGOT)-19 LD(LDH)-186 CK(CPK)-66 ALK PHOS-32* AMYLASE-92 TOT BILI-0.2 [**2133-3-4**] 06:30PM LIPASE-47 [**2133-3-4**] 06:30PM CK-MB-NotDone cTropnT-0.07* [**2133-3-4**] 06:30PM ALBUMIN-3.8 [**2133-3-4**] 06:30PM WBC-6.4 RBC-2.19*# HGB-6.9*# HCT-20.3*# MCV-93 MCH-31.4 MCHC-33.9 RDW-15.6* [**2133-3-4**] 06:30PM PLT COUNT-155 [**2133-3-4**] 06:30PM PT-47.6* PTT-44.0* INR(PT)-5.6* . ON TRANSFER: [**2133-3-7**] 04:00AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.1* Hct-29.7* MCV-89 MCH-30.2 MCHC-34.1 RDW-16.5* Plt Ct-UNABLE TO [**2133-3-7**] 06:00AM BLOOD Plt Ct-102* [**2133-3-7**] 04:00AM BLOOD Glucose-100 UreaN-107* Creat-3.2* Na-144 K-3.8 Cl-102 HCO3-25 AnGap-21* [**2133-3-7**] 04:00AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.5 . SPEP: negative UPEP: negative . EKG ([**2133-3-7**]): Atrial fibrillation @ 108. Intraventricular conduction delay with left axis deviation which is probably atypical left bundle-branch block. ST-T wave abnormalities may be secondary to intraventricular conduction delay . Imaging: CXR ([**2133-3-4**]): 1. Stable mild congestive heart failure. 2. Possible left small pleural effusion versus pleural thickening. . Renal ultrasound ([**2133-3-5**]): 1. No evidence of hydronephrosis. Slightly echogenic kidneys consistent with chronic parenchymal disease. 2. Small amount of ascites. . Echocardiogram ([**2133-3-5**]): 1. The left atrium is moderately dilated. The right atrium is moderately dilated. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. 4. The aortic valve leaflets are mildly thickened. 5. A bileaflet mitral valve prosthesis is present. Moderate [2+] tricuspid regurgitation is seen. 6. There is mild pulmonary artery systolic hypertension. 7. Compared with the findings of the prior study (images reviewed) of [**2132-9-1**], there has been no significant change. . CT head ([**2133-3-6**]): 1. Curvilinear hyperdensity bilaterally in temporal horns of the ventricle, somewhat more prominent on the left, probably representing calcified and prominent choroid, given the absence of other abnormal density in the ventricle. In this patient with anticoagulation, if the symptom persists or worsens, please consider short-term followup by CT scan or MRI. 2. Sinusitis. . CXR: [**2133-3-7**]: IMPRESSION: Worsening patchy opacities at the lung bases, most likely representing worsening atelectasis. Pneumonia cannot be fully excluded . KUB ([**2133-3-7**]): The air is identified throughout the small bowel and colon probably indicating mild ileus. The pelvis is not completely included in the radiograph. If clinically indicated, please evaluate with repeated supine and erect AP radiographs of the abdomen. . The patient has prior MVR and median sternotomy. Temporary pacer wire is identified. . CXR ([**2133-3-10**]): Tip of the right PIC catheter projects over the right brachiocephalic vein at the level of the upper margin of the manubrium. ET tube in standard placement. Nasogastric tube passes below the diaphragm and out of view. Moderate cardiomegaly stable. Pulmonary vascular engorgement is mild but there is no pulmonary edema or appreciable pleural effusion. Patient has had median sternotomy and mitral valve replacement. . Brief Hospital Course: # GIB: 78 y.o. female with h/o gastric angioetasia, CHF with EF = 15-20%, s/p MVR on coumadin p/w maroon red OGT output and black stool with 10 point HCT drop and shortness of breath in the setting of a supra-therapeutic INR. Pt was given FFP to reverse coagulopathy. Initially given 4 units of blood with increase in hct from 20 to 30. Most likely felt to be UGIB, with initial ddx including AVM, ulcer, malignancy, gastritis. Pt was intermittently hypotensive initially, so GI held off on EGD given hypotension and risk of further BP drop with sedation. Pt was then intubated for respiratory distress (see below). EGD was performed on [**2133-3-9**] which showed gastric ulcer with evidence of recent bleeding, clean based pyloric ulcer, and petechiae and erosions in esophagus and stomach secondary to NG trauma. Most likely source of bleeding is gastric ulcer. [**Hospital1 **] hct checks were continued and pt was given an additional 2 units of blood for slight drops in hct. Pt didn't have any further episodes of bloody stool. Pt was initially maintained on IV bid protonix, which was switched to po BID protonix after resolution of GIB. Pt needs a repeat EGD in [**4-23**] weeks to document resolution of gastric ulcer and for possible biopsy. . # DYSPNEA: On HD5 ([**3-8**]), pt was intubated secondary to respiratory failure. Respiratory failure was felt to be likely multifactorial [**12-18**] to COPD exacerbation and CHF. Sputum cx grew Pseudomonas, but there was no evidence of pna on CXR. Pt was treated for COPD with around the clock nebulizer treatments. She received intermittent IV lasix for clinical evidence of volume overload. Pt was successfully extubated on [**3-10**]. Pt was started on IV solumedrol on [**3-11**] for wheezing and dyspnea. Pt will need to transition to po steroid with a taper. . # HYPOTENSION: Pt was hypotensive on admission to MICU. Hypotension was thought to be secondary to hypovolemia and underlying severe CHF. Pt has a low BP at baseline. Pt was afebrile without leukocytosis thus sepsis unlikely. She initially responded to IVF and PRBC. However, she transiently required pressors. Pt was initially on Levophed, but was noted to have intermitten rapid AF (110-120s) and was switched to Neo which was titrated off. BP meds were held. Pt's BP subsequently stabilized. . # CHF - Pt has severe systolic dysfunction with EF <20% (confirmed by TTE this admission). Pt diuresed with intermittent IV lasix for CHF. Pt was started on digoxin for AF, which will help with inotropy. . # A FIB: Pt has known afib. She is s/p DCCV at last admission. Beta-blocker was held secondary to hypotension. Amiodarone was held on admission, then restarted. Pt was started on digoxin in the setting of rapid HR in 110-120s. Coumadin was initially held. Pt was on heparin bridge. . # MVR: coumadin was initially held. Pt was maintained on heparin gtt for goal PTT 60-80. Coumadin was restarted prior to discharge: goal INR is 2.5-3.5. . # ARF: Pt's baseline cr is 1.4. Creatinine on admission was 3.9, and decreased/stabilized at 2.5. The etiology of ARF is likely ATN due to pre-renal state [**12-18**] GIB. FeNa=8.3% and FeBUN=37%, c/w ATN. Renal U/S was negative for hydro. U eos negative. Pt continued to have good UOP. . # HTN: Antihypertensives were held . # DM:Continued on RISS . # Hypercholesteremia - Gembibrozil held during admission . # UTI: Pt was found to have +UA on admission. Urine cx grew pan sensitive proteus Pt was treated with cipro for 5/7 days. . # Headache: Likely tension/migraine. Head CT [**3-6**] with likely calcified choroid plexus on the left and sinusitis. given tylenol prn. . # Pain: Pt c/o mild diffuse pain, requiring prn IV morphine. Pt was started on fentanyl 25mcg qd. . # CODE status: Per discussion with pt's HCP, pt was made DNR/DNI. Medications on Admission: On Admission: 1. Carvedilol 3.125 mg PO BID 2. Gemfibrozil 600 mg PO BID 3. Ferrous Sulfate 325mg PO DAILY 4. Amiodarone 200 mg PO QAM 5. MagOx 400 mg PO twice a day. 6. Albuterol 90 mcg: 1-2 Puffs Inhalation Q4-6H 7. Ipratropium Bromide 18 mcg Two (2) QID. 8. Lasix 20 mg PO QOD. 9. Vitamin D 400 IU 10. Calcium Vit D [**Hospital1 **] Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Transdermal Q72H (every 72 hours). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 18. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): please continue heparin bridge until INR is 2.5-3.5. 19. Methylprednisolone Sodium Succ 40 mg Recon Soln Sig: Two (2) Recon Soln Injection Q8H (every 8 hours): 80mg tid. 20. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 2 days. 21. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 22. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnoses: GIB Respiratory failure (requring intubation) CHF COPD Hypotension ARF ([**12-18**] ATN) UTI . Secondary diagnoses: AF s/p MVR HTN DM hyperlipidemia Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Call your doctor or return to the ED if you develop fevers, chills, chest pain, difficulty breathing, lightheadedness, bloody stools, or any other concerningn symptoms. Followup Instructions: Follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of discharge. [**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 2936**] Follow up with Dr. [**First Name (STitle) 450**] [**Doctor Last Name **] for repeat EGD in [**4-23**] weeks. Call ([**Telephone/Fax (1) 21742**] to schedule an appointment.

Admission Date: [**2193-3-13**] Discharge Date: [**2193-3-28**] Date of Birth: [**2140-11-17**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: INR 7 Major Surgical or Invasive Procedure: OLT History of Present Illness: Patient is a 52 yo spanish-speaking F with PBC and auto-immune cirrhosis on the [**First Name3 (LF) **] list who was called to the ED after routine labs showed INR of 5.3. She was recently admitted with back pain and found to have a T12/L1 acute burst compression fracture for which she is being treated with a TLSO brace for 3 months. Her INR on discharge was 2.8. There was some question of BRBPR or bleeding in the mouth, but the patient denied this on interview with an interpretor. She is known to have mucosal bleeding from her GI tract with stools positive for occult blood and she was going to have outpatient endoscopy as part of her discharge. No other signs of infection. Past Medical History: Cirrhosis [**1-1**] Primary biliary cirrhosis and autoimmune hepatitis complicated by: Esophageal bleed, varices- 2 cords grade 2 varices [**6-7**] Massive splenomegaly hepatic artery to portal venous fistula within segment VIII of the liver H/o benign breast biopsy [**2-4**] Osteoporosis Pancytopenia- thought secondary to hypersplenism Social History: Pt states she lives with her parents, sister, brother-in-law and nephew. They also have a couple of boarders in their home. She states she does all of her own medications without assistance. Sister is [**Name (NI) 3508**] [**Name (NI) 61035**] [**Name (NI) 61036**]. Tobacco hx - quit 6 yrs ago (prior was smoking 1 ppw) EtOH - has not had drink in 6 years Denies recreational or IVDU. Family History: Denies history of liver disease in her family. Reports that her mother is alive and has HTN. Denies DM, heart disease, cancer in family. Physical Exam: VS - Temp 98.7F, BP 139/70 , HR 106 , R 18, O2-sat 100 % RA GENERAL - chronically ill-appearing very pleasant woman in NAD HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear NECK - supple, no thyromegaly, JVP 10 cm H2O LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, III/VI SM throughout ABDOMEN - NABS, soft/NT/distended but not tense, palpable spleen, liver not palpable, bruit vs tranduced murmur heard throughout EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - jaundiced, scattered spider angiomata NEURO: grossly intact. LE strength and sensation intact. No asterixis. Pertinent Results: ADMISSION: [**2193-3-13**] WBC-2.6* RBC-3.25* Hgb-9.8* Hct-31.0* MCV-96 MCH-30.2 MCHC-31.6 RDW-18.8* Plt Ct-55* Neuts-71.7* Lymphs-15.2* Monos-10.8 Eos-2.2 Baso-0.1 PT-64.2* PTT-46.7* INR(PT)-7.4* Glucose-111* UreaN-6 Creat-0.5 Na-132* K-3.6 Cl-100 HCO3-28 AnGap-8 ALT-80* AST-147* AlkPhos-279* TotBili-14.0* Albumin-2.4* D-Dimer-3012* Fibrino-205 [**2193-3-13**] 11:02PM URINE Color-DKAMB Appear-Clear Sp [**Last Name (un) **]-1.015 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-LG Urobiln-2* pH-7.0 Leuks-NEG Creat-67 Na-83 US [**3-13**]: IMPRESSION: 1. Morphology of the liver is consistent with cirrhosis. Of note, there is partial clot within the main and right portal veins, with flow, therefore this is non-occlusive. This does, however had the appearance of recanalization. Additionally, there is no flow within the posterior branch of the right portalvein which is completely occluded with echogenic clot. The flow within the main portal vein, left portal vein and anterior branch of the right portalvein is hepatopetal. 2. Trace ascites, varices and splenomegaly, findings consistent with portal hypertension. 3. Hypodense lesion within the periphery of the spleen may represent an infarct, especially in the setting of clot within the portal venous system. However, other diagnostic considerations include a focal hematoma in the appropriate clinical setting of trauma. Of note, there is no flow within thesplenic lesion. Brief Hospital Course: Ms. [**Known lastname **] is a 52 yo woman with cirrhosis secondary to PBC and autoimmune hepatitis who presented from home after routine labs showed INR of 5.3. INR was 7.0 on admission. It did decrease some with IV vitamin K. During her admission, a liver donor became available and she accepted the donor liver offer. On [**2193-3-15**], she underwent liver [**Date Range **] with aortic conduit. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Induction immunosuppression was given (solumedrol and cellept). Please refer to operative notes for further details. She was sent to the SICU immediately postop for care. LFTs increased immediately postop, but trended down each day. A liver duplex demonstrated patent vessels. Medial and lateral JPs were non-bilious. She was extubated o [**3-16**] and transferred out of the SICU after 3 days on [**3-17**]. Diet was slowly advanced and she was able to take in 1600 kcals/58 grams protein. She was assisted to get oob to ambulate wearing her TLSO brace for known thoracic and lumbar compression fractures. The medial JP was removed on [**3-20**] with a daily output of 130cc. The lateral JP output remained high (1500 cc) and serum sodium was low (down to 126)requiring IV saline fluid replacements and albumin. This continued for several more days. Serum sodium normalized and JP output decreased to 500cc/day by postop day 12 ([**3-27**]). At this point, the lateral jp was removed and site sutured. This site as well as the incision remained dry. She did well with medication teaching and insulin sliding scale injection (due to hyperglycemia from steroids). An interpreter was present for these sessions. Immunosuppression consisted of cellcept 1gram [**Hospital1 **] that was well tolerated. Steroids were tapered to 20mg daily and prograf was adjusted by trough levels. Discharge dose was 3mg [**Hospital1 **]. She was discharged with low dose lasix daily for 2 + lower leg edema to knees. VNA services were arranged for nursing, PT and evaluation of home health services. Medications on Admission: Furosemide 40 mg PO DAILY Spironolactone 150 mg PO DAILY Alendronate 70 mg PO once a week. Nadolol 20 mg PO DAILY Rifampin 150 mg PO Q24H Ursodiol 300 mg PO TID Calcium Carbonate 500 mg PO TID Metoclopramide 5 mg PO three times a day. Lactulose (30) ML PO TID Omeprazole 40 mg PO once a day Magnesium Oxide 400 mg PO BID Clotrimazole 10 mg 5X/DAY Hydroxyzine HCl 10 mg PO Q6H as needed for itching. Lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY Camphor-Menthol 0.5-0.5 % Lotion QID (4 times a day) as needed for itching. Ferrous Sulfate 300 mg PO DAILY Tramadol 50 mg PO BID Ergocalciferol (Vitamin D2) 50,000 unit PO 1X/WEEK (MO) for 8 weeks. Zofran 4 mg PO three times a day as needed for nausea. Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): see printed dose taper schedule. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to back. remove after 12 hours. Disp:*10 Adhesive Patch, Medicated(s)* Refills:*1* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for incision pain. Disp:*30 Tablet(s)* Refills:*0* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: may purchase over the counter. 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 13. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 14. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous ASDIR (AS DIRECTED). Disp:*1 bottle* Refills:*0* 15. FreeStyle Lancets Misc Sig: One (1) Miscellaneous four times a day: check blood sugar prior to meals and bedtime. Disp:*1 box* Refills:*1* 16. FreeStyle Lite Strips Strip Sig: One (1) In [**Last Name (un) 5153**] four times a day. Disp:*1 box* Refills:*1* 17. mutivitamin Sig: One (1) once a day. 18. Insulin Syringes supply low dose insulin syringes U-100 syringes 25 or 26 gauge needles supply 1 box refill: 1 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: primary billiary cirrhosis, vertebral compression fractures, osteoporosis, splenomegaly s/p liver [**Hospital **] hyperglycemia related to steroids hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane and TLSO brace). Discharge Instructions: Please call the [**Hospital 1326**] Office [**Telephone/Fax (1) 673**] if you experience any of the warning signs listed below. You will need to come to [**Hospital1 18**] for lab work twice a week on Mondays and Thursdays at [**Last Name (NamePattern1) 439**] [**Location (un) 453**] No heavy lifting/straining You may shower with assistance **Remember that the only time that you can take the brace off is when you are lying down in your bed. If your head is elevated on more than two pillows, the brace needs to be on. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2193-4-4**] 9:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] [**Name11 (NameIs) **] SOCIAL WORK Date/Time:[**2193-4-4**] 10:30 Completed by:[**2193-3-29**]

Admission Date: [**2181-12-10**] Discharge Date: [**2181-12-19**] Date of Birth: [**2114-3-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2024**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 1968**] is a 67 yo F with hx of stage IV pancreatic cancer with peritoneal carcinomatosis, mets to liver, and palliative abdominal port for drainage of malignant ascites, who presents with nausea and vomiting. This morning at 1AM, Pt's daughter, [**Name (NI) 7279**], called oncologist to state pt has been nauseated and having multiple episodes of bilious non-bloody vomiting throughout night. Daughter notes that she has been nauseated for several days now, since Thursday. Has not taken anything by mouth since then. No worsening abdominal pain, no fevers or chills. She has been more fatigued per her daughter and has not been getting out of bed much. She has had a recent bout with thrush and endorses some paroxyms of throat pain and occasional odynophagia but this is distinct from her newer sensation of nausea/vomiting. She has noticed a new rash recently on her legs and back, ever since using a lidocaine patch last week. This is occasionaly itchy but not painful. She did contact her oncologist who prescribed cephalexin for a possible cellulitis but she has not taken any of this. . Of note, pt had recent admission [**Date range (1) 93970**] for abdominal pain felt due to her worsening disease burden, and underwent palliative abdominal pleurex catheter placement on [**12-7**]. Has not used pleurex cath for ascites drainage yet, was shceudled to do so today. She has had an ongoing problem with severe constipation, being treated as an outpatient with magnesium citrate (last BM 2 days ago on Saturday). She has not had any further BMs or flatus since then. . In the ED, VS: 96.7 137/78 96 16 99% RA. Exam significant for mild lower abd pain b/l lower quadrants, no CVAT, 1+ bilat pitting edema. WBC returned elevated at 32 (95% neutrophils), with hyponatremia to Na 118 and non-hemolyzed K of 6.4. EKG with mild peaked T waves. She was given kayexalate, calcium, insulin, and D50. KUB was non specific without overt bowel obstruction. Abdominal CT scan showed large amount of ascites with catheter in place, pancreatic mass with liver mets, and new peritoneal infiltration, possible lymphatic involvement, with diffuse omental caking and infiltrated mesentery. Thrombosis of left portal vein also noted (stable). She was given Cipro/flagyl and started on NS 150 cc/hr via her port, and was admitted to the [**Hospital Unit Name 153**]. . Currently, she is feeling better but still has some nausea. She denies abdominal pain at the moment. . ONCOLOGIC HISTORY: - [**7-/2181**]: CT scan revealed a pancreatic and liver mass (in the setting of several years of ongoing/worsening abdominal pain) - [**2181-9-6**]: EGD with EUS-guided biopsy of pancreatic msas showed poorly-differentiated pancreatic adenocarcinoma - [**2181-9-19**]: Began palliative weekly gemcitabine (completed 3 cycles) - [**2181-11-10**]: CT scan showed progressive disease in pancreas and liver, as well as a lytic sternal lesion concerning for metastasis - [**2181-11-22**]: started on capecitabine/oxaliplatin due to progressive disease - [**11-16**] - decision made to hold further chemotherapy to maximize [**Hospital 93971**] hospice discussion initiated with palliative care Past Medical History: ONCOLOGIC HISTORY: - [**7-/2181**]: CT scan revealed a pancreatic and liver mass (in the setting of several years of ongoing/worsening abdominal pain) - [**2181-9-6**]: EGD with EUS-guided biopsy of pancreatic msas showed poorly-differentiated pancreatic adenocarcinoma - [**2181-9-19**]: Began palliative weekly gemcitabine (completed 3 cycles) - [**2181-11-10**]: CT scan showed progressive disease in pancreas and liver, as well as a lytic sternal lesion concerning for metastasis - [**2181-11-22**]: started on capecitabine/oxaliplatin due to progressive disease - [**11-16**] - decision made to hold further chemotherapy to maximize [**Hospital 93971**] hospice discussion initiated with palliative care OTHER PAST MEDICAL HISTORY: 1. Status post oophorectomy. 2. Prior blood clot in her fingers for which she was on aspirin. 3. Hypothyroidism. 4. Pulmonary emboli, diagnosed on [**2181-11-10**] for which she is on Lovenox. 5. Metastatic pancreatic cancer Social History: SOCIAL HISTORY: Retured administrative assistant; lives with husband; former smoker Family History: FAMILY HISTORY: Father died of cardiovascular disease; mother died of a stroke; no known history of malignancy Physical Exam: Physical Exam on Admission: VITAL SIGNS: T= 96.3 BP= 109/69 HR= 96 RR= 16 O2= 98% RA GENERAL: chroniciallt ill appearing, cachectic. NAD HEENT: Normocephalic, atraumatic. + conjunctival pallor. No scleral icterus. PERRLA/EOMI. MM quite dry. OP without evidence of thrush. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: slightly distended with pleurex catheter in place in LUQ. BS decreased throughout. + TTP in b/l lower quadrant, no perioneal signs. EXTREMITIES: 2+ peripheral edema, dopplerable dorsalis pedis b/l SKIN: mottled appearance to flanks and lower back with few discrete erythematous macules on anterior thighs. NEURO: A&Ox3. Appropriate. Limited exam grossly intact. Gait assessment deferred . Physical exam on discharge: expired Pertinent Results: Labs on Admission: [**2181-12-10**] 03:40AM BLOOD WBC-32.1*# RBC-4.31 Hgb-13.8 Hct-39.9 MCV-93 MCH-32.1* MCHC-34.6 RDW-18.1* Plt Ct-380 [**2181-12-10**] 03:40AM BLOOD Neuts-95.1* Lymphs-1.6* Monos-3.0 Eos-0 Baso-0.2 [**2181-12-10**] 03:40AM BLOOD Plt Ct-380 [**2181-12-10**] 03:40AM BLOOD PT-12.4 PTT-35.1* INR(PT)-1.0 [**2181-12-10**] 03:40AM BLOOD Glucose-98 UreaN-60* Creat-1.4* Na-114* K-7.6* Cl-83* HCO3-26 AnGap-13 [**2181-12-10**] 03:40AM BLOOD ALT-23 AST-39 AlkPhos-212* TotBili-0.5 [**2181-12-10**] 10:35AM BLOOD Calcium-9.1 Phos-4.5 Mg-3.1* [**2181-12-11**] 05:18AM BLOOD Cortsol-45.1* [**2181-12-10**] 04:56AM BLOOD Lactate-2.2* Na-118* K-6.4* EKG ([**2181-12-10**]): Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing there is no significant change. KUB ([**2181-12-10**]): IMPRESSION: Non-obstructive bowel gas pattern. Left nephrolithiasis. CT a/p ([**2181-12-10**]): IMPRESSION: 1. New large volume ascites. Catheter in place for peritoneal drainage. 2. Large pancreatic mass. Liver metastasis. 3. New areas of peritoneal thickening along the left hemi-diaphragm, infiltration of the mesentery, and diffuse omental cake suggesting peritoneal carcinomatosis. Small bowel wall thickening, probably due to peritoneal tumor involvement. 4. Partial thrombosis of left portal vein, also seen on prior scan. CXR ([**2181-12-10**]): IMPRESSION: No pneumonia. Pathology of Peritoneal fluid [**2181-12-11**]: Positive for malignant cells, consistent with poorly differentiated carcinoma with necrosis. Brief Hospital Course: [**Hospital Unit Name 13533**] [**Date range (1) 93972**]: 67F with stage 4 pancreatic cancer now p/w 4 days of nausea and vomiting, inabaility to tolerate po, and fatigue, found to have hyponatremia, hyerkalemia, and ARF. Each of the problems addressed during this hospitalization are described in detail below. Nausea and vomiting - most likely etiology was believed to be profound ileus from meds, carcinomatosis, vs incomplete SBO vs. extrinsic compresison of mass into UGI tract. Despite recent thrush, it did not appear to be a primary esophageal cause. Other DDx includes peritonitis, primary or secondary, esp given recent catheter placement and elevated WBC count. Has been deemed an unacceptable risk for surgical palliation. The patient was on sips/ clear liquids. Symptomatic control was provided with ondansetron, compazine, ativan. Reglan was added with symptomatic improvement. Pain control was achieved with prn dilaudid and fentanyl patch. 2 liters of Peritoneal fluid was drained and showed 2750 WBCs, 73% polys. The patient was initially started on Cipro/Flagyl/Ceftriaxone for bacterial peritonitis, but was switched to 2g daily Ceftriaxone for treatment of SBP and Cipro/Flagyl were discontinued. Peritoneal fluid Gram stain revealed 4+ PMNs, peritoneal fluid culture is pending at the time of callout from [**Hospital Unit Name 153**]. Urine culture was negative. Blood cultures are pending at this time. IR was called to evaluate the Pleurex catheter. Stage IV Pancreatic Cancer - has been on palliative chemo with recent decision to move towards hospice care as an outpatient. The patient was seen by her oncologist Dr. [**Last Name (STitle) **] during her stay in [**Hospital Unit Name 153**]. Therapeutic drainage of ascites for comfort was performed for comfort (on schedule M, W, F). 2 liters were taken off on [**2181-12-12**]. Hyperkalemia - K 5.5 on admission. The patient received calcium, kayexylate, insulin/D50 in ED. There were no EKG changes. Hyperkalemia resolved by the time of callout from [**Hospital Unit Name 153**]. Hyponatremia - The patient with chronic hyponatremia (Was 129 on d/c on [**11-29**]). Exaceration was believed to be due to a combination of hypovolemia given n/v, ketonuria, urine SG, and ARF as well as siADH. There were no evidence of MS changes or seizure activity. Urine lytes were initially consistent with the picture of hypovolemia. The patient was started on normal saline IVF, sodium levels were monitored q6 hours, with the goal to increase Na levels by 0.5 mEq/hr. By day 2, urine sodium leveled off beween values of 117 and 123 and was not changing with IVF. Urine lytes were conistent with a picture of siADH. Free water restriction was initiated, but salt tablets and other agents for siADH were not given, as the numbers were stable, and the correction during this hospitalization would not affect long term management of this condition. ARF - On admission Cr. 1.4 from a baseline 1.0. Prerenal etiology based on urine lytes. Resolved to baseline with IVF. We renally dosed all medications. Constipation: The patient was started on [**Hospital1 **] standing colace and senna. We also daily miralax and [**Hospital1 **] lactulose. The patient got enemas (Fleet and tap water) and had a bowel movement. h/o PE: The patient received Lovenox, which was renally dosed. Rash - The patient was noted to have fine macular rash on admission of unclear etiology. The rash improved on its own. Hypothyroid: The patient was not able to tolerate PO levothyroxine, and stated that she no longer wants to see this medication. Depression: The patient was not taking PO Citalopram as she was not able to tolerate PO meds. FEN: The patient was able to tolerate sips of water, ice chips. Her diet was not advanced as of callout from [**Hospital Unit Name 153**]. . . . . Pt was called out of [**Hospital Unit Name 153**] on [**2181-12-12**] and transferred to the OMED service. She continued to refuse most PO medications. On [**2181-12-13**], she was made comfort measures only with input from palliative care. All medications were stopped except PPI [**Hospital1 **] as it improved her nausea, enemas for constipation and dialudid. Her vitals and daily were not checked. She had therapeutic paracentesis when her belly was distended and uncomfortable. She was transitioned to a dilaudid drip titrated to comfort. Mrs. [**Known lastname 1968**] passed away on [**2181-12-19**] with her family present. Medications on Admission: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 4. Polyethylene Glycol 3350 17 gram/dose Powder PO DAILY prn 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 9. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours).( if this is at 125mcg/hr??) 10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous every twelve (12) hours. (? if 70 mg) 11. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day. 12. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO daily 13. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Stage IV pancreatic cancer Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

Admission Date: [**2147-6-28**] Discharge Date: [**2147-6-30**] Date of Birth: [**2088-3-8**] Sex: F Service: OTOLARYNGOLOGY Allergies: Penicillins / Ciprofloxacin Attending:[**First Name3 (LF) 4181**] Chief Complaint: throat pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 59 year-old Greek woman who has no history of throat infections or throat abscesses, who presents with 1-2 days of worsening throat pain, pain with swallowing, and decreased oral intake with subjective fevers. She also noted some intermittent drooling during these two days. She has noted some muffled-sounding voice change. She also notes minimal difficulty with breathing, but her breathing is not noisy.She has no trismus or neck stiffness. She denies chest pain, exertional shortness of breath, nausea, vomiting or sick contacts. She was admitted on [**2147-6-28**] to the ICU given concern for airway compromise in the setting of pharyngitis, supraglottitis. Past Medical History: Chronic Sinusitis with nasal polyposis s/p FESS x 2, HTN, Asthma, GERD, Osteoarthritis Social History: Operates a greek restaurant with her husband. [**Name (NI) **] denies smoking, acknowledges social drinking, and denies illicit substance abuse. Family History: Non-contributory. There is a history of ovarian cancer in two family members. Physical Exam: UPON DISCHARGE ([**2147-6-30**]): VITALS: T 99.1 97.6 P 76 BP 138/62 RR 12 95%RA HEENT: Normocephalic, atraumatic. Extraocular muscles intact with equally symmetric and reactive pupils bilaterally. Nares clear. Oropharynx with minimal posterior oropharyngeal erythema, but no plaques or exudates. Mucous membranes moist. Neck supple without lymphadenopathy. [**2147-6-29**] NPL: Minimal aryepiglottic edema with watery epiglottic edema noted, but improved from admission laryngoscopy. Some evidence of aryepiglottic erythema, but glottic opening and vocal folds normal, with widely patent airway. [**2147-6-30**] NPL: Improved aryepiglottic edema with no erythema noted. Widely patent glottis with normal true vocal folds. CVS: Regular rate and rhythm, no murmur, rub or gallop. RESP: Bilaterally decreased breath sounds anteriorly, but without other adventitious sounds. No wheezing, rhonchi or rales. EXTR: 2+ peripheral pulses, no cyanosis, clubbing or edema. Pertinent Results: [**2147-6-28**] 01:03PM BLOOD WBC-12.1*# RBC-5.08 Hgb-14.2 Hct-41.9 MCV-82 MCH-28.0 MCHC-34.0 RDW-13.8 Plt Ct-317 [**2147-6-29**] 04:05AM BLOOD WBC-9.9 RBC-4.41 Hgb-12.5 Hct-36.5 MCV-83 MCH-28.3 MCHC-34.2 RDW-13.7 Plt Ct-281 [**2147-6-29**] BLOOD CULUTRE: Pending, but no growth. Brief Hospital Course: NEURO/PAIN: The patient was admitted without neurologic issue or pain control issues. While she complained of some sore throat, this was treated adequately with Morphine sulfate 2 mg IV as needed. She had minimal pain issues. CARDIOVASCULAR: The patient remained hemodynamically stable throughout her admission, and on telemetry while in the ICU. She had no cardiac issues. Her home antihypertensive medication, Valsartan, was maintained. Her daily dose of Lipitor was continued. RESPIRATORY: The patient was admitted without evidence of respiratory distress. Her oxygen saturations in the ED were >95% with nasal cannula at 3-5 L O2. The patient was admitted to the ICU with close monitoring. She was weaned from 3 L O2 nasal cannula to room air, and she maintained her oxygen saturations. She had no drooling or stridulous noises. She has a known asthma history, and was maintained on albuterol nebs with montelukast and fluticasone-salmeterol at her home dose. FEN/GI: She was maintained NPO while in the ICU and then started on a diabetic/MCC diet after 12 hours of close airway monitoring, without issue. IV fluid hydration was maintained until she had adequate PO intake. RENAL: No active issues. ENDOCRINE: The patient has an unconfirmed history of diabetes. She received Decadron 10 mg IV Q8 hours upon admission and into HOD#2 for airway edema. She was maintained on a low dose sliding scale of insulin. Her blood sugars were maintained <200 mg/dL on sliding scale insulin. She was discharged on a Medrol dose pak for steroid taper. HEME/ID: Her hematocrit was normal on admission and she remained hemodynamically stbale. Her white count on admission was 12.1 and had come down to 9.9 on HOD#2. She was maintained on Clindamycin and Levquin IV on HOD#1 and switched to PO Bactrim DS for antibiotics. She remained afebrile after admission. She was discharged on 10 days of Bactrim DS [**Hospital1 **] for an antibiotic course. PROPHYLAXIS: She was maintained on DVT prophylaxis with Heparin 5000 Units SQ TID. She was encouraged to ambulate twice daily. Medications on Admission: Advair, Diovan, Lipitor, Pantoprazole, Proair, Singulair, Nasonex, Claritin OTC Discharge Medications: 1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: [**11-26**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 2. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Medrol (Pak) 4 mg Tablets, Dose Pack Sig: Four (4) Tablets, Dose Pack PO as directed (). Disp:*1 Tablets, Dose Pack(s)* Refills:*2* 6. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Supraglottitis, airway edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Seek immediate medical attention for fever >101.5, chills, increased redness, swelling of neck, decreased oral intake, drooling or difficulty opening your mouth, chest pain, shortness of breath, or anything else that is troubling you. No strenuous exercise or heavy lifting until follow up appointment, at least. You should call Dr.[**Name (NI) 37917**] office at [**Telephone/Fax (1) **] to schedule a follow up appointment. Please call to reschedule if you cannot make this appointment time. Plase take the Bactrim DS antibiotic for 10 days, as prescribed. Please take the Medrol dose pak steroids, as prescribed. Call your primary care provider to make [**Name Initial (PRE) **] follow up appointment in [**11-26**] weeks. Followup Instructions: You should call Dr.[**Name (NI) 37917**] office at [**Telephone/Fax (1) **] to schedule a follow up appointment in [**11-26**] weeks. Please call your primary care physician to schedule [**Name Initial (PRE) **] follow-up appointment in [**11-26**] weeks.

Admission Date: [**2142-11-19**] Discharge Date: [**2142-12-2**] Date of Birth: [**2084-9-17**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4282**] Chief Complaint: fever, fatigue Major Surgical or Invasive Procedure: none History of Present Illness: 58 year-old lifetime nonsmoking female with metastatic lung adenocarcinoma with widespread liver and spine metastases, EGFR mutation positive, s/p radiation of T7-S1 finishing [**2142-10-10**], on erlotinib 150 mg daily started [**2142-10-12**], who presented to clinic today with fever, nausea and fatigue x 1 day. . Over the past 24 hours she has felt increasingly fatigued. This morning she had nausea and some diaphoresis. She was seen in pain clinic where she was noted to have a temperature of 102 and she was sent to [**Hospital 478**] clinic where an emergency chest film shows a probable LLL pneumonia despite the absence of cough or other respiratory symptoms. She has no urinary symptoms but is quite bothered by her "clamshell" back brace. Past Medical History: ONCOLOGIC HISTORY: # metastatic lung cancer: - [**6-/2142**]: experienced laryngitis and 2 episodes of hemoptysis - [**7-/2142**]: diagnosed with right shoulder tendinitis - [**8-/2142**]: had lower back pain, decreased appetite and early satiety. CT at [**Hospital **] hospital on [**2142-9-14**] revealed mass lesion in the posterior inferior left hilum, involving the superior segment of the left lower lobe. Multiple bony mets were found in the spine and multiple liver mets noted. Liver biopsy on [**2142-9-18**] confirmed adenocarcinoma that is TTF+. MRI of the brain showed no intracranial mets but a right parietal bony met with soft tissue mass. Being followed by Dr. [**Last Name (STitle) **] [**Name (STitle) **] at [**Location (un) **] Oncology with a plan for chemotherapy. OTHER MEDICAL HISTORY: OCD osteopenia depression and anxiety Social History: SOCIAL HISTORY: Never smokes. No alcohol use. Works in the food service. Married with 2 children. Family History: FAMILY HISTORY: no family history of cancer Physical Exam: GENERAL: No acute distress, pleasant HEENT: sclera anicteric, mucous membranes moist. Oropharynx clear without lesion. HEART: regular rhythm and rate without murmur, rub, or gallop LUNGS: clear to auscultation bilaterally ABDOMEN: soft, nontender, nondistended EXTREMITIES: warm, well perfused without clubbing, cyanosis, or edema NEURO: cranial nerves II-XII grossly intact. Strength 5/5 x4 extremities, sensation intact to light touch x4 extremities Pertinent Results: [**2142-11-19**] 10:39PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2142-11-19**] 10:39PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2142-11-19**] 06:55PM GLUCOSE-134* UREA N-9 CREAT-0.2* SODIUM-136 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-11 [**2142-11-19**] 06:55PM estGFR-Using this [**2142-11-19**] 06:55PM ALT(SGPT)-55* AST(SGOT)-48* ALK PHOS-192* TOT BILI-0.4 [**2142-11-19**] 06:55PM CK-MB-2 cTropnT-<0.01 [**2142-11-19**] 06:55PM CALCIUM-7.9* PHOSPHATE-2.4* MAGNESIUM-2.0 [**2142-11-19**] 06:55PM WBC-3.4* RBC-3.19* HGB-9.6* HCT-29.0* MCV-91 MCH-30.0 MCHC-33.1 RDW-20.0* [**2142-11-19**] 06:55PM PLT COUNT-203 [**2142-11-19**] 01:39PM WBC-4.7 RBC-3.73* HGB-11.0* HCT-34.1* MCV-91 MCH-29.5 MCHC-32.3 RDW-19.9* [**2142-11-19**] 01:39PM NEUTS-93.7* LYMPHS-2.8* MONOS-3.1 EOS-0.3 BASOS-0.1 [**2142-11-19**] 01:39PM PLT COUNT-220 Brief Hospital Course: 58 year-old lifetime nonsmoking female with metastatic lung adenocarcinoma with widespread liver and spine metastases, EGFR mutation positive, s/p radiation of T7-S1 finishing [**2142-10-10**], on erlotinib 150 mg daily started [**2142-10-12**], admitted with pneumonia presumed to be PCP s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] stay [**Date range (1) 22045**]. . #PNA, presumed PCP: [**Name10 (NameIs) **] with fever/new oxygen requirement with CTA negative for PE, negative blood/urine cx, and normal cardiac enzymes/ekg. CXR concerning for pneumonia. Bglucan elevated. Bronchoscopy deferred. Unable to obtain sputum sample despite multiple attempts. Developed hypoxic respiratory failure [**11-23**] and transferred to [**Hospital Unit Name 153**]. Improved on bactrim treatment and transferred back to OMED [**11-26**]. Will continue bactrim DS 2 tabs TID for total 21 days. Continue prednisone taper. histo antigen pending upon discharge. Primary oncologist notified and will f/u regarding need for PCP [**Name Initial (PRE) 1102**]. . #Diarrhea: developed diarrea [**11-23**] with placement of rectal tube, removed [**11-27**]. C diff negative x 2. Resolved prior to discharge . #Back Brace: pt complaing of discomfort with brace. re-evaluated by orthopedic spine team who concluded that patient needs to continue to wear the back brace. Medications on Admission: CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 3 Tablet(s) by mouth DAILY (Daily) DEXAMETHASONE - (Prescribed by Other Provider) - 4 mg Tablet - 1 Tablet(s) by mouth twice a day for 5 days then [**11-12**] begin 4mg daily for 5 days, then 2mg daily for 5 days, then 2 mg every other day until [**2142-11-29**] then stop. ERLOTINIB [TARCEVA] - 150 mg Tablet - 1 Tablet(s) by mouth once a day GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times a day HYDROMORPHONE [DILAUDID] - 2 mg Tablet - 1 Tablet(s) by mouth q 3-4 hrs as needed for pain not to exceed 6 per day HYDROMORPHONE [DILAUDID] - 4 mg Tablet - [**1-20**] Tablet(s) by mouth q 3-4 hrs as needed for pain no more than 12 tabs per day LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL Solution - 30 ml by mouth daily as needed for constipation LIDOCAINE - (Prescribed by Other Provider) - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1 patch to affected area 12 hours daily LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for anxiety MORPHINE - 100 mg Tablet Sustained Release - 1 Tablet(s) by mouth three times a day POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17 gram/dose Powder - 1 Powder(s) by mouth DAILY (Daily) as needed for constipation RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet - 1 Tablet(s) by mouth twice a day Medications - OTC DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 2 Tablet(s) by mouth twice a day Discharge Medications: 1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for PCP [**Name Initial (PRE) **] 15 days. Disp:*84 Tablet(s)* Refills:*0* 2. prednisone 20 mg Tablet Sig: [**1-20**] as directed below Tablets PO DAILY (Daily) for 15 days: Please take 2 tablets (40 mg) daily until [**12-3**]. Then take 1 tablet (20 mg) daily until [**12-14**]. Disp:*20 Tablet(s)* Refills:*0* 3. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-24**] hours as needed for pain: Do not combine with alcohol. please do not drive while taking this medication as it may make you sleepy. Disp:*30 Tablet(s)* Refills:*0* 7. lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO once a day as needed for constipation. 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 1 patch to affected area 12 hours daily . 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) powder PO DAILY (Daily) as needed for constipation. 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 12. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*2* 13. MS Contin 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day: This medication may make you sleepy. Please do not drive while taking narcotic medications. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 14. MS Contin 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day: This medication may make you sleepy. Please do not drive while taking narcotic medications. Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: pneumonia, presumed PCP Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 **] for fever and fatigue. You were found to have pneumonia, likely due to an infection from pneumocystis (PCP). You developed difficulty breathing requiring a stay in the ICU from [**11-23**] to [**11-26**]. Your breathing improved as you were treated for PCP with antibiotics and steroids. You should discuss with your oncologist whether or not you should continue with your steroids after you finish the prednisone and if you continue with the prednisone or dexamethasone you should take bactrim prophylaxis for PCP which is usually one tablet three times per week. Please make the following changes to your medications: START Bactrim DS 2 tabs three times daily for a total of 21 days until [**12-14**] START Prednisone 40 mg daily until [**12-3**], then 20 mg daily until [**12-14**] STOP Dexamethasone Please STOP your current pain regimen of morphine and dilaudid. Please START the following regimen: MS Contin 45 mg twice a day (take one 30 mg tablet and one 15 mg tablet for a total of 45 mg) Dilaudid 2 mg every 4-6 hrs as needed for pain. Please follow up with your oncologist and in pain clinic. Please continue all other home medications Followup Instructions: The following appointments have been made for you: Department: Primary Care Name: Dr. [**First Name (STitle) 1154**] MAZZONI When: Tuesday [**2142-12-11**] at 10:10 AM Location: [**Location (un) 2274**]-[**Location (un) **] Address: 2 [**Location (un) **] CENTER DR, [**Location (un) **],[**Numeric Identifier 29936**] Phone: [**Telephone/Fax (1) 79695**] Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2142-12-6**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], 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: THURSDAY [**2142-12-6**] at 9:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PAIN MANAGEMENT CENTER When: MONDAY [**2142-12-17**] at 11:00 AM With: [**First Name4 (NamePattern1) 3049**] [**Last Name (NamePattern1) 8155**], NP [**Telephone/Fax (1) 1652**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site

Admission Date: [**2120-3-10**] Discharge Date: [**2120-4-18**] Date of Birth: [**2120-3-10**] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 46197**] was the 1080 gram product of a 27 and [**5-20**] week twin gestation born to a 36 year-old G7P5 mother. Serologies are O negative, hepatitis surface antigen negative, hepatitis C positive, RPR nonreactive, antibody negative, rubella immune, GBS unknown. other living children. This was a spontaneous twin pregnancy. Mother reports normal amniocentesis and normal second trimester ultrasound. The pregnancy was going well without complications until the morning of [**2120-3-9**] at 7:30 when the mother reported spontaneous rupture of membranes (twin two). She presented to Labor & Delivery from the Emergency Room. The mother was noted to be in early Ampicillin and Erythromycin and was given one dose of betamethasone at 1300 [**2120-3-9**]. She was later transferred to the floor. Early a.m. [**2120-3-10**] mother found to have progressive cervical dilatation and the decision was made to deliver twins by cesarean section. Mother was unable to get effective spinal anesthesia and was placed under general anesthesia. This infant's membranes ruptured at the time of delivery. The infant emerged with decreased activity and no spontaneous respirations. He was bulbed suctioned, dried, stimulated and give positive pressure ventilation. He responded well, but did have progressive respiratory distress consistent with a respiratory distress syndrome. The patient's CPAP was started and he was intubated prior to transfer to the MICU with improvement of aeration and color. Apgars were 5 and 7. PHYSICAL EXAMINATION ON ADMISSION: Weight 1080 (50th percentile). Length 37 cm (25 to 50th percentile). Head circumference 26 cm (50 to 75th percentile). Anterior fontanel open and flat, pink well perfuse, no rashes. Skin intact. Positive red reflexes bilaterally. Equal chest excursion with retractions, poor aeration consistent with a respiratory distress. Skin extensive bruising throughout. Normal S1 and S2. No murmurs. 2+ pulses. Abdomen without hepatosplenomegaly, three vessel cord. Normal external genitalia for a preterm male. Spine straight intact. Patent anus. Infant tone appropriate for gestational age. HOSPITAL COURSE: Respiratory: The patient had increased respiratory distress requiring intubation and treatment with Surfactant times two. He extubated to CPAP by 24 hours of age and is continued on CPAP with brief periods of trials off up until day 47, [**2120-4-16**] at which time he was extubated to room air. He has been stable without increase in apnea and bradycardia spells. He was started on caffeine citrate for management of apnea and bradycardia on day of life one and continues on caffeine citrate currently with good management. On average has one to three apnea bradycardia spells per day. Cardiovascular: Initially required normal saline boluses times two and Dopamine at 7.5 micrograms per kilogram per minute for management of hypotension. He weaned off his Dopamine by 24 hours of age and has been cardiovascularly stable throughout remainder of hospital course with no history of a cardiac murmur. Fluid and electrolytes: His birth weight was 1080. He was initially started on 80 cc per kilo per day of D10W. He required a D10 bolus on admission for hypoglycemia. He has had no further issues with hypoglycemia. He started enteral feedings on day of life number one, advanced to full enteral feedings by day of life eight and has been stable on 150 cc per kilogram per day, max of PE 30 with ProMod. He is currently receiving 150 cc per kilogram per day of PE 26 demonstrating good weight gain. His discharge weight is 2055. His most recent nutrition laboratories were obtained on [**2120-4-18**], sodium was 139, potassium 5.7, chloride 107, total CO2 26, BUN 14, creatinine .3 alkaline phosphatase 432, phosphorus 6.3. Gastrointestinal: Initially was treated with phototherapy for a peak bilirubin of 6.5/0.4 likely secondary to extensive bruising from delivery process. He received double phototherapy times three days, decreased single phototherapy and phototherapy was discontinued on day of life eight with a rebound bilirubin of 3.1/0.3. This issue has been resolved. Hematology: Hematocrit on admission was 54.6. His most recent hematocrit on [**2120-4-18**] was 30.8. He has not required any blood transfusions during this hospital course. Infectious disease: A CBC and blood culture was obtained on admission. CBC was benign. The culture remained negative at 48 hours and Ampicillin and Gentamicin were discontinued. On day of life five the infant increased with apnea and bradycardia spells, had a temperature of 101. At that time a CBC was obtained. CBC was benign. Blood cultures were positive for staph aureus. The infant was treated with Vancomycin and Gentamicin for a total of three days and then changed to Penicillin and Oxacillin for a total of a seven day course. Antibiotics were discontinued on [**2120-3-23**] and he has not had any further issues with sepsis during this hospital course. Neurological: Head ultrasound was performed on day of life one, four and 30 days all within normal limits. He is appropriate for gestational age. Sensory: Audiology has not been screened. Recommended prior to discharge. Ophthalmology: The patient was seen by ophthalmology on [**2120-4-17**] revealing stage 1 zone 2 10 o'clock hours in his right eye and 11 o'clock hours in his left eye with recommended follow up in one week. Psycho/social: A [**Hospital1 69**] social worker has been involved with this family. Mom has agoraphobia and visits infrequently. Dad visits on a fairly frequent basis. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: To [**Hospital3 **] level two facility. Name of primary pediatrician is in process. Mom is trying to identify a pediatrician in the [**Hospital1 **] system. CARE AND RECOMMENDATIONS: Continue 150 cc per kilogram per day of PE 26 calorie with iron and wean as appropriate. Medications, continue caffeine citrate. Car seat position screening has not been performed. State newborn screens have been sent per protocol and have been within normal limits. Immunizations received: he has not received any immunizations. Immunizations recommended: hepatitis B vaccine once consent obtained. Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: born at less then 32 weeks, born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or a preschool sibling or with chronic lung disease. Influenza immunizations 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. DISCHARGE DIAGNOSES: 1. Former 27 and [**5-20**] week twin B now 39 days old, 32 and 1/7 weeks gestation. 2. Status post respiratory distress syndrome treated with Surfactant, rule out sepsis with antibiotics. 3. Hypoglycemia, transient. 4. Hypotension, transient. 5. Staph aureus bacteremia. 6. Hyperbilirubinemia, resolved. 7. Anemia of prematurity. 8. Apnea and bradycardia prematurity. 9. Retinopathy of prematurity. Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**] Dictated By:[**Last Name (NamePattern1) 46198**] MEDQUIST36 D: [**2120-4-18**] 11:14 T: [**2120-4-18**] 11:26 JOB#: [**Job Number 46199**]

Admission Date: [**2105-11-18**] Discharge Date: [**2105-11-21**] Date of Birth: [**2080-5-30**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Sulfonamides / Latex Attending:[**First Name3 (LF) 2698**] Chief Complaint: Dizziness/lightheaded Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Please see MICU note for full details, briefly 25 yo F w/ Hx of severe HTN, diagnosed while pregnant (preeclampsia) who presented on [**11-18**] with chest pain and hypotension. Patient reports several episodes of N/V/D last weekend but improvement of symptoms earlier this week. She states medication compliance as prescribed (900mg labetalol [**Hospital1 **], 90mg nifedipine QD and HCTZ 25mg QD). Prior to presentation she had an episode of SSCP that radiated down the L arm that was accompanied by dizziness. She was found to be severely hypotensive and given 6L of NS, 2mg glucagon X2 for BB overdose, 10mg dexamethasone, 1g calcium gluconate for CCB overdose, 2g Mg in the ED. EKG--> TWI in III and aVF (unchanged from prior). A TTE was done while she was having active CP and this was normal with an EF of 70%. CTA--> no PE or dissection. Abd U/S--> thickened gall bladder, could be consistent w/ cardiac or liver disease. She remained hypotensive, started on peripheral dopamine and admitted to the MICU. . In the MICU, she remained on peripheral dopamine for only a few hours and has been off pressors for >12hrs with SBP in the 120's. This am she developed acute onset SSCP that was similar to the episode she had on presentation. She received 3 SLN and her pain resolved. EKG--> TWI in III, aVF and V1, and TW flattening in V5-V6 (only new finding). CE's were drawn initially Trop - <0.01-->0.04-->0.16; CK - 166, 141, 168; MB - 2, 4, 6; likely representing an NSTEMI. Started on heparin gtt, ASA and statin. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: NONE -CABG: NONE -PERCUTANEOUS CORONARY INTERVENTIONS: NONE -PACING/ICD: NONE Multiple 1st trimester SABs and TABs - 1 LTCS for NRFHR with intermittent gHTN; no meds postpartum - 1 VBAC with gHTN postpartum requiring blood pressure meds and VNA care - 1 VBAC [**2105-7-31**] 7# 5 oz; 600 mg TID Labetalol; followed by VNA as outpatient. GDMA2 - PCOS, with HbA1C of 6.1-6.6%. - Anemia - Asthma - Lumbosacral spondylosis - Transient visual blurriness, chronic s/p MVA in [**2103**]; reportedly followed by [**Hospital 13128**]. - D+Cs Social History: -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Family History: Father with HTN, DM, leukemia, MI (1st at 30 yo) and CVA Mother with Parkinsons, sarcoma, G6PD deficiency Brother with HTN at age 20 Aunt with hx of CVA at age 19 Paternal cousin with cardiovascular death while playing basketball at age 21. No family history arrhythmia or cardiomyopathies. Physical Exam: VS: T 98.7, BP 129/75, HR 102, RR 20, Sat 100% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**5-11**] cm. CARDIAC: RR, normal S1, S2. No m/r/g. 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: Trace ankle edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**2105-11-18**] 02:20PM BLOOD WBC-11.6* RBC-3.88* Hgb-10.2* Hct-31.3* MCV-81* MCH-26.2*# MCHC-32.5# RDW-15.8* Plt Ct-237 [**2105-11-19**] 04:26AM BLOOD WBC-11.4* RBC-4.35 Hgb-11.6* Hct-36.0 MCV-83 MCH-26.6* MCHC-32.1 RDW-15.6* Plt Ct-261 [**2105-11-21**] 05:35AM BLOOD WBC-10.2 RBC-4.29 Hgb-11.0* Hct-35.0* MCV-82 MCH-25.6* MCHC-31.4 RDW-15.3 Plt Ct-273 [**2105-11-18**] 02:20PM BLOOD Neuts-67.5 Lymphs-25.0 Monos-3.0 Eos-4.3* Baso-0.2 [**2105-11-19**] 04:26AM BLOOD Neuts-87.5* Lymphs-10.7* Monos-0.9* Eos-0.7 Baso-0.1 [**2105-11-18**] 02:20PM BLOOD PT-13.1 PTT-27.0 INR(PT)-1.1 [**2105-11-18**] 04:45PM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1 [**2105-11-21**] 05:35AM BLOOD Lupus-NEG [**2105-11-21**] 05:35AM BLOOD ACA IgG-PND ACA IgM-PND [**2105-11-18**] 02:20PM BLOOD Glucose-200* UreaN-5* Creat-0.9 Na-141 K-3.5 Cl-110* HCO3-23 AnGap-12 [**2105-11-18**] 08:46PM BLOOD Glucose-136* Na-144 K-3.7 Cl-114* HCO3-19* AnGap-15 [**2105-11-20**] 07:10AM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-143 K-4.2 Cl-107 HCO3-24 AnGap-16 [**2105-11-21**] 05:35AM BLOOD Glucose-85 UreaN-18 Creat-0.8 Na-141 K-4.0 Cl-107 HCO3-26 AnGap-12 [**2105-11-18**] 04:45PM BLOOD ALT-19 AST-24 AlkPhos-71 TotBili-0.2 [**2105-11-19**] 04:26AM BLOOD CK(CPK)-168* [**2105-11-20**] 07:10AM BLOOD CK(CPK)-90 [**2105-11-19**] 03:14PM BLOOD CK(CPK)-133 [**2105-11-18**] 08:46PM BLOOD CK(CPK)-141* [**2105-11-18**] 04:45PM BLOOD Lipase-9 [**2105-11-18**] 02:20PM BLOOD Lipase-12 [**2105-11-18**] 02:20PM BLOOD CK-MB-2 proBNP-103 [**2105-11-18**] 02:20PM BLOOD cTropnT-<0.01 [**2105-11-19**] 04:26AM BLOOD CK-MB-6 cTropnT-0.16* [**2105-11-19**] 03:14PM BLOOD CK-MB-4 cTropnT-0.12* [**2105-11-20**] 07:10AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2105-11-18**] 02:20PM BLOOD Calcium-8.3* Phos-3.2 Mg-1.4* [**2105-11-18**] 04:45PM BLOOD Albumin-3.0* [**2105-11-18**] 08:46PM BLOOD Calcium-8.8 Phos-1.8* Mg-1.8 [**2105-11-20**] 07:10AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.1 [**2105-11-21**] 05:35AM BLOOD Calcium-9.2 Phos-5.0* Mg-2.0 [**2105-11-19**] 04:26AM BLOOD calTIBC-437 VitB12-360 Folate-11.2 Ferritn-24 TRF-336 [**2105-11-21**] 05:35AM BLOOD Homocys-12.3 [**2105-11-19**] 03:14PM BLOOD Triglyc-61 HDL-46 CHOL/HD-3.3 LDLcalc-96 [**2105-11-21**] 05:35AM BLOOD TSH-4.0 [**2105-11-18**] 02:20PM BLOOD Cortsol-26.8* [**2105-11-19**] 04:26AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2105-11-20**] 07:37AM BLOOD Lactate-1.5 [**2105-11-18**] 10:14PM BLOOD Lactate-2.8* [**2105-11-18**] 05:00PM BLOOD Lactate-1.9 [**2105-11-18**] 05:00PM BLOOD Hgb-10.5* calcHCT-32 [**2105-11-21**] 05:35AM BLOOD FACTOR V LEIDEN-PND [**2105-11-18**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.1 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Left Atrium - Peak Pulm Vein D: 0.7 m/s Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.1 cm Left Ventricle - Fractional Shortening: 0.40 >= 0.29 Left Ventricle - Ejection Fraction: 70% >= 55% Left Ventricle - Stroke Volume: 65 ml/beat Left Ventricle - Cardiac Output: 6.59 L/min Left Ventricle - Cardiac Index: 3.26 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.15 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 11 < 15 Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aorta - Ascending: 1.7 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 23 Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - E Wave: 1.5 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 2.50 Mitral Valve - E Wave deceleration time: *132 ms 140-250 ms Pulmonic Valve - Peak Velocity: 1.2 m/sec <= 1.5 m/sec Findings LEFT ATRIUM: Normal LA and RA cavity sizes. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: ?# aortic valve leaflets. Normal AVR leaflets. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting tachycardia (HR>100bpm). Emergency study performed by the cardiology fellow on call. Conclusions The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The prosthetic aortic valve leaflets appear normal There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No significant valvular disease seen. Cardiology Report ECG Study Date of [**2105-11-18**] 2:18:56 PM Sinus rhythm. Borderline prolonged/upper limits of normal QTc interval. Low T wave amplitude. Findings are non-specific but cannot exclude drug/electrolyte/metabolic effect. Clinical correlation is suggested. Since the previous tracing of [**2105-8-9**] there is probably no significant change. TRACING #1 Cardiology Report ECG Study Date of [**2105-11-18**] 3:39:34 PM Sinus rhythm. Prolonged QTc interval. Modest inferolateral lead ST-T wave abnormalities. Findings are non-specific but clinical correlation is suggested. Since the previous tracing of same date ST-T wave changes are more prominent. TRACING #2 Cardiology Report ECG Study Date of [**2105-11-18**] 9:45:00 PM Sinus tachycardia. Modest inferolateral T wave changes are non-specific. Since the previous tracing of the same date sinus tachycardia is now present and the QTc interval appears shorter. TRACING #3 Radiology Report CHEST (PORTABLE AP) Study Date of [**2105-11-18**] 2:20 PM COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation. No appreciable pleural effusion or evidence of pneumothorax is seen. The carina is relatively splayed with relative underlying increased density, which may be due to an enlarged left atrium. The cardiac silhouette is borderline in size, which may be accentuated by supine, AP technique. IMPRESSION: 1. Clear lungs. 2. Possible left atrial enlargement. 3. Borderline cardiac silhouette size, which is likely accentuated by AP technique and supine position. Radiology Report CT PELVIS W/CONTRAST Study Date of [**2105-11-18**] 3:14 PM CT CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arterial tree is well opacified, and there is no pulmonary embolus. The thoracic aorta is normal in caliber without dissection, pseudoaneurysm, intramural hematoma or other acute abnormality. The great vessels are unremarkable. The heart size is normal without pericardial effusion. There is a 1 cm soft tissue density in the right hilus, likely reactive lymph node. In the right axilla, several prominent lymph nodes measure up to 1 cm in short axis, demonstrating a normal configuration with normal fatty hila. Normal appearing left axillary lymph nodes are also present. In anterior mediastinum, there is soft tissue density material which may be due to residual thymic tissue. Lungs demonstrate mild dependent atelectasis bilaterally, without consolidation or pleural effusion. There is prominence of septal markings suggesting fluid overload and mild pulmonary edema. The tracheobronchial tree is patent to subsegmental levels. CT ABDOMEN WITH IV CONTRAST: Assessment of solid organs is limited given the arterial phase of the exam, tailored for evaluation of the aorta. The abdominal aorta is normal in caliber, without dissection, pseudoaneurysm, or other acute abnormality. The major branches are patent. Incidentally noted is an accessory right renal artery. The liver demonstrates increased hypodense material surrounding the vascular structures at the porta hepatis and extending towards the periphery. This could represent periportal edema, or could indicate periductal soft tissue material. At the liver dome (3:81), there is a suggestion of a 6-mm arterially enhancing focus, although this area is obscured by metallic artifact from an object external to the patient. A small amount of perihepatic fluid is noted adjacent to the diaphragm. The gallbladder demonstrates a markedly thickened, hypodense wall, with intermediate density intraluminal contents. This pronounced gallbladder wall edema is more severe than usually seen in the setting of rapid rehydration. Alternatively, this could be seen in gallbladder outlet obstruction or soft tissue infiltration of the gallbladder wall. The pancreas appears slightly enlarged, although the pancreatic parenchyma enhances uniformly. There is no pancreatic ductal dilatation. Surrounding the pancreas, there is fluid or soft tissue density material and a mild amount of mesenteric stranding. The spleen, adrenal glands, stomach, and duodenum are unremarkable. The kidneys are unremarkable without hydronephrosis, stones, or worrisome renal masses. Assessment of the mesentery is limited given the relative lack of mesenteric fat, but there may be some mesenteric edema. There is no free air in the upper abdomen. CT PELVIS WITH IV CONTRAST: Loops of large and small bowel are unremarkable. The appendix is normal. The uterus demonstrates a large exophytic fibroid extending off the left fundus. There is no intrauterine device or vaginal foreign body seen. The urinary bladder is collapsed around a Foley catheter, with small amount of air. There is no free fluid in the pelvis. There is no pelvic or inguinal lymphadenopathy by size criteria. OSSEOUS STRUCTURES: There is no fracture or worrisome bony lesion. IMPRESSION: 1. No pulmonary embolus or acute aortic abnormality. No aortic dissection in the chest or abdomen. 2. Small amount of fluid along the superior margin of the liver, surrounding the pancreas, and gallbladder wall thickening versus edema, and likely periportal edema. These findings may be due to rapid rehydration, but given the phase of imaging, other etiologies cannot be ruled out. Serum lipase was normal making pancreatitis unlikely. This can be further evaluated with a non-emergent right upper quadrant ultrasound to evaluate the gallbladder wall and for perihepatic lymphadenopathy. 3. Anterior mediastinal soft tissue, most likely consistent with thymic tissue, although other mediastinal mass (ie lymphoma) can not be entirely excluded. Consider further evaluation with MRI. 4. Mild pulmonary edema. 5. Possible 6mm enhancing hepatic lesion near the hepatic dome. This can be further evaluated with nonemergent ultrasound or MRI. Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2105-11-18**] CT CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arterial tree is well opacified, and there is no pulmonary embolus. The thoracic aorta is normal in caliber without dissection, pseudoaneurysm, intramural hematoma or other acute abnormality. The great vessels are unremarkable. The heart size is normal without pericardial effusion. There is a 1 cm soft tissue density in the right hilus, likely reactive lymph node. In the right axilla, several prominent lymph nodes measure up to 1 cm in short axis, demonstrating a normal configuration with normal fatty hila. Normal appearing left axillary lymph nodes are also present. In anterior mediastinum, there is soft tissue density material which may be due to residual thymic tissue. Lungs demonstrate mild dependent atelectasis bilaterally, without consolidation or pleural effusion. There is prominence of septal markings suggesting fluid overload and mild pulmonary edema. The tracheobronchial tree is patent to subsegmental levels. CT ABDOMEN WITH IV CONTRAST: Assessment of solid organs is limited given the arterial phase of the exam, tailored for evaluation of the aorta. The abdominal aorta is normal in caliber, without dissection, pseudoaneurysm, or other acute abnormality. The major branches are patent. Incidentally noted is an accessory right renal artery. The liver demonstrates increased hypodense material surrounding the vascular structures at the porta hepatis and extending towards the periphery. This could represent periportal edema, or could indicate periductal soft tissue material. At the liver dome (3:81), there is a suggestion of a 6-mm arterially enhancing focus, although this area is obscured by metallic artifact from an object external to the patient. A small amount of perihepatic fluid is noted adjacent to the diaphragm. The gallbladder demonstrates a markedly thickened, hypodense wall, with intermediate density intraluminal contents. This pronounced gallbladder wall edema is more severe than usually seen in the setting of rapid rehydration. Alternatively, this could be seen in gallbladder outlet obstruction or soft tissue infiltration of the gallbladder wall. The pancreas appears slightly enlarged, although the pancreatic parenchyma enhances uniformly. There is no pancreatic ductal dilatation. Surrounding the pancreas, there is fluid or soft tissue density material and a mild amount of mesenteric stranding. The spleen, adrenal glands, stomach, and duodenum are unremarkable. The kidneys are unremarkable without hydronephrosis, stones, or worrisome renal masses. Assessment of the mesentery is limited given the relative lack of mesenteric fat, but there may be some mesenteric edema. There is no free air in the upper abdomen. CT PELVIS WITH IV CONTRAST: Loops of large and small bowel are unremarkable. The appendix is normal. The uterus demonstrates a large exophytic fibroid extending off the left fundus. There is no intrauterine device or vaginal foreign body seen. The urinary bladder is collapsed around a Foley catheter, with small amount of air. There is no free fluid in the pelvis. There is no pelvic or inguinal lymphadenopathy by size criteria. OSSEOUS STRUCTURES: There is no fracture or worrisome bony lesion. IMPRESSION: 1. No pulmonary embolus or acute aortic abnormality. No aortic dissection in the chest or abdomen. 2. Small amount of fluid along the superior margin of the liver, surrounding the pancreas, and gallbladder wall thickening versus edema, and likely periportal edema. These findings may be due to rapid rehydration, but given the phase of imaging, other etiologies cannot be ruled out. Serum lipase was normal making pancreatitis unlikely. This can be further evaluated with a non-emergent right upper quadrant ultrasound to evaluate the gallbladder wall and for perihepatic lymphadenopathy. 3. Anterior mediastinal soft tissue, most likely consistent with thymic tissue, although other mediastinal mass (ie lymphoma) can not be entirely excluded. Consider further evaluation with MRI. 4. Mild pulmonary edema. 5. Possible 6mm enhancing hepatic lesion near the hepatic dome. This can be further evaluated with nonemergent ultrasound or MRI. Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of [**2105-11-18**] 6:43 PM COMPARISON: CT torso obtained approximately four hours earlier. RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture without focal abnormalities. There is a small amount of perihepatic fluid. In the right upper quadrant, incidentally noted is a tiny right pleural effusion. There is no intra- or extra-hepatic biliary ductal dilatation. The common duct measures 4 mm. The main portal vein demonstrates normal hepatopetal flow. The gallbladder is not distended, but demonstrates marked gallbladder wall edema. The wall measures approximately 1.6 cm. There is no echogenic debris are gallstones within the gallbladder. There is no pericholecystic fluid. The spleen is normal in size. There is a small amount of abdominal fluid tracking around the spleen. Additionally, there is a small left pleural effusion. Views of the abdominal midline are limited due to overlying bowel gas. IMPRESSION: 1. Pronounced gallbladder wall edema, without evidence of acute cholecystitis. This can be seen in the setting of underlying liver or heart disease. This can also be seen in aggressive rehydration, although this degree of wall edema is somewhat unusual. 2. Trace ascites tracking around the liver and spleen. This may also be related to rehydration. 3. Interval development of small bilateral pleural effusions. Cardiology Report Cardiac Cath Study Date of [**2105-11-20**] *** Not Signed Out *** BRIEF HISTORY: This 25 year old female with a history of hypertension and strong family history of premature coronary artery disease referred for evaluation of atypical chest pain and elevated cardiac biomarkers. Chest CT angiogram was negative for pulmonary embolism or aortic dissection. INDICATIONS FOR CATHETERIZATION: Hypertension. Family history of premature coronary disease. Atypical chest discomfort. Elevated cardiac biomarkers. PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 4 French left [**Last Name (un) 2699**] catheter, advanced to the ascending aorta through a 4 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 4 French JL4 and a 4 French JR4 catheter, with manual contrast injections. HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.07 m2 HEMOGLOBIN: 11.1 gms % REST **PRESSURES AORTA {s/d/m} 158/103/128 **CARDIAC OUTPUT HEART RATE {beats/min} 75 RHYTHM SINUS **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA NORMAL 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA NORMAL 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 24 minutes. Arterial time = 10 minutes. Fluoro time = 4.1 minutes. IRP dose = 543 mGy. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 30 ml Premedications: Midazolam 0.5 mg IV, 1 mg IV Fentanyl 25 mcg IV ASA 325 mg P.O. Clopidogrel 600 mg PO Anesthesia: 1% Lidocaine subq. Cardiac Cath Supplies Used: - ALLEGIANCE, CUSTOM STERILE PACK - [**Company **], LEFT HEART KIT COMMENTS: 1. Coronary angiography in this right dominant system demonstrated no angiographically apparent disease in the LMCA, LAD, LCx, or RCA. 2. Resting hemodynamics limited to central aortic pressure revealed systolic and diastolic arterial hypertension with SBP 158 mmHg and DBP 103 mmHg. FINAL DIAGNOSIS: 1. Coronary arteries are normal. Brief Hospital Course: # CORONARIES: Patient presented with chest pain and hypotension. She was initially admitted to the MICU as her BP remained low after treatment for BP med overdose and 6 L IVF. Urine and serum toxicology tests (-). In the MICU she was transiently on dopamine but this was discontinued after only a few hours. She has no hx of CAD only risk factors are HTN and family histroy. Given her age, it was thought that it was unlikely NSTEMI but given the (+) troponins, that peaked at 0.16, and her multiple episodes of chest pain a cardaic catheterization was done. Cath showed normal vessels. A lipid profile was done and found to be WNL. Oncer her BP strarted to trend up she was re-started on labetalol and HCTZ. Hypercoagulability testing was ordered prior to discharge. Some of these results are back today and are (-), others should be followed up. TSH was WNL. . # Hypotension: Patient presented with severe hypotension (SBP 60s-70s) thought to be due to excessive BP med dosing and recent viral illness causing dehydration. This resolved after aggressive IV hydration, BP med overdose treatment and brief treatment with dopamine. Details as above. . # PUMP: Patient with no hx of cardiac abnormalities, TTE--> nl. study with EF of 70%. Not fluid overloaded per exam. BNP WNL. . # RHYTHM: Patient in NSR, with no hx of arrhythmias. . # Anion gap: Patient with anion gap (16) acidosis, on transfer from MICU. This resolved without intervention. Lactate was WNL. . # G6PD deficiency: Patient states she was told she had this disease during childhood. No records in system. G6PD testing was WNL in [**2096**]. . # Pericholecystic fluid/peripancreatic fluid: This was found on ED CT abd/pel. Surgery was consulted and concluded that this did not represent infection/bleeding given stable Hct and completely normal LFTs/lipase. A RUQ U/S was done which showed same finding as before and this was thought to be due to aggresive rehydration. Patient might benefit from reapeat RUQ U/S to assess for resolution. . # Asthma: Stable, asymptomatic. . # Anemia: Patient was found to have Hct of 31 on admission. This trended up throughout admission into the mid-30s range and remained stable. Iron studies, B12/folate levels WNL. Medications on Admission: Labetalol 900mg [**Hospital1 **] Nifedipine 90mg QD HCTZ 25mg QD MVI Albuterol prn Discharge Medications: 1. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: neighborhood health plan Discharge Diagnosis: Primary diagnosis: Hypotension Secondary: preeclampsia, chest 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 [**Hospital1 18**] because you were having dizziness and chest pain. In the ED you were found to have very low blood pressure that was thought to be due to dehydration, because of your previous stomach sickness, and because of too many blood pressure mediations. You had chest pain again while in the hospital and your blood test showed your heart was not getting enough blood during this episode. You underwent cardiac catheterization which was normal. Medication Changes: STOP: Nifedipine START: Aspirin 81 mg No other changes were made to your medications. Followup Instructions: Appointment #1 MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Primary Care Date/ Time: Tuesday, [**12-1**] at 2:40pm Location: [**Location (un) 2129**] , [**Location (un) 86**] Phone number: [**Telephone/Fax (1) 32630**]

Admission Date: [**2175-1-29**] Discharge Date: [**2175-2-4**] Date of Birth: [**2089-2-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1145**] Chief Complaint: shortness of breath and chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 85 year old man with CAD, chronic systolic CHF EF40%, HTN, HLD, CKD, peripheral vascular disease, presents with shortness of breath and chest pain. Pt states that two days ago he developed some CP pain and sob. He took ntg with resolution of CP, however the sob got progressively worse. He felt that he had a "lack of O2", and also that there was "fluid on his lungs". He denies n/v/diaphoresis but did have some coughing with "pinkish phlegm". He denies acute onset but states rather that the SOB progressed over night, worse with exertion and laying flat. He also notes some increased LE edema. He denies f/c/n/v. He also notes that 2wks ago he had flu like symptoms and since then has been feeling generally unwell. . In the ED, initial vitals were 97.7 78 136/86 18 100% RA. Labs significant for trop 2.13, Na 129, Cr 1.9, K 5.7, Hct 32.8, INR 1.1. CXR showed bilateral pulmonary edema. ECG showed NSR at 75bpm, borderline left axis, q waves V1-V3 and III and avF, t wave inversion avL, no other ST/T changes. He was given 20mg IV lasix. Most recent vitals prior to transfer: . On arrival to the floor, patient was seen with the nurse who speaks Russian. The patient states that approximately 7-10 days ago, he started developing shortness of breath and fatigue on exertion. He states that around the same time, he developed a cold that involved sinus congestion and a cough and a cold sore on his lip. The patient states that his shortness of breath got progressively worse as the days passed. He states that he has also gained approx 9 pounds and now weighs 209 pounds, since these symptoms began. He also states that approx 3 days ago, he developed chest pain. He states that the pain did not radiate anymore. He states that the pain resolved after 2-3 hours when he took 2 sublingual nitroglycerin tabs. He denies any nausea, vomiting, GI upset, changes in stools, or any other symptoms with the chest pain. The patient states that he was seen as an outpatient approx 10 days ago and had an EKG and an ECHO done. THe patient now presented with concerns with his worsening shortness of breath. . On the floor, he was initially treated with heparin drip for NSTEMI, but then dced. He was started on a lasix drip for CHF. Down 1.5L at 5pm, pressures tending down from SBP 160s/90s to 100s/40s, then 70s-80s/30s-40s. Flipped into Afib with RVR today at 11pm. PMH of Afib on one occasion following epistaxis in [**2173**]. He got 2.5 Metoprolol, BP trended down, now high 60s/70s. Got 500cc bolus, considering amiodarone, but decided to transfer to CCU for further management. . Currently, he is alert and orientated x 3, denies any chest pain, headache, dizziness, palpitations, dyspnea. BP improved to high 80s/60, remains tachycardic around 120s. He was given 5 mg IV metoprolol, but remained tachycardic, and dropped BP to 70s systolic, MAP around 55. Past Medical History: Percutaneous coronary intervention, in [**2167**] with stent of distal LCx PERIPHERAL VASCULAR DISEASE with CLAUDICATION CORONARY ARTERY DISEASE with ANGINA HYPERTENSION HYPERCHOLESTEROLEMIA ABDOMINAL AORTIC ANEURYSM GERD MONOCLONAL GAMMOPATHY GOUT MEMORY LOSS HEARING LOSS PSORIASIS H/O RETINAL ARTERY OCCLUSION H/O PYELONEPHRITIS Social History: The patient emigrated to the United States from [**Country 532**]. The patient is retired, used to be on an Armenian submarine in [**Country 532**]. The patient quit smoking in [**2137**] after 20 pack year history, has an average of one drink a week, no history of recreational drug use. Family History: The patient states his father had heart problems but lived until 84 years of age. No other known medical history. Physical Exam: ON ADMISSION VS: T= 97.7 BP= 145/98 HR= 75 RR= 22 O2 sat= 97 RA GENERAL: some dyspnea. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Nasal Cannula in place. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. holosystolic murmur. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. some dyspnea. bilateral crackles in bases. ABDOMEN: Soft, NTND. No HSM or tenderness. no masses. no rebound tenderness or guarding EXTREMITIES: 1+ pitting edema in lower extremities bilaterally, warm and well perfused Rectum - stools are guaiac negative. . PT [**Name (NI) 5485**]. Pertinent Results: CBC: [**2175-1-29**] 01:50PM BLOOD WBC-6.8 RBC-3.28* Hgb-10.8* Hct-32.4* MCV-99* MCH-33.0* MCHC-33.5 RDW-15.2 Plt Ct-190 [**2175-2-4**] 03:15AM BLOOD WBC-12.6*# RBC-2.64* Hgb-9.2* Hct-26.4* MCV-100* MCH-34.8* MCHC-34.9 RDW-16.2* Plt Ct-262 DIFF: [**2175-1-29**] 01:50PM BLOOD Neuts-84.2* Lymphs-10.7* Monos-4.0 Eos-0.6 Baso-0.4 COAGS [**2175-2-4**] 03:15AM BLOOD PT-12.1 PTT-134.6* INR(PT)-1.1 ELECTROLYTES: [**2175-1-29**] 01:50PM BLOOD Glucose-155* UreaN-53* Creat-1.9* Na-129* K-5.7* Cl-96 HCO3-19* AnGap-20 [**2175-1-30**] 07:50PM BLOOD Glucose-129* UreaN-73* Creat-2.4* Na-130* K-4.7 Cl-95* HCO3-21* AnGap-19 [**2175-2-2**] 03:49AM BLOOD Glucose-213* UreaN-71* Creat-1.9* Na-131* K-3.8 Cl-94* HCO3-21* AnGap-20 [**2175-2-4**] 03:15AM BLOOD Glucose-95 UreaN-111* Creat-2.2* Na-136 K-4.4 Cl-97 HCO3-24 AnGap 19 LFTS: [**2175-1-31**] 07:50AM BLOOD ALT-125* AST-87* CK(CPK)-226 AlkPhos-141* TotBili-1.1 CEs: [**2175-1-29**] 01:50PM BLOOD CK-MB-8 proBNP-[**Numeric Identifier 5486**]* [**2175-1-29**] 01:50PM BLOOD cTropnT-2.13* [**2175-1-29**] 05:30PM BLOOD CK-MB-9 cTropnT-2.41* [**2175-1-30**] 01:49AM BLOOD CK-MB-10 MB Indx-5.8 cTropnT-2.77* [**2175-1-30**] 03:00AM BLOOD CK-MB-9 cTropnT-2.55* [**2175-1-31**] 05:00PM BLOOD CK-MB-36* MB Indx-13.2* cTropnT-2.68* [**2175-2-4**] 03:15AM BLOOD CK-MB-5 cTropnT-2.67* OTHER: [**2175-2-1**] 10:28AM BLOOD Lactate-1.2 [**2175-2-4**] 12:18PM BLOOD Lactate-8.5* [**2175-2-4**] 12:18PM BLOOD Type-CENTRAL VE pO2-39* pCO2-28* pH-7.30* calTCO2-14* Base XS--11 . URINE: [**2175-1-29**] 03:20PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2175-1-29**] 06:33PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE CULTURE (Final [**2175-1-30**]): NO GROWTH. URINE CULTURE (Final [**2175-1-31**]): NO GROWTH. blood cultures no growth to date on day of death. . IMAGING: CXR [**2175-1-29**] FINDINGS: Frontal and lateral views of the chest were obtained. Low lung volumes limit evaluation. There are bilateral pulmonary opacities which are most confluent in the lung bases. Central pulmonary hilar engorgement with interstitial and alveolar edema is present. Bilateral pleural effusions are small to moderate. No pneumothorax. Heart size appears enlarged though poorly assessed. Mediastinal contour is stable with atherosclerotic calcification along the aortic knob. Bony structures are intact. IMPRESSION: Findings compatible with pulmonary edema/heart failure. Small-to-moderate bilateral pleural effusions also present. . CXR: [**2175-2-2**] FINDINGS: As compared to the previous radiograph, there is a decrease in extent of the bilateral pleural effusions. Sequence decrease in severity of the basal areas of atelectasis. Unchanged moderate cardiomegaly, currently without evidence of pulmonary edema. . KUB [**2175-2-4**] ABDOMEN, SUPINE The distribution of gas in the abdomen is unremarkable. No edematous areas of bowel are seen. There is no evidence of obstruction or infarction. Vascular calcification is noted. . EKG on admission [**2175-1-29**]: Rate 133, atrial fibrillation with RVR, occasional PVCs, normal/borderline left axis deviation., LV hyprtrophy. normal rhythm, normal/borderline left axis, Q waves in III, V2-V4. ST segments depressed in I, AVL, V6 but unchaged from prior EKG. . ECHO [**2175-1-2**]: The left atrium is mildly dilated. The right atrium is moderately dilated. The left ventricular cavity is moderately dilated. There is mild to moderate regional left ventricular systolic dysfunction with inferolateral akinesis, inferior akinesis/hypokinesis and apical hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. On color Doppler imaging, there is an interatrial shunt consistent with stretched PFO or an atrial septal defect. (Images of the interatrial septum were suboptimal in the prior study). Compared with the prior study (images reviewed) of [**2174-7-4**], the mid anterolateral wall now appears more hypokinetic and the anterior apex is now hypokinetic (may have been foreshortened in the prior study). The aortic valve gradient is similar. Estimated pulmonary artery systolic pressure is now higher. . CARDIAC CATH: [**4-/2173**]: COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated severe three vessel disease. The LMCA had mild disease. The LAD had a 90% occlusion before S1 with filling of a small, diffusely diseased distal vessel via septal collaterals that was unchanged from [**2169**]. The LCx had four widely patent stents with no significant disease in the large major marginal. The very small marginals before the major marginal and AV Cx were occluded which was also unchanged from [**2169**]. The RCA was known occluded and was not injected; the distal vessel fills via septal collaterals. 2. Limited resting hemodynamics revealed moderate systemic hypertension with SBP of 162 mm Hg and DBP of 76 mm Hg. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease with patent LCx stents, unchanged from [**2169**]. 2. NSTEMI related to collateral insufficiency during rapid atrial fibrillation. . ECHO [**2175-1-31**] The left atrium is moderately dilated. 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. The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with inferior akinesis, inferolateral akinesis/hypokinesis, anteroseptal hypokinesis/akinesis and apical akinesis. No left ventricular thrombus identified but cannot exclude. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There is no ventricular septal defect. The remaining left ventricular segments contract normally. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [**2175-1-2**], left ventricular systolic function is now worse. Right ventricular systolic function is now worse. Tricuspid regurgitation is now more prominent. Brief Hospital Course: 85 year old gentleman with extensive cardiac history including BMS, CAD, CHF (EF40%), moderate AS 1.0-1.2, 3+ MR, CKD, HTN, HL, presents with 7-10 days of worsening SOB, edema in legs b/l, increased weight. These symptoms began with a URI at the same time. Had one episode of chest pain that resolved with sl nitro. Pt found to be in Afib with RVR. . # Chronic congestive heart failure with acute exacerbation: patient had increasing weight and pitting edema in lower extremities and increased shortness of breath prior to admission. These symptoms began with "URI symptoms" and one episode of chest pain that was likely a cardiac event. The patient takes 10 mg lasix daily at home. Was diuresed 2L on admission to floor but given back almost 1L in response to hypotension after developing afib/RVR. Lasix was held at that time. ECHO [**2175-1-31**] revealed severe AS valve area 1.0-1.2cm2 with 3+ mitral and tricuspid regurg and EF of 20%. . # abdominal distension and pain with elevated lactate - unclear etiology however on [**2175-2-4**] pt developed abdominal pain and distension which progressively worsened, KUB without evidence of obvious pathology. Suspicion for volvulus or some other intra-abdominal process causing ischemia. Pt developed worsening hypotension. Pt had been otherwise improving from a cardiovascular standpoint. Pt declined any surgical intervention and was made CMO. Pt [**Date Range **] on [**2175-2-4**]. . # Atrial Fibrillation with RVR: Pt was initially admitted to [**Hospital1 **]. On day of admission he flipped into AFib around 11pm, with decreased BP to 70s systolic. Was given 2.5 mg metoprolol with no improvement in HR, worsening BP. Patient has history of paroxysmal A-fib. Was given 5mg metoprolol with BP drop to MAP of 50 and minimal improvement in rate. Amiodarone was started for rate/rhythm control. Cardioversion was attempted x3 200, 300, 300 - unsuccessful. Pt received ketamine and versed during cardivoersion ettempt with further hypotension after shocks see hypotension below. The afternoon after cardioversion on [**2175-1-31**] pt spontaneously converted to sinus rhythm. He went back into afib on [**2175-2-1**] until he received IV metoprolol for an episode of ventricular tachycardia, see below, at which point he converted back to sinus with frequent ectopy. Infectious processes were ruled out as pt had no growth on blood and urine cultures and without evidence of localized infiltrate on CXR. . #ventricular tachycardia - on [**2175-2-2**] pt was in Afib but had roughly 3 minutes of ventricular tachycardia - this was asymptomatic and pt remained stable with slight decrease in blood pressure, maintained on pressors see hypotension below. Pt had no further episodes of sustained VT. . # Hypotension: In the setting of 2L diuresis on admission and recurrence of afib with RVR. Lowest MAPs were in the 50s immediately after metoprolol, but MAP generally around 60. Held home antihypertensives (isosorbide, metoprolol, lisinopril, lasix). Cardioversion was attempted, unsucessful as above but followed by further hypotension Maps in the 50s. Pt was started on neosynephrine for MAPs consistently below 55. PICC was placed on [**2175-2-1**]. . # Acute on Chronic Renal Failure: baseline creatinine is 1.3-1.5. He presented with creatinine of 1.9, creatinine trended up to peak at 2.4. Likely pre-renal given severe AS and severe MR. Pt then required pressors for 48 hours which was felt to be responsible as well. Pt was diuresed successfully and creatinine remained stable at roughly 2.0 . # Elevated troponins - likely MI. patient had one episode of chest pain that resolved with 2 SL nitroglycerin tabs. Patient has extensive cardiac history. Was found to have elevated cardiac enzymes in ED. Patient denies any other symptoms with chest pain including acute SOB, sweating, nausea, vomiting. Patient's EKG shows some changes since a year ago, but mainly q waves. The heart axis is more leftward than a year ago. It was suspected that pt had experienced an MI which explained the troponin bump and symptoms. . # Hypertension: history of hypertension. Held home antihypertensives in the setting of hypotension. Is on lisinopril, isosorbide, lasix at home. . # Hypercholesterolemia: started atorvastatin 80 (on simva 80 at home). . # oliguria - felt to be secondary to poor perfusion of kidneys in setting of hypotension requiring pressors, see [**Last Name (un) **] above. Resolved with successful diuresis in response to lasix. . #Hyperkalemia - K of 5.7 on presentation, felt secondary to [**Last Name (un) **]. Resolved, pt asymptomatic. No ECG changes of hyperkalemia. . #hyponatremia: presented with Na of 129. Sodium remained in the low 130s for several days but improved with optimization of volume status, see CHF above. Medications on Admission: ALLOPURINOL - 300 mg daily CLOPIDOGREL [PLAVIX] - 75 mg daily DUTASTERIDE [AVODART] - 0.5 mg qHS FUROSEMIDE - 10 mg QDAILY ISOSORBIDE MONONITRATE - 60 mg daily LISINOPRIL - 10 mg daily METOPROLOL SUCCINATE [TOPROL XL] - 200 mg daily SIMVASTATIN - 80 mg daily ASCORBIC ACID [VITAMIN C] - 500 mg daily ASPIRIN - 81 mg daily DOCUSATE CALCIUM - 240 mg daily FERROUS SULFATE - 325 mg daily Discharge Medications: n/a Discharge Disposition: [**Last Name (un) **] Discharge Diagnosis: congestive heart failure Discharge Condition: [**Last Name (un) **] Discharge Instructions: n/a Followup Instructions: n/a

Admission Date: [**2145-9-4**] Discharge Date: [**2145-9-7**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: hypoxia & hypotension Major Surgical or Invasive Procedure: Expired History of Present Illness: This is a [**Age over 90 **] y/o woman with DM2, CAD, CHF EF 40% and recurrent pneumonias, DNR/DNI, presented from Heb Reb with persistent cough/SOB, hypoxia/tachypneic after 3d keflex and azithromycin until [**8-26**], started MUST protocol for presumed pneumonia. Became progressively more hypoxic and hypotensive over the 24 hours in the ED, Got one dose of levaquin, flagyl, vanco, ceftazidine, was on levophed but weaned off with 4L IVF. Past Medical History: CAD, CHF EF35-40%, pulm HTN, LVH, 1+MR and mod-severe AS, HTN, DM2, h/o atrial tach/A fib/flutter rate controlled on coumadin, known recurrent pleural effusions-transudative, recurrent pna and aspirations, CVA with R hemiparesis, parkinsons, depression, spinal stenosis, LBP Social History: Lives at [**Hospital 100**] Rehab Family History: n.c. Physical Exam: 97.7, 97% NRB, 24, 96, 109/47, . General:pleasant, elderly woman, looking fatigued but conversant Heent:anicteric, mmm, supple neck CV:prominent JVD and JVP at 12 cm, tachy rate, quiet s1 and s2, did not hear s2 split, 3/6 systolic m at LSB, [**12-25**] late-peaking systolic murmur at base, no R/G Resp:accessory mm use, tachypneic on NRB, I:E 1:2, crackles throughout respiratory cycle Abd:soft, distended, nontender, no organomegaly, no bruits, cherry angiomata Extrem:no c/c/edema, radial 2+ b/l delayed upstroke, dp 1+ b/l Neuro:CN 2-12 grossly intact, alert, oriented to self, location, situation Skin: warm, no rashes, did not evaluate back/sacral area yet Access: R IJ TLC with considerable oozing, foley . Pertinent Results: EKG: irreg ectopic atrial, 110, nl axis, st depressions v5/v6, I,L, TWI v4 by [**9-4**] rate 95 with near-resolution of ST/TW changes noted . CXR:R pleural effusion, no distinct infiltrate . Brief Hospital Course: Pt was admitted to the [**Hospital Unit Name 153**] on the MUST protocol with a RIJ and on pressors. The patient was in respiratory distress and hypoxia. The patient was started on levaquin/vanco/cefipime for nosocomial pneumonia. Pressors were weaned off and patient was transferred to the floor after gentle diuresis. Within one day, the patient was again hypoxic and hypotensive and was transferred to the [**Hospital Unit Name 153**]. At this time, after discussion with her daughter, her health care proxy, the patient was made "CMO" (comfort measures only) and a morphine drip was started. At 5:58pm, the patient expired. Medications on Admission: Discharge Medications: Discharge Disposition: Home Discharge Diagnosis: Pneumonia Pneumonia Discharge Condition: Expired Expired Discharge Instructions: Pt expired Pt expired Followup Instructions: Expired

Admission Date: [**2172-8-25**] Discharge Date: [**2172-9-6**] Date of Birth: [**2114-3-8**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: dyspnea, hoarseness, and cough Major Surgical or Invasive Procedure: Bronchoscopy x2 Tracheal Y-stent placement [**2172-8-25**] Pigtail catheter placement (right) [**2172-8-25**] for pleural effusion Intubation [**2172-8-25**], re-intubated [**2172-8-26**] after attempted extubation Chest tube placement (right) [**2172-8-26**] for pneumothorax Radiation therapy x2 Chemotherapy x3days Lumbar puncture [**2172-9-3**] History of Present Illness: 58 year-old female, 60 pack-year smoker, with dyspnea, hoarseness, and cough x1 month admitted to [**Hospital1 18**] SICU [**2172-8-25**] after found to have large mediastinal mass, today found to be poorly-differentiated carcinoma, suspected small cell. On initial evaluation, patient was found to have 3mm opening of distal trachea secondary to external compression from mediastinal mass, RUL mass, RUL collapse, and clinical findings consistent with SVC sydrome. Y-stent was placed that evening, in addition to Pigtail catheter for right-sided effusion. Patient remained intubated following surgery, on paralytics due to low-lying ET tube and small volume bleeding after endobronchial biopsy. On [**2172-8-26**], extubated was attempted. Patient was reintubated within 10 minutes due to neurological unresponsiveness, hypoxia (O2 saturation 80s), and hemodynamic instability. She was found to have a right pneumothorax, which improved with subsequent placement of chest tube. Patient was also noted to have pericardial effusion; given absence of physiologic tamponade, cardiology decided against pericardiocentesis. . Hospital course also complicated by hyponatremia on admission (Na 118) attributed to SIADH and improved with fluid restriction (Na 126). Also with hypotension (sBP 90s) following reintubation on [**2172-8-26**]. Given hyperkalemia, hyponatremia adrenal insufficiency was suspected; evaluated by endocrine team who recommended stress dose steroids pending further evaluation of etiology of hypotension. Also with non-anion gap metabolic acidosis, transient hypothermia (T 95 [**2172-8-26**]) of unknown etiology. . Per report, patient has done well today. She remains intubated, on pressure support. Given the above pathology results, patient is transferred to the medical ICU ([**Hospital Ward Name 332**]) for radiation therapy. . On arrival to the [**Hospital 332**] medical ICU, patient is intubated, sedated, and unable to provide history. Past Medical History: Hypertension s/p cerebral sneurysm repair x3 GERD Social History: Per review of records, 60 pack-year history Family History: Unable to obtain. Physical Exam: On [**Hospital Unit Name 153**] admission [**2172-8-27**]: 96.0, 103, 120/68, 13, 97% [PS 14/5 50%] General: Intubated, sedated, not responsive to verbal stimuli; swelling of head, neck, and upper extremities; wasting of lower extremities Skin: Mottled at arms and superior to nipple line; telangiectasias on chest wall HEENT: Temporal wasting; pupils symmetric, minimal reactivity to light; sclerae anicetric; scleral edema; dry mucous membranes Neck: Large; unable to appreciate neck veins secondary to swelling; right anterior chain palpable lymph node Chest: Right chest tube, pigtail catheter in place Lungs: Upper airway noise; by anterior ausculation, few expiratory wheezes diffusely; breath sounds appreciable in all lung fields CV: Tachycardic; regular rhythm; pronounced S2 at apex; I/VI early systolic murmur at left LLSB; unable to assess pulsus paradoxus given quiet Korsakoff sounds Abdomen: Hypoactive bowel sounds; soft, non-distended GU: Foley Ext: Right DP 1+, left DP appreciated with Doppler; no lower extremity edema; upper extremity nonpitting edema Pertinent Results: On admission [**2172-8-26**]: WBC-11.1* RBC-3.47* Hgb-10.9* Hct-31.9* MCV-92 MCH-31.5 MCHC-34.2 RDW-12.5 Plt Ct-393 Glucose-112* UreaN-9 Creat-0.8 Na-118* K-4.8 Cl-82* HCO3-24 AnGap-17 ALT-7 AST-21 LD(LDH)-584* AlkPhos-75 TotBili-0.2 Cortsol-25.7* Hgb-13.5 calcHCT-41 O2 Sat-82 . Imaging: [**8-25**] CT Chest without contrast: 1. Large mediastinal mass causes narrowing of the right pulmonary artery, superior vena cava, and trachea and occlusion of the pulmonary artery supplying the right upper lobe in addition to the right upper lobe bronchus. These findings are most concerning for a primary lung carcinoma. 2. Right upper lobe collapse with nonenhancing lung parenchyma. Tumor involvement cannot be excluded. Atelectasis of the right lower and middle lobe. 3. Large right pleural effusion. . [**8-25**] Tracheal mass tissue pathology: Immunohistochemical studies show that tumor cells are positively stained by TTF-1 and CK7; they are negative for CK20, chromogranin, and synaptophysin. The tumor shows areas of necrosis, extensive apoptosis and focal lymphatic vascular invasion; some areas the tumor cell size approaching that of a small cell carcinoma, but much of the tumor has larger nuclei. Overall, the tumor probably fits into the spectrum of a small cell carcinoma of lung. . [**8-26**] Pleural fluid cytology: Rare groups of epithelioid cells, too few to characterize further. By immunohistochemistry: mesothelial cells stain for calretinin and WT-1. Epithelial markers [**Last Name (un) **]-31, CEA, and B72.3 are negative. Rare cells are highlighted by TTF-1; however, these cells are not cytologically atypical and may represent non-specific reactivity. . [**8-26**] EKG: Sinus tachycardia. Low QRS voltage in limb leads. No previous tracing available for comparison. . [**8-26**] Echo: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a small to moderate sized, primarily anterior pericardial effusion without right ventricular diastolic collapse. IMPRESSION: Suboptimal image quality. Mild-moderate, primarily anterior pericardial effusion. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. If clinically indicated, a follow-up study is suggested. . [**8-27**] CT chest/abdomen/pelvis with and without contrast: 1. Vascular findings unchanged from [**2172-8-25**]. Narrowing of SVC and left brachiocephalic vein by large mediastinal mass. The SVC is narrowed to approximately 5 mm over a region extending 3 cm in craniocaudal dimension. Indirect evidence of right brachiocephalic vein occlusion, likely complete. Unchanged narrowing of right pulmonary artery. Splayed but patent aortic arch branches. 2. Interval decrease in large right pleural effusion, with small anterior pneumothorax. Right chest tube terminating at apex. 3. No interval change in large infiltrative hypoattenuating right hilar/mediastinal mass. 4. No evidence of metastases in the abdomen or pelvis. Slightly bulky left adrenal gland without discrete nodule or mass. 5. Anasarca and small amount of peritoneal fluid collecting in the pelvis, likely related to edema. 6. Interval tracheal stenting with improved caliber of airway. . [**2172-8-27**] ECHO: Compared with the prior study (images reviewed) of [**2172-8-26**], the size of the pericardial effusion is unchanged with no signs of tamponade. The left ventricle seems to be underfilled. . [**8-28**] CT Head: 1. Within limits of this modality, no evidence of enhancing mass or edema to suggest metastatic disease. 2. Status post bilateral frontal craniotomy and probable aneurysm clipping with encephalomalacic changes in the right frontotemporal and left temporal lobes. No evidence of acute hemorrhage or infarct. 3. Probable chronic bifrontal subdural hygromas with minimal mass effect on the subjacent frontal gyri; these may relate to the extensive remote surgery . [**2172-9-2**] CT Head (performed due to worsened mental status): 1. Unchanged examination from recent exam of [**2172-8-28**]. 2. Status post bilateral frontal craniotomies with aneurysm clipping and encephalomalcia, as described above. No evidence of acute hemorrhage or infarct. . [**2172-9-3**] Renal US: 1. Mildly echogenic kidneys consistent with medical renal disease. There is no evidence of hydronephrosis, stone, or mass. 2. The left kidney remains atrophic and lobulated, similar to [**2172-8-27**]. . [**2172-9-4**] CT Chest w/o contrast (to evaluate tumor s/p XRT and chemo for future XRT sessions): 1. Right anterior pneumothorax has resolved. 2. Mixed response of the tumor to radiotherapy with a decrease of the central component of the tumor and a mixed response of the peripheral tumor components: 3. The peripheral consolidations in the right upper lobe have overall decreased in size, however, a new cavitary lesion has formed measuring 11 x 19 mm. 4. The peripheral consolidations in the right lower lobe and left lower lobe have increased in size, number and density and may be part of post- obstructive, post-radiotherapy, post-infectious, or acute inflammatory changes. 5. Lymphangio-carcinomatosis in the right upper lobe. 6. There is new small right pleural effusion and increased moderate left pleural effusion. 7. Left adrenal gland mass is only partially visualized in this study. . [**2172-9-3**] EEG: Markedly abnormal portable EEG due to the very disorganized and slow background rhythms. This suggests a widespread and moderately severe encephalopathy in both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. Although there were fleeting asymmetries, there was no reliable area of focal slowing. Encephalopathies may obscure focal findings. There are some sharp features, but no clearly epileptiform abnormalities and no electrographic seizures. . [**2172-9-5**] LENI: no DVT . [**2172-9-5**] ECHO: final read pending . Micro: [**2172-8-26**] Pleural fluid: GRAM STAIN (Final [**2172-8-26**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2172-8-29**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2172-9-1**]): NO GROWTH. ACID FAST SMEAR (Final [**2172-8-27**]): no AFB seen on direct smear ACID FAST CULTURE (Preliminary): PENDING Cytology: Atypical cells, non-specific findings . [**2172-9-4**] BAL: GRAM STAIN (Final [**2172-9-4**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): . [**2172-9-3**] CSF: GRAM STAIN (Final [**2172-9-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. Cytology: no malignant cells . C. diff negative . [**8-30**] Blood Cx ?????? NGTD [**9-5**] Blooc cx - pending . Bronchoscopy [**2172-9-4**]: lots of necrotic tissue noted, ETT tube dislodged between stent and tracheal wall, repositioned during bronch. Brief Hospital Course: [**Hospital Unit Name 153**] Course [**Date range (3) 84902**] 58F with likely small cell carcinoma complicated by SVC syndrome, airway compromise requiring Y-stent, pericardial effusion, resolved pleural effusion and pneumothorax, and electrolytes disturbances admitted to [**Hospital Unit Name 153**] for radiation decompression therapy and chemotherapy. Pt developed respiratory failure and renal failure. . #. Hypoxic respiratory failure: Pt was initially transferred from SICU to [**Hospital Unit Name 153**] on CPAP/PS. She developed increasing respiratory failure and was changed to AC mode. In the [**Hospital Unit Name 153**], she underwent XRT x2 and then chemotherapy for 3 days. Increased hypoxia may have been due to pneumothorax, which resolved, pleural effusions, atelectasis, possible VAP, tumor compression. During hypoxic episodes, pt underwent bronchoscopy twice, both times of which demonstrated the ETT lodged between tracheal wall and stent. Pt's saturation improved with repositioning. Respiratory status also complicated by possible underlying COPD given smoking history with possible air stacking/trapping. Pt was started on vancomycin, cefepime and ciprofloxacin (started [**2172-8-31**] for 8 day course) for VAP. Vanco was later held as the level was elevated in the setting of renal failure. Patient's family decided to persue comfort only care on [**2172-9-6**], and she was terminally extubated. Patient expired 15 minutes later from respiratory failure and asystole secondary to lung cancer. . # Altered Mental Status: Pt had decline in mental status over time. She initially withdrew from noxious stimuli but later was less responsive. AMS continued despite sedation being off. AMS most likely due to toxic metabolic syndrome in setting of uremia and multi-system organ failure. Differential also included seizure (given hx of cerebral aneurysm repair, on anti-epileptics presumably prophylactically) although EEG did not demonstrate focal abnormalities. LP did not demonstrate infection or spread of malignancy. CT head [**2172-9-2**] negative for acute process. . #. Small cell lung carcinoma: per pathology, the tumor probably fits into the spectrum of a small cell carcinoma of lung. Given associated SVC syndrome, prognosis poor. CT head/[**Last Name (un) 103**]/pelvis negative for metastases. Pt underwent 3 days of chemotherapy and 2 sessions of XRT. Initially, XRT was clinical emergency - normal and pathologic tissue was likely treated; necrotic tissue noted on bronchoscopy [**2172-9-4**]. Pt was to undergo formal tissue planning session on [**2172-9-8**] to better delineate area of radiation however family decided to persue comfort only care on [**2172-9-6**]. . # Acute Renal failure: In setting of chemo with carboplatin. Urine casts consistent with ATN. Uric acid and electrolytes elevated 4-5d post chemotherapy concerning for tumor lysis syndrome. The next therapeutic step was dialysis as patient became oliguric despite volume overload but the family wished for comfort only care given dismal prognosis of her lung cancer. . #. Metabolic acidosis: Originally thought to be non-gap metabolic acidosis due to hypoaldosteronism and type IV RTA. With low albumin, however, this is a gap metabolic acidosis, most likely due to uremia. Unable to increase RR to compensate due to concern for auto-peeping in setting of possible COPD. Goal pH is 7.3-7.35. On [**2172-9-5**], pt's acidosis worsened with pH 7.16-7.18. Despite adjusting ETT placement and decreasing RR to reduce auto-peep, pt's acidosis worsened. Bicarbonate was given. . # Tachycardia/Hypotension ?????? Pt with tachycardia to 140s and episodes of hypotension to SBP low 80s. Pt with new A-fib on telemetry and EKG. DDx includes possible enlarging pericardial effusion/tamponade but pulsus paradoxus was normal and ECHO [**2172-9-5**] was unchanged from prior. No pneumothorax seen on CXR. Unable to assess for PE by CTA as pt in renal failure and VQ would not be helpful in setting of other lung pathology. LENI's negative for DVT. PE likely given malignancy and prolonged bed rest but unable to do CTA given renal failure and VQ scan not helpful in setting of lung changes. Even if it had been positive, heme/onc recommended against anti-coagulation in setting of possible tumor necrosis/hemorrhage. Pt remained tachycardic to 130s despite numerous fluid boluses. . #. Electrolyte disturbances: Pt developed hypernatremia on [**2172-9-4**] most likley due to dehydration with free water deficit of 1.4L, started on D5W. Pt had hyponatremia and hyperkalemia on admission, both resolved. Unclear etiology of electrolyte disturbances on admission- hyponatremia thought to be secondary to possible adrenal insufficency (now discarded) or possibly SIADH. Low UNa does not exclude SIADH; renal recommended rechecking urine lytes with saline load, whcih was not done in setting of pt??????s other medical issues. Hyperkalemia originally attributed to hypoaldosteronism and Type IV RTA, but unlikely per endocrine because of low urine sodium. . #. SVC syndrome: Incomplete occlusion of SVC; near complete occlusion of brachiocephalic veins. Clinically identified by upper extremity and facial swelling/plethora and mottled skin. Also with scleral edema. Unable to assess jugular venous distension given considerable swelling. Seen in appoximately 10% cases of SSLC. Improved edema on exam compared to admission. SVC syndrome occurred after Y-stent placed. Possible that tumor pushing into trachea shifted to compress SVC after stent placement. She underwent radiation therapy and chemotherapy for decompression. . #. Pleural effusion: s/p right pigtail catheter placement [**2172-8-25**], removed [**2172-8-31**]. LDH effusion/serum 0.68 (exudate by Light??????s criteria). Greatest concern for malignant effusion however cytology was nonspecific. Cultures of fluid all preliminary negative. . #. Pneumothorax: Developed pneumothorax in setting of re-intubation that resolved after chest tube placement. . #. Pericardial effusion: Suspected by cardiology to be malignant effusion. Felt not to be large enough for percutaneous drainage. EKG without signs of electrical alternans but does have low voltages. Repeat ECHO done [**2172-9-5**] in setting of hypotension demonstrated no change in pericardial effusion. . # Sinus Pause on telemetry: Pt had episodes of sinus pauses on tele night of [**8-30**] with turning to right side. Occurred again [**2172-9-4**] again with re-positioning. Metoprolol was held and glucagon given in case this was due to beta blocker toxicity, but pauses decreased in frequency and duration on their own without intervention. Cardiology consulted who felt it was vagally mediated. [**Month (only) 116**] have been due to ETT tube displacement pressing on carotid when pt was turned. . # Leukopenia/thrombocytopenia ?????? Most likely due to chemotherapy and no improvement in counts on neupogen. She was repeatedly pan-cultured with negative results. . #. Anemia: Normocytic and likely due to anemia of chronic disease given malignancy. Hemolysis labs were negative. . # s/p cerebral aneurysm repair: History of cerebral aneurysm repair with a number of chronic changes on head CT. Her antiepileptic medications were continued. Medications on Admission: Home medications: Metoprolol Omeprazole Levetiracetam Carbatrol Medications on transfer to [**Hospital Unit Name 153**] [**2172-8-27**]: Furosemide 10 mg IV ONCE Duration: 1 Doses Carbamazepine 900 mg PO QPM Carbamazepine 400 mg PO QAM Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes Potassium Phosphate IV Sliding Scale Insulin SC Sliding Scale Insulin Regular 10 UNIT IV ONCE, Dextrose 50% 25 gm IV ONCE Duration: 1 Doses 08/20 @ 0608 Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO moderate/heavy sedation Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **] Hydrocortisone Na Succ. 100 mg IV Q8H Nicotine Patch 14 mg TD DAILY LeVETiracetam 500 mg IV BID Magnesium Sulfate IV Sliding Scale Calcium Gluconate IV Sliding Scale Potassium Chloride IV Sliding Scale Albuterol-Ipratropium [**1-10**] PUFF IH Q6H Pantoprazole 40 mg IV Q24H Heparin 5000 UNIT SC TID Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Admission Date: [**2159-7-28**] Discharge Date: [**2159-8-13**] Date of Birth: [**2106-12-11**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 52-year-old man who woke up on the day of admission with the worst headache of his life. He fell to the floor unconscious. There were no neurologic deficits. He was taken to [**Doctor Last Name 40277**] Hospital, where a head CT revealed a subarachnoid [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for further management. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: 1. Umbilical hernia repair. 2. Status post knee surgery. MEDICATIONS: None. ALLERGIES: None. HOSPITAL COURSE: The patient was taken to angio upon arrival, which revealed an ACOM aneurysm and he was taken to the operating room and underwent clipping of the aneurysm. He tolerated the procedure well with no intraoperative complications. VITAL SIGNS: Heart rate 57, blood pressure 113/60, respiratory rate 17, saturations 98%. Postoperatively, he was alert, oriented times three. Sensation was grossly intact. Pupils equal, round, and reactive to light. Cranial nerves II through XII intact. CARDIOVASCULAR: Regular rate and rhythm. RESPIRATORY: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No clubbing, cyanosis or edema. The patient was status post craniotomy with clipping of an ACOM aneurysm. He was in stable condition. The patient also had vent drain placed at the time of surgery. On [**7-30**], the patient was somewhat sleepy. The patient received a 500 cc fluid bolus. He also had question of a right drift. The patient was taken to angio for evaluation for vasospasm, which was negative. On [**2159-8-2**], the patient went back to angio, which showed no residual aneurysm and minimal vasospasm. There was no treatment done at that tine. The patient was transferred back to the Intensive Care Unit for close monitoring. On [**2159-8-4**], the patient spiked to 102. CSF was sent for culture. The patient continued to be on a high rate of IV fluid and monitored for vasospasm. He was alert, oriented times three with slight right pronator drift. The patient remained neurologically stable with drain, eventually raised up to 20 cm above the tragus on [**2159-8-7**]. All cultures to date have been negative. The patient continued to have low grade temperature. Vital signs were stable. He was afebrile. CSF was negative. On [**2159-8-9**], the patient neurologically was awake, alert, and oriented times three. Face was symmetrical with no drift and he was moving all extremities with good strength. The ventriculostomy drain was discontinued. On [**2159-8-10**], the patient had LP to check opening pressure, which was 22. Ventriculostomy drain was discontinued on the 26th. The patient was transferred to the regular floor on [**2159-8-10**] in stable condition. The patient was seen by the Departments of Physical Therapy and Occupational Therapy. On [**8-13**]/2902 the patient had a repeat head CT, which showed increased size of the ventricles. He had LP, which did not show a significant opening pressure. The patient was discharged to home in stable condition with followup with Dr. [**Last Name (STitle) 1132**] in one to two weeks. MEDICATIONS ON DISCHARGE: 1. Dilantin 100 mg PO t.i.d. 2. Nimodipine 60 mg q.4h. 3. Senna one tablet PO b.i.d. 4. Colace 100 mg PO b.i.d. 5. Zantac 150 mg PO b.i.d. CONDITION ON DISCHARGE: Stable on discharge. FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 1132**] in two weeks' time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2159-11-14**] 11:38 T: [**2159-11-14**] 11:49 JOB#: [**Job Number 43164**]

Admission Date: [**2171-3-26**] Discharge Date: [**2171-3-29**] Date of Birth: Sex: F Service: GYN/ONCOLOGY HISTORY OF PRESENT ILLNESS: The patient is a 58 year-old P3 who presented to Dr. [**First Name (STitle) 1022**] with a large pelvic mass. She had a history of undergoing exploratory laparotomy for appendicitis in [**2170-5-28**]. At that time a necrotic right fallopian tube was excised and the patient was noted to have a pelvic mass. No further follow up until recently when she presented to [**Hospital6 1597**] with severe anemia and a gastrointestinal bleed. She had a transfusion with 7 units of whole blood. She had a CT during her hospitalization, which revealed a large abdominal and pelvic mass. She had a full gastrointestinal evaluation, which included an upper endoscopy, colonoscopy and small bowel follow through all of which were negative. The patient states that during colonoscopy the right side of the colon could not be visualized due to the presence of the mass. The patient complains of nausea and increased abdominal girth. She has chronic constipation and there is nothing new. There is no other change in bowel or urinary habits. She denies any vaginal bleeding and any weight loss. PAST MEDICAL HISTORY: 1. Hypertension. 2. Psoriasis. 3. Chronic pain syndrome. PAST SURGICAL HISTORY: Uterine embolization [**2169-11-28**]. Tubal ligation in [**2143**]. Decompression and fusion [**2169**]. Appendectomy [**2169**]. Multiple breast adenoma excisions. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Tylenol. 2. Lasix. 3. Ativan. 4. OxyContin. 5. Celexa. 6. Atarax. 7. Neurontin. OB HISTORY: Vaginal delivery times three. GYN HISTORY: Last pap smear several years ago normal. Last mammogram [**2171-1-26**] normal. FAMILY HISTORY: Significant for mother with breast cancer. Sister with anal cancer and a brother with skin cancer. SOCIAL HISTORY: The patient does not smoke or drink. She is a retired nurse. REVIEW OF SYSTEMS: As above and otherwise noncontributory. PHYSICAL EXAMINATION: General appearance, well developed, well nourished, thin. HEENT lymph node survey was negative. Lungs were clear to auscultation. Heart was regular rate and rhythm without murmurs. Breasts were without masses. Abdomen was soft and moderately distended. There was a large palpable mass in both the upper and lower abdomen. There was no evidence of ascites. Extremities were without edema. On bimanual examination vulva and vagina were normal. The cervix was normal. Bimanual rectovaginal examination revealed a large pelvic mass, which was somewhat ill-defined. There was no cul-de-sac nodularity and the rectum was intrinsically normal. It was explained to the patient that this mass could be benign or malignant and it was recommended to undergo surgical excision including exploratory laparotomy, TAH/BSO and resection of the mass. The risks and benefits were discussed. Surgical consent was signed. HOSPITAL COURSE: The patient underwent an examination under anesthesia, exploratory laparotomy, TAH/BSO and resection of a pelvic mass on [**2171-3-26**]. Intraoperative findings include an enlarged uterus with a subserosal fibroid and evidence of tumor extending to the right lateral rectoperitoneum as well as centrally and left into the sigmoid and small bowel mesentery up to the splenic flexure of the colon. The anatomic survey was otherwise unremarkable. There was subcentimeter periaortic lymph nodes and normal ovaries bilaterally with 2 liters of bloody ascites in the abdomen. Estimated blood loss 3 liters. Secondary to the patient's blood loss, large amount of ascites and extensive surgery, the patient was admitted to the Intensive Care Unit for critical care. On postoperative day zero her vital signs were stable. Her abdomen was nondistended with only a small amount of drainage from the inferior aspect of the incision. The patient's hematocrit was 27.2, INR 1.2, PTT 28.3, electrolytes were within normal limits. The patient at this time had been transferred to the unit for further monitoring. She had been given 7 units of packed red blood cells. She was in stable condition. Postoperative day one the patient's vital signs continued to be stable with adequate urine output overnight. Her examination was appropriate postoperatively. On postoperative day one hemodynamically yesterday's hematocrit was 27, which improved to 34 after 2 more units of packed red blood cells. There is no evidence of ongoing intraabdominal bleeding. Fluids, electrolytes and nutrition: the patient had adequate urine output with no evidence of fluid overload. Pain, the patient was on a Dilaudid PCA. On postoperative day two the patient was extubated. Her pain was controlled. She was tolerating clears. No nausea or vomiting. No chest pain or shortness of breath. She was afebrile. Her vital signs were stable. She had adequate urine output. Her most recent hematocrit was 34.5. Her electrolytes were within normal limits. Her abdomen was appropriately tender and nondistended. Renal: her urine output was normal. Her Foley catheter was discontinued. Her creatinine was 0.6. The patient was encouraged to ambulate. Her diet was advanced. Hematology: patient had 9 units of packed red blood cells, 4 units of fresh frozen platelets. Her blood pressure was stable. Her hematocrit was 34.5. Coumadinization was started on postoperative day two. Pulmonary, the patient's supplemental oxygen was weaned for oxygenation of greater then 93%. On postoperative day three the patient was without complaints. She was tolerating clears. The pain was adequately controlled on 40 mg of OxyContin t.i.d. and Percocet for breakthrough pain. Cardiovascularly the patient has a history of hypertension, which was controlled with Lasix 40 mg q day. The patient was deemed stable enough for discharge to home. DISCHARGE DIAGNOSES: 1. Pelvic mass status post exploratory laparotomy, pelvic washings, TAH/BSO, pelvic mass resection. 2. Blood loss anemia requiring blood transfusion. 3. Hypertension. 4. Chronic pain syndrome. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient was discharged to home without services. She will follow up with Dr. [**First Name (STitle) 1022**] as an outpatient in approximately two weeks for postoperative visit. DISCHARGE MEDICATIONS: 1. Percocet. 2. Motrin. 3. Celexa. 4. Lasix. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 16-314 Dictated By:[**Last Name (NamePattern1) 6763**] MEDQUIST36 D: [**2171-9-30**] 02:41 T: [**2171-10-1**] 08:23 JOB#: [**Job Number 49231**]

Admission Date: [**2167-10-30**] Discharge Date: [**2167-10-31**] Date of Birth: [**2134-3-3**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 3984**] Chief Complaint: ALTERED MENTAL STATUS, HYPONATREMIA Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: 33 yo F with h/o asthma, anxiety (not on medication). Has had BRBPR with blood on toilet paper. Changed diet about 5 days prior and was reporting feeling light headed. Asked to get colonoscopy by GI at [**Hospital1 112**], and had bowel prep in progress. Also drinking lots of GatorAid. Was attempting prep late last night. About 10pm, started vomiting at home. Called 911, despite husband's reassurances. Husband believed she was simply anxious. EMS arrived at 1:30AM, found to be frankful delusional, with thought of 'limb swelling'. No h/o psychiatric hospitalizations, not currently taking psychoactive medications. Upon arrival, was found by ED resident to be crawling across the floor, crying out for help. Serum osms very low. ? Seizure by ED resident although no activity observed. Found to be hyponatremic at 122 and diaphoretic. Serum Tox negative, no h/o ingestion. Given continued confusion, attempted LP in ED, given Ativan 4mg in process. Could not obtain by either resident or Attending. Given Ceftriaxone and Azithromycin for meninigitis to cover infection. Did get stat head CT without r/o ICH. Started on hypertonic saline, in consultation with pharmacy --> 350 cc of current hypertonic saline; first 8 hours correct half (not more than 10u). 45cc x next 8 hours total. Then gets second half over 24 hours at 15cc/hr. Also getting KCl through IV. HR 60s, SBP 95-115, RR 20s, 99% on RA. Daughter is [**Name2 (NI) **] with fever (stated to be viral infection by Pediatrician, F 103.2) and Ms. [**Known lastname 19916**] apparently felt unwell prior to incident. Past Medical History: Asthma Anxiety G1P1 Social History: Lives with husband and one daughter who is an infant. No tobacco use, EtOH or other medications. Family History: Non-Contributory Physical Exam: 96.7, 101, 108/88, 18, 99/RA GEN: Appears distressed, not responsive to verbal stimuli HEENT: NCAT, PERRL, symmetric, could not assess oropharynx CV: Mildly tachycardic, no m/g/r PULM: CTAB anteriorly and posteriorly without w/r/r ABD: Soft, active BS, no palpable masses EXT: WWP with 2+DP pulses bilaterally NEURO: Withdraws to painful stimuli, does not respond to voice, withdraws to sternal rub, toes downgoing b/l PSYCHE: Difficult to assess [**2-14**] mental status Pertinent Results: Admission Labs: [**2167-10-30**] 02:00AM WBC-13.1* RBC-3.98* HGB-12.2 HCT-33.7* MCV-85 MCH-30.7 MCHC-36.2* RDW-12.6 [**2167-10-30**] 02:00AM NEUTS-81.9* LYMPHS-15.9* MONOS-1.8* EOS-0.3 BASOS-0.1 [**2167-10-30**] 02:00AM PLT COUNT-250 [**2167-10-30**] 02:00AM PT-13.8* PTT-36.6* INR(PT)-1.2* [**2167-10-30**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2167-10-30**] 02:00AM HCG-<5 [**2167-10-30**] 02:00AM CORTISOL-42.5* [**2167-10-30**] 02:00AM TSH-3.1 [**2167-10-30**] 02:00AM OSMOLAL-254* [**2167-10-30**] 02:00AM calTIBC-280 FERRITIN-57 TRF-215 [**2167-10-30**] 02:00AM IRON-108 [**2167-10-30**] 02:00AM LIPASE-22 [**2167-10-30**] 02:00AM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-55 TOT BILI-1.5 [**2167-10-30**] 02:00AM CREAT-0.6 SODIUM-121* POTASSIUM-3.2* [**2167-10-30**] 02:55AM GLUCOSE-153* LACTATE-3.4* NA+-122* K+-2.9* CL--91* TCO2-19* [**2167-10-30**] 02:55AM PH-7.38 COMMENTS-GREEN TOP [**2167-10-30**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2167-10-30**] 03:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2167-10-30**] 03:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2167-10-30**] 03:00AM URINE OSMOLAL-314 [**2167-10-30**] 03:00AM URINE HOURS-RANDOM UREA N-272 CREAT-48 SODIUM-59 POTASSIUM-28 CHLORIDE-79 [**2167-10-30**] 05:06AM NA+-120* K+-2.7* CL--95* [**2167-10-30**] 11:10AM URINE OSMOLAL-504 [**2167-10-30**] 11:10AM URINE HOURS-RANDOM UREA N-222 CREAT-30 SODIUM-175 [**2167-10-30**] 11:10AM OSMOLAL-247* [**2167-10-30**] 12:42PM ALBUMIN-3.9 [**2167-10-30**] 12:42PM ALBUMIN-3.9 [**2167-10-30**] 12:42PM GLUCOSE-110* UREA N-5* SODIUM-122* POTASSIUM-3.9 CHLORIDE-92* TOTAL CO2-20* ANION GAP-14 [**2167-10-30**] 05:40PM OSMOLAL-263* [**2167-10-30**] 05:40PM CALCIUM-8.4 PHOSPHATE-2.5* MAGNESIUM-2.1 [**2167-10-30**] 05:50PM URINE OSMOLAL-74 [**2167-10-30**] 05:50PM URINE HOURS-RANDOM CREAT-7 SODIUM-22 CHLORIDE-19 [**2167-10-30**] 11:15PM URINE OSMOLAL-113 [**2167-10-30**] 11:15PM URINE HOURS-RANDOM CREAT-16 SODIUM-28 CHLORIDE-31 [**2167-10-30**] 11:15PM SODIUM-131* . Pertinent Labs: [**2167-10-31**] 04:14AM BLOOD WBC-8.8 RBC-4.07* Hgb-12.7 Hct-34.2* MCV-84 MCH-31.1 MCHC-37.0* RDW-12.8 Plt Ct-232 [**2167-10-31**] 04:14AM BLOOD Plt Ct-232 [**2167-10-31**] 12:22PM BLOOD Na-139 K-3.8 [**2167-10-31**] 04:14AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.0 [**2167-10-31**] 12:22PM BLOOD Phos-1.6* Mg-2.1 . Pertinent Imaging: . EEG: This is a normal routine EEG in the waking and drowsy states. There are no focal, lateralized, or epileptiform features noted. . Non-Contrast Head CT: There is no acute intracranial hemorrhage, shift of normally midline structures, hydrocephalus, major or minor vascular territorial infarction. The density values of the brain parenchyma are maintained. The soft tissues and osseous structures are intact. The visualized paranasal sinuses and mastoid air cells appear well aerated. IMPRESSION: No acute intracranial hemorrhage. . CXR: Mild increase in interstitial markings at the left base could be due to bronchitis. There is no focal area of consolidation. Lungs are otherwise clear. The cardiomediastinal silhouette and hilar contours are normal. There is no pleural effusion. Mild levoscoliosis is present. Brief Hospital Course: 33 yo F with PMH reportedly of asthma and anxiety, p/w altered mental status and hyponatremia of unclear etiology. # Hyponatremia: The pt presented with acute change in mental status and was found to be hyponatremic as low as 119 (lab details above). The patient was initially worked up for acute change in MS including a negative CT, LP and EEG. The patient was also given meningeal dosing for Ceftriaxone, Vancomycin and Acyclovir, which were later dc'd. Urine and serum tox were negtaive. The patient was initially hypotensive upon admission to the MICU to SBP in the 80s, however it was unclear what the patients baseline SBP was in addition the patient had been given empiric dose of ativan. Per report, patient was undergoing bowel prep with Golytley when became acute ill and began vomiting. Her hx indicated that she was drinking increased hypotonic fluids including Gatorade. The patients urine osms were low at 314, but not maximally dilute, also with Na > 50, so not retaining maximum Na. Thus the etiologies include sodium loss due to a recent change to low salt diet with excessive water replacement while others included adrenocortical insufficiency (although increased cortisol in hemolyzed sample) and SIADH. The patient was initially given hypertonic saline and later changed to normal saline. The patient was water restricted and after 24hrs her mental status cleared to baseline, however she did not recall the prior days events. The patient was discharged directly from the MICU to home at her baseline mental status, only complaining of mild symptoms of nausea and headache (? secondary to an LP) and able to take adquate but decreased POs. . # Anemia: The patient was previously being worked-up by GI for BRBPR. There was no evidence of bleeding during her admission. The pt's Hct remained stable in the mid 30s. This should be followed up as an outpatient. However it should be noted that the patient appeared to become hyponatremic secondary to her Go Lytley dosing and thus this should be addressed if the patient is to undergo further endoscopic evaluations. . # Asthma: Per report. No signs of acute respiratory problems. The pt was continued on her Albuterol PRN Medications on Admission: No known outpatient medications Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 3. Phenergan 25 mg Tablet Sig: One (1) Tablet PO q4:6hr PRN. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hyponatremia Altered mental status . Secondary: Asthma Anxiety Discharge Condition: Good. Alert and oriented x3. Tolerating POs. Discharge Instructions: You were admitted with confusion and found to have a very low blood sodium level. This likely occurred due to your bowel prep for colonoscopy and drinking excess water and other fluids. Your sodium improved with intravenous fluids and your mental status returned to baseline. A lumbar puncture was performed without evidence of meningitis. You developed a headache that was likely related to the lumbar puncture and should resolve on its own over the next 24 hours. . Please take all medications as prescribed. . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, abdominal pain, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: Call your PCP to schedule [**Name Initial (PRE) **] followup appointment within 2 weeks. . You should have your blood sodium checked on Monday, [**2167-11-3**], at your PCP's office. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Admission Date: [**2154-6-12**] Discharge Date: [**2154-7-4**] Date of Birth: [**2088-5-23**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 165**] Chief Complaint: SOB, volume overload Major Surgical or Invasive Procedure: none History of Present Illness: This 66WF underwent an AVR(21mm St. [**Male First Name (un) 923**] mechanical) on [**2154-5-17**]. She was discharged to rehab and over the past 3 days had gotten progressively SOB and was anuric. She presented to the clinic and was very edematous and SOB. Past Medical History: Aortic Stenosis-s/p AVR [**2154-5-17**] Type II Diabetes Mellitus Hypertension Hyperlipidemia Obesity Hysterectomy Cholecystectomy Appendectomy Tonsillectomy Post op afib Social History: Quit tobacco in [**2116**]. Denies ETOH. She is married and retired. Family History: Father died of MI ?age Physical Exam: At the time of discharge, Ms. [**Known lastname **] was found ot be in no acute distress. She was awake, alert, and oriented times three. Her heart was of regular rate and rhythm. Her sternal incision was noted to have no drainage and no erythema. Her abdomen was soft, non-tender, and she had bowel sounds. Her extremities were warm and she had 1+ edema. Pertinent Results: Cardiology Report ECHO Study Date of [**2154-6-13**] PATIENT/TEST INFORMATION: Indication: Aortic valve disease s/p AVR. Small ericardial effusion, r/o tamponade. Height: (in) 61 Weight (lb): 306 BSA (m2): 2.27 m2 BP (mm Hg): 174/75 HR (bpm): 74 Status: Inpatient Date/Time: [**2154-6-13**] at 15:26 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W000-0:00 Test Location: West Other Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: >= 65% (nl >=55%) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). AVR leaflets move normally. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. PERICARDIUM: Small pericardial effusion. No echocardiographic signs of tamponade. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was provided by benzocaine topical spray. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The posterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related complications. 0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and simple atheroma in the descending thoracic aorta. A mechanical aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. There is no paravalvular leak. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2154-6-13**] 16:21. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Brief Hospital Course: Ms. [**Known lastname **] was admitted on [**2154-6-2**] from [**Hospital 38**] Rehab, to which she was discharged after undergoing a St. [**Male First Name (un) 923**] mechanical AVR on [**2154-5-17**] with Dr. [**First Name (STitle) **] and [**Hospital1 827**]. [**Hospital 38**] rehab reported increased dyspnea, tachypnea, diarrhea, and failure to thrive over the past 36-48 hours. Upon admission she was seen in consultation by the renal service. She was dialyzed during her stay and her renal function improved markedly. It was determined that she likely wound not need long term dialysis. She was also seen in consultation by the infectious disease service during her admission and she was placed on Vancomycin per their recommendations. Once it was determined that she would not require long term dialysis access, she was re-coumadinized for her mechanical aortic valve. By hospital day ###### she was ready for discharge to a rehabiliation facility. Medications on Admission: Metformin 1000mg PO BID Oxybutynin 5 mg PO BID Senna 2 tabs qhs Lactinex [**Hospital1 **] Lasix 20 mg PO BID Amiodorone 200 mg PO daily Lopressor 75 mg PO BID Digoxin mg PO daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 5. Insulin Glargine 100 unit/mL Solution Sig: One (1) 35 Subcutaneous at breakfast. Disp:*1 35* Refills:*0* 6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days. Disp:*56 Capsule(s)* Refills:*0* 10. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: Target INR 2-2.5 Pt received 0.5/1/1mg doses over the last 3 days-. 11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Acute renal failure s/p AVR [**5-4**] IDDM Obdsity ^chol. Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks. Make an appointment with Dr. [**First Name (STitle) **] for 4 weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2154-7-4**]

Admission Date: [**2139-7-22**] Discharge Date: [**2139-8-6**] Date of Birth: [**2069-8-5**] Sex: F Service: MEDICINE Allergies: Captopril / Neurontin / Shellfish / Nsaids / Promethazine / Valproate Sodium Attending:[**First Name3 (LF) 1990**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 69 year old female with history of DM, COPD, ventilator dependent, hypertension, rectus sheath hematoma [**6-/2139**] who was brought to [**Hospital 8**] Hospital with altered mental status and abdominal pain. Abdominal CT was done at outside hospital which showed partial SBO. CT head at OSH was negative for intracranial process. She was transferred to [**Hospital1 18**] for further work up given her recent admission here. . In our ED, vital signs were BP 115/50, HR 90, RR 16, O2 sat 100% on trach collar. Labs notable for positive UA, WBC count 12.9 (73% neutrophils), creatinine 6.2 up from last d/c 4.2, troponin 1.51 (CKMB normal), hct 30.2 (up from b/l of 24-25 last admission). Blood and urine cultures sent from ED. She was given 1L NS, Cipro 400mg x1, Aspirin 600mg PR, Tylenol 1g. She was also given ?????? amp D50 for low BG. She was seen by surgery for evaluation of partial SBO. Decision was for no surgical intervention but NGT was placed. The patient was recently admitted to the [**Hospital Unit Name 153**] on [**4-25**] with urosepsis treated with Linezolid, MRSA RLL PNA treated with Ceftazadime and Cipro. Also noted to have RUE edema last admission, UE US was negative for DVT. . ROS: Patient unable to provide . Past Medical History: 1. Recent admission [**6-/2139**] -ICU for MRSA and highly resistant pseudomonal pneumonias. Sputum culture data indicates multiple colonies of pseudomonas without overlapping sensitivities -Rectal sheath hematoma, s/p embolization in [**4-/2139**] -Tracheostomy placed for chronic ventilator dependence 2. Diabetes Mellitus type 2 3. GERD 4. COPD -On home Oxygen 5. Obstructive sleep apnea 6. Depression 7. HTN 8. s/p TAH 9. s/p PE in [**2135**], -with IVC filter, -not anticoagulated after developed abdominal wall hematoma 10. Focal seizures 11. Diastolic CHF, -ECHO [**6-17**] EF >55%, mild pulm artery hypertension 12. s/p CVA x 2 with right facial droop 13. CKD -baseline Cr 1.3-1.5 . Surgical History: s/p coil embo of L inf epigastric ([**4-18**] [**Doctor Last Name **]) s/p hematoma evacuation and debridement ([**Date range (1) 15051**] [**Doctor Last Name **], [**Doctor Last Name **], [**Doctor Last Name **]) s/p repair incarc ventral hernia repair c mesh ([**6-17**] [**Doctor Last Name **]) s/p ex lap, LOA, omentectomy ([**6-14**] [**Doctor Last Name **]) ex-lap, ventral hernia repair, rigid sig ([**4-14**] [**Doctor Last Name **]) for CDiff. Social History: Resides at [**Hospital1 **], chronically ventilator dependent since her last hospitalization. Retired seamstress, waitress. Daughter [**Name (NI) **] is HCP. Pt was a former smoker, 3ppd x 30 years, quit in [**2128**], per the records pt has a distant history of ETOH abuse ([**2091**]), but no current ETOH or drug use. . . Family History: FH:Malignancy (pancreas, larynx), CAD, HTN, DM, asthma; daughter recently diagnosed with leukemia Physical Exam: General Appearance: No acute distress, Overweight / Obese, No(t) Thin, Not Anxious, Not Diaphoretic Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No Endotracheal tube, No NG tube, No OG tube, no teeth Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), HD line in place on right upper chest Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : anterior and lateral, No Crackles : , No Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese, tender in right flank/lateral mid right back Extremities: 2+ peripheral edema Musculoskeletal: Unable to stand Skin: two dressed wounds on right leg. C/D/I dressings and non-tender around area Neurologic: Somnolent but arousable, follows simple commands, A&Ox1 Guaiac: negative in ED Pertinent Results: EKG: Sinus arrhythmia, left axis deviation, nl intervals, Q waves II, III, TWF III, avF, I, aVL, V1-V3, no ST changes. Compared to EKG dated [**6-27**] new Q wave in aVF, TWF in V1-V3. . [**2139-7-22**] 11:52AM WBC-12.0* RBC-3.09* HGB-9.0* HCT-27.7* MCV-90 MCH-29.1 MCHC-32.5 RDW-17.3* [**2139-7-22**] 11:52AM PLT COUNT-465* [**2139-7-22**] 10:29AM GLUCOSE-66* UREA N-53* CREAT-6.3* SODIUM-138 POTASSIUM-2.7* CHLORIDE-108 TOTAL CO2-15* ANION GAP-18 [**2139-7-22**] 10:29AM CK(CPK)-328* [**2139-7-22**] 10:29AM CK-MB-12* MB INDX-3.7 cTropnT-1.42* [**2139-7-22**] 10:29AM CALCIUM-8.8 PHOSPHATE-5.9* MAGNESIUM-1.8 [**2139-7-22**] 10:29AM PT-14.8* PTT-30.4 INR(PT)-1.3* [**2139-7-22**] 04:32AM LACTATE-1.3 K+-3.6 [**2139-7-22**] 04:15AM GLUCOSE-53* UREA N-55* CREAT-6.2*# SODIUM-141 POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-15* ANION GAP-23* [**2139-7-22**] 06:08PM GLUCOSE-80 UREA N-54* CREAT-6.1* SODIUM-139 POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-14* ANION GAP-19 [**2139-7-22**] 06:08PM CK(CPK)-424* [**2139-7-22**] 06:08PM CK-MB-14* MB INDX-3.3 cTropnT-1.30* [**2139-7-22**] 06:08PM CALCIUM-8.8 PHOSPHATE-6.3* MAGNESIUM-1.6 [**2139-7-22**] 04:15AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2139-7-22**] 04:15AM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2139-7-22**] 04:15AM URINE RBC-[**12-31**]* WBC->50 BACTERIA-MANY YEAST-MOD EPI-[**4-15**] RENAL EPI-0-2 [**2139-7-22**] 04:15AM URINE CA OXAL-MOD . Micro: [**2139-7-22**] 4:15 am BLOOD CULTURE Blood Culture, Routine (Pending): [**2139-7-22**] 4:15 am URINE Site: CATHETER URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. . TTE [**7-22**] LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Normal aortic valve leaflets. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Right pleural effusion. Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2139-6-29**], moderate pulmonary artery systolic pressure is now identified. Biventriclar systolic function is similar. Brief Hospital Course: # Altered mental status: On admission patient somnolent but responding to commands. According to team she is only slightly more somnolent than her prior baseline. Head CT negative for evidence of bleed. AMS likely due to infection and Acute renal failure. . #. Acute on Chronic Renal Failure - Baseline creatinine 1.5-1.8 prior to last admission, however on last discharge Cr was 4.2 (felt to be her new baseline secondary to ATN. On admission the pt was found to have a Cr of 6.2. She received 1L NS in ED, and additional 1-2L NS bolus in ICU with little subsequent improvement in renal function. Urine lytes obtained with FeNa of 9%. Renal team consulted after as the family had expressed a desire to proceed with aggressive care (dialysis). After a family meeting with extensive discussion about the patients multiorgan system failure that continued to worsen despite medical management, the family and medical team agreed that dialysis was not indicated and chose to make patient CMO. . #. Chronic Respiratory Failure - s/p trach 03/[**2139**]. Evidence of COPD exacerbation with expiratory wheezes and prolonged expiratory phase on [**7-24**]. Prednisone increased to 60 mg po qday and nebulized albuterol scheduled. The patient required support with mechanical ventilation and her prednisone was changed to a solu-medrol taper. Current dose 30mg daily with plan to taper Q4 days. The pt's respiratory status improved with increased steroids and she was weaned from the ventilator and continued on trach collar. The family has agreed to hold any further mechanical ventilation should it become necessary and to focus on comfort. . # Lower GI bleed - The patient had an episode of significant lower gi bleeding in setting of coagulopathy related to poor nutritional status. Given the patient's worsening multiorgan system failure the medical team and family agreed to hold on any blood transfusions and possible procedures which may lead to discomfort. . # UTI: The patient has a history of multiple UTIs with highly resistant organisms. Recently completed course of linezolid and cipro for VRE and cefepime resistant nonfermenter nonpseudomonas. On admission pt was found to have a positive UA with mod leuk, pos nit. Elevated WBC count, currently afebrile. BP stable. Lactate within normal limits. Given previous culture data the pt was started on linezolid and cipro pending repeat culture. Linezolid discontinued [**7-24**] after culture grew gram negative rods. Final speciation and sensitivities demonstrated resistance to cipro and the patient was transitioned to meropenem. 7 day course of meropenem completed on [**7-30**]. . # Small bowel obstruction/ileus: Partial SBO noted on CT scan from outside hospital. She was seen by surgery in the ED - nonoperative candidate, NG tube placed. Abdominal exam notable for distension, nontender, diminished BS. Plan to continue serial abdominal exams, continue NGT and manage conservatively. Improved quickly, had large bowel movements the second day of admission. . # NSTEMI: Troponin of 1.51 on admission to ED in setting of increased creatinine. Case discussed with cardiology who did not feel intervention necessary at this time. At this point timing of event is unclear. [**Name2 (NI) **] echo on [**6-29**] showed EF 50-55%. Repeat TTE unchanged from prior. continued medical management with aspirin, beta blocker, statin. Aspirin discontinued as pt developed lower GI bleed. . # Goals of Care: Dr. [**Last Name (STitle) **], primary physician, [**Name10 (NameIs) **] active in discussion about goals of care with family, as recent hospitalizations have been very complicated. Intially the family had requested consideration of continued aggressive care including mechanical ventilation, PEG placement and dialysis if necessary. However the patient continued to worsen despite maximal medical therapy and given overall poor prognosis due to multi-organ system failure the family decided to hold on dialysis, reinstating mechanical ventilation. She was transferred from the ICU to the medical floor with the goal on maintaining comfort care only. . She was maintained on morphine IV, titrated to comfort. She died peacefully at 1900 hours on [**2139-8-6**]. Her son was present, as was the attending physician. # PPx: PPI, heparin subq, bowel regimen . # Code: DNR/DNI, CMO Medications on Admission: Meds: (per OMR) Atorvastatin 20mg daily Acetaminophen 160mg/5mL q8H PRN Albuterol NEB q4H PRN Aspirin 81mg daily Diltiazem 90mg QID Colace 100mg [**Hospital1 **] Fentanyl 50mcg patch q72h Fluticasone 50mcg [**2-11**] sprays daily Heparin subq Hydralazine 25mg q6H Ipratroprium 17mcg 2 puffs QID Reglan 5mg tab TID w/ meals, hs Metoprolol 50mg TID Prednisone 2.5mg tab daily Protonix 40mg daily Multivitamin daily Nystatin suspension Oxcarbazepine 300mg [**Hospital1 **] Percocet 5/325 q6H prn pain Senna 8.6mg tab [**Hospital1 **] prn Advair diskus 250/50 IH [**Hospital1 **] Insulin SS Nortriptyline 50mg hs Sucralfate 1g QID Discharge Disposition: Expired Discharge Diagnosis: COPD ARF Discharge Condition: expired Discharge Instructions: Expired Followup Instructions: Expired

Admission Date: [**2198-2-11**] Discharge Date: [**2198-3-14**] Date of Birth: [**2150-10-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3624**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: 1. Intubation/extubation 2. Bronchoscopy 3. PICC placement 4. Right internal jugular placement 5. Blood transfusions 6. [**Last Name (un) 1372**]-intestinal feeding tube placement 7. Arterial line placement History of Present Illness: Mr. [**Known lastname 931**] is a 47 yo male with h/o DM, kidney/pancreas transplant in [**2183**] and recent STEMI that was medically managed in late [**12-18**] who was transferred from OSH with SOB. Hx was obtained mostly from notes as pt quite somnolent on exam. Pt presented to OSH today with c/o 2 weeks of progressive dyspnea and pedal edema. His sats were 70% on RA and 92% on NRB with RR 40. He was placed on Bipap with sats 94-95% and CXR showed whiteout in his lungs. He was treated with Rocephin,solumedrol 125 mg, 80 mg IV lasix, ativan and nitro gtt. Additionally, his troponin T was noted to be 1.17, proBNP 70,000 (baseline 30,000), WBC 21.8 with a left shift. ABG there was 7.39/32/71. He was then transferred to [**Hospital1 **]. . Upon arrival to the ER here his blood pressures were stable. His sats were 98% on 15L NRB. Since he appeared to be using his ascessory muscles he was switched to BIPAP with sats of 95%. An additional 80 of IV lasix was administered at that time and he put out 1.1L over the past 6 hours. CXR was done and showed evidence of PNA. Additionally in the ER troponin was noted to elevated and ST elevations were seen on EKG. After d/w cards it was determined the trop was trending down from previous STEMI and ST changes were residual from previous STEMI. . Currently patient is on BIPAP and answering questions periodically and falling back asleep. Past Medical History: STEMI (admitted [**Date range (1) 26574**]) decided to medically manage in the setting of renal failure and Cr of 6 and the fact that event had likely occurred several days prior. MIBI showed EF of18%. DM1 x 12 yo- pt has been off insulin and no longer checks BS R toe amputation Osteopenia Urethral stricture Penile implant Sleep apnea history bilateral IVH in [**2195**] Kidney/pancreas transplant [**2183**]: His kidney transplant is present in his RLQ, pancreas transplant is in his LLQ (enteric conversion was performed where pancreas was moved from bladder to GI). Rejection [**2183**] Recent admit for elevated Cr thought [**3-16**] to lasix and ACEI as well as recent STEMI Social History: No ETOH, 20 pky smoker, quit [**2183**] before transplant, smokes marijuana rarely, no heroin, no cocaine. Married with 2 children, works for [**Company 11293**]. Family History: Brother - deceased from MI at age 52, also had diabetes s/p transplant Father - deceased from MI at age 53 Physical Exam: VS:T 97.7 BP 125/83 HR 79 RR 23 O2 94% on bipap 8/10 Fio2 0.5 GEN: somnolent but arousable male, NAD HEENT: bipap in place, unable to open eyes, limited by BIPAP mask Neck: supple, JVP 6 cm Cardio: RRR, 2/6 systolic murmur loudest LUSB, nl S1 S2 Pulm: CTA b/l ant Abd: soft, NT, ND, hypoactive BS Ext: 3+ pitting edemal b/l Neuro: somnolent but arousable, withdraws to painful stimuli, not cooperative with exam Pertinent Results: EKG: NSR with LAD; TWI in I,AVL,V2-V6 (new in V2,V3) q in v2-v5; persistent ST elevations V3-V5 (present previously in V3,V4). . CXR [**2198-2-10**] prelim read: Worsening airspace opacities likely representing consolidation with some element of edema; pneumonia. No effusions. . Exercise MIBI [**12-18**]: 1. Moderate, predominantly fixed perfusion defect involving the mid-distal anterior wall, the apex, and the distal septum. 2. Marked left ventricular enlargement. 3. Severe global hypokinesis, with superimposed apical dyskinesis. LVEF=18%. . ECHO [**2198-1-1**]: Moderate aortic valve stenosis, AoV area 0.8 cm2. Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (mid-LAD territory), EF 30%. Moderate pulmonary artery systolic hypertension, PASP 48mm Hg. . LENI [**2198-2-13**]: Possible old, nonocclusive thrombus within a duplicated left superficial femoral vein. Remainder of the deep veins in the lower extremities bilaterally are unremarkable. . RENAL U/S [**2198-2-13**]: 1) Tardus parvus waveforms within the segmental arteries supplying the renal parenchyma with decreased resistive indices suggestive of parenchymal hypoperfusion. 2) No hydronephrosis. . TTE [**2198-2-13**]: The left atrium is moderately dilated. The estimated right atrial pressure is >20 mmHg. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed. Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened with mild to moderate aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic Regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . CT HEAD [**2198-2-28**]: 1. No evidence of acute intracranial hemorrhage. Stable appearance of the brain compared to [**2195-9-2**]. 2. New opacification of the mastoid air cells bilaterally and right middle ear cavity in this intubated patient. . RENAL U/S [**2198-3-11**]: Overall stable appearance of the renal transplant with tardus-parvus waveforms within the parenchymal segmental arteries suggestive of parenchymal hypoperfusion. Brief Hospital Course: A/P: 47 yo male with h/o DM, kidney/pancreas transplant in [**2183**] and recent STEMI that was medically managed in late [**12-18**] who was transferred from OSH with SOB, likely PNA and CHF exacerbation. . 1) Respiratory failure: Patient's sats were in the 70s on RA at OSH. CXR showed whiteout c/w bilateral patchy PNA +/- CHF exacerbation. Following admission, patient was initially maintained on BiPAP for what appeared to be increased work of breathing, though sats were stable at the time. On transfer to [**Hospital1 18**], patient failed to improve clinically with diuresis, making CHF seem less likely to be the etiology of his respiratory failure. Bilateral patchy infiltrate was visualized; this atypical pattern for community-acquired pneumonia raised concerns for PCP [**Last Name (NamePattern4) **]. fungal vs. multifocal bacterial pneumonia in this chronically immunosuppressed host. On HD#2, he was intubated for respiratory distress. Diagnostic bronchoscopy and BAL were performed with unrevealing culture data. He was initially was treated empirically for PCP, [**Name10 (NameIs) **] Bactrim discontinued due to nephrotoxicity and highly sensitive BAL negative for PCP. [**Name10 (NameIs) **] was treated with a 10-day course of levaquin and vancomycin for broad spectrum coverage as no organism was isolated. Serum fungal markers negative for aspergillus, equivocal for beta-glucan. Patient remained ventilator-dependent from [**2-12**] - [**3-1**], on CPAP + PS with ongoing high ventilatory requirements likely due to fluid overload which was compounded by acute oliguric on chronic renal failure. Course was complicated by a MSSA ventilator-acquired pneumonia which was treated with 8 days of vancomycin and zosyn. Following improvement of renal function, we diuresed aggressively with lasix gtt and lasix boluses. On [**3-1**], he was extubated despite poor prognostic indicators due to the chronicity of his vent-dependence, with plan for tracheostomy if he did not tolerate non-invasive respiratory support. He was transitioned to face-mask O2 and ultimately did not require the planned tracheostomy. . 2) Cardiac: (a) Pump - Patient is s/p STEMI in [**12-18**] with resultant CHF, last EF measured at 30% in [**Month (only) **], now 25% this admission. On admission, the heart failure service was consulted. Because his clinical status early in admission did not improve with diuresis, we did not feel as though heart failure was the predominant precipitating factor for his initial respiratory failure. However, his poor pump function and poor renal function compounded his course significantly and led to a protracted course on the ventilator due to worsening pulmonary edema. He was tried on a trial of nitroglycerin drip for afterload reduction, which was later discontinued in favor of hydralazine. His beta-blockade therapy was uptitrated as tolerated by BP. Throughout the hospital course, he was diuresed only as tolerated, with careful monitoring of his tenuous renal function. (b) Vessels - Per cards, persistent troponin elevation was likely residual from prior STEMI, as CKMB not elevated. Continued medical management with ASA, plavix, statin, BB. ACEI held in the setting of ARF. (c) Rhythm - Previously NSR with new onset paroxysmal atrial fibrillation during this hospitalization. He was initially started on beta-blocker for rate control while in the ICU. On [**3-3**] went into afib without resolution to Lopressor, then with dropping blood pressure. An amiodarone drip was started, with loading bolus of 150 mg, with improvement. Coumadin initiated on [**3-5**] for CVA prophylaxis in this relatively young man with [**Name (NI) 16064**] score of 3 (1 point each for DM, HTN, and CHF); Goal INR [**3-17**]. There was some difficulty with regulation of his coumadin dosing as the patient became supratherapeutic likely secondary to renal failure. His dose was held for a few days and restarted. However, the patient refused to take the coumadin once reinitiation was recommended because he was concerned about having an elevated INR again. Multiple attempts were made to encourage him to take his medications as recommended. He was eventually started and discharged on daily oral amiodarone for his irregular rhythm. . 4) Anemia: NG lavage gastroccult positive. Stools reported as guiac-negative. GI consulted on [**2-24**] for ? UGIB and EGD deferred. Consider stress ulcer vs. OG trauma. Iron studies c/w anemia of chronic disease. He was transfused periodically in the setting of his low output state. His hematocrit was stable while on the medicaly floor. . 5) ARF: In the setting of his acute pulmonary illness, patient developed acute on chronic renal insufficiency s/p renal transplant x 14 years. Suspect initially pre-renal picture as precipitant for ARF, given intravascular volume depletion. Renal ultrasound of transplant kidney shows hypoperfusion but no hydronephrosis (which was queried in the acute setting of post-renal obstruction, now resolved). Likely overall picture c/w prerenal azotemia, which resolved throughout the hospitalization with improving Cr and improving UOP. The Renal service followed him throughout his stay and felt that he had no acute HD needs despite his poorly functioning renal graft. He was continued on Vitamin D analogue Calcitriol for secondary hyperparathyroidism (PTH 225). He received Epo 10,000 units 3x/week for anemia of chronic disease. His aAceI in the setting of acute renal failure. He was maintained on prednisone and tacrolimus for chronic immunosuppression. His tacrolimus dose was decreased under the direction of the Nephrology service. . 6) Urinary retention: Patient also has unusual phallic anatomy with penile implant, stricture, ? prostatic enlargement, and it is possible that post-renal obstruction also contributed to the onset of his ARF. Following multiple nursing and house officer attampts at foley placement, Urology was consulted and ultimately were able to place a 12 french Coude catheter. Had no difficulties with urinary retention once foley discontinued. He was restarted on flomax once his hemodynamics were stable and tolerated it well. . 7) FEN: Nutrional support with tube feeds was provided while patient was ventilator-dependent. A S&S evaluation demonatrated possible delayed signs of aspiration. A video swallow study was ultimately performed which revealed moderate silent aspiration with nectar-thick consistencies and multiple episodes of laryngeal penetration, which were able to be cleared with cued cough. He underwent a repeat swallow evaluaiton [**3-14**] with improved swallowing mechanics. His diet was advanced to regular and he tolerated it well. While on the medical floor, the patient remained stable and was monitored mainly for return of renal function to baseline and medication management. It was recommended to the patient initially that he be discharged to a rehabilitation facility for further PT/OT. However, the patient and his wife felt very strongly that he would be safe at home. He worked with PT throughout his admission who felt that he was improving and was appropriate for home PT. He was discharged home with home PT and VNA for medication teaching. He will follow up with his Renal and Diabetic physicians. Medications on Admission: Tacrolimus 2 mg qAM Tacrolimus 1 mg qPM Atorvastatin 80 mg qd Aspirin 325 mg Tablet qd Ferrous Sulfate 325 [**Hospital1 **] Cholecalciferol (Vitamin D3) 400 unit qd Prednisone 12.5 mg qhs Metoprolol Succinate 150 mg qd Calcium Acetate 667 mg 2 tabs PO TID Sodium Citrate-Citric Acid Thirty ml TID Clopidogrel 75 mg Tablet qd Hydralazine 10 mg Tablet q8hours Lasix Discharge Medications: 1. Atorvastatin 80 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). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*1* 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*1* 10. 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:*1* 11. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*1* 12. Epogen 10,000 unit/mL Solution Sig: Three (3) Injection once a week. Disp:*10 * Refills:*1* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: 1. Congestive Heart Failure 2. Diabetes Mellitus 3. Pneumonia 4. non-St elevation myodardial infarction 5. Atrial Fibrillation Discharge Condition: Stable. Able to walk safely with walker. Tolerating general diet. Discharge Instructions: You should weight yourself every day. If your weight is up more than 3 pounds, you should call your doctor. Adhere to a low sodium diet. Your tacrolimus level was changed. You are now taking 1.5 mg of tacrolimus twice a day. This change was made by the Renal doctors. You also were started on amiodarone for atrial fibrillation (irregular heart rate). You should continue to take that medication until seen by your primary care physician. Contact a physician for fever > 101.5, nausea, vomiting, loss of conciousness, abdominal pain, persistent diarrhea, or any other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2198-3-27**] 11:40 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2198-6-12**] 10:10 Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] MD Phone: [**Telephone/Fax (1) 26575**] or [**Telephone/Fax (1) 2378**]. Follow-up within 2 weeks. You must call to make that appointment. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

Admission Date: [**2196-12-2**] Discharge Date: [**2196-12-11**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: Fall in bathroom at [**Hospital3 **] with R humerus fx and C7-T1 anterolisthesis Major Surgical or Invasive Procedure: none History of Present Illness: 86M s/p an unwitnessed fall at [**Hospital3 **]. He was found in his bathroom yesterday complaining of right arm pain and neck pain. He was taken to [**Hospital1 18**] [**Location (un) 620**] to be evaluated. There he was found to have a right humerus mid-shaft fracture along with C7-T1 anterolithesis. He was transferred to [**Hospital1 18**] for further treatment. He does not remember the fall and states that he has no pain. He is oriented to person only. He denies headache, neck pain, nausea, emesis, chest pain, shortness of breath, and abdominal pain. Social History: Lives in an [**Hospital3 **], married Tobacco none ETOH none Family History: non contributory Physical Exam: PE: 98.4, 88, 135,85, 18, 100% on 2L Gen: no distress, oriented to person only HEENT: PERLA, EOMI, anicteric, mucus membranes moist Neck: c-collar in place, no cervical spine tenderness Chest: RRR, lungs clear Abdomen: soft, nontender, nondistended Rectal: normal tone, no gross blood Back: no spinal tenderness or step offs . Pertinent Results: [**2196-12-2**] 05:45AM WBC-15.8* RBC-4.21 HGB-12.3 HCT-36.5 MCV-87 MCH-29.3 MCHC-33.8 RDW-14.1 [**2196-12-2**] 05:45AM NEUTS-91.7* LYMPHS-4.4* MONOS-3.3 EOS-0.2 BASOS-0.4 [**2196-12-2**] 05:45AM PLT COUNT-255 [**2196-12-2**] 05:45AM PT-12.7 PTT-28.2 INR(PT)-1.1 [**2196-12-2**] 05:45AM DIGOXIN-0.3* [**2196-12-2**] 05:45AM GLUCOSE-136* UREA N-22* CREAT-1.1 SODIUM-141 POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14 [**2196-12-2**] Cardiac echo : The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal inferior and inferolateral hypokinesis. The remaining segments contract normally (LVEF = 45%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Dilated aortic root. [**2196-12-2**] Right These radiographs are significantly limited by positioning and overlying cast. There is an oblique comminuted fracture of the humerus, however the full extent is not clearly assessed on these images. [**2196-12-4**] Chest CTA : 1. Small segmental pulmonary embolism at the right middle lobe branch. No evidence of pulmonary infarcts. 2. Increased left lower lobe patchy opacity, nonspecific, could represent, atelectasis, aspiration or consolidation. [**2196-12-5**] Non invasive venous studies both lower extremities : Deep vein thrombosis seen in the left popliteal vein. [**2196-12-5**] Carotid studies : < 40% stenoses B/L ICA's [**2196-12-7**] MRI C spine : 1. No evidence of ligamentous disruption or marrow edema in the vertebral bodies. 2. Multilevel degenerative changes with mild spinal stenosis at C2-3 and C3-4 with minimal extrinsic indentation on the spinal cord and mild-to-moderate spinal stenosis at C5-6 level. Foraminal changes as above. Brief Hospital Course: Mr. [**Known lastname **] was evaluated by the Trauma service in the Emergency Room and admitted to the hospital for further evaluation including a syncopal work up. The Orthopedic service placed a [**Last Name (un) 8688**] brace on his right shoulder for closed treatment of his humeral fracture and the Spine service wanted his C7-T1 anterolisthesis further imaged with MRI. F/u MRI without contrast showed no evidence of ligamentous disruption or marrow edema in the vertebral bodies but a possible collection anterior to the T-spine. F/u MRI w/wo contrast showed no collection. His carotid studies showed < 40% ICA stenosis bilaterally and his Cardiac echo revealed an EF of 45% with basal inferior and inferolateral hypokinesis. He denied any dizziness, chest pain or shortness of breath but on [**2196-12-3**] became hypoxic and developed rapid atrial fibrillation and was subsequently transferred to the ICU for further management. A chest CTA revealed a pulmonary embolism in the RML branch and venous studies documented a left popliteal DVT. He was placed on IV Heparin and Coumadin was started. His oxygenation improved with pulmonary toilet. He never required reintubation. His chest Xray showed some LLL consolidation and he was briefly placed on antibiotics however when the diagnosis of PE was made the antibiotics were discontinued. The Geriatric service followed the patient closely during his admission and assisted with management of his PAF which was eventually controlled with maximizing his beta blockers. His Coumadin was adjusted to maintain an INR of 2.5 - 3.0. The Ortho Spine service followed Mr. [**Known lastname **] during his course and based on his MRI recommended that he wear a [**Location (un) 2848**] J collar for 2 weeks and follow up then for another exam and possibly more Xrays. Physical therapy saw the patient and recommended short term rehabilitation. On the day of discharge, the patient was tolerating regular diet, having bowel movements and flatus, and his pain was well-controlled with PO pain medications. He will need to have further voiding trials at rehabilitation and is going with a foley in place. Medications on Admission: 1. Lisinopril 10 mg PO Daily 2. HCTZ 25 mg PO Daily 3. Digoxin 0,125 mg PO Daily 4. Aricept 10 mg PO Daily 5. Aspirin 325 mg PO Daily 6. Simvastatin 40 mg PO Daily 7. Namenda 10 mg PO BID Discharge Medications: 1. Simvastatin 40 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 10 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 12.5 mg Capsule [**Location (un) **]: One (1) Capsule PO DAILY (Daily). 4. Oxycodone 5 mg Tablet [**Location (un) **]: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 5. Acetaminophen 325 mg Tablet [**Location (un) **]: Two (2) Tablet PO Q6H (every 6 hours). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 9. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 12. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Aricept 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Disp:*0 Tablet(s)* Refills:*2* 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*0 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 15. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*5 Adhesive Patch, Medicated(s)* Refills:*2* 17. Warfarin 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO once a day: adjust per INR. Disp:*90 Tablet(s)* Refills:*2* 18. Namenda 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) 169**] Discharge Diagnosis: Primary diagnosis S/P Fall 1. Right humerus fracture 2. C7-T1 anterolisthesis 3. Left popliteal DVT 4. PE 5. Acute blood loss anemia Secondary diagnosis 1. CAD 2. Hypertension 3. Hypercholesterolemia 4. CHF 5. PAF 6. dementia 7. Prostate cancer PSH 1. S/P CABG,MVRepair and Maze procedure Discharge Condition: good Discharge Instructions: * Keep your cervical collar on at all times until you next exam with Dr. [**Last Name (STitle) 1007**]. He will advise further treatment at that time. * Keep the right shoulder brace on at all times except bathing. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? To the rehab facility: Please attempt foley catheter removal with void at rehabilitation. ?????? You will need frequent blood tests initially while your Coumadin is being regulated. Dr. [**Last Name (STitle) 23430**] will adjust the dose as needed. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up appointment in 1 week with [**First Name8 (NamePattern2) 29778**] [**Last Name (NamePattern1) **], NP. You will need Xrays of your right shoulder at that time. Call Dr. [**Last Name (STitle) 1007**] or [**Doctor Last Name 1352**] at [**Telephone/Fax (1) 1228**] for a follow up appointment in 2 weeks. Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 18052**] for a follow up appointment in 2 weeks. Call Dr.[**Name (NI) 84312**] office at [**Telephone/Fax (1) 23431**] for a follow up appointment in [**1-29**] weeks. He will also adjust your Coumadin dose. Call the [**Hospital 159**] Clinic at [**Telephone/Fax (1) 164**] for a follow up appointment for a voiding trial in 1 week.

Admission Date: [**2151-12-10**] Discharge Date: [**2151-12-24**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: Seizure and Increased Rt subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: The information was provided by the patient's daughter and son-in-law. The patient is a [**Age over 90 **]-year-old hypertensive diabetic gentleman with a past medical history of Atrial fibrillation(not on anticoagulation due to hemorrhagic stroke in [**2151-3-27**]), PMR/RA, BPH, urinary retention/chronic foley after stroke in [**4-4**], and prostate CA (on hormonal therapy, mets to pelvic bone) who was transferred from [**Hospital3 **] to the neurosurgical service for seizures and enlarging Right subdural hematoma (he has bilateral chronic subdural hematoma). He fell down on [**2151-12-6**] while he was hospitalized for UTI & PNA (s/p Lt thoracentesis for para-pneumonic effusions) at [**Hospital1 **] that was treated with imipenem. He had a CT head the same day that showed a bilateral chronic subdural hematoma. A repeat CT head next day was done which showed no significant change. On [**2151-12-10**] he was transferred to rehab, where he had a generalized seizure, for which he was transferred back to [**Hospital1 2519**]. CT head at that time showed enlargement of the right subdural hematoma, and CXR showed a fractured left clavicle. He was brought to [**Hospital1 18**] for neurosurgical evaluation. Past Medical History: HTN, hemorrhagic stroke, NIDDM, PMR/RA, BPH and prostate CA. AFIb (not on coumadin), chronic urine retention on chronic foley's Social History: Lives with daughter at home Family History: NC Physical Exam: On admission: ************* Vitals: 95.9, 116/73, 94 bpm irregular, RR 24, sat99%RA GEN: Not in acute distress sitting comfortably in bed. HEENT: Mucous membranes moist, no lesions noted. Sclerae anicteric. No conjunctival pallor noted. NECK: JVP not elevated. No lympadenopathy. CV: irregular rhythm with normal rate, no murmurs, rubs or gallops PULM: relatively good A/E bilaterally, harsh exp gurggling sounds bilaterally and harsh end-insp "wheeze" like sounds are heard, particularly midzone and lower zone while upper zones are clear. ABD: Soft, non-tender, non distended, bowel sounds present. No hepatosplenomegaly EXTR: No edema, Dorsalis pedis not palpable NEURO: Alert, oriented to person, not time (something that has 0 and 1), not place. CN II-XII grossly intact. Motor power: [**2-28**]+/5 Lt UE, [**3-30**] Rt UE. lower limb power [**3-30**]. Wasn't capable of doing finger-to-nose test or rapid-alternating test. Gait was not assessed. SKIN: No ulcerations or rashes noted. On discharge: ************* Vitals: T96, 135/90, 84 bpm irregular , RR 18, 94%sat on RA GEN: Not in acute distress, lying flat with elevated bed head at 30 degrees. HEENT: Mucous membranes relatively dry, no lesions noted. Sclerae anicteric. No conjunctival pallor noted. NECK: JVP not elevated. No lympadenopathy. CV: irregular rhythm with normal rate, no murmurs, rubs or gallops PULM: relatively good A/E bilaterally, faint insp crackles on the right side, but no insp crackles could be appreciated on the left side. no wheezes. ABD: Soft, non-tender, non distended, bowel sounds present. No hepatosplenomegaly EXTR: No edema, Dorsalis pedis not palpable NEURO: Alert, oriented to person, not place or time. SKIN: grade I ulcer at the sacral area. Pertinent Results: On admission: ------------- [**2151-12-10**] 08:36PM BLOOD WBC-15.5* RBC-3.75* Hgb-11.0* Hct-32.9* MCV-88 MCH-29.2 MCHC-33.3 RDW-15.7* Plt Ct-293 [**2151-12-10**] 08:36PM BLOOD Neuts-92.3* Lymphs-5.3* Monos-2.3 Eos-0.1 Baso-0.1 [**2151-12-10**] 08:36PM BLOOD PT-14.1* PTT-27.1 INR(PT)-1.2* [**2151-12-10**] 08:36PM BLOOD Glucose-226* UreaN-14 Creat-0.8 Na-135 K-4.4 Cl-98 HCO3-27 AnGap-14 [**2151-12-11**] 12:50AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.8 [**2151-12-10**] 08:44PM BLOOD Lactate-2.0 On discharge: ------------- [**2151-12-22**] 05:06AM BLOOD WBC-8.5# RBC-2.82* Hgb-8.3* Hct-24.5* MCV-87 MCH-29.4 MCHC-33.9 RDW-16.2* Plt Ct-203 [**2151-12-21**] 05:15AM BLOOD Glucose-111* UreaN-15 Creat-0.5 Na-138 K-3.6 Cl-100 HCO3-34* AnGap-8 [**2151-12-21**] 05:15AM BLOOD Mg-1.9 Iron-21* [**2151-12-21**] 05:15AM BLOOD calTIBC-199* Ferritn-70 TRF-153* Microbiology: -------------- Blood Cultures 1/14 and [**12-14**]: No growth (finalized) Urine Culture [**2151-12-10**]: (Final [**2151-12-11**]): YEAST. >100,000 ORGANISMS/ML.. Imaging: --------- CXR [**2151-12-10**]: 1. Left costophrenic angle not fully included. 2. Right base opacity raises concern for consolidation, such as pneumonia or aspiration. PA and lateral views would be helpful when/if patient able. 3. Non-displaced distal left clavicle fracture of indeterminate age, but which may be acute. CXR [**2151-12-14**]: As compared to the previous radiograph, there is a newly appeared retrocardiac opacity. The opacity is relatively homogeneous, favoring atelectasis over pneumonia. However, the presence of pneumonia cannot be excluded. The right lung base shows a minimal area of atelectasis. CT head [**2151-12-11**] 1. Essentially unchanged bilateral subacute-to-chronic subdural hematomas compared to outside hospital studies. No definite new foci of acute intracranial hemorrhage. No significant midline shift. 2. Chronic-appearing right frontoparietal and parietal infarcts. CT Head [**2151-12-13**]: Evaluation of the posterior fossa is slightly limited by motion artifacts despite multiple scan acquisitions. Allowing for differences in patient positioning, there is essentially no change in bilateral hypodense subdural collections, right greater than left. No new hemorrhage is identified. There is unchanged minimal leftward shift of the anterior falx and septum pellucidum. Parenchymal hypodensity and encephalomalacia in the right posterior frontal and parietal lobes are again noted, likely a chronic right MCA infarct. Scattered periventricular and subcortical white matter hypodensities are also again seen, likely due to chronic small vessel ischemic disease. There is a small amount of fluid in the right maxillary sinus. No osseous abnormality is identified. IMPRESSION: Bilateral hypodense subdural collections, right greater than left, appear similar to [**2151-12-11**], but larger than on [**2151-12-7**]. EEG [**2151-12-16**]: IMPRESSION: Abnormal EEG in the waking and drowsy states due to the slow posterior and other background and due to the occasional generalized slowing. These findings indicate a widespread encephalopathy. They suggest a concomitant infectious, metabolic, or [**Last Name 89736**] problem as causing the encephalopathy. This would less likely derive from the subdural hematomas. With regard to the hematomas, there was no prominent loss of background voltage on either side though that is a very insensitive indicator of subdural fluid. There may have been a bit of slowing on the left, but nothing persistent or prominent. The single epileptiform sharp wave was likely related to movement artifact, and there were no similar findings in the rest of the tracing. An abnormal cardiac rhythm was noted. Brief Hospital Course: [**Age over 90 **] yo gentleman, DM, HTN, Afib (not on anticoagulation), BPH, urine retention on chronic foley after stroke on [**2151-3-27**], prostate Ca (mets to pelvic bone) was transferred to [**Hospital1 18**] for evaluation of his very recent seizure on [**2151-12-10**] and enlarging right subdural hematoma (has chronic bilateral subdural hematomas). . # Goals of Care: Over the course of his hospitalization, the patient had a substantial clinical decline. He was unable to interact with family and medical team in a meaningful way, and was unable to take oral nutrition and medications without aspiration. Consequently, several family meetings were held, and a decision was made to move from aggressive care to more of a comfort-focused approach. The family and medical team decided that the patient should be allowed to eat pureed foods despite the risk of aspiration. Furthermore, per palliative care discussion and note with his daughter [**Name (NI) **], the health care proxy, the "Goal of care is optimal mental status so he can interact with family in a meaningful manner. If pt continues to improve goals of care should be continually readdressed and modified. Family is aware that pt is still seriously ill and may not regain function, and may not survive this event. If he is improving, there should be discussion about treatment of next infection ( resp or urine) with options to treat aggressively if this is within keeping of goals/current status. If pt is improving, option of intermittent catheterization, to reduce chances of UTI, should be considered. This option will only be favorable if pt does not experience discomfort with catheterization. If he has not improved or is failing, options for moving to hospice/care and comfort should be offered and discussed. [**Doctor First Name **] is aware of hospice options and would like to meet the hospice team. Family has made decision that artificial feeding is not in keeping with overall goals of care. No PEG placement desired. Pt is DNR/DNI but is not "Do Not Hospitalize" - this should be discussed with his daughter. Pt has had delirium- use of anticholinergics (scopolamine, levsin) for secretions should be limited if possible and positioning, good oral care and oral suction can be used in place of medications. Use of end of life care medications to manage respiratory distress should only be started after discussion with daughter." . # Seizure & chronic subdural hematoma: Pt was thought to possibly have a seizure focus from the previous stroke, subdural hematoma, or significant lowering of seizure threshold secondary to imipenem that he received in his admission on [**2151-11-30**] to [**Hospital3 4107**] for UTI/PNA. He was evaluated by the neurosurgeon who concluded that the patient was neurologically stable and no interventions were indicated. He was also evaluated by neurology who recommended that he continue Keppra 500 mg twice daily for seizure prophylaxis. If the patient does have a seizure lasting more than several minutes, he can be treated with crushed sublingual ativan, or rectal diazepam (please see attached directions). . # Altered mental status: His mental status was noticed to deteriorate dramatically following his seizure (according to the daughter and son in law). During his stay, his mental status gradually and slowly deteriorated. Possibly causes included multiple intracranial co-morbidities, and infections (pneumonia and UTI). He was agitated several times at night, and Seroquel 12.5 mg PO qhs was started with good effect. He was evaluated by speech and swallow several times which revealed his poor swallowing capability and high risk of aspiration. NG tube was placed initially to deliver nutrition and medications. However, NG tube was removed after a family decision was made to improve the patient's comfort despite risk of aspiration. According to the daughter's wishes, she would like her father to receive speicific diet that might reduce the chance of aspiration, that is pureed, nectar thickened diet. . # Pneumonia: The patient was admitted on [**2151-11-30**] to [**Hospital1 **] for complex UTI and pneumonia. CXR on admission showed Rt lower zone infiltrate with blunting of Rt costophrenic angle. The infiltrate improved compared to [**12-10**] CXR. It was felt to be a new Rt sided pneumonia since from OSH his prior pneumonia was on the left side. Aspiration was the most likely cause given his poor speech and swallow function. He received a course of IV Vancomycin and Cefipime that started on [**2151-12-14**] for 7 days for Hospital acquired pneumonia. There was no growth on blood culture. . # UTI: Culture grew significant yeast, however this is most likely contamination from his indwelling foley. He received fluconazole for 7 days starting on [**2151-12-14**] to treat possible candidal UTI, and foley catheter was changed. . # Diabetes Mellitus: The patient was initially on fixed dose lantus and humalog sliding scale with meals. However, when his NG tube feeds were discontinued and the patient allowed to eat, his lantus was significantly decreased and humalog stopped. At discharge, he was on Lantus 8 units at night. However, his oral intake should be carefully monitored and his finger sticks checked at least once daily. If his intake of food and finger sticks decline, his lantus should also be decreased and possibly discontinued. . # Atrial fibrillation: Patient has been in atrial fibrillation for the duration of his hospitalization. He had a few episodes of HR in the 130's-140's along with agitation. These episodes were dramatically reduced after his Toprol XL 50 mg was switched to metoprolol 50 mg twice daily. Coumadin has been held since [**2151-3-27**] due to recent hemorrhagic stroke. . Medications on Admission: Ca Vit D Glyburide 5mg OD Toprol 50 mg OD Humigan eye drops Ferrous Sulface 325 BD Colace BD Senna OD Vit C 500 OD Ranitidine 150 mg OD Discharge Medications: 1. levetiracetam 100 mg/mL Solution Sig: Five (5) ml PO BID (2 times a day). 2. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)). 3. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)) as needed for agitation: [**Month (only) 116**] give 1 hour after standing dose for total of 25mg/night if agitated. 4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold if SBP < 100 or HR < 60. 5. insulin glargine 100 unit/mL Solution Sig: Eight (8) unit Subcutaneous HS (at bedtime). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain or fever. 8. diazepam 12.5-15-17.5-20 mg Kit Sig: 12.5 mg Rectal PRN: q4-12 hours as needed for seizure: do not use for more than 5 episodes per month or more than one episode every 5 days. . 9. Ativan 1 mg Tablet Sig: One (1) Tablet PO q15mins as needed for seizure: Can crush and place sublingually for seizure. Use either ativan or rectal diazepam, but not both. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay [**Hospital **] Nursing and Rehab. Discharge Diagnosis: Primary diagnoses: chronic bilateral subdural hematoma UTI Pneumonia Left Clavicle fracture Secondary diagnoses: Diabetes Hypertension Atrial fibrillation (not on coumadin) metastatic prostate cancer chronic urine retention with indwelling foley's Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. DNR - DNI Discharge Instructions: Dear Mr. [**Known lastname **] and family, Mr. [**Known lastname **] was admitted to [**Hospital1 18**] because of seizure and increase in the size of blood around his brain on the right side. He was evaluated by the brain surgeons on admission who felt that there was no indication to intervene regarding the blood around his brain. During his stay, he was evaluated by speech and swallow team several times that showed impaired swallowing and high risk of aspiration. A tube was fixed that goes from his nose to his stomach to deliver food and medications. He became agitated a few times at night which made it neccessary to give him a medication at evening time on regular basis to control his agitation. On admission, there was an infection in his right lower lung, for which he was receiving an IV antibiotic. After few days of hospitalization, he had another infection in his left lower lung, most likely due to aspiration. Because of this, his IV antibiotics was changed to two medications that he received for a total course of 7 days. He also received an oral [**Doctor Last Name 360**] to treat the fungus in his urine for 7 days. His Toprol XL 50 mg was changed to metoprolol 50 mg orally twice daily. Keppra 500 mg twice daily was added to prevent further seizure. Given his poor health status, a family meeting was held and it was discussed with [**Doctor First Name **], the daughter and health care proxy of Mr [**Name (NI) **] and her husband, [**Name (NI) **], regarding the long term goals for Mr [**Known lastname **]. It was agreed to take him to a Hospice care and move to comfort measures. His IV line and feeding tube were removed, but his blood pressure, anti-seizure and insulin was continued. Followup Instructions: None

Admission Date: [**2124-2-14**] Discharge Date: [**2124-2-20**] Date of Birth: [**2077-2-5**] Sex: M Service: NEUROLOGY Allergies: Penicillins / Peanut / Egg Attending:[**First Name3 (LF) 57490**] Chief Complaint: seizure and hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 47 L handed male with PMH sig for transverse myelitis dx [**12-8**] undergoing tx with 6mo of steroids presents from OSH with hematemesis, gastric ulcer with visible vessel s/p EGD and cauterization here on [**2-14**]. In [**2123-11-3**], he started developing severe lower back pain with weakness in his legs and numbness in his hands. He had been diagnosed by his PCP as having back arthritis. He was progressively getting worse and one day he fell and could not stand up. His symptoms did not improve and he presented to [**Hospital1 2025**] on [**2123-11-18**] with worsened hand/LE weakness 1/5 strength, hyperreflexia. Full spine MRI at [**Hospital1 2025**] revealed questionable mass and intramedullary T2 hyperintense from C2-L2 with cord expansion and patchy enhancement. Further workup for malignancies included negative abd/chest CT and brain MRI. CSF analysis revealed WBC 8 [L 97% M 3%], glucose 85, protein 38. [**Doctor First Name **], RF, HSV; mycoplasma PCR, VRDL pending; Gram stain, cx showed NG. He was started on solu-medrol 1g IV daily x5d with considerable improvement of LE strength. Repeat MRI showed diminished T2 hyperintesities. He was discharged to home on [**2123-11-27**] and arranged for solu-medrol taper. He was also started on balcofen for spasticity, and told to f/u as outpatient in [**Hospital 878**] clinic. Shortly after d/c of steroids, symptoms relapsed. Presented here [**12-6**] with bacteremia, septic right knee and weakness. At that time pt was found to have a septic joint and gout which was treated appropriately with antibiotics and NSAIDs. He was later transfered to the neurology service for w/u of his weakness. An MRI of the head was normal, but MRIs of the spine revealed edema and enhancement C3-C6 suggestive for lymphoma vs sarcoid vs myelitis. A chest CT revealed pulmonary nodules. A biopsy of the nodules were performed, which showed only lung parenchyma, however it is uncertain that the nodules were truly biopsied. An LP revealed increased protein, though tap was traumatic and many RBCs were present. CSF viral studies-->+VZV, -EBV, and -HSV PCR. ACE normal. He was started on a second course of high dose steroids 1gm soulmedrol x5days to be followed by a 6 month course of PO steroids. Pt was d/c'd home on [**12-30**] with improving exam. Pt had been doing well at home with PT/OT until [**2124-2-8**], when pt's wife noticed pt undergo a possible seizure followed by coffee ground emesis. The pt's body stiffened. He then began having a rhythmic shaking of the LUE for about 30 seconds. Pt was then unresponsive for 5-10 minutes, after which he had coffee ground emesis. He was taken to OSH, where an EGD showed a gastric ulcer with a visible vessel and a Hct was 26. Pt was treated with H2 blocker and d/c'd home on [**2-13**]. The following day, pt developed a second episode, which per the wife, was exactly like the first, and was followed by a large amount of hematemesis. Pt taken to OSH and then transferred to [**Hospital1 18**], where a HCT on admission was 24.3. He was admitted to the MICU for UGIB. Past Medical History: HTN gout hypercholesterolemia asthma C4-C6 spinal stenosis (recent dx) eczema Social History: non-smoker Former EtOH user [**2-4**] drinks per night no h/o IVDU married x 8yrs works as computer analyst Family History: non-contributory no history of neurologic or CT disease Physical Exam: Vitals: 97.3 110-138/70-90 HR68-90 RR16-18 O2 Sat 95-100%. Gen: sitting in chair, NAD. HEENT: supple neck Pulmonary: CTA bilaterally Cardiovascular: RRR, S1/S2 no murmur Abd: +BS, soft NT/ND Ext: no edema Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Is attentive says [**Doctor Last Name 1841**] backwards. Able to relay coherent history. Speech is fluent with normal comprehension and repetition; naming intact. Registers [**2-3**], Recalls [**2-3**]. No evidence of apraxia or neglect. No right-left agnosia. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally without nystagmus. ?subtle right lid ptosis. Sensation intact V1-V3. No facial movements symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical shoulder shrug normal bilaterally. Tongue midline without fasciculations, intact movements Motor: Normal bulk bilaterally. Tone normal. [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IO APB IP H Q DF PF TE TF R 4+ 5 5- 5 5 5 5 4 4 4 5- 5 5- 5 5- 5 L 5 5 5- 5 5 5 5 4 4 5- 5- 5 5- 5 5- 5 Sensation: Decreased vibration bilaterally. Impaired JPS in toes bilaterally. Decreased sensation to pin R>L, patchy, no level. Reflexes: B T Br Pa Ach Right 2 2 2 2 2 Left 2 2 2 2 2 BRISK THROUGHOUT +crossed adductors Toes were upgoing bilaterally Coordination: Intact FNF task Gait: slow, narrow based, uses walker Pertinent Results: [**2124-2-14**] 11:05PM WBC-10.7 RBC-3.13* HGB-9.1* HCT-26.7* MCV-85 MCH-29.0 MCHC-34.0 RDW-18.1* [**2124-2-14**] 11:05PM PLT COUNT-155 [**2124-2-14**] 06:21PM WBC-9.0 RBC-2.91* HGB-8.4* HCT-24.2* MCV-83 MCH-28.8 MCHC-34.6 RDW-18.4* [**2124-2-14**] 06:21PM NEUTS-88.7* LYMPHS-6.1* MONOS-4.8 EOS-0.3 BASOS-0.2 [**2124-2-14**] 06:21PM PLT COUNT-188 [**2124-2-14**] 03:08PM GLUCOSE-145* UREA N-28* CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-23 ANION GAP-13 [**2124-2-17**] 10:48AM BLOOD WBC-10.3 RBC-3.96* Hgb-11.6* Hct-33.1* MCV-84 MCH-29.3 MCHC-35.0 RDW-16.8* Plt Ct-239 [**2124-2-14**] 06:21PM BLOOD Neuts-88.7* Lymphs-6.1* Monos-4.8 Eos-0.3 Baso-0.2 [**2124-2-17**] 10:48AM BLOOD Plt Ct-239 [**2124-2-17**] 10:48AM BLOOD Glucose-93 UreaN-18 Creat-0.7 Na-138 K-4.2 Cl-102 HCO3-27 AnGap-13 [**2124-2-15**] 04:49AM BLOOD CK(CPK)-57 MRI (brain) No abnormalities noted MRI (c-spine) Compared to the previous examination, there is decreased abnormal signal within the cervical cord, largely confined to the region of C3 and C4. There does not appear to be abnormal cord swelling at the present time. There is still some contrast enhancement but this also appears to be reduced compared to the previous examination. Degenerative disease is again seen involving C3- C4, C4-C5, and C5-C6, and C6-C7 essentially unchanged compared to the previous examination. For details, see that report. EEG pending Brief Hospital Course: 1. NEURO- His last seizure was in [**2122-9-2**]. Based on his history, probably had additional seizures before admission. Here, he was started on Trileptal and has remained seizure free. MRI showed no evidence of intracranial pathology that may have led to his recent seizures. C-Spine MRI showed similar, though decreased region of enhancement in the cervical cord at C3/4. The etiology of his his cord pathology is not yet clear. Was thought to be neurosarcoid due to presence of pulmonary nodules, but no clear evidence of granulomas or elevated ACE was seen. Repeat CT of his chest here was normal, with no LAD and clear lungs. He has been on chronic steroids for several months though, so his initial findings may have cleared in this setting. In terms of malignancy, biopsy of the lung nodules was non diagnostic in the past and the CSF cytology did not contain adequate cells to rule this out as a possible cause. Infectious causes seem unlikley, but VZV was positive (pt never had clinic varicella). Had a repeat LP here with essentially normal cell count, glucose, and very mildly elevated protein at 50. This was sent for TB-PCR and cytology. Both pending at D/C. He has been on prednisone 60 mg for several months and apparently worsened when they tried to taper him off this medication. We decreased him to 40 mg here and he will f/u with neurology where they can continue to taper this as he tolerates. He had EEG here with no evidence of seizure activity, but his episodes do sound suspicious for seizure. Given this, will continue his Trileptal as an outpt. Etiology of his neurological dysfunction still unclear, but ddx includes TB, lymphoma, neurosarcoid(less likely), MS. Apparently had diffuse enhancement of spinal cord on past MRI, which is not classic for any of the above. Repeat scan here is much improved as above. Will f/u on CSF studies. 2. GI - UGIB likely secondary to vessel in ulcer as seen on EGD. Received 2 units PRBCs. This vessel was cauterized during this admission and his Hct remained stable afterwards. His diet was slowly advanced and he was tolerating solids without issue by discharge. He did have 1 episode of heme positive stool while here, but would expect this given his recent bleed and fact that it was first BM since this. No drop in his Hct with this. Started on iron. Also started on Protonix 40 mg [**Hospital1 **]. WIll continue this as outpt and f/u with his PCP [**Last Name (NamePattern4) **] 10 days. 3. CV - He was ruled out for MI here. He did have tachycardia on telemetry with activity at times, but wasn't orthostatic. Unclear etiology, but didn't suspect PE, dehydration, arrhythmia. Encouraged PO intake. Held his ACE-I for the majority of admission, but restarted when he was stable. BP was in 140s systolic without medication. 4.Gout:Continued his home allopurinol. No issues. Told pt to avoid NSAIDS. 5.Pulm:Pt was continued on theophylline. COuld have been contributing to tachycardia, but has been on this for a long time, so decided to continue it. 6.ID:Continued Bactrim for ppx as he is on high dose steroids. Medications on Admission: theophylline 200mg po bid beclovent 5qid prednisone 60mg po q24h allopurinol 300mg po qd zocor 40mg po qd enalapril 20mg po qd pepcid 20mg po bid bactrim 1tab po bid iron PO supplement Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Theophylline 200 mg Capsule, Sust. Release 12HR Sig: One (1) Capsule, Sust. Release 12HR PO BID (2 times a day). Disp:*60 Capsule, Sust. Release 12HR(s)* Refills:*2* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* 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. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Seizure Myelitis Upper GI bleed/duodenal ulcer Discharge Condition: Improved-Hct stable, no seizures, weakness at baseline Discharge Instructions: Please continue to take your medications as directed. Your dose of prednisone has been decreased to 40mg daily, you should continue on this dose until your follow up appointment with Dr. [**Last Name (STitle) 1206**]. You have been started on a new medication called Trileptal to prevent seizures, please continue to take this medication. If you have another seizure, or develop new or increasing weakness or numbness, please call Dr. [**Last Name (STitle) 1206**] or Dr. [**Last Name (STitle) 7994**] or come to the emergency room for evaluation. Followup Instructions: 1. NEUROLOGY: Provider: [**Name10 (NameIs) 540**],[**Name11 (NameIs) **] Where: CC CLINICAL CENTER NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2124-3-1**] 2:30 2. Primary Care: Dr. [**Last Name (STitle) 58756**] [**Telephone/Fax (1) 58757**] [**2124-2-28**] 1:20PM

Admission Date: [**2182-4-10**] Discharge Date: [**2182-4-12**] Date of Birth: [**2128-3-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: none History of Present Illness: 53 yo f w/ h/o HCV, HCC and cirrhosis with h/o SBP and variceal hemorrhage who presents to ED with UGIB and hyperkalemia. Pt is well known to the Liver Service through previous admission and w/u for cirrhosis and HCC. Pt has had several admissions to OSH's, recently for anemia requiring transfussions as well as for complications of portal hypertension and SBP in the past. Pt recently d/c to rehab where he has been suffering from worsening fatigue and anorexia. Day of admission, Pt reports several episodes of dark emesis. . Transferred to OSH where he had several episodes of hematemesis; and found to be afebrile and hypotensive (SBP 70's). Labs at the time significant for Hct 29, HCO3 13 and K+ 7.0. ECG with possible peaked TW's. Subsequently recieved 10u insulin, one amp D50, Calcium, Kayexelate and covered with Cefotan and Flagyl. Right femoral line placed and transfused one unit of PRBCs and bolus 2.5 L NS. Transfered to BDIMC where in the ED was hemodynamically stable. NGL with evidence of blood despite 1 L flush and gross melena. . ROS: Pt denies F/C/CP/SOB/Girth/Abd pain but ? increasing abd girth. . Past Medical History: DM HTN HCV (chronic active) x 20 years ([**1-16**] IVDU) HCC started on Xeloda cirrhosis with known varices and h/o ascites/SBP diverticulosis s/p hemicolectomy Social History: Lives alone Previous h/o etoh abuse, now sober x 24 years +tobacco 15yrs x2ppd, no longer smoking Family History: NC Physical Exam: VS 100/30, 80, 19 99% 2L . gen-WOWN man, moaning, alert but disoriented time/place heent-icteric sclera, PERRL, dry MM, OP clear neck-2+ carotids [**Last Name (un) **]-CTAB CVS-Regular s1,s2. 2/6 SEM abd-Midline abdominal scar. protuberent distended abdomen, +caput. +bs. soft, diffuse tenderness; no rebound, +fluid wave. ext-2+ le edema, chronic venous stasis changes. neuro-A&O-1, mild asterexis, moving all extremities. Pertinent Results: [**2182-4-10**] 07:00PM BLOOD WBC-27.9*# RBC-2.66* Hgb-8.2* Hct-27.2* MCV-102* MCH-30.9 MCHC-30.2* RDW-20.9* Plt Ct-57* [**2182-4-10**] 07:00PM BLOOD PT-22.7* PTT-47.8* INR(PT)-3.2 [**2182-4-10**] 07:00PM BLOOD Glucose-203* UreaN-127* Creat-2.9*# Na-135 K-6.9* Cl-102 HCO3-8* AnGap-32* [**2182-4-11**] 05:12AM BLOOD ALT-409* AST-2728* AlkPhos-222* Amylase-59 TotBili-8.2* [**2182-4-10**] 07:00PM BLOOD Albumin-1.5* Calcium-8.2* Phos-10.7*# Mg-2.6 [**2182-4-10**] 09:00PM BLOOD Type-ART pO2-77* pCO2-23* pH-7.16* calHCO3-9* Base XS--18 [**2182-4-11**] 03:45AM BLOOD Lactate-13.5* K-5.7* CXR: IMPRESSION: 1) Pulmonary vascular congestion suggestive of early CHF. 2) Patchy retrocardiac opacity, which may be related to the low lung volumes, however, an early consolidation cannot be excluded. When possible, a dedicated PA and lateral radiographs are recommended. U/S IMPRESSION: 1) Thrombosis of the left portal vein with slow flow in the main and right portal vein. 2) Cirrhosis with multifocal hepatocellular carcinoma and ascites. Brief Hospital Course: 53 yo f w/ h/o HCV, HCC and cirrhosis with h/o SBP and variceal hemorrhage who was admitted to MICU with UGIB and hyperkalemia. Pt with underlying incurable malignancy and that superimposed variceal bleeding in setting of renal and hepatic failure carried a very poor prognosis. Family was aware of Pt's mortality risk and were interested in less aggressive measures of care that would preclude intubation, dialysis or other aggresive procedures but still remained full code as per Pt's initially wishes. Pt was maintained on octreotide/protonix gtts and supported/resucitated with blood products during first hospital day. Pt without recurrent hematemesis and remained hemodynamically stable off pressors but requiring aggressive resucitation. Hepatology and Transplant surgery services consulted and help in pt management. Pt with continued worsening liver and renal function despite aggressive resucition presumed [**1-16**] hypovolemia at OSH in setting of variceal bleed. Belief was that Mr [**Known lastname 131**] at best had several weeks to live given clinical picture. Discussions between MICU team, Hepatology servicem, Social work and ethics support with Family; decision was made to make Pt comfort measure only. Subsequently Pt died [**2182-4-12**]. Medications on Admission: Nadalol 40 qd Protonix 40 qd Oxycodone 5 q6 spironolactone 200 qd glyburide 5 qd cipro 250 qd lasix 40 qd Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: DM HTN HCV HCC cirrhosis variceal hemorrhage liver failure renal failure sepsis hyperkalemia Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

Admission Date: [**2110-5-5**] Discharge Date: [**2110-5-7**] Service: MEDICINE Allergies: Naproxen Attending:[**First Name3 (LF) 398**] Chief Complaint: Melena Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 81F CAD s/p "silent MI", here w/ melena after course of NSAIDs. USOH until three days prior to admission, developed melena, weakness, gnawing discomfort in epigastrium, no CP, SOB. Guaiac pos in PCP office and sent to ED. Found to have decrease in Hct to 31.5 from baseline ~37. Given IV protonix and brought to unit for EGD, which revealed gastritis, shallow ulcer, but no active bleeding. Recommended IV PPI [**Hospital1 **], [**Hospital1 **] Hct while in house, NPO overnight, then f/u scope in two months while on PPI. Past Medical History: HTN Hyperlipidemia CAD s/p "silent MI" Osteoarthritis Social History: Occasional alcohol. Does not smoke. Independent ADLs. Family History: NC Physical Exam: VS 67 118/45 16 98%2L GENERAL: NAD sleepy after scope HEENT: EOMI, OMMM NECK: Supple, no LAD CARDIOVASCULAR: S1, S2, reg, I/VI systolic, no RG LUNGS: CTAB ABDOMEN: Soft, NT, ND, active bowel sounds. EXTREMITIES: Warm, no CCE NEURO: sleepy, but arousable Pertinent Results: [**2110-5-5**] 11:57PM HCT-25.8* [**2110-5-5**] 07:15PM HCT-27.7* [**2110-5-5**] 04:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2110-5-5**] 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR [**2110-5-5**] 04:50PM URINE RBC-0 WBC-[**2-2**] BACTERIA-MOD YEAST-NONE EPI-[**5-10**] [**2110-5-5**] 02:15PM GLUCOSE-106* UREA N-15 CREAT-0.8 SODIUM-140 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14 [**2110-5-5**] 02:15PM CALCIUM-9.9 PHOSPHATE-3.7 MAGNESIUM-2.2 [**2110-5-5**] 02:15PM WBC-6.6 RBC-3.30* HGB-11.2* HCT-31.5* MCV-96 MCH-34.0* MCHC-35.6* RDW-13.5 [**2110-5-5**] 02:15PM NEUTS-64.9 LYMPHS-28.4 MONOS-4.8 EOS-1.6 BASOS-0.3 [**2110-5-5**] 02:15PM MACROCYT-1+ [**2110-5-5**] 02:15PM PLT COUNT-269 [**2110-5-5**] 02:15PM PT-11.6 PTT-21.3* INR(PT)-1.0 EGD: Small hiatal hernia Ulcer in the stomach body and antrum Erythema, friability, congestion and erosion in the antrum and stomach body compatible with erosive gastritis Erythema, friability and congestion in the proximal bulb Brief Hospital Course: 81F with erosive gastritis likely [**1-2**] NSAIDS. * Gastritis: Noted to have shallow nonbleeding ulcers by EGD, continued on PPI [**Hospital1 **]. Initially found to have continued Hct drop overnight, and as such was kept in ICU for further observation. Transfused two units, and bumped appropriately. No further episodes of melena, and tolerated PO diet with no difficulty. Counseled to avoid NSAIDs, however, allowed to continue taking ASA for presumed secondary prevention of CAD. * CAD: N tachycardia or demand ischemia noted during this admission. * FEN: NPO initially, then soft diet in AM following scope. Discharged to home following observation and transfusion. To return in [**5-8**] weeks for followup endoscopy. Medications on Admission: Atenolol 12.5 Lipitor 80 Lisinopril 10 ASA 325 Ibuprofen Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Atenolol Oral 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Gastritis Melena Blood loss anemia Discharge Condition: Patient had stable hct at discharge. No further bleeding or melena. Discharge Instructions: Please take your medications as prescribed. Please do not take any ibuprofen (Advil or Motrin). You may still take tylenol for pain. . Please call your doctor or return to the ER if you have chest pain, shortness of breath, dizziness, black stools or bloody stools, blood when you vomit or have other concerning symptoms. Followup Instructions: You should follow-up to have an endoscopy in 6 weeks. . You should follow-up with your primary care doctor, Dr. [**Last Name (STitle) **] [**Name (STitle) 1728**], in [**12-2**] weeks. His phone number is [**Telephone/Fax (1) 904**].

Admission Date: [**2176-11-4**] Discharge Date: [**2176-11-8**] Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old female status post myocardial infarction on [**11-2**] with substernal chest pain and shortness of breath. On arrival to the Emergency Room she had electrocardiogram changes with increased CK. Diagnosis was coronary artery disease, unstable angina. She was taken to the Operating Room for coronary artery bypass graft times three by Dr. [**Last Name (STitle) **]. PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia, peripheral vascular disease, hypothyroidism. CATHETERIZATION REPORT: Left main was normal. Left anterior descending coronary artery 90% stenosis. Left circumflex 20%. Obtuse marginal two 30% stenosis. Obtuse marginal three 60% stenosis. Right coronary artery 80% stenosis. MEDICATIONS AT HOME: Hyzaar 125, Synthroid .112 mcg po q day, Pletal 100 mg po b.i.d., Lipitor 10 mg po q day. HOSPITAL COURSE: The patient was taken to the Operating Room for a coronary artery bypass graft times three, left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to posterior descending coronary artery, and saphenous vein graft to obtuse marginal. Postoperatively, the patient did well. Chest tube was extubated promptly in the Intensive Care Unit. Chest tube was taken out on postop day number one. The patient was subsequently transferred to the floor on postop day number one. Upon arriving on the floor the patient was able to work with physical therapy to ambulate. Upon discharge the patient was able to ambulate approximately 300 feet with assistance. The patient will be discharged to rehab facility on [**2176-11-9**]. DISCHARGE MEDICATIONS: Lopressor 50 mg po b.i.d., Synthroid .112 mcg po q day, Lasix 20 mg po b.i.d. times ten days, K-Ciel 20 milliequivalents po b.i.d. times ten days and ASA 81 mg po q day, Lipitor 10 mg po q.d., and iron sulfate 325 mg po t.i.d. CONDITION ON DISCHARGE: Stable. She was in sinus rhythm. Her pulse was at 95 and her blood pressure was at 126/67. The patient was sating at 98% on 2 liters. Her hematocrit was 25.3. PHYSICAL EXAMINATION ON DISCHARGE: Lungs were clear to auscultation. The heart was regular rate and rhythm. Incision was clean and dry. No drainage. Sternum was stable. The patient is to discharged to a rehab facility on [**2176-11-9**]. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 33515**] MEDQUIST36 D: [**2176-11-8**] 12:16 T: [**2176-11-8**] 13:02 JOB#: [**Job Number 111135**]

Admission Date: [**2106-3-20**] Discharge Date: [**2106-4-2**] Date of Birth: [**2028-5-12**] Sex: F Service: Medicine ADMISSION DIAGNOSIS: Metastatic ovarian cancer. HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old woman with metastatic ovarian cancer with multiple medical problems who presented with hypoxia after being found hypoxic at rehabilitation with an elevated white count. The patient had been discharged from the [**Hospital1 346**] two days prior to this admission. A brief summary of her most recent history includes a diagnosis of an inoperable nonamenable small-bowel obstruction secondary to her tumor. She was managed medically for this and discharged to rehabilitation in early [**Month (only) 958**]. On [**2-16**] she was found by her family at rehabilitation to be unresponsive except to painful stimuli, hypoxic, and febrile to 104.6 degrees Fahrenheit. She was also tachycardic and tachypneic. She was brought to the Emergency Department at [**Hospital1 346**]. She was intubated and started on pressors and antibiotics; including vancomycin, ceftriaxone, and Flagyl. These antibiotics were then changed to Unasyn and vancomycin. She was weaned from pressors. She had several brief episodes of supraventricular tachycardia which were self-limited. She was also found to have renal failure which was attributed to obstructive uropathy from tumor along with a small prerenal component. On [**2-19**], antibiotics were changed to vancomycin and ceftazidime. On [**2-21**], these were changed to vancomycin and meropenem for pneumonia once sensitivities were determined. She was extubated on [**2-21**]. She received hydrocortisone for adrenal insufficiency. She was diuresed and called out to the floor on [**2-22**]. A Neurology consultation on [**2-23**] found the patient able to follow one-step commands and state her name, and her encephalopathy was attributed to sepsis. On [**2-24**], she was found to have dark drainage from her nasogastric tube which was thought to be blood. Her right arm was found to be swollen, and an ultrasound revealed a deep venous thrombosis. Anticoagulation was not started given the patient's risk of a gastrointestinal bleed. On [**2-25**], she was found tachypneic and hypoxic and began to be febrile as well. There was concern about aspiration. She was managed with oxygen up to 100% on nonrebreather and then weaned downward. She had blood from her ostomy as well as occult blood positive nasogastric tube output. Her mental status worsened, and she no longer responded to pain or voice. She had no spontaneous eye movements. She was transfused multiple times for a falling hematocrit. She was noted to be in respiratory distress by her family on [**3-1**]. At that time, she was also noted to pulseless. Cardiopulmonary resuscitation was begun. A code was called. The patient had asystole after a prolonged code which included epinephrine, intubation, cardiopulmonary resuscitation, and atropine. The patient went into ventricular fibrillation. She was shocked at 300 joules and given one ampule of bicarbonate. She then developed a narrow complex tachycardia with a systolic blood pressure in the 110s with a palpable carotid pulse. She was transferred to the Medical Intensive Care Unit where she was rapidly weaned from pressors, and she was treated for her pseudomonal pneumonia and urinary tract infection. The patient was extubated and then failed secondary to her mental status and had to be reintubated. She was found to be adrenally insufficient as well. She suffered from thrombocytopenia. She was negative for heparin-induced thrombocytopenia antibody. She had a negative blood smear. Medications were not felt to be causing the thrombocytopenia. Eventually, her platelets recovered. The patient had a tracheostomy. She continued to have minimal output from her colostomy secondary to her obstruction by tumor. She was deemed not to be a surgical candidate. The patient was intermittently febrile, but cultures were not revealing. She did develop positive cultures on [**3-15**] and [**3-16**]; which were not treated as there had been no change in her clinical status. Her urinalysis was negative for signs of infection. She was discharged to rehabilitation on [**3-18**]. At the rehabilitation facility she was found to be hypoxic and have an elevated white blood cell count with thick material being suctioned from the tracheostomy. She was returned to the Emergency Department. PAST MEDICAL HISTORY: 1. Ovarian cancer diagnosed in [**2104-11-1**]; status post debulking, status post total abdominal hysterectomy, status post omentectomy, status post sigmoid resection, and end colostomy. 2. Status post bleeding ulcer and duodenal mass. 3. Status post oversewing of ulcer and pyloroplasty. 4. History of vancomycin-resistant enterococcus and methicillin-resistant Staphylococcus aureus sepsis. 5. History of malignant pleural effusions; status post pleurodesis times two. 6. Breast cancer; status post left lumpectomy in [**2093**] and radiation therapy. 7. Hypertension. 8. Gastroesophageal reflux disease. 9. High cholesterol. 10. Depression. 11. Polyneuropathy. 12. Status post appendectomy. 13. History of zoster. 14. Recently (in [**2106-1-30**]) diagnosed with a small-bowel obstruction related to tumor burden which was inoperable and not responsive to chemotherapy. 15. An echocardiogram in [**2106-1-30**] showed a left atrium of normal size. The left ventricular wall thickness and cavity size were normal. The left ventricular systolic function was hyperdynamic with an ejection fraction of greater than 75%. The right ventricular chamber size and free wall motion were normal. A number of aortic valve leaflets could not be determined. The aortic valve leaflets were mildly thickened. There was no significant aortic valve stenosis. There was 1+ aortic regurgitation. There was no mitral valve prolapse. There was trivial mitral regurgitation. There was no pericardial effusion. ALLERGIES: LEVOFLOXACIN (causes a rash) and ENALAPRIL (causes a cough). MEDICATIONS ON ADMISSION: 1. Lopressor 25 mg p.o. twice per day. 2. Protonix 40 mg intravenously q.12h. 3. Artificial Tears. 4. Hydrocortisone 50 mg intravenously q.8h. 5. Regular insulin sliding-scale. 6. Morphine as needed. 7. Miconazole powder. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 95.6, heart rate was 108, blood pressure was 125/49, and respiratory rate was 25. The patient had a tracheostomy and unresponsive to deep sternal rub. The patient was jaundiced with scleral icterus. The pupils were reactive bilaterally. The mucous membranes were dry. The chest revealed coarse breath sounds bilaterally. The heart was regular. No murmurs, rubs, or gallops. The abdomen was distended, hard, and with no bowel sounds. Her extremities were warm. There was 2+ right upper extremity pitting edema. There was left upper extremity trace edema. There was bilateral lower extremity 2+ pitting edema. Neurologically, the patient withdrew her feet to pain. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed sodium was 145, potassium was 3.5, chloride was 109, bicarbonate was 17, blood urea nitrogen was 90, creatinine was 1.5, and blood glucose was 124. ALT was 160, AST was 191, amylase was 524, alkaline phosphatase was 397, lipase was 68, and total bilirubin was 12.2. White blood cell count was 17.6, hematocrit was 22, and platelets were 82. Prothrombin time was 13.6, partial thromboplastin time was 30.1, and INR was 1.2. A urinalysis had moderate leukocyte esterase, moderate blood, negative nitrites, trace protein, moderate bilirubin, greater than 50 white blood cells, greater than 50 red blood cells, many bacteria, and 3 to 5 squamous epithelial cells. PERTINENT RADIOLOGY/IMAGING: A computed tomography of the head done on [**2-16**] showed minimal mucosal thickening present in the right maxillary sinus and within the ethmoid air cells; otherwise, no acute process. A right upper quadrant ultrasound on [**2-19**] showed no evidence of cholecystitis with septated fluid regions representing metastatic spread adjacent to the liver. An upper extremity ultrasound from [**2-24**] showed an occluding thrombus in the right cephalic vein. A abdominal ultrasound from [**3-2**] showed no intrahepatic bowel ductal dilation. There was extensive metastatic disease throughout the peritoneum. There was unchanged bilateral hydronephrosis. A chest x-ray done on [**3-18**] showed an increasing left pleural effusion, retrocardiac, and a right lower lobe opacity which may have been atelectasis versus pneumonia. A sputum from [**3-15**] had greater than 25 white blood cells, less than 10 epithelial cells, and had 4+ gram-negative rods, yeast, and methicillin-resistant Staphylococcus aureus. A urine culture from [**3-16**] grew greater than 100,000 Klebsiella which was pan-resistant except for to meropenem and Zosyn. A urinalysis from [**3-16**] was negative for nitrites and leukocyte esterase. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. She was initially put on a ventilator. She had a tracheostomy and needed no sedation at that time. She did require frequent suctioning for thick sputum. She was treated for pneumonia with vancomycin. She was also started on Zosyn for her urinary tract infection. Her small-bowel obstruction was medically managed with a nasogastric tube to intermittent suction. She was maintained on a proton pump inhibitor for her history of gastrointestinal bleeds. The patient had a known right upper extremity deep venous thrombosis and was not anticoagulated given her risk of a gastrointestinal bleed. The patient was noted to have worsening liver function when compared with the laboratories from her previous admission. This was felt to be secondary to her metastatic disease. There was no further treatment possible for the patient's ovarian cancer. The patient remained encephalopathic. She did not respond to voice or pain. This was felt to be secondary likely to an anoxic brain injury as well as her multiple metabolic abnormalities from her multiple medical problems. The patient was noted to be anemic and was felt to be loosing blood from gastrointestinal losses. Initially, she had occult-blood positive nasogastric tube output. She was transfused to keep her hematocrit above 21. The patient was also noted to have renal failure. This was secondary to obstructive disease from her ovarian cancer. The patient was maintained on hydrocortisone for adrenal insufficiency. Initially, the patient was seen by the Gastroenterology Service who felt that her gastrointestinal bleed should be managed conservatively with proton pump inhibitors. Her gastrointestinal bleeding slowed down somewhat. The patient required multiple blood transfusions to keep her hematocrit above 21. It was felt that Ms. [**Known lastname 96805**] was dying from her terminal metastatic ovarian cancer. Multiple meetings were held with the family expressing this. The family wished to continue supportive care; despite the extremely grim prognosis. On [**3-23**], a family meeting was held, and the decision was made that cardiopulmonary resuscitation was not indicated in this patient. The following day, the patient had a large amount of coffee-grounds emesis. Her nasogastric tube was placed to intermittent suction. The patient was weaned off the ventilator by [**3-25**]. She did well on a tracheostomy mask and eventually was weaned down to an FIO2 of 40%. On [**3-26**], the patient was called out to the floor. The patient remained stable on the floor for a few days. At no point was she responsive to voice or pain. Her vital signs were stable. On [**3-29**], the patient was noted to have a large amount of frank blood output from her nasogastric tube. Again, she required transfusions to keep her hematocrit above 21. Meetings were held with the family once again about the patient's extremely grim prognosis. However, the patient's family continued to want everything possible to be done. On the night of [**3-29**], the patient was noted to have a large amount of blood coming out of her tracheostomy tube. This required aggressive suctioning which could not be managed on the floor. At no time did the patient's oxygen saturation fall below 93% on 40% tracheostomy mask. An Ethics consultation was once again obtained. After much discussion with the Ethics Service, Medicine attending, and Medical Intensive Care Unit attending the decision was made that the patient should be transferred to the Intensive Care Unit for management of her airway. While in the Intensive Care Unit, the patient was aggressively suctioned. She was noted to have a coagulopathy with an INR of 1.7. This was reversed with vitamin K. The patient was transfused several units of platelets as well as units of packed red blood cells to maintain a platelet count of above 50 and a hematocrit level above 21. A Gastroenterology consultation was obtained once again. Once again, the Gastroenterology Service felt that there was no intervention that was possible in this extremely ill and terminal woman. The patient's bleeding from her tracheostomy tube slowed down. She was then called again out to the floor on [**3-31**]. On [**4-2**] she required an additional transfusion of platelets to keep her platelet count above 50. Her hematocrit was stable at that time at 27 to 28. At 7 p.m. that evening, the patient was found expired. The patient was pronounced dead at 7:15 p.m. The family and the attending (Dr. [**Last Name (STitle) 665**] were notified. The family declined an autopsy. DISCHARGE DIAGNOSES: 1. Death. 2. Metastatic ovarian cancer. 3. Small-bowel obstruction. 4. Methicillin-resistant Staphylococcus aureus pneumonia. 5. Klebsiella urinary tract infection. 6. Upper gastrointestinal bleed. 7. Hemoptysis. 8. Total parenteral nutrition dependent. 9. Adrenal insufficiency. 10. Obstructive nephropathy. 11. Renal failure. 12. Liver failure. 13. Right upper extremity deep venous thrombosis. 14. Thrombocytopenia. 15. Blood loss anemia. 16. Encephalopathy. 17. Anoxic brain injury. 18. Coagulopathy. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**MD Number(1) 5046**] Dictated By:[**Last Name (NamePattern1) 222**] MEDQUIST36 D: [**2106-4-3**] 14:38 T: [**2106-4-8**] 13:22 JOB#: [**Job Number 96809**]

Admission Date: [**2176-4-22**] Discharge Date: [**2176-5-7**] Date of Birth: [**2103-8-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim / Aspirin / Compazine / Nifedipine / Morphine Attending:[**First Name3 (LF) 783**] Chief Complaint: Hemoptysis. Major Surgical or Invasive Procedure: 1. Endotracheal intubation (x2) 2. Thoracentesis (x2 with pigtail catheter placement x1) 3. Bronchoscopy History of Present Illness: 72 YOF Hx of pulmonary hypertension who presents with massive hemoptysis. Per the family had a recent hospitalization for heart failure. Has been having small amounts of hemoptysis for weeks (less than a teaspoon). This evening patient became acutely short of breath and hit her lifeline. She is on anticoagulation and has had several falls recently. She fell ~ 2 days ago and has had abdominal pain ever since (mostly LLQ). No N/V. In the ED, patient was coughing up blood and clots. INR reversed with FFP and vit K. Intubated. Gastric tube placed also with blood return. Was tachycardic and hypertensive, never hemodynamically unstable. Given levofloxacin for empiric pneumonia coverage. Past Medical History: 1. Pulmonary hypertension 2. Severe [4+] tricuspid regurgitation 3. Atrial fibrillation on coumadin 4. TIA ([**2166-1-28**]) 5. Hypertension 6. SLE with joint involvement, malar rash 7. Chronic Pain syndrome 8. Fibromyalgia 9. OSA on CPAP 10. GERD 11. IBS 12. Gout 13. Anemia: Iron deficency anemia with negative upper and lower endoscopy 14. Falls (history of) Social History: Lives on her own with daughter upstairs and son downstairs. H/o social smoking and drinking. Family History: Hypertension, CAD, Cancer. Physical Exam: Vitals: T:99.5 BP:126/72 P:88 R:17 SaO2: 100% General: Awake, alert, intubated. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, dried blood on lips. Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs coarse b/l Cardiac:irregular, distant, tachy, nl. S1S2 Abdomen: soft, diffusely tender, ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No edema, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: awake, alert. moving all 4 extremeties Pertinent Results: Admit Labs: [**2176-4-22**] WBC-22.7*# RBC-5.16# HGB-13.0# HCT-40.2# MCV-78* MCH-25.3* MCHC-32.4 RDW-20.5* PT-150* PTT-113.8* INR(PT)->22.8* GLUCOSE-159* LACTATE-3.8* NA+-138 K+-3.2* CL--84* TCO2-37* UREA N-47* CREAT-1.5* Discharge Labs: [**2176-5-5**] WBC-7.9 RBC-3.81* Hgb-9.7* Hct-31.6* MCV-83 MCH-25.5* MCHC-30.7* RDW-24.0* Plt Ct-503* Glucose-97 UreaN-11 Creat-1.0 Na-138 K-3.3 Cl-97 HCO3-30 AnGap-14 EKG: irregular. rate 130 bpm. nl axis. narrow qrs. LVH. ST depression in II, aVF, V4-6 CXR ([**2176-4-22**]): There has been interval placement of endotracheal tube, which lies 4 cm above the carina. Nasogastric tube is seen extending below the diaphragm and out of view. Patient is slightly rotated on current radiograph, limiting evaluation. Marked global cardiomegaly is probably unchanged. Mediastinal widening is difficult to assess given the degree of rotation. No focal consolidations are seen, and there is no pleural effusion or pneumothorax. ABD US ([**2176-4-22**]): Cholelithiasis without son[**Name (NI) 493**] evidence of cholecystitis. ECHO ([**2176-4-23**]):The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2176-3-8**], global biventricular systolic function is similar. The severity of tricuspid regurgitation and the estimated pulmonary artery systolic pressure are now lower (may be related to technical quality rather than a true decline). XRAY SHOULDER and HIP and WRIST ([**2176-4-23**]): Mild left acromioclavicular joint arthrosis. No fracture. No hip fracture. Wrist - Diffuse demineralization. Mild degenerative change about the articular surfaces of the scapholunate interval. The intercarpal spaces are normal on this non-stress view. CT HEAD ([**2176-4-23**]): No intracranial hemorrhage. Mild chronic microvascular ischemic changes. CT CHEST ([**2176-4-23**]): 1. New large left pleural effusion, predominantly loculated. 2. Bronchomalacia bronchus intermedius. Possible air extravasation. 3. Marked cardiomegaly, especially right atrial enlargement due to tricuspid insufficiency. Pulmonary hypertension. 4. Bibasilar atelectasis. Right lower lobe pneumonia cannot be excluded. 5. Mediastinal lymphadenopathy, slightly increased, most likely reactive, but other causes such as neoplasm can not be excluded. CT CHEST/ABD/PELVIS ([**2176-4-28**]): 1. Decrease in left pleural effusion, status post left pleural catheter. Loculated effusion persists in the anterior pleural space with new focal areas of air within the effusion that could be secondary to recent intervention. 2. Increasing atelectasis with consolidation of the right lower lung with opacification of the right lower lobe bronchus with endobronchial secretions. 3. Persistent cardio megaly and small pericardial effusion. 4. Right renal cysts Brief Hospital Course: 1. Hemoptysis/anemia: In setting of supratherapeutic INR (22) and pulmonary hypertension. Bleeding stopped once INR reversed. Bronchoscopy initially showed large clot across the carina but no active bleeding. Repeat bronchoscopy showed slight ooze from LLL. Again no active bleeding but a large clot. IP subsequently came and removed the clot. After INR reversal and clot removal, patient no longer had hemoptysis and hematocrit remained stable. 2. Respiratory failure (pneumonia and pleural effusions): Patient intubated in ED for hemoptysis. Extubated the following morning but had increasing respiratory difficulty through out the day and was re-intubated in early evening. In addition to hemoptysis and heart failure, patient developed aspiration pneumonia. Sputum showed GPC on gram stain but cultures negative (taken while on levofloxacin). Vancomycin was added. CT scan of the chest showed left loculated pleural effusion that was tapped on [**4-25**] by IR showed 4+ PMNs but no organism. IP further drained the L posterior loculated fluid (~900cc) and a pigtail catheter was placed on [**2176-4-26**]. The pigtail catheter can be removed when drainage stops. Pt developed fever on [**4-27**] despite being on vanc/levofloxacin and aztreonam was added after panculture was obtained. Repeat CT chest subsequently showed improved L posterior pleural effusion, unchanged L loculated pleural effusion (too small to tap) and increased opacities in the RLL. Because all her sputum, pleural fluid cultures were negative, vancomycin and aztreonam were discontinued on [**4-29**] and [**4-30**], respectively. A 10 day course of Levaquin was completed. Patient was extubated successfully on [**4-29**], and at the time of transfer was satting well on room air. 3. Coagulopathy: On coumadin for a fib. Her coumadin dose was increased a week prior to admission. Unclear why INR so dramatically elevated. Reversed with FFP and PO vitK. and had no longer hemoptysis. 4. Congestive heart failure, diastolic: Initially BB/diuretics were held due to hypotension. They were reintroduced once hemodynamically stable. 5. Atrial fibrillation: Initially held BB given hypotension. Metoprolol was readded to control her rate (and titrated up). Her elevated INR was reversed as above. Given her recurrent falls per family and hemoptysis, patient was not felt to be a good candidate for anticoagulation; given her aspirin allergy, Plavix was started. 6. Renal failure: Likely in the setting of blood loss and hypertension. SCr 1.0 at the time of discharge after peaking to 1.5 on admission. 7. Mental status change: After arriving to the floor, the patient would become mildy agitated at night and would also become disoriented. This was felt to be secondary to narcotics provided earlier in her stay. Her pain regimen was changed with the hope to minimize narcotics use. Tylenol RTC was given and a Lidocaine patch was applied to her left flank. Low doses of oxycodone IR and Ultram were used. Geriatrics was consulted and recommended low dose of [**Hospital1 **] Haldol and re-institution of Klonopin, given that the patient presented on chronic benzoes. This worked well and the patient improved greatly with no issues over the final 3-4 days of her stay. 8. Pain: The patient presented with a history of chronic pain. Based on prior PCP notes, multiple regimens have been tried with no only moderate success. At the time of discharge, her pain regimen was as outlined in #7. Consideration could be given to eliminating oxycodone in favor of the Ultram if the latter is working well. 9. Hypertension: Presented on Nifedipine SR 60mg daily, HCTZ 25mg daily and Metoprolol 100mg [**Hospital1 **]. The first two medications were not restarted before discharge, but likely could be as the patient's blood pressure was no optimized. The metoprolol was initially held, then restrated and titrated to 100mg TID. 10. Obstructive sleep apnea: CPAP settings are -- Mask Ventilation: Nasal CPAP w/ PSV (BIPAP) Inspiratory pressure: 8 cm/h2o Expiratory pressure: 5 cm/h2o Backup rate: 10 bth/min Supp O2: 2 L/min. 11. Hyperglycemia: Blood glucose 223 on admission finger sticks as high as 160s thereafter. Sliding scale inslulin was used during stay. [**Month (only) 116**] require oral hypoglycemics. Medications on Admission: 1. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for pain. 2. Fluvoxamine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 4. Clindamycin Phosphate 1 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed for constipation. 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 9. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 16. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. 2. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a day as needed for PAIN. 4. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Fluvoxamine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a day. 7. Lactulose 10 g/15 mL Solution Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed for constipation. 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. Insulin Regular Human 100 unit/mL Solution Sig: As directed. Injection ASDIR (AS DIRECTED): See sliding scale. 16. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 18. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 21. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 22. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 23. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: 1. Hemoptysis 2. Pulmonary hypertension 3. Pneumonia 4. Pleural effusion 5. Acute renal failure 6. Mental status change 7. Chronic pain syndrome / Fibromyalgia Secondary: 1. Congestive heart failure, diastolic 2. Atrial fibrillation 3. Hypertension 4. Anemia, iron deficient 5. Tricuspid regurgitation 6. Prior TIA 7. Systemic lupus 8. Obstructive sleep apnea 9. Gastroesophageal reflux disease 10. Gout Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted after having hemoptysis (bloody coughing). This was likely related to your pulmonary hypertension and an elevated INR (coumadin level). Given the deconditioning you experienced while hospitalized, you will require rehab to get stronger. Please note that there have been a number of changes to your medication regimen. Please weigh yourself every morning and call your doctor if your weight increases by 3 lbs or more. Followup Instructions: Please follow-up with your primary care doctor 1-2 weeks after discharge from rehab. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

Admission Date: [**2148-10-6**] Discharge Date: [**2148-12-30**] Date of Birth: [**2148-10-6**] Sex: M Service: HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is a former 936 gram product of a 26 and [**3-8**] week gestation, twin pregnancy, born to a 45 year old, Gravida II, now Para II woman. PRENATAL SCREENS: Blood type 0 negative, antibody negative, Rubella immune; rapid plasma reagent nonreactive; hepatitis B surface antigen negative; hepatitis C negative; HIV negative, group beta strep status unknown. The maternal pregnancy was notable for hypothyroidism on Synthroid, ureteral reflux, status post repair; fibroids, status post resection and HSV with last lesion in [**2148-9-2**]. This was an in-[**Last Name (un) 5153**] fertilization pregnancy with donor eggs. The donor was 26 years old. The pregnancy was remarkable for dichorionic, diamniotic twins with concordant growth. Cervical shortening diagnosed at 21 weeks, treated with bed rest at home and then admitted on [**9-17**]. The mother was beta complete as of [**9-20**]. There was premature labor treated with Terbutaline and then magnesium on [**9-21**]. There was a questionable premature rupture of membranes on [**9-21**]. On the date of delivery, the mother was noted to have advanced cervical dilatation with breech/breech presentation. Intrapartum antibiotics were given and the mother received a cesarean section under spinal anesthesia. Twin 1 emerged with initial cry but then poor respiratory effort, requiring bagged mask ventilation. He was intubated in the delivery room. Apgar scores were six at one minute and seven at five minutes. The child was brought to the Neonatal Intensive Care Unit. PHYSICAL EXAMINATION: Physical examination was notable for a premature male, orally intubated with poor perfusion. Birth weight was 936 grams, which was the 50th percentile; length was 35.5 cm (50th percentile); head circumference 24.5 cm (50 percentile). The infant is a non dysmorphic male with overall appearance consistent with gestational age. The anterior fontanel was soft, open and flat. Palate intact. Fair aeration with crackly breath sounds, no murmur, a soft abdomen. No hepatosplenomegaly. 1+ pulses throughout. Normal male genitalia with the testes high in the canal, a patent anus, no sacral dimple, no hip click; mild bruising on the arms and a 1.5 by 5 cm birth mark/versus bruise in the back mid thoracic region. HOSPITAL COURSE: 1.) Respiratory: The patient was initially intubated on settings of 20/5 at a rate of 25. He received three doses of Surfactant. On day of life #3, he was weaned to C-pap of 6 cm on room air. He was also started on caffeine on day of life three. He weaned from C-pap to room air on day of life #20. He remained on caffeine with mild apnea of prematurity. The caffeine was discontinued on day of life 45. He has remained apnea free and, at the time of discharge, he is breathing comfortably on room air with good saturations, with no evidence of apnea of prematurity for over two weeks. 2.) Cardiovascular: He initially required two normal saline boluses and was started on Dopamine. He was weaned off Dopamine on day of life number two. He continued to have stable blood pressures. He never had a patent ductus arteriosus. At the time of discharge, he has stable blood pressures with good perfusion. 3.) Fluids, electrolytes and nutrition: The infant was initially made n.p.o. and was started on intravenous nutrition. Feeds were started on day of life 6 and gradually advanced. He reached full feeds on day of life 13 and calories were gradually increased to a maximum of 30 calories per ounce. His growth continued to be good and he started orally feeding. At the time of discharge, he was tolerating full feeds of breast milk for Enfamil supplement at 24 calories per ounce. His discharge weight is 3.525 kg. 4.) Gastrointestinal: The infant developed unconjugated hyperbilirubinemia of prematurity and was treated with phototherapy from day of life #1 through day of life #8. His maximum total bilirubin level was 4.9 over 0.3 on day of life number one. 5.) Hematology: The infant did receive one blood transfusion on day of life #12 for a low hematocrit. 6.) Infectious disease: Initial complete blood count showed neutropenia as subsequent CBC on day of life one had an impressive left shift. He was started on Ampicillin and Gentamycin on day of life one and completed a 7 day course. All cultures remained negative. A lumbar puncture was performed on day of life number four which revealed zero red blood cells and three white blood cells. Cultures in the spinal fluid were also negative. At the time of discharge, the patient has remained off antibiotics with negative cultures. 7.) Neurology: Head ultrasounds were performed on day of life number 3, day of life number 10 and day of life number 31. All head ultrasounds remained within normal limits. 8.) Ophthalmology: Ophthalmology examination was performed on [**11-18**] and Mid- [**Month (only) 1096**] and revealed immaturity bilaterally in zone three. Follow-up ophthalmology is required. DISCHARGE STATUS: Discharged to home. PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 50100**] [**Last Name (NamePattern1) 10132**] at [**Hospital 3146**] Pediatrics. CARE RECOMMENDATIONS: Feedings: Continue breast milk and Enfamil 24 calories per ounce and monitor growth. MEDICATIONS: Ferrous sulfate at 0.2 cc p.o. q. day. Poly-Vi-[**Male First Name (un) **] 1 cc p.o. q. day. Eye examination should be performed in 2 to 3 weeks. State newborn screen was sent. Results are pending. Automated auditory brain stem response screen prior to discharge. Car seat position screening: passed. IMMUNIZATIONS: The patient received hepatitis B vaccine on [**11-22**]. He received DTAP and HIB vaccines on [**12-6**]. He received IPV and pneumococcal conjugant vaccine on [**12-5**]. Prior to discharge, a dose of Synagis vaccine will be given. IMMUNIZATIONS RECOMMENDED: Synagis-RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: 1.) Born at less than 32 weeks. 2.) Born between 32 and 35 weeks with two of the three following: Day care during the RSV season, with a smoker in the household, neuromuscular disease, airway abnormalities or with preschool siblings. 3.) With chronic lung disease. Influenza immunization should be considered annually in the Fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. DISCHARGE DIAGNOSES: Prematurity at 26 and 3/7 weeks gestation. Sepsis ruled out. Respiratory distress, resolved. Apnea of prematurity, resolved. Unconjugated hyperbilirubinemia, resolved. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**] Dictated By:[**Name8 (MD) 50101**] MEDQUIST36 D: [**2148-12-13**] 02:31 T: [**2148-12-13**] 15:32 JOB#: [**Job Number 50102**]

Admission Date: [**2154-5-2**] Discharge Date: [**2154-5-11**] Date of Birth: [**2090-9-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6169**] Chief Complaint: CC:[**CC Contact Info 25337**] Major Surgical or Invasive Procedure: Stereotactic brain biopsy History of Present Illness: HPI:Pt is a 63 yo with CAD s/p MI and stents, DM2, NASH cirrhosis, and recent diagnosis of lymphomatoid granulomatosis who presents from an OSH after GTC seizure. He was diagnosed in [**Month (only) 404**] with large B-cell lymphoma, but on further review, they have diagnosed him with probable lymphomatoid granulomatosis. He received Rituxan-CHOP, but when diagnosis changed, he was switched to Rituxan weekly only, with last dose 6 days prior to admission. He has been told that definitive treatment will require a bone marrow transplant. He has been suffering from diarrhea for 2 months and has had 10 days of an unknown med for this at home. His PET scan apparently showed disease mainly in lungs and possibly in liver. he has never had head imaging apparently. He was at home today and took his temp. He had a 103.2 fever and his wife brought him to an OSH. En route, he stopped talking and apparently started having GTC activity. They got to the ED and he either stopped briefly or continued to convulse, it is unclear. Ativan 3 mg was given with resolution. He was intubated. ? left gaze preference. CT there showed 2 cm round left temporal lobe mass with mild local edema. No shift or brainstem involvement. His temp there was 101.7. He got vanco, CTX, acyclovir, and 1 g cerebyx. He was then transferred here. Past Medical History: Large B-cell lymphoma, this has not been changed to lymphatoid granulomatosis, it is large B-cell lymphoma per Dr. [**First Name (STitle) 1557**]. iron deficiency anemia- Long standing per patient. recently treated with IV iron. Recent colonoscopy negative for bleeding source Hypertension Coronary Artery Disease s/p MI with 2 setnts placed at [**Hospital1 18**] Type II Diabetes Mellitus with retinopathy, neuropathy, nephropathy Non-Alcoholic Steatorrheic Hepatitis cirrhosis - verified by liver bx 5 years ago per pt report s/p cholecystectomy psoriasis vitiligo Social History: SH: Lives with wife. [**Name (NI) **] EtOH. No smoking. Exposed to [**Doctor Last Name 360**] [**Location (un) 2452**] in [**Country 3992**]. Family History: FH: Sister with metastatic colon CA Physical Exam: Exam:100.3, 112/50->97/48, RR=14-19, O2=99% on vent Medications received prior to exam: See above. On propofol Mental Status:Intubated and sedated. Pt is lightly sedated, and does pull against restraints at times. CN: Pupils: 3 to 2 and sluggishly reactive. Nasal Tickle: Grimaces equally and turns away briskly. Gag/Cough: Coughs on tube Corneal Reflex:Present bilaterally OCRs: Sluggish, but intact. Motor:Some spontaneous movement of all exts. Withdraws UE and LE briskly and equally to painful stimulus(nailbed pressure). Toes:Upgoing bilaterally DTRs: [**Name2 (NI) **] Tri Br Pa [**Doctor First Name **] R t t t t t L t t t t t Respiration:Pt is overbreathing ventilator. Pertinent Results: Labs/Radiology/Procedure: OSH: CBC:15/38.7\91 Chems:138/3.5/105/14/14/0.7/195 Ca=8.5 UA with neg nit, neg LE, 0-5 wbcs, 1+ bact. Coags: PTT=30, INR=1.3, PT=12.7 CT head [**5-1**]: 2 cm left medial temp lobe mass with ? vague ring of hyperdensity. Slight edema, but no shift or brainstem involvement. CXR [**5-1**]: 1. Endotracheal tube 3.3 cm above the carina. Nasogastric tube in good position. 2. Low lung volumes with bibasilar consolidations - atelectasis or pneumonia. 3. 1cm rounded opacity at the left lung base. Bilateral hilar fullness out of proportion to the vasculature. Evaluation via contrast enhanced CT is recommended. 4. Stones and surgical clips in the right upper quadrant. Correlation with patient's surgical history is requested. MRI Head [**5-2**]: 1. Left temporal lobe mass likely represents a focus of infection. Rim enhancement and edema suggests an abscess, though there is no restricted diffusion. Demyelinating process or neoplasm are also possible, though the lesion is not enhancing. 2. No other lesions within the brain parenchyma. 3. Probable developing hydrocephalus. Echocardiogram [**5-6**]: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic interatrial septum. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). False LV tendon (normal variant). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve 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: No valvular pathology or pathologic flow identified. Brief Hospital Course: Mr. [**Known lastname 25338**] was admitted with seizures, fevers and a left temporal lobe mass. He was placed on Dilantin and planning for a tissue biopsy was begun. He was placed on Flagyl for concern of C. dificile. He was extubated on HD2, and subsequently transferred to the floor. He underwent radiographic studies, which may be reviewed inthe results section. He underwent a cardiac echocardiogram as part of an infectious etiology workup. On HD7, he underwent a stereotactic brain biopsy, with a preliminary diagnosis of lymphoma. With a tissue biopsy obtained, he was begun on decadron. His postoperative CT scan was unremarkable. His dilantin levels were difficult to maintain, and he was converted to Keppra. On HD7, he received 500 mg [**Hospital1 **]. The goal dose is 1500 mg [**Hospital1 **], with a wean of dilantin. He was then transferred to the medicine oncology service under the care of Dr. [**First Name (STitle) 1557**]. Mr. [**Known lastname 25338**]' staples should be removed on [**2154-5-17**]. If he is still an inpatient at that point, the Neurosurgery service would be happy to remove them. Medications on Admission: Meds(list may be old per daughters who will bring in meds as soon as possible): Immodium metoprolol 50mg daily norvasc 5mg daily lisinopril 10mg daily aspirin PRN recently d/c'd insulin glucophage HCTZ isosorbide Discharge Disposition: Home With Service Facility: ALL care VNA Discharge Diagnosis: CNS lymphoma B cell lymphoma Generalized tonic Clonic Seizures Diarrhea __________________________ Diabetes Cirrhosis Discharge Condition: good, tolerating pos, satting well on RA, ambulating without assistance Discharge Instructions: Please seek medical attention should you develop headache, nausea, vision changes, dizziness, weakness, numbness or tingling. Also seek medical attention should you develop fever, chest pain, shortness of breath, or any other concerning symptoms. Please follow up as below. Take all medications exactly as prescribed. We have stopped your aspirin, and other heart medications currently and started you on dexamethasone which you should take twice a day and keppra which you should also take 1500mg twice a day. You should finish your course of flagyl for three more days. We have also started you on lomotil for your diarrhea and pantoprazole which you should take as long as you are taking dexamethasone. Followup Instructions: Folllow as directed with Dr. [**First Name (STitle) **] [**Name (STitle) 3929**] of radiation oncology next week. his office number is ([**Telephone/Fax (1) 8082**]. You should also follow up with Dr. [**First Name (STitle) 1557**] next friday Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2154-5-17**] 12:30 Follow up on [**2158-5-17**]:00 AM with Dr. [**Last Name (STitle) **] for suture removal at [**Last Name (NamePattern1) 439**]. ([**Telephone/Fax (1) 88**]. You also have the following appointment which you should attend. Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2154-6-21**] 10:30 Please also make a follow up appointment with your opthamologist within 3 months to follow up your diabetic retinopathy

Admission Date: [**2125-10-31**] Discharge Date: [**2125-11-13**] Date of Birth: [**2049-8-25**] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: This 76-year-old male was hospitalized from [**2130-2-26**] on the trauma service, status post a fall backwards down five steps. He suffered bilateral subdural hematomas and extensive subarachnoid hemorrhage, and a left frontal intraparenchymal hemorrhage with surrounding edema. He had an evacuation of a right subdural hematoma on [**2125-10-2**], and developed respiratory distress, required intubation, tracheostomy, and eventually PEG placement. At that time, an MRI revealed a new infarct around his right hemisphere and his left white matter, which caused him to have left hemiparesis. He also developed MRSA pneumonia while hospitalized, and atrial fibrillation. Prior to discharge, he was found to be awake, alert and following simple commands with decreased attention on the left side and left hemiparesis. On [**10-29**], while at his rehab facility, he was found to be lethargic and arousable with only deep stimulation. He had a head CT on [**10-30**] showing an increased subdural on the left side and was brought to the Emergency Room with a fever of 103.8, and had a repeat head CT on arrival which showed increased interval change of a chronic left subdural, now with midline shift and mass effect. PAST MEDICAL HISTORY: CAD, status post MI in 09/[**2124**]. Peripheral vascular disease. Hypertension. Right occluded ICA. Myelodysplasia. Squamous cell skin cancer, status post XRT. Atrial fibrillation which occurred during his hospitalization. CVA. MRSA pneumonia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Lovenox 40 mg subcutaneous once daily. 2. Amiodarone 200 mg once daily. 3. Nicotine 14 mg transderm q 3 days. 4. Folic acid 1 mg once daily. 5. Epogen 4,000 micromilligrams 3 x week. 6. Seroquel 12.5 mg [**Hospital1 **]. 7. Vitamin B12 100 po once daily. 8. Zoloft 50 mg 1 po once daily. 9. Lopressor 25 mg [**Hospital1 **]. SOCIAL HISTORY: He currently lives in a rehab facility. He is married with children. Former smoker. PHYSICAL EXAM: Temp on admission was 103.8, heart rate 119, blood pressure 148/54, 100 percent on room air. HEENT: He had a right frontal craniotomy site which was healing well. Tracheostomy was in place. CARDIAC: He was tachycardic at 103 without a murmur, S1, S2. PULMONARY: Lungs were clear bilaterally in his lower lobes. Abdomen was soft, nontender. G-tube was in place. EXTREMITIES: He had a left scabbed area over his Achilles tendon. Pupils were 4-2 mm, briskly reactive on the right, and pupils were 3.5-2 mm, briskly reactive, on the left. He blinked to threat. Appeared to track when his eyes were opened manually. He would open his eyes briefly to deep painful stimulation. He moved his right hand spontaneously. Localized with his right arm. Withdrew his bilateral lower extremities. He had slight withdrawal of his left upper extremity, which was baseline for him. Toes were upgoing. Did not appear to follow commands, though did somewhat better with his family. HOSPITAL COURSE: He was admitted to the neurosurgery service. While in the Emergency Room, he received a medicine consult. He had a full fever panculture work-up and was started on empiric antibiotic coverage with vancomycin, ceftaz and Flagyl. He had a chest x-ray which did not show any pneumonia at that time. He received a packed red blood cell transfusion and volume resuscitation. He was admitted to the Intensive Care Unit, where he went to the operating room on [**2125-10-31**] and underwent a left subdural evacuation. Postoperatively, he was moving his bilateral lower extremities spontaneously. He had trace movement in his right upper extremities. His pupils were [**3-27**]. His blood pressure was kept strictly below 130. Postoperatively, his head CT essentially showed little change of the blood evacuation on the left side, though he seemed to be somewhat more responsive neurologically postop. His first blood cultures came back gram-positive cocci in pairs and chains. Medicine recommended just continuing him on vancomycin and discontinuing his Flagyl and ceftaz. He developed a rash on [**2125-11-1**], which a dermatology consult was obtained. He had multiple nonfollicular based erythematous papules on the left side of his trunk, which was felt to be miliaria crystallina which was thought to be acquired from the blockage of sweat ducts. He was treated with Lidex gel which cleared up the rash and was followed up with dermatology approximately one week later without any new recommendations. On [**2125-11-2**], his subdural drain was removed. On [**2125-11-3**], a repeat head CT showed little change in the amount of blood on the subdural site. However, he remained awake, alert, followed simple commands, interacting with his family. He also had an IVC filter placed on [**2125-11-3**]. On [**2125-11-5**], he was transferred to the neuro stepdown, where he again was opening his eyes to stimulation, moving purposely on the right. He also had a PICC line placed on [**11-5**] in anticipation of long-term antibiotics. Infectious disease was consulted on [**11-5**], as his blood cultures showed Enterococcus in his blood, which was VRE 4/4 bottles, with 2 speciated as enterococcus, [**1-28**] with MRSA. ID recommended starting linezolid 600 mg IV q 12 h, and discontinuing vancomycin. On [**11-5**], they also recommended that Mr. [**Known lastname 3805**] [**Last Name (Titles) 19806**] a TTE to rule out endocarditis, an ultrasound of his PEG to rule out fluid collection, and an ultrasound of his right IJ to rule out any hematoma. Ultrasound of his upper extremity showed no right internal jugular vein clot detected. Echo results indicated a moderate risk for endocarditis, and they recommended prophylaxis, and he will be treated with linezolid for 6 weeks. Surveillance blood cultures were also obtained on [**11-5**] and [**11-6**]. Due to the echocardiogram results, we had asked to have a TEE done; however, Mrs. [**Known lastname 3805**] did not want Mr. [**Known lastname 3805**] to [**Known lastname 19806**] a TEE at this time. She understood the risks and benefits, and personally discussed these risks and benefits with the TEE Fellow. On [**11-9**], his nutrition was addressed, and he had already been started on tube feedings. However, the goal was changed and tube feedings to Impact with fiber to a goal rate of 70 cc/h to provide 1680 kcal/D. His blood cultures on [**2125-11-6**] were final for no growth. On [**11-10**], he was noted to have some left shoulder weakness. He was seen by orthopedics who evaluated the patient, obtained an AP and lateral shoulder film which showed no acute fracture or dislocation, and recommended some physical therapy. Mr. [**Known lastname 3805**] was noted to have skin breakdown over his coccyx area for which he has been having a DuoDerm placed. He also is currently at this recording receiving a podiatry consult for left Achilles tendon erythema and eschar. They also recommend that he have a possible KinAir bed for his skin breakdown. Neurologically, prior to discharge Mr. [**Known lastname 3805**] was following commands, awake, alert, moving his right side greater than his left. A repeat head CT was done prior to discharge and felt that his left-sided subdural hematoma had much improved and was close to resolving. DISCHARGE INSTRUCTIONS: He needs aggressive physical and occupational therapy. He needs 6 weeks of linezolid with q week CBC. He should follow-up with ID, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11382**], phone number [**Telephone/Fax (1) 457**]. He should follow-up with Dr. [**Last Name (STitle) 1132**] in 2 weeks with a head CT. Any changes in his neurologic status, or if he develops any fever, he should return back to [**Hospital6 256**] Emergency Room. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg po once daily. 2. Folic acid 1 mg po once daily. 3. Quetiapine fumarate 25 mg [**1-26**] tablet po bid. 4. Epoetin 4,000 units 1 q Monday, Wednesday, Friday. 5. Insulin sliding scale. 6. Percocet elixir prn. 7. Tylenol prn. 8. Miconazole nitrate powder to topical areas prn. 9. Albuterol prn. 10.Linezolid 600 mg IV q 12 h. The linezolid may be converted to PO if felt his PO absorption is adequate enough. 11.Protonix 40 mg IV q 24 h. DISCHARGE DIAGNOSES: Acute on chronic left subdural hematoma, now resolving. Left hemiparesis. Enterococcus. Positive vancomycin resistant enterococcus and methicillin resistant Staphylococcus aureus blood cultures. Atrial fibrillation. Previous cerebrovascular accident. Right occluded ICA. Myelodysplasia. Squamous cell skin cancer. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 8633**] MEDQUIST36 D: [**2125-11-13**] 12:10:59 T: [**2125-11-13**] 13:06:12 Job#: [**Job Number 56026**]

Admission Date: [**2195-4-1**] Discharge Date: [**2195-4-22**] Date of Birth: [**2115-11-6**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Sulfa (Sulfonamide Antibiotics) / clindamycin Attending:[**First Name3 (LF) 3918**] Chief Complaint: chills, rigors Major Surgical or Invasive Procedure: [**2195-4-3**] - Colonoscopy [**2195-4-13**] - Colonoscopy History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE . Date: [**2195-4-2**] Time: 0130 ___________________________________________________ PCP: [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]. Onc: [**Doctor First Name **] [**Doctor Last Name **] . CC:[**CC Contact Info 93625**]___________________________________________________ HPI: 79 yo F with MDS--> AML, HTN, hyperlipidemia, diverticulosis, h/o anal fissure, AVM s/p recent cauterization who was recently admitted from [**Date range (1) 93626**] for decitabine and was in outpatient center today for platelet transfusion for dropping plt count (22) and nosebleeds. She tolerated the infusion but on her way home, she developed rigors, chills and she returned to the outpatient unit. Upon arrival, she was hypertensive and had a temp to 99.8. She was given benadryl, demerol, tylenol, hydrocortisone. She subsequently became hypotensive to 90/40 and received IVF bolus. She had intermittent, mild hypoxia 93-96%. She was thought to have a transfusion reaction (work-up ordered) but her labs were notable for neutropenia and she was referred to the ED for admission. In ER: (Triage Vitals: 99.1 85 118/50 18 93% RA) CBC notable for hct 19.6 from 24.9 earlier in the day. hemolysis labs negative. CXR revealed mild interstitial edema. CT scan was performed to r/o a RP bleed. Currently, she feels completely well. She reports that she felt while prior to the platelet infusion and denies any fever, chills, abd pain, N/V/D, cough, headache. Her only concern is a bruise/canker sore in her L mouth which is mildly tender. . PAIN SCALE: none ___________________________________________________ REVIEW OF SYSTEMS: CONSTITUTIONAL: [] All Normal [ ] Fever [x ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats [ ] _____ lbs. weight loss/gain over _____ months HEENT: [] All Normal [ ] Blurred vision [ ] Blindness [ ] Photophobia [ ] Decreased acuity [ ] Dry mouth [x ] Bleeding gums [ ] Oral ulcers [ ] Sore throat [ x] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ]Tinnitus [ ] Other: RESPIRATORY: [x] All Normal [ ] SOB [ ] DOE [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [x] All Normal [ ] Angina [ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ] Chest Pain [ ] Other: GI: [x] All Normal [ ] Blood in stool [ ] Hematemesis [ ] Odynophagia [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Anorexia [] Nausea [] Vomiting [ ] Reflux [ ] Diarrhea [ ] Constipation [] Abd pain [ ] Other: GU: [x] All Normal [ ] Dysuria [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [x] All Normal [ ] Rash [ ] Pruritus MS: [x] All Normal [ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [x] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache ENDOCRINE: [x] All Normal [ ] Skin changes [ ] Hair changes [ ] Temp subjectivity HEME/LYMPH: [] All Normal [ ] Easy bruising [x ] Easy bleeding [ ] Adenopathy PSYCH: [x] All Normal [ ] Mood change []Suicidal Ideation [ ] Other: [x]all other systems negative except as noted above Past Medical History: Past Oncologic history: - MDS initially diagnosed in [**8-/2194**] during workup for anemia. Initial BM biopsy with e/o hypercellular marrow with peripheral blasts. The patient was maintained with transfusion as needed and aranesp qweek. In winter [**2194**], pt was also found to have increasing white count, as high as 143K on most recent BMT admission, at which point repeat biopsy revealed blasts consistent with acute myeloiod transformation. . PMH: - diverticulosis complicated by bleeding - bleeding anal fissures - bleeding AVMs ([**2-/2195**]) - GERD - emphysema(mild) - dental extraction - myelodysplastic syndrome dx [**8-/2194**] with persistent blastemia - hysterectomy at age 39 - hemorrhoidectomy x 4 - colon polyps, AVM - bilateral bunion surgery - hypertension - hyperlipidemia - proctalgia fugax - TMJD Social History: The patient is married and lives with her husband. She has three grown children. Has a twin sister. Ex-[**Name2 (NI) 1818**], quit 14 year ago; has 35 pack year history. Denies any illicit drug use. Reports having a glass of wine nightly. Family History: No known fhx of MDS or leukemia. Physical Exam: Admission physical exam: T 95.9 P 82 BP 98/56 RR 20 O2Sat 96% RA GENERAL: non-toxic, well-appearing, mentating clearly Eyes: NC/AT, post-surgical pupils (cataracts), EOMI, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM,small purplish nodule on tongue, bruising on inside of her mouth on left side Neck: supple, no JVD Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: Reg S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, + bowel sounds Genitourinary: no flank tenderness Skin: no rashes or lesions noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics/Heme/Immun: No cervical, supraclavicular lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: pleasant and interactive ACCESS: [x]PIV . Discharge PE: VS: Tc 97.2 Tmax 97.8 BP 118/68 (110-130'/60-80') HR 76 (70-80') RR 18 Sat 99 RA General: pleasant, well appearing elderly female, sitting comforably in chair, NAD, HEENT: EOMI, PERRL, OP clear, MM moist neck: supple CV: 3/6 SEM loudest at RUSB, normal S1, S2 lungs: clear to auscultation b/l, no wheezes/rhonchi/crackles abdomen: soft, mild tenderness at left lower quadrant and minimal tenderness at right upper quadrant, no rebound tenderness or guarding, nondistended, +BS extremities: warm, well perfused, no LE edema, 2+DP pulses Neuro: CN2-12 grossly intact, normal muscle strength and sensation throughout Pertinent Results: Admission labs: =============== [**2195-4-1**] WBC-2.2* RBC-2.67* HGB-8.4* HCT-24.9* MCV-94 MCH-31.5 MCHC-33.7 RDW-18.4* [**2195-4-1**] NEUTS-30* BANDS-0 LYMPHS-42 MONOS-8 EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-1* BLASTS-17* NUC RBCS-2* [**2195-4-1**] PLT SMR-VERY LOW PLT COUNT-22* [**2195-4-1**] GRAN CT-704* [**2195-4-1**] WBC-3.7*# RBC-2.21* HGB-6.8* HCT-19.6* MCV-89 MCH-30.8 MCHC-34.7 RDW-19.6* [**2195-4-1**] NEUTS-87* BANDS-0 LYMPHS-2* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-10* [**2195-4-1**] PLT SMR-VERY LOW PLT COUNT-21* [**2195-4-1**] PLT COUNT-31* [**2195-4-1**] ALT(SGPT)-12 AST(SGOT)-27 LD(LDH)-274* ALK PHOS-67 TOT BILI-1.8* DIR BILI-0.6* INDIR BIL-1.2 [**2195-4-1**] HAPTOGLOB-197 [**2195-4-1**] GLUCOSE-116* UREA N-25* CREAT-0.8 SODIUM-138 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 [**2195-4-1**] URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2195-4-1**] URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-<1 . Discharge labs: =============== [**2195-4-19**] BLOOD ALT-8 AST-22 LD(LDH)-222 AlkPhos-51 TotBili-1.1 [**2195-4-22**] BLOOD WBC-1.8* RBC-2.94* Hgb-9.1* Hct-27.3* MCV-93 MCH-31.0 MCHC-33.3 RDW-19.1* Plt Ct-84* [**2195-4-22**] BLOOD Neuts-53 Bands-0 Lymphs-33 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* Blasts-12* NRBC-1* [**2195-4-22**] BLOOD Plt Smr-LOW Plt Ct-84* [**2195-4-22**] BLOOD PT-15.4* INR(PT)-1.4* [**2195-4-22**] BLOOD Gran Ct-979* [**2195-4-22**] BLOOD Glucose-101* UreaN-16 Creat-0.8 Na-137 K-3.8 Cl-99 HCO3-29 AnGap-13 [**2195-4-22**] BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 . Microbiology: ============= Urine culture: mixed flora Blood culture: no growth MRSA screen: negative . Imaging: ======== [**4-1**] CHEST (PA & LAT) - Calcified pleural plaque is better assessed on the prior CT. There is mild interstitial edema with no large effusions or pneumothorax. No signs of pneumonia. Cardiomediastinal silhouette is stable. Calcified tracheobronchial tree noted. Bony structures are intact . [**4-1**] CT ABD & PELVIS WITH CO - No acute intra-abdominal or pelvic process. No evidence of retroperitoneal hemorrhage. Stable gallbladder polyp. Stable gallbladder polyps versus a focus of adenomyomatosis within the gallbladder fundus. Sigmoid diverticulosis. Patchy bibasilar opacities within the lung bases, with subpleural scar formations and bronchiectasis within the lung bases. . [**2195-4-8**] CT head without contrast: IMPRESSION: 1. No evidence of acute intracranial hemorrhage or mass effect. Slightly dense appearance of the cortex lateral to the Sylvian fissure ( se 2, im 12) is likely related to volume averaging rather than hemorrhage; a follow up can be considered if necessary. No prior CT studies are available. 2. Bilateral mastoid opacification from fluid/mucosal thickening . CTA [**2195-4-18**] Abd-Pelvis IMPRESSION: 1. No contrast extravasation to suggest GI bleeding. 2. Stable gallbladder polyp and fundal adenomyomatosis. 3. Colonic diverticulosis without evidence of diverticulitis. 4. Small left adrenal adenoma. 5. Unchanged Focal celiac artery and aortic dilation as described above. . Colonoscopy: ============ [**3-1**] Colonoscopy prior to this admission: Abnormal mucosa in the colon. Diverticulosis of the sigmoid colon. A small posterior rectal fissure was noted in the anal canal. This was not bleeding. Blood was noted throughout the entire colon. Otherwise normal colonoscopy to cecum. . [**2195-4-3**] colonoscopy: Non bleediong diverticulosis of the whole colon. Bleeding angioectasias in the cecum treated with APC. Polyp in the transverse colon. Blood and stool throughout colon. Non bleeding posterior anal fissure. . [**2195-4-13**] colonoscopy: Blood in the whole colon. Diverticulosis of the sigmoid colon and descending colon. Ulcers in the cecum. A large adherent blood clot was found in the cecum with surrounding oozing of bright red blood. Given the risk of uncontrollable bleeding in the setting of low platelets, the clot was not removed. Otherwise normal colonoscopy to cecum Brief Hospital Course: Ms. [**Known lastname 73078**] is 79 year old pleasant woman with a Past medical history significant for MDS with AML transformation on Dacogen, diverticulosis, known cecal AVMs admitted from clinic on [**2195-4-1**] in the setting of a transfusion reaction to platelets with thrombocytopenia who was noted to develop bright red blood per rectum with acute hematocrit drop who underwent repeat colonoscopy showing non-bleeding diverticulosis of the entire colon and bleeding angioectasias of the cecum treated with Argon Plasma coagulation. She required a second colonoscopy for repeated bloody bowel movements which showed a clot adherent to the cecum. She remained stable for a while then had frequent bloody bowel movements again which was controlled by amicar drip for 8 hours. Gradually her platelets started to increase. After these events, she remained stable and was discharged home in stable condition. She will require HLA matched platelet transfusions in the future if needed. . # cecal AVMs: She was transferred to the ICU twice for bright red blood per rectum. The patient developed BRBPR, and was found to have cecal AVMs on colonoscopy s/p APC. Specifically, repeat colonoscopy demonstrated cecal angioectasias that were actively bleeding, non-bleeding colonic diverticula and small polyp. Hemostasis achieved with Argon Plasma coagulation therapy on [**2195-4-3**]. During her stay she required several units of PRBC and platelets. After remaining stable, she was transferred back to the floor however she had the same situation again and was transferred back to the ICU where she had her second colonoscopy which showed a clot adherent to the cecum with oozing around the clot. The clot was not removed (not amenable to endoscopic management). GI recommended surgical consult for possible resection however given her underlying disease and low platelet counts, they felt this will not be a favorable management. After having stable H/H, she was transferred back to the floor. While on the floor, she had a few bloody bowel movements however the night of [**4-17**] she had total of 450 cc bloody watery stools which required amicar drip for 8 hours (her platelets were in the 40-50's). CTA was negative. Following this, she did not have any further significant bloody stools. She remained vitally stable with stable H/H and gradually rising platelet count. . # thrombocytopenia: Secondary to chemotherapy and MDS/AML concerns. Concern for consumptive process following transfusion of platelets in the setting of possible ITP vs. TTP however Hematologic smear was without schistocytes and there was no evidence of renal failure or neurologic concerns; no fevers. The patient also had two transfusion reactions to platelets when first admitted. She was premedicated with anti-histamines. While the patient was actively bleeding, she was also given Amicar (2 grams IV with 1gram/hour IV infusion overnight on [**2195-4-2**]). This was repeated over the night of [**4-17**] as above. She was found to have a positive PRA and required HLA matched platelets for all subsequent transfusions. Her twin sister was tested at Red Cross for potential candidate to donate platelets for her sister however since she takes aspirin and plavix, this was not a suitable option. Of note, her platelet count was improving already and did not require further platelet transfusions. Platelet count was in the 90's upon discharge. . # transfusion reaction/PRA positive: The patient had transfusion reaction to platelet transfusion (once in clinic, and once while on the floor). She was premedicated with famotidine, benadryl, and hydrocortisone. A blood bank work up was initiated, and the patient was given group specific platelets. She was found to be PRA positive and requires HLA matched platelets. However, during her second episode of BRBPR on [**4-12**], it was found that there was no more HLA matched platelets available in [**Location (un) 86**] area. Red Cross was contact[**Name (NI) **] for more HLA matched platelets. Sister was a potential donor however it wasn't suitable given her anti-platelet therapy as above. She did not require further platelet transfusions once her platelet count started to increase. . # MDS with AML transformation: While the patient was on the floor, it was noticed that her blast count was trending up and her neutrophil count was trending down. It was then decided to start her on second cycle of Dacogen (day 1 = [**2195-4-8**]). The patient tolerated the Dacogen well, with little side effects. 12% blast cells on peripheral blood upon discharge. . # GERD: The patient was continued on her home PPI. . # constipation: The patient has a history of severe constipation, however, her home medications were held in the setting of her BRBPR and then restarted upon discharge given resolution of bloody bowel movements. . Transitional Issues: - The patient had transfusion reaction to platelets; a blood bank work up was initiated and she was found to be PRA positive; she will require HLA matched platelets for all subsequent transfusions. Medications on Admission: 1. loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO QHS (once a day (at bedtime)). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO QHS (once a day (at bedtime)). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Medications: 1. loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Miralax 17 gram Powder in Packet Sig: One (1) PO at bedtime as needed for constipation. 4. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml PO at bedtime as needed for constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: myelodysplastic syndrome/acute myloid leukemia cecal atriovenous malformations Lower GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 73078**], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted to the hospital because you had a transfusion reaction after getting platelets at clinic. We did some tests and found that you will need specially screened platelets from now on because your body reacts to normal platelets. While you were here, you also developed some bleeding from your rectum. You were transferred to the intensive care unit and they gastrointestinal doctors looked into your intestines with a camera and found some areas of bleeding called AV malformations that were clipped. After this, you were sent to the floor then sent back to the ICU when you had further bleeding. Second colonoscopy was done which showed a large clot attached to your colon in the same area where the AVM's were clipped. Your blood level was stable as well as your blood pressure and you were transferred to the floor. While on the floor, you had a few loose bloody stools that subsequently resolved. Your diet was gradually advanced and you tolerated it well prior to discharge. Your platelets gradually increased and it was in the 80's on your discharge day. The surgeons evaluated you for possible surgical removal of part of your colon, however they felt it is unsafe to do surgery for the moment. We did not discharge you on Amicar which is a clot stabilizer medication since you did not have further bloody stools, your blood level was stable and your platelets were gradually increasing. We also noticed some changes in your blood work that made us think that your leukemia was acting up again; because of that we started you on another five day cycle of chemotherapy. You tolerated the chemo well. . While in the hosiptal, it was noted that occasionally your blood pressure was high and you were started on a medication for brief time. However, given your GI bleeds, this was held. We will not discharge you at the moment with anti-hypertensive medication. We did the following changes in your medication list: - Please stop allopurinol Please continue the rest of your home medications the same way you were taking them at home prior to admission. Your PICC line was removed prior to discharge. It will be important for you to follow up with Dr. [**Last Name (STitle) **]. Please follow with your appointments as illustrated below. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2195-4-27**] at 12:30 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: MONDAY [**2195-4-27**] at 12:30 PM With: [**First Name8 (NamePattern2) 2747**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3983**], NP [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: MONDAY [**2195-4-27**] at 1 PM With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

Admission Date: [**2146-6-16**] Discharge Date: [**2146-6-21**] Date of Birth: [**2072-1-25**] Sex: M Service: SURGERY Allergies: Penicillins / Fluarix Attending:[**First Name3 (LF) 6088**] Chief Complaint: Common hepatic artery aneurysm Major Surgical or Invasive Procedure: [**2146-6-16**] Resection of common hepatic artery aneurysm, with right greater saphenous vein interposition graft. History of Present Illness: This is a 74-year-old male with a history of chronic weight loss of unknown etiology, who, while undergoing a workup, was found to have a 2- to 3-cm common hepatic artery aneurysm. He was consented for resection of the aneurysm. Past Medical History: HTN DJD hepatic artery aneurism migraines PSH: status post cholecystectomy bilateral carpal tunnel releases recent biateral laparoscopic inguinal hernia repairs C3-C4 posterior discectomy. Social History: current tobacco use - 7 cigarettes/day no EtOH use Family History: non contributory Physical Exam: vss afebrile Gen: thin male in nad Neck: supple, no jvd, trach midline Card: RRR Lungs: CTA bilat Abd: soft +bs, no m/t/o; incision c/d/i Extremities: fem/dp/pt pulses palpable bilat Pertinent Results: [**2146-6-21**] 06:55AM BLOOD WBC-4.6 RBC-3.71* Hgb-11.7* Hct-33.2* MCV-90 MCH-31.7 MCHC-35.4* RDW-14.2 Plt Ct-208 [**2146-6-20**] 08:10AM BLOOD WBC-4.9 RBC-3.69* Hgb-11.3* Hct-32.8* MCV-89 MCH-30.6 MCHC-34.4 RDW-14.3 Plt Ct-218# [**2146-6-18**] 03:45AM BLOOD WBC-6.1 RBC-3.32* Hgb-10.6* Hct-30.8* MCV-93 MCH-32.0 MCHC-34.4 RDW-14.7 Plt Ct-137* [**2146-6-17**] 04:26AM BLOOD WBC-6.4 RBC-3.45* Hgb-10.8* Hct-31.4* MCV-91 MCH-31.3 MCHC-34.3 RDW-14.9 Plt Ct-204 [**2146-6-16**] 02:21PM BLOOD WBC-9.2 RBC-3.75* Hgb-12.0* Hct-35.2* MCV-94 MCH-31.9 MCHC-34.0 RDW-14.9 Plt Ct-255 [**2146-6-21**] 06:55AM BLOOD Glucose-107* UreaN-10 Creat-0.8 Na-138 K-4.0 Cl-98 HCO3-35* AnGap-9 [**2146-6-20**] 08:10AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-133 K-3.8 Cl-94* HCO3-31 AnGap-12 [**2146-6-19**] 03:30AM BLOOD Glucose-152* UreaN-7 Creat-0.5 Na-133 K-3.8 Cl-97 HCO3-30 AnGap-10 [**2146-6-18**] 03:45AM BLOOD Glucose-113* UreaN-10 Creat-0.6 Na-134 K-3.7 Cl-100 HCO3-30 AnGap-8 [**2146-6-17**] 04:26AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-137 K-4.0 Cl-104 HCO3-27 AnGap-10 [**2146-6-16**] 02:21PM BLOOD Glucose-138* UreaN-13 Creat-0.9 Na-140 K-4.6 Cl-111* HCO3-23 AnGap-11 [**2146-6-21**] 06:55AM BLOOD ALT-229* AST-44* AlkPhos-71 Amylase-77 TotBili-0.5 [**2146-6-20**] 08:10AM BLOOD ALT-333* AST-91* AlkPhos-72 Amylase-64 TotBili-0.5 [**2146-6-19**] 03:30AM BLOOD ALT-507* AST-355* AlkPhos-66 Amylase-66 TotBili-0.4 [**2146-6-18**] 03:45AM BLOOD ALT-555* AST-592* AlkPhos-63 Amylase-65 TotBili-0.3 [**2146-6-17**] 04:26AM BLOOD ALT-325* AST-336* AlkPhos-67 Amylase-88 TotBili-0.4 [**2146-6-16**] 02:21PM BLOOD ALT-316* AST-333* AlkPhos-71 Amylase-81 TotBili-0.3 [**2146-6-19**] 03:30AM BLOOD Lipase-30 [**2146-6-18**] 03:45AM BLOOD Lipase-30 [**2146-6-17**] 04:26AM BLOOD Lipase-42 [**2146-6-16**] 02:21PM BLOOD Lipase-88* [**2146-6-21**] 06:55AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0 [**2146-6-20**] 08:10AM BLOOD Calcium-8.1* Phos-3.6# Mg-1.9 [**2146-6-19**] 03:30AM BLOOD Albumin-3.0* Calcium-8.0* Phos-1.8* Mg-1.4* Iron-20* [**2146-6-18**] 03:45AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9 [**2146-6-17**] 04:11PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.7 [**2146-6-17**] 04:26AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.0 [**2146-6-16**] 11:47PM BLOOD Calcium-8.1* Mg-2.4 [**2146-6-16**] 02:21PM BLOOD Calcium-8.2* Phos-4.7* Mg-1.6 [**2146-6-16**] 2:20 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2146-6-19**]** MRSA SCREEN (Final [**2146-6-19**]): No MRSA isolated. Brief Hospital Course: Mr. [**Known lastname 68553**] was admitted and underwent hepatic artery aneurysm repair under general anesthesia with a tohoracic epidural on [**2146-6-16**]. He tolerated the procedure well, was extubated and was transfered to the CVICU postoperativey. He was hemodynamically stable but did have some brief episodes of bradycardia which resolved on their own. On POD 1 he was noted to have some elevated LFTs, as expected. He was quite stable and was transfered to the VICU for further recovery. In the vicu he remained hemodynamically stable with good pain control. On POD 2 he tolerated a clear liquid diet and was OOB with assistance. A nutrition consult was obtained given his recent weight loss and preoperative status of having poor nutrition. He was advanced to a regular diet on POD 3 with ensure supplements which he tolerated well. He was transfered to the floor on POD 3 as well. On POD 4 his epidural was removed. He tolerated PO pain meds quite well. Later that day his foley was removed, and he voided a small amount, however, by the evening he had not voided in several hours and a bladder scan showed over 800cc of residual, hence a foley was re placed. He was also started on flomax . His jp drain was also removed on POD 4 without difficulty. He was hemodynamically stable and able to ambulate without assistance. On POD 5 he was tolerating his diet well and felt comfortable with his foley and leg bag. He was evaluated by PT and found stable to go home. He will follow up with his PCP on friday for foley removal. Medications on Admission: Atenolol 50 mg orally once a day, lisinopril 10 mg orally once a day, trazodone 150 mg at night, a multivitamin, vitamin B12, and vitamin C supplements. Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* 4. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Diphenhydramine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Itching. 9. Resume OTC vitamins and minerals Discharge Disposition: Home Discharge Diagnosis: Common hepatic artery aneurysm. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-31**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**1-26**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions You had urinary retention and had your foley catheter replaced. You will go home with a leg bag and catheter in place. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] in [**2-25**] days for removal of the catheter. Followup Instructions: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2146-7-6**] 9:45 Dr. [**Last Name (STitle) 11302**] [**Name (STitle) **] 1115 am - follow up and foley removal Completed by:[**2146-6-21**]

Admission Date: [**2174-11-25**] Discharge Date: [**2174-12-5**] Service: MEDICINE Allergies: Nsaids / Ace Inhibitors Attending:[**First Name3 (LF) 7934**] Chief Complaint: shortness of breath and hemoptysis Major Surgical or Invasive Procedure: - History of Present Illness: This a [**Age over 90 **]y/o female with a history of COPD, hypertension, gastroespohageal reflux who presented with shortness of breath and dyspnea on exertion X 3 days. Per nursing home records, the patient was reported to have had 10cc of hemoptysis. O2 sat was 92%. Patient reports substernal chest pain radiating to the back, lasting seconds. By history the pain is pleuritic, because coughing makes it worse. . On presentation peak flow was 140; improved to 240 after 1st neb in the ED. Chest X-ray showed multilobular consolidation. CT-A showed no PE or obstructive bronchial lesion, but central bilateral consolidation secondary to pneumonia and CHF was noted. An EKG showed TWI in I and avL, and in V4-V6, unchanged from previous. Trop was 0.10 in the setting of renal insufficiency. Past Medical History: COPD Rash back of neck GERD HTN Social History: Lives in [**Hospital 100**] Rehab Denies alcohol and ciggarette smokine Family History: Non-contributory Physical Exam: VS t98.8, hr82, bp, r26, 99%on2lNC Gen elderly petite Caucasian female sitting upright in stretcher, in mod distress, using accessory muscles to breath HEENT MMM, OP, -JVD, bruits Heart nl rate, S1S2, unable to assess due to breathing Lungs coarse, rhonchorous breath sounds Abdomen round, soft, nt, nd, +bs Extremities [**1-2**]+pitting edema, posterior aspect of legs bilaterally Neuro: A&O X3, II-XII grossly intact Pertinent Results: Labs on Admission [**2174-11-25**] 11:30AM BLOOD WBC-17.1*# RBC-3.86* Hgb-11.2* Hct-34.6* MCV-90 MCH-29.0 MCHC-32.4 RDW-14.0 Plt Ct-290 [**2174-11-25**] 11:30AM BLOOD Plt Ct-290 [**2174-11-25**] 11:30AM BLOOD Glucose-119* UreaN-47* Creat-1.9* Na-142 K-4.4 Cl-101 HCO3-31 AnGap-14 [**2174-11-25**] 11:30AM BLOOD CK(CPK)-48 [**2174-11-25**] 11:30AM BLOOD CK-MB-3 cTropnT-0.10* . Chest X-ray [**2174-11-25**] 1. Multilobar consolidation, which could reflect asymmetrical edema and/or multilobar pneumonia. A postobstructive process in the right middle lobe cannot be excluded. By report, the patient is scheduled to undergo CTA, which will be helpful for more complete characterization of these findings. 2. Bilateral pleural effusions, right greater than left. . CT-A [**2174-11-25**] 1. No parenchymal mass lesion or mediastinal lymphadenopathy. No acute pulmonary embolus. 2. Central bilateral consolidation mainly along the inferior hilar regions with patchy areas of consolidation in the upper and lower lobes. Enlargement of the central arterial pulmonary vasculature and mild cardiac enlargement suggestive of background pulmonary hypertension. Small bibasilar pleural effusions. These findings may all be due to cardiac failure with pulmonary hypertension. Infective consolidation should be also considered depending on the current clinical correlation. Interval followup post-treatment initially with chest x-ray is advised. Brief Hospital Course: 1. Pneumonia The patient was initially maintained on ceftriaxone and azithromycin for community acquired pneumonia. Because the patient came from rehabilitation, the decision was made to change the antibiotic coverage to Levaquin. Her treatment also consisted of Q2 nebulizer treatments, oxygen and her home dose of prednisone. On the morning of HD #2, the patient's course was complicated by transient desaturation to 88% on 6L NC and a shovel mask. On exam the patient had rhonchorous breath sounds, difficulty mobilizing her secretions. O2 sats improved with coughing to 91%. Despite improvement in her O2 sats, the patient continued to have labored breathing. She received 10 of IV lasix and nebulizer treatments. O2sats improved to 95-99% on the same amount of O2. Respiratory therapy recommmended humidified air to help loosen the secretions. Patient course deteriorated on the morning of HD #3. 02sats were initially stable in the 90s. The patient became tachypneic breathing at an average rate of 30. Antibiotic coverage was changed to Ceftazadine because prelim sputum cultures grew gram negative rods. Despite lasix, morphine and frequent nebulizer treatments, patient's O2sats decreased to 86% on 6LNC and 100%NRB. The decision was made to transfer her to the [**Hospital Unit Name 153**] for further management. . In the [**Hospital Unit Name 153**], the pt continued to desaturate to the 80s on NC and FM. She had one episode of desaturation to the 80s which did not resolve after one minute. CXR showed mucus plugging of the entire left lung. Pt was placed on her right side and had rigorous chest PT, and saturations improved to low 90s. Family was called in. After several days of pt's respiratory status not improving, pt's status was discussed with family, who decided to make her CMO. Pt was placed on morphine gtt and died on [**2174-12-5**] am surrounded by her family. . 2. Leukocytosis: Pt's leukocytosis was likely [**2-2**] to pneumonia and UTI. Pt was afebrile throughout admission. Pt was placed on levaquin, and blood cultures were negative. . 3. Hemoptysis: Pt had episodes of hemoptysis on the floor, but not in the [**Hospital Unit Name 153**]. This was likely [**2-2**] pneumonia. Pt's Hct stayed stable, and stool was guaiac negative. . 4. Chest pain: Pt had episodes of fleeting, pleuritic chest pain on the floor, with Trop 0.10, which was likely due to renal insufficiency. The family and patient agreed not to have any intervention for any possible cardiac issues. . 5. Acute renal failure: Pt's acute renal failure was likely due to a dye load with the CT. Cr improved with fluids. . 6. HTN: Pt was continued on Isordil and norvasc. . 7. CHF: Pt had evidence of CHF on CXR, with trace edema on the posterior aspect of her legs. She was continued on daily lasix prn. Medications on Admission: Acetaminophen Aluminum Hydroxide Suspension Albuterol 0.083% Neb Soln Amlodipine Bicitra Calcium Carbonate Cyanocobalamin Fexofenadine Fluticasone-Salmeterol (250/50) Furosemide Hydrocortisone Cream 1% Hyoscyamine Ipratropium Bromide Neb Isosorbide Dinitrate Pantoprazole Prednisone Simethicone Sorbitol Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: pneumonia non ST elevation myocardial infarction congestive heart failure, EF 15-20% COPD Secondary Diagnoses: Hypertension GERD Discharge Condition: expired Discharge Instructions: None. Followup Instructions: None Completed by:[**2175-3-26**]

Admission Date: [**2117-3-30**] Discharge Date: [**2117-4-7**] Date of Birth: [**2052-1-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: CABG x 3 [**2117-4-1**] History of Present Illness: Mr. [**Known lastname 102632**] is a 65-year-old man with HIV, HTN, ^Chol, and type II diabetes mellitus who has been having chest pain for the past 2 years. This was initially found on ROS during cardiac evaluation for a planned dorsocervical fat pad removal. Pt initially thought CP was indigestion. He is now experiencing resting chest pain. Cardiac cath performed on [**2117-3-31**] revealed 3 vessel disease and left main disease with an EF of 49%. Referred for CABG. Past Medical History: PAST MEDICAL HISTORY HIV ([**2102**]) - CD4 866, viral load undetectable on HAART [**2-23**] Type II diabetes mellitus ([**2112**]) Hypertension Hypercholesterolemia Lightheadedness and LOC ([**2113**]) Recurrent perirectal herpes ([**2099**]) Lipodystrophy Varicose veins Erectile dysfunction Diverticulae in sigmoid and descending colon ([**2114**]) Left ankle subacute cellulitis, venous stasis ulcer ([**2110**]) Left tibia fracture from fall ([**2092**]) Posterior vitreous detachment OD Right arm fracture ([**2055**]) PAST SURGICAL HISTORY Facelift ([**2113**]) Left inguinal herniorraphy with gortex mesh ([**2108**]) Arthroscopic surgery Hemorrhoidectomy ([**2092**]) Esophageal ring dilation Appendectomy ([**2055**]) Tonsillectomy/adenoidectomy ([**2055**]) Social History: Denies smoking. Drinks socially on occasion. Born and raised in [**Location (un) 86**], currently lives on a horse farm in [**Location (un) **] Fall, N.H. Works as a cosmetologist, used to own salon [**Location (un) 102633**]. Now trains, breeds, and sells horses. Family History: Notable for uterine cancer (mother), CAD (mother), lupus (sister), stroke (grandmother in 70's), and diabetes (two aunts). [**Name2 (NI) **] history of hypertension. Physical Exam: Tm 98, Tc 97.1, BP 110/70, P 80, RR 20, O2Sat 97 RA, weight 68.0 kg General: NAD Skin: 2cm x 2cm discolored patch in area of L medial malleolus. Tanned skin in exposed areas. HEENT: Mucous membranes dry; mildly icteric sclerae; PERRLA; large dorsocervical fat pad; oral mucosa without lesions. No carotid bruits. Pulm: CTAB, no wheezes, rales, ronchi. Symmetric expansion of the chest cavity on inspiration. Diaphragmatic excursion of 2cm. Cor: II/VI blowing, mid-systolic crescendo-decrescendo murmur auscultated best at the LLSB. Abd: Soft, distended, nontender. Active BS x4. No hepatomegaly, splenomegaly appreciated. Ext: No peripheral edema. Some varicosities. Neuro/Psych: CNII-XII intact on screen. AOx3. Walking gait, heel-to-toe performed without difficulty. Slight tremor of left 5th digit on rest. Pertinent Results: Cardiac catheterization ([**2117-3-31**]): 1. Coronary angiography of this right dominant circulation revealed severe three vessel disease. The LMCA had a 60% narrowing at its origin with pressure damping noted during engagement of the artery. The LAD had serial 80-90% lesions in the mid vessel and diffuse luminal irregularities that narrowed to 30-40% in the distal vessel. The RCA also had diffuse luminal irregularities and a focal 70% lesion in the distal vessel. The RCA supplied a moderate sized PDA that had a 50% lesion. 2. Resting hemodynamics revealed mildly elevated left ventricular filling pressures with an LVEDP of 18 mmHg and a mean PCWP of 13 mmHg in the setting of normal systemic arterial blood pressure. There was evidence of mild pulmonary artery hypertension with PA pressures of 38/17/26 mmHg. No gradient across the aortic valve was detected. 3. Left ventriculography demonstrated mild anterolateral hypokinesis with a calculated LVEF of 49%. Mild (1+) mitral regurgitation was seen. [**2117-3-30**] 05:17PM BLOOD WBC-8.8 RBC-4.49* Hgb-15.3 Hct-44.9 MCV-100* MCH-34.1* MCHC-34.0 RDW-15.0 Plt Ct-307 [**2117-4-2**] 07:23PM BLOOD WBC-11.4* RBC-3.13* Hgb-10.1* Hct-28.8* MCV-92 MCH-32.2* MCHC-35.0 RDW-16.5* Plt Ct-147* [**2117-4-7**] 05:50AM BLOOD WBC-11.9* RBC-3.00* Hgb-9.2* Hct-29.0* MCV-97 MCH-30.8 MCHC-31.9 RDW-16.4* Plt Ct-353 [**2117-3-30**] 05:17PM BLOOD PT-12.0 PTT-21.1* INR(PT)-1.0 [**2117-4-5**] 05:30AM BLOOD PT-13.4* PTT-21.5* INR(PT)-1.2 [**2117-3-30**] 05:17PM BLOOD Glucose-267* UreaN-26* Creat-1.0 Na-138 K-4.5 Cl-101 HCO3-24 AnGap-18 [**2117-4-5**] 05:30AM BLOOD Glucose-148* UreaN-23* Creat-0.9 Na-139 K-4.3 Cl-101 HCO3-25 AnGap-17 [**2117-3-30**] 05:17PM BLOOD Calcium-9.9 Phos-3.3 Mg-2.2 [**2117-3-31**] 06:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2117-3-31**] 06:45PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2117-3-31**] 06:45PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 102632**] presented to Cardiac Surgery service following his Cardiac Cath On HD #2 which revealed severe 3VD. The following day, [**2117-4-1**], pt was brought to the operating room where he underwent Coronary Artery Bypass surgery. Please see op note for full details. Pt. tolerated the procedure well with a total byoass time of 93 minutes and cross clamp time of 75 minutes. He was transferred to CSRU in stable condition with a MAP of 76, CVP 12, PAD 15, [**Doctor First Name 1052**] 22, HR 92 SR and being titrated on Neo, Propofol, and Insulin. Pt transfused 1 unit pRBC and cryo x 2 in CSRU. Later on op day pt was weaned from propofol and mechanical ventilation and was extubated without incidence. He was awake, alert, mae, and following commands. POD #1 pt was still requiring Neo for BP support. Lasix was started. [**Last Name (un) **] consult today and cont. to see pt. throughout hosp. course and help managed his diabetes. Chest tubes removed. Transfused 1 unit of pRBCs. POD #2. pt was doing better. Is now weaned off of Neo. Pacing wires removed. Lopressor started. HIV meds started. POD #3 Pt remained in the CSRU, but was transferred to telemetry floor today. POD #[**2-24**] Pt improved steadily throughout these 3 days and was ready for discharge on POD #6. He was seen by PT throughout his post-op course and was now level 5. Labs were stable and exam was unremarkable. Pt was slightly above his pre-op wt and was d/c'd with lasix. Medications on Admission: 1. ACTOS 30MG--One tablet daily. 2. ACYCLOVIR 400MG--Two tablets (800 mg) by mouth twice a day 3. ANDROGEL 1%(50MG)--Use the contents of one packet daily. apply to skin. 4. ASPIRIN 81MG--One daily for cardiovascular prophylaxis. 5. ATAZANAVIR SULFATE 150MG--Two capsules by mouth once daily, with one capsule of ritonavir. 6. ATENOLOL 25MG--One tablet daily. 7. ATORVASTATIN CALCIUM 10MG--One tablet daily for control of cholesterol. 8. EFFEXOR XR 75MG--One tablet daily for depression 9. GLYBURIDE 5MG--2 tablets (10 mg) by mouth twice a day for control of type ii diabetes mellitus. 10. LAMIVUDINE 150MG--One tablet by mouth twice a day 11. LEVITRA 5MG--One tablet once per day prn. 12. LISINOPRIL 2.5MG--One tablet daily. 13. NITROGLYCERIN 0.3MG--One tablet under the tongue as needed for chest pain. repeat in 5 minutes if pain persists. if pain persists 5 minutes after 2nd dose, seek medical attention. 14. OXANDRIN 10MG--Take one tablet by mouth twice a day 15. PROSCAR 5MG--[**11-25**] of a tablet daily for hair growth. 16. RANITIDINE HCL 300MG--One tablet daily for chronic esophageal reflux. 17. RITONAVIR 100MG--One capsule by mouth daily, with two capsules of atazanavir. 18. STAVUDINE 15MG--One capsule by mouth twice a day 19. TENOFOVIR 300 MG (VIREAD)--Take one tablet by mouth 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. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 21 days. Disp:*40 Tablet(s)* Refills:*0* 5. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 6. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:*90 Capsule(s)* Refills:*2* 7. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Stavudine 15 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 9. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2* 11. Zantac Maximum Strength 150 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 13. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*2* 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 15. Proscar 5 mg Tablet Sig: one fifth Tablet PO once a day: one fifth of a tablet for hair growth. Disp:*30 Tablet(s)* Refills:*1* 16. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous at bedtime. Disp:*22 vials* Refills:*2* 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: see sliding scale units Subcutaneous four times a day: Sliding scale: BS Units 120-140 2 141-160 4 161-180 6 181-200 8 [**Telephone/Fax (2) 102634**]1-240 12 241-260 14 261-280 16 [**Telephone/Fax (2) 102635**]1-320 20 greater than 300 call doctor . Disp:*2 vials* Refills:*2* 18. Insulin Syringe Ultra Fine II Syringe Sig: One (1) needle Miscell. five times a day. Disp:*qs 1 month supply* Refills:*2* 19. Ultra TLC Lancets Misc Sig: One (1) lancet Miscell. five times a day. Disp:*qs 1 month supply* Refills:*2* 20. ultra one glucose test strips 1 5x per day 1 month supply refills: 2 Discharge Disposition: Home With Service Facility: [**Location (un) 8300**],NH VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 HIV ([**2102**]) - CD4 866, viral load undetectable on HAART [**2-23**] Type II diabetes mellitus ([**2112**]) Hypertension Hypercholesterolemia Lightheadedness and LOC ([**2113**]) Recurrent perirectal herpes ([**2099**]) Lipodystrophy Varicose veins Erectile dysfunction Diverticulae in sigmoid and descending colon ([**2114**]) Left ankle subacute cellulitis, venous stasis ulcer ([**2110**]) Left tibia fracture from fall ([**2092**]) Posterior vitreous detachment OD Right arm fracture ([**2055**]) PAST SURGICAL HISTORY Facelift ([**2113**]) Left inguinal herniorraphy with gortex mesh ([**2108**]) Arthroscopic surgery Hemorrhoidectomy ([**2092**]) Esophageal ring dilation Appendectomy ([**2055**]) Tonsillectomy/adenoidectomy ([**2055**]) Discharge Condition: good Discharge Instructions: may not drive for 4 weeks may not lift greater than 10 pounds for 2 months shower only, let water flow over wounds, pat dry Followup Instructions: make an appt. and follow up with Dr. [**Last Name (STitle) 2148**] in [**11-22**] weeks make an appt. and follow up with Dr. [**Last Name (STitle) 1445**] (card) in [**12-24**] weeks Make an appt. ([**Telephone/Fax (1) 26721**]) and follow up with Dr. [**Last Name (STitle) **] in 4 weeks make an appt. ([**Telephone/Fax (1) 2384**]) and follow up with [**Hospital **] Clinic in [**11-22**] weeks Completed by:[**2117-4-26**]

Admission Date: [**2134-5-27**] Discharge Date: [**2134-6-3**] Date of Birth: [**2059-11-12**] Sex: M Service: HISTORY: The patient is a 74-year-old gentleman with right hemifacial paralysis status post posterior fossa decompression on [**2134-5-14**] complicated by postoperative delirium and bilateral subdural hygromas. The patient was operated on at [**Hospital3 **] Hospital. Postoperatively, he was transferred to the ICU down at [**Hospital3 **] Hospital and the family requested transfer to [**Hospital1 69**] for further management. PHYSICAL EXAMINATION: The patient is pleasant, sleepy, but arousable. Pupils are under 3 mm. His chest is clear to auscultation. His cardiac status is regular rate and rhythm, no murmur, rub or gallop. He is awake, alert, oriented times one. He has a left-sided weakness, left upper greater than lower extremity weakness, with right facial due to the Bell's palsy and facial paralysis. He moves the right side purposely and spontaneously. The left upper extremity is now anti-gravity strength with poor fine motor coordination. Left lower extremity is anti-gravity strength on the left side as well. HOSPITAL COURSE: The patient was monitored in the ICU for four or five days. Initially had drains in place from his subdural hygroma incisions. Those were DC'd. His operative incision is clean, dry, and intact, and the staples will be removed prior to discharge. Mental status: He was lethargic, but easily arousable, confused at times. Would follow commands on the right side. Had some garbled speech which has greatly improved. His heart rate was in the 50's to 60's, normal sinus rhythm with episodes of sinus tachycardia up to the 140's. He was started on PO Lopressor for that. CPK's were sent and they were negative. He was in the ICU until [**2134-5-28**]. He was sent to the regular floor. He opened his eyes spontaneously and his pupils were 5 down to 3 mm. He has a right ptosis. He, again, had anti-gravity strength on the left side, which was improved from a pretty dense paralysis on admission. Head MRI was negative for stroke. Head CT showed inproved bilateral subdural hygromas. He was seen by Physical Therapy and Occupational Therapy and found to require acute rehab. He was discharged in stable condition with improving neurologic status. DISCHARGE MEDICATIONS: 1. Famotidine 20 mg PO b.i.d. 2. Metoprolol, 50 mg PO b.i.d. 3. Heparin, 5,000 units SQ q 12 hours. 4. Tylenol, 650 PO q 4 hours p.r.n.. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2134-6-4**] 09:36 T: [**2134-6-4**] 10:14 JOB#: [**Job Number 48702**]

Admission Date: [**2154-2-22**] Discharge Date: [**2154-2-26**] Date of Birth: [**2079-6-10**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: Cholangitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: Mr. [**Known lastname 8029**] is a 74 M with a medical history notable for cholecystectomy and post-cholecystectomy cholangitis requiring ERCP in [**2144**] at [**Hospital1 18**]. He reports intermittent biliary colic for the past year. However, on [**2-21**] he noted a [**11-25**] RUQ pain that did not improve. He became weak and delirious and his wife called 911. [**Name2 (NI) **] initially presented to his local hospital and shortly after arrival he spiked a fever and his SBP dropped to the 80s. His initial evaluation was notable for the following: ALT 722, AST 365, alk phos 241, lipase 470, bili 3.1, and a CT scan that revealed common bile duct dilation and possible gallstones. He received IV fluids, Vancomycin, and Zosyn. His blood pressure was fluid-responsive and did not require vasoactive medications. He was transferred to the [**Hospital1 18**] ED. On arrival to the [**Hospital1 18**] ED he recieved additional IV fluids and Unasyn. He then went for ERCP on [**2154-2-22**]. The ERCP revealed a single 15 mm round stone that was partially-obstructing and pus in the biliary tree. A double pigtail biliary stent was placed and he was transferred to the ICU for closer monitoring. While in the ICU he required no vasoactive medications to support his blood pressure and was not intubated. One of his admission blood cultures grew gram negative rods and his antibiotics were changed from Unasyn to cefepime and gentamycin. Other active issues in the ICU included a rising white blood cell count without additional fevers, acute renal failure that improved with IV fluids, and left upper extremity swelling of unclear etiology. On arrival to the floor he noted no abdominal pain. He had no nausea and was hungry. Review of Systems: Pain assessment on arrival to the floor: 0/10 (no pain). No recent illnesses other than above. No SOB, cough, or chest pain. No urinary symptoms. No arthralgias or joint swelling. Other systems reviewed in detail and all otherwise negative. Past Medical History: previous cholecystectomy ERCP for cholangitis as above in [**2144**] at [**Hospital1 18**] gastric ulcers status post Billroth-I gastric resection lung cancer status post RUL resection in [**7-/2153**] bradycardia s/p pacemaker hypertension type II diabetes previous knee and shoulder surgeries chronic back pain Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Social History: He lives with his wife. [**Name (NI) **] does not currently smoke; he quit 30 yrs ago and had a previous 30-45 pack-year history. He drinks 1 glass of wine three times a week. Family History: Father had a stroke, brother died of an unclear type of cancer. Physical Exam: Exam on arrival to the floor: - Vital signs: T 97.7, P 74, BP 136/77, 97% on RA. - Gen: Well-appearing in NAD. - HEENT: Sclera anicteric. Somewhat hard of hearing. Oropharynx clear w/out lesions. - Neck: Supple. - Chest: Normal respirations and breathing comfortably on room air. Lungs clear to auscultation bilaterally. - CV: PMI normal size and not displaced. Regular rhythm. Normal S1, S2. No murmurs or gallops. JVP 7 cm. - Abdomen: Normal bowel sounds. Soft, nontender; somewhat distended. - Extremities: Tace ankle edema. - Skin: 2 small blisters on left hand. Left upper arm slightly swollen. - Neuro: Alert, oriented x3. Good fund of knowledge. Able to discuss current events and memory is intact. CN 2-12 intact. Speech and language are normal. - Psych: Appearance, behavior, and affect all normal. Discharge: - ENT: Dry/chapped lips with mild swelling; white plaque on tongue - Abdomen: Soft and non-tender - LUE with mild edema and two vesicule on left hand Pertinent Results: Admission Labs [**2154-2-22**] WBC-16.8* RBC-4.39* Hgb-13.0* Hct-36.9* MCV-84 MCH-29.7 MCHC-35.4* RDW-14.1 Plt Ct-105* Neuts-84* Bands-4 Lymphs-8* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 PT-14.5* PTT-28.6 INR(PT)-1.3* Glucose-92 UreaN-28* Creat-1.8* Na-145 K-3.0* Cl-109* HCO3-26 AnGap-13 ALT-348* AST-481* AlkPhos-167* Amylase-205* TotBili-2.8* DirBili-2.2* IndBili-0.6 Discharge Labs [**2154-2-26**] WBC-11.6* RBC-4.11* Hgb-12.2* Hct-35.2* MCV-86 MCH-29.6 MCHC-34.6 RDW-13.4 Plt Ct-96* Glucose-89 UreaN-15 Creat-1.1 Na-140 K-3.4 Cl-102 HCO3-29 AnGap-12 ALT-87* AST-29 LD(LDH)-285* AlkPhos-131* TotBili-0.9 ERCP ([**2154-2-22**]): Previous sphincterotomy noted. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. A single 15 mm round stone that was causing partial obstruction was seen at the biliary tree with pus suggesting cholangitis A 5cm by 10FR double pigtail biliary stent was placed successfully U/S LUE ([**2154-2-23**]): No evidence of DVT in the left upper extremity. Non-visualization of the left basilic vein. Brief Hospital Course: 1. Cholangitis: Underwent succesful ERCP on [**2-22**] but will need repeat ERCP to confirm duct clearance in [**5-22**] weeks. In addition to ERPC, treated with supportive care and antibiotics (cipro sensitive e.coli grew in blood). 2. Bacteremia: Initially treated emperically with cefepime and gentamicin, but this was narrowed to ciprofloxacin given sensitivies. 10 days planned. 3. Acute renal failure: Improved with supportive care with creatinine at baseline 1.1 4. Right upper extremity swelling: Unclear cause; LENI was negative. Treated with elevation with improvement noted. 5. Thrush: Noted on hospital day [**4-19**]. Improved with nystatin oral. 6. Type II Diabetes without complications: Metformin and Januvia were held on admission but restarted on discharged. Insulin used as inpatient. 7. Hypertension: Continued on carvedilol; ACE inhibitor and Lasix were intially held but both were resumed at discharge. 8. Chronic lumbar back pain: Home standing Oxycontin was decreased to [**Hospital1 **] dosing from TID given renal failure and illness but also written for PRN oxycodone. Resumed TID on discharge. 9. Coagulopathy: Likely secondary to critical illness. Medications on Admission: -list confirmed with patient on admission- Carvedilol 6.25mg daily Furosemide 20mg daily Lisinopril 40mg daily Oxycontin 80mg q8h Percocet q4h PRN Metoclopromide 5mg QID Levemir 24U qhs Januvia 100mg daily Metformin 500mg [**Hospital1 **] Simvastatin 40mg qhs Discharge Medications: 1. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxycodone 80 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every eight (8) hours. 3. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times a day. 6. Levemir 100 unit/mL Solution Sig: Twenty Four (24) units units Subcutaneous at bedtime. 7. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. 8. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 10. nystatin-TCN-HC-diphenhydramin 1.2-1.5-0.06 gram/237 mL Suspension for Reconstitution Sig: One (1) dose Mucous membrane once a day as needed for mouth pain for 5 days. Disp:*qs mL* Refills:*0* 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1. Cholangitis 2. Bacteremia, e.coli 3. Acute renal failure 4. Coagulopathy 5. Thrombocytopenia 6. LUE swelling 7. Diabetes, type II 8. Hypertension 9. Back pain, chronic Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with cholangitis and treated with ERCP and also with antibiotics. Please be sure to complete a full 10 day course of antibiotics, as directed (6 days more). You will need a repeat ERCP, which has been scheduled by the ERCP service for [**3-29**]. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Address: [**Street Address(2) 17177**], [**Location (un) **],[**Numeric Identifier 33806**] Phone: [**0-0-**] Appointment: Friday [**3-1**] at 9:45AM Department: ENDO SUITES When: FRIDAY [**2154-3-29**] at 12:30 PM Department: DIGESTIVE DISEASE CENTER When: FRIDAY [**2154-3-29**] at 12:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage

Admission Date: [**2130-1-26**] Discharge Date: [**2130-1-26**] Date of Birth: [**2055-4-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2763**] Chief Complaint: Pulmonary Embolus Major Surgical or Invasive Procedure: Arterial Line Placement History of Present Illness: 74 yo f with hx of dementia, transfered from OSH today after cardiac arrest. Pt was found to be complaining of feeling dizzy and SOB at her NH, then was found down. CPR was initiated at the NH, she was intubated in the field and given atropine x2 and epi x 4 enroute to OSH. She arrived with PEA arrest. She was coded, after multiple rounds of atropine and epi, went to VF and was shocked x 1, then returned to PEA. After more CPR and epi, dopa, calcium gluconate, and bicarb the pt returned to a sinus tach with perfusion. Cooling began in ER with return of pulse. Code lasted about 30 min in ER + time in field. After CPR she had a subclavial line attempted on the right resulting in a pneumothorax. She was on 3 pressors, then a chest tube was placed with BP improvment. CT of the chest showed a large almost saddle right sided PE with multiple small right PEs. She had a femoral line placed. She was started on heparin due to the PE. Pt was given flagyl, zosyn. She had possible seizure activity prior to trasfer and was given ativan x 1. ABG at 19:55 had a ph of 7.04. . Upon arrival in the MICU, she had a BP in 80s, that then declined to the 50s. She was on dopa gtt, levo gtt, and heparin. Neo was started on arrival with improvment of BP. A-line was placed. ABG showed pH still at 7.01 and PO2 of 40, so bicarb was restarted. . Review of systems: unable to compete a ROS Past Medical History: -Dementia -HTN -hyperlipdiemia Social History: unable to get, pt is from a [**Name (NI) **], husband died this past fall, is [**Name (NI) 8003**] speaking, from [**Male First Name (un) 1056**] Family History: NC Physical Exam: Vitals: T: 94.1 BP: 90/66 P: 99 R: 27 O2: 95% on [**Male First Name (un) **] General: having myclonic jerks on left>right, unresponsive, intubated HEENT: ET tube in place, conjuctiva with edema Neck: supple, no LAD, unable to assess JVD Lungs: rhochi bilaterally, no crackles, crepitus on chest wall extending into neck, possible rub on right, CT in place, dressing clean CV: Regular rate and rhythm, no murmurs Abdomen: soft, non-tender, non-distended, no bowel sounds GU: foley with hematuria Ext: cool, 2+ pulses except for 1+ in right wrist, trace edema NEURO: no corneal reflex, pupils fixed at midline, constrict from 5mm to 4mm, no gag, not responsive to pain, no DTR, no purposeful movement, having myclonic jerks Pertinent Results: Labs: [**2130-1-26**] 03:10AM BLOOD WBC-28.3* RBC-3.54* Hgb-10.5* Hct-31.9* MCV-90 MCH-29.7 MCHC-33.0 RDW-12.1 Plt Ct-223 [**2130-1-26**] 03:10AM BLOOD Neuts-92* Bands-4 Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2130-1-26**] 12:50PM BLOOD PTT-150* [**2130-1-26**] 03:10AM BLOOD PT-22.5* PTT-150* INR(PT)-2.1* [**2130-1-26**] 03:10AM BLOOD Glucose-278* UreaN-42* Creat-1.7* Na-136 K-3.9 Cl-103 HCO3-15* AnGap-22* [**2130-1-26**] 03:10AM BLOOD ALT-329* AST-502* CK(CPK)-1503* AlkPhos-90 Amylase-420* [**2130-1-26**] 03:10AM BLOOD Calcium-7.0* Phos-6.9* Mg-2.6 [**2130-1-26**] 03:10AM BLOOD CK-MB-71* MB Indx-4.7 [**2130-1-26**] 04:37AM BLOOD Type-MIX Temp-33.3 Rates-/33 Tidal V-480 PEEP-9 FiO2-99 pO2-24* pCO2-58* pH-7.03* calTCO2-16* Base XS--18 AADO2-645 REQ O2-100 Intubat-INTUBATED [**Month/Day/Year 5442**]-CONTROLLED [**2130-1-26**] 04:58AM BLOOD Type-ART pO2-40* pCO2-54* pH-7.01* calTCO2-15* Base XS--19 [**2130-1-26**] 07:36AM BLOOD Type-ART pO2-46* pCO2-42 pH-7.15* calTCO2-15* Base XS--13 [**2130-1-26**] 10:00AM BLOOD Type-ART pO2-49* pCO2-39 pH-7.27* calTCO2-19* Base XS--8 [**2130-1-26**] 12:57PM BLOOD Type-ART pO2-83* pCO2-33* pH-7.21* calTCO2-14* Base XS--13 [**2130-1-26**] 04:37AM BLOOD Glucose-253* Lactate-8.3* Na-135 K-3.9 [**2130-1-26**] 04:58AM BLOOD Lactate-8.0* [**2130-1-26**] 07:36AM BLOOD Lactate-9.7* [**2130-1-26**] 12:57PM BLOOD Lactate-11.1* Na-135 Micro: [**2130-1-26**] 3:11 am URINE Source: Catheter. **FINAL REPORT [**2130-1-27**]** URINE CULTURE (Final [**2130-1-27**]): GRAM NEGATIVE ROD(S). ~4000/ML. Blood Cultures: Pending Studies: The current study demonstrates the right chest tube in place with no apparent right pneumothorax, although small pneumothorax can be obscured by significant amount of subcutaneous air. The ET tube tip is 5 cm above the carina. The NG tube tip is in the proximal stomach and might be advanced another 10 cm. There is a lucency surrounding the aortic arch that potentially might represent small amount of pneumothorax. Minimal left apical pneumothorax also cannot be excluded. Currently, the amount of subcutaneous air is higher on the left than on the right. The left basal opacity has some triangular appearance and most likely a combination of consolidation and atelectasis of the left lower lobe. Brief Hospital Course: 74 yo f with hx of dementia, now s/p cardiac arrests in setting of PE and PEA arrest, with pneumothorax s/p chest tube, now intubated and unresponsive having myoclonic jerks. # Hypotension/Cardiac arrest: Secondary to large PE. Pt had a prolonged arrest and is continuing to have hypotension. On admission patient was continued on Levophed and Dopamine, Neosynepherine was started. CE at the OSH and her CK here are elevated, likely secondary to her CPR, but ischemia can not be excluded. She was at risk for hypoperfussion induced cardiac ischemic injury. Pt cooled to temp of 92 at OSH, now at 94. However, due to PE and prolonged code and time since her code patient was not a good candidate for cooling protocol given concern for coagulopathy and overall poor outcome. Patient was monitored on telemetry and started on a bicarb gtt given her profound acidosis. The patient's extremly poor prognosis was shared with the family and it was determined that the patient would be made Comfort Measures Only. Patient pasted shortly after being made CMO. # Pulmonary embolism: Pt had a large right PE and this likely triggered the cardiac arrest. She was started on heparin at the OSH. Unclear her risk factors for PE or if she had any clots in the past. Continued heparin gtt. No thrombolysis given extremely poor prognosis. # Altered mental status/myoclonic jerks: Pt was unresponsive to all stimuli except a minimal amount of pupilary constriction. This was likely [**1-31**] both her prolonged hypoperfusion during her code likely causing anoxic brain injury and her elevated lactate causing a significant metabolic acidosis. Pt is overbreathing the [**Last Name (LF) **], [**First Name3 (LF) **] she does retain some brain function. Whe initially had jerks on her left side but these generalized over the course of her admission. Unclear if she had a hx of sz, since the pt was on depakote at her NH. Her head CT at [**Hospital1 **] had no significant findings, but was likely too soon after her event to show anoxic injury. Sedation was held and metabolic abnormalities were corrected. # Acidosis: Metabolic acidosis and respiratory acidosis. Lactate is likely causing her AG acidosis. It was 8 on arrival. She is also CO2 retaining despite her elevated RR. Bicarb gtt continued until pH>7.2. # Pneuomthorax: Secondary to subcalvian line placement attempt on right. Chest tube is currently in place. CXR with decreasing pneumo. Pt has extensive subcutanteous air on chest wall. Further Pneumothorax noted on the left surronding the aortic arch. Left sided pneumothorax was small and did not reguire chest tube. # Coagulopathy: Likely in setting of shock, fibrinogrin likely low due to clot formation. Coags and bleeding monitored. # Hypertension: Held home lasix, atenolol, nifedipine, and lisinopril # Dementia: Unsure her baseline, currently unresponsive. Medications on Admission: nifedipine ER 30mg lasix 20mg Vit B12 1000mcg Vit D 1000 units Divalproex 125mg sprinkle [**Hospital1 **] Aricept 10mg HS simvastatin 40mg HS zolpidem 10mg HS tylenol prn Evista 1 tab atenolol 20mg qday lisinopril 20mg milk of mag prn compazine prn bisacodyl prn trazadone 50mg HS Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

Admission Date: [**2145-1-24**] Discharge Date: [**2145-2-23**] Date of Birth: [**2092-9-19**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3645**] Chief Complaint: Motor vehicle accident Major Surgical or Invasive Procedure: 1. Open reduction treatment of C7-T1 fracture/dislocation with spinal cord injury. 2. Posterior decompression, C6-7, C7-T1, T1-T2 laminectomy, facetectomy and foraminotomy. 3. Posterior cervical arthrodesis, C5-T2. 4. Posterior segmental instrumentation, C5-T2. 5. Left ICBG 6. Application of local Autograft 7. Application and removal of tongs for traction/reduction. History of Present Illness: 52 yo male trauma transfer who was rear ended at 30mph with neck pain and LE paralysis. Past Medical History: None Social History: Married. Living at home with wife Family History: Non contributory Physical Exam: A+O x 3, mildly confused PERRLA C-collar intact Lungs CTA/B Reg Rate Rhythm Abd soft non-tender Pelvis stable CN 3-12 intact, Motor L1 spinal level decreased strength 1/5, neuro intact to light touch, DTR decreased Pertinent Results: [**2145-1-24**] 12:30PM BLOOD WBC-8.0 RBC-4.85 Hgb-14.4 Hct-41.9 MCV-87 MCH-29.6 MCHC-34.2 RDW-13.7 Plt Ct-146* [**2145-1-24**] 11:47PM BLOOD WBC-9.3 RBC-4.63 Hgb-13.8* Hct-40.0 MCV-86 MCH-29.8 MCHC-34.5 RDW-13.9 Plt Ct-143* [**2145-1-26**] 05:55AM BLOOD WBC-12.0* RBC-3.79* Hgb-11.1* Hct-33.4* MCV-88 MCH-29.2 MCHC-33.2 RDW-14.3 Plt Ct-138* [**2145-1-27**] 04:57AM BLOOD WBC-8.4 RBC-3.64* Hgb-10.7* Hct-31.5* MCV-87 MCH-29.5 MCHC-34.0 RDW-13.9 Plt Ct-119* MRA Cervical Spine [**2145-1-24**] FINDINGS: The examination was performed with the patient's neck in a collar. This prevented using an optimal coil configuration and resulted in a low signal to noise for this study. Within these limitations, no vascular injuries are identified. Specifically, the carotid arteries and their cervical branches, and the vertebral arteries appear to be patent. Although no stenoses or pseudoaneurysms are detected, sensitivity for such abnormalities will be severely limited by the technical limitation as discussed above. Sensitivity for mural dissection will be quite low, although no such dissections are detected. CONCLUSION: Limited study for the reasons described above. No evidence of arterial injury on this limited examination. MRI Cervical Spine [**2145-1-24**] FINDINGS: This study is of very poor quality due to extremely limited signal- to-noise ratio secondary to the lack of employment of the neck coil, due to the patient's injuries, as well as the marked anterior subluxation of C7 upon T1. Within these limitations, the grade 3 traumatic subluxation of C7 upon T1 is clearly demonstrated. There may be a small amount of cord edema immediately cephalad to this level, but again, interpretation is extremely limited by virtue of the reduced signal-to-noise ratio. For similar reasons, it is not possible to state with certainty if there is any intramedullary hematoma present. At C3-4, there is a shallow left paracentral disc protrusion causing mild indentation upon the left ventrolateral cord margin. At C4-5, there is a shallow posterior disc protrusion causing mild cord compression, exacerbated by congenital narrowing of the AP diameter of the bony spinal canal. Uncovertebral spurs appear to produce moderate left and prominent right foraminal stenosis. At C5-6, there is a probable shallow posterior spondylytic ridge along with infolding of the ligamentum flavum, creating a moderate degree of spinal cord compression, exacerbated by congenital narrowing of the AP diameter of the bony spinal canal. At C7-T1, the cord is sharply angulated over the grade III anterior subluxation. The wedge fracture of T1 is visible, but not nearly as clearly as that seen on the accompanying CT scan. There is marked splaying of the C7 and T1 spinous processes. There is widening of the epidural space anterior to the thecal sac at the C7 level. It is likely that this represents the consequences of the subluxation, although an accompanying hematoma in this area cannot be excluded. Best seen on the STIR images is marked edema within the posterior paraspinal soft tissues, including the interspinous region between C7 and T1. Clearly, these findings represent the effects of trauma, including disruption of the intraspinous ligament at C7-T1. There does also appear to be edema extending between the C1 posterior arch and the C2 spinous process, again likely representing some ligamentous injury. There is prevertebral soft tissue swelling seen only at the level of the C7-T1 subluxation. CONCLUSION: 1. Grade 3 traumatic subluxation of C7 upon T1. 2. Technically very limited study, precluding precise analysis of the signal pattern of the spinal cord by either edema or hematoma. These findings were discussed in detail at the time of this examination by the resident, Dr. [**Last Name (STitle) 12919**], with the team caring for the patient. CT C spine [**2145-1-24**] IMPRESSION: 1. Grade [**3-14**] traumatic subluxation of C7 on T1 with anterior wedge compression fracture of T1 vertebral body, with bilateral locked facets of C7 on T1. Widening of the interspinous distance between C7 and T1 at this level suggests underlying ligamentous injury. 2. Possible right T1 transverse process fracture along with anterior and posterior tubercle fractures at this level. Right C7 transverse process fracture. Possible right T1 and T2 right-sided rib fractures which are minimally displaced. These findings were discussed in detail with the trauma team shortly after examination acquisition. The diagnosis of "perched" was changed to "locked" facets after attending review, by which time the patient was already in the operating room for spinal surgery. [**2145-1-27**] Ultrasound bilateral lower extremity Findings: Grayscale, color flow and Doppler images of both lower extremities were obtained. The common femoral veins, superficial femoral veins, and popliteal veins demonstrate normal compressibility, respiratory variation in venous flow and venous augmentation. IMPRESSION: No evidence of DVT in both lower extremities. Blood Cultures MRSA MRSA SCREEN (Final [**2145-1-27**]): No MRSA isolated. Urine culture: URINE CULTURE (Final [**2145-1-27**]):NO GROWTH. Brief Hospital Course: Mr. [**Known lastname 76462**] was [**Last Name (un) 4662**] to [**Hospital1 18**] from [**Hospital3 4107**] after being rearended by a vehicle moving at approximately 30 mph. There was no loss of consciousness. Pt complaining of low back pain and inablity to move legs. CT of c-spine showed C7 perched over T1 with central cord compression. C7-T1 subluxation- Mr. [**Known lastname 76462**] was brought to the OR to undergo a posterior decompression, C6-7, C7-T1, T1-T2 laminectomy, facetectomy and foraminotomy with posterior cervical arthrodesis, C5-T2. He was brought to the TSICU after the procedure intubated. On POD #1 he was extubated without complication and transfered to the floor. On POD#2 an IVC filter was placed without complication. The rest of his hospital course was unremarkable. He was then transfered to an outside rehab facility. Dural Tear- Mr. [**Known lastname 76462**] continued to have a presistant drainage from his posterior cervical incision. He was brought to the OR and was found to have a non-iatrogenic cervical dural tear. fibrin glue and Duragen patch were applied. A lumbar drain was placed to decrease CSF leakage. The head of bed was kept at greater than 30 degress. His posterior incision continued to heal. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. 5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as needed for pain. 6. Famotidine 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Diphenhydramine HCl 50 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for itching. 9. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 14. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 15. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 16. Lorazepam 0.5 mg IV Q4H:PRN Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: 1. Motor vehicle accident. 2. Fracture/dislocation C7-T1 with incomplete spinal cord injury. 3. Obesity Discharge Condition: Stable to rehab facility Discharge Instructions: Please keep incision clean and dry. You may shower in 48 hours, but please do not soak the incision. Change the dressing daily with clean dry gauze. If you notice drainage or redness around the incision, or if you have a fever greater than 100.5, please call the office at [**Telephone/Fax (1) **]. Please resume all home mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **] have been given additional medication to control pain. Please allow 72 hours for refills of this medication. Please plan accordingly. You can either have this prescription mailed to your home or you may pick this up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for narcotics to the pharmacy. If you have questions concerning activity, please refer to the activity sheet. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1352**] at THREE weeks from the date of your discharge. You can make that appointment by calling [**Telephone/Fax (1) **] Completed by:[**2145-2-22**]

Admission Date: [**2128-1-17**] Discharge Date: [**2128-2-6**] Date of Birth: [**2047-6-10**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: 80 M s/p unwitnessed fall on ice in driveway ? [**Hospital **] transfer to [**Hospital **] Hospital, initially c/o bilateral upper extremity weakness. Major Surgical or Invasive Procedure: [**2128-1-21**] Anterior Cervical Discectomy and Fusion/Posteriror Cervical Laminectomy and Fusion [**2128-2-3**] Tracheostomy & Percutaneous Gastrostomy Tube Placement History of Present Illness: 80 M s/p unwitnessed fall on ice in driveway ? [**Hospital **] transfer to [**Hospital **] Hospital, initially c/o bilateral upper extremity weakness. Past Medical History: MI [**2127-3-4**] -> cath, occluded RCA treated medically s/p pacemaker DDD HTN Hypercholesterolemia s/p Appy Family History: Non-contributory Physical Exam: VS upon admission to trauma bay: 148/92 81 16 O2 Sats 96% on NRB mask GCS 15 HEENT: No lacerations, EOMI Neck: collared, no pain Chest: CTA bilat Cor: RRR S1S2, No m/r/g Abd: soft, NT/ND Rectum: Normal tone, guaiac negative Pelvis: Stable Extr: strength 4/5 except for LUE [**4-4**] Pertinent Results: [**2128-1-17**] 02:00PM URINE RBC-[**4-4**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2128-1-17**] 12:58PM GLUCOSE-138* LACTATE-2.5* NA+-146 K+-4.4 CL--101 TCO2-25 [**2128-1-17**] 12:55PM WBC-21.2* RBC-5.13 HGB-16.5 HCT-46.3 MCV-90 MCH-32.1* MCHC-35.6* RDW-13.3 [**2128-1-17**] 12:55PM PLT COUNT-221 [**2128-1-17**] 12:55PM PT-12.8 PTT-20.6* INR(PT)-1.1 [**2128-1-17**] 12:55PM FIBRINOGE-283 CT C-SPINE W/O CONTRAST [**2128-1-17**] 1:07 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: fract [**Hospital 93**] MEDICAL CONDITION: 80 year old man with s/p fall REASON FOR THIS EXAMINATION: fract CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: 80-year-old man status post fall. He has new upper extremity weakness and cord contusion is strongly suspected clinically. COMPARISONS: None. TECHNIQUE: Axial non-contrast CT images of the cervical spine were obtained, and sagittal and coronal reaffirmations were performed. FINDINGS: There is prevertebral soft tissue swelling as well as soft tissue density in the nasopharynx, which could represent vomitus or blood, but the appearance is nonspecific. There is no definite fracture, but there are severe multilevel degenerative changes. These include large osteophytes which are partly fragmented along the anterior aspect of C2, particularly C3 as well, there is a huge osteophyte along C4 extending upwards. This may have represented an anterior flowing osteophyte, which extends from C3 through C6. There is slight retrolisthesis and exaggerated lordosis at the C3-C4 level. There are posterior disc protrusions at C3-C4 and C5-C6 with severe spinal stenosis at these levels, and the neural foramina are also very narrow at C3- C4. The thecal contents are difficult to evaluate with CT, but limited view shows impression on the thecal sac at C3-C4 and C5-C6. It is difficult to assess for contusion or hematoma. IMPRESSION: 1. Prevertebral soft tissue swelling. 2. No definite fracture. 3. Severe spinal stenosis particularly at C3-C4. 4. Given severe degenerative changes and ankylosing osteophytes, MRI would be helpful in excluding ligamentous injury. The patient is being treated for presumed cord contusion clinically. C-SPINE NON-TRAUMA [**3-5**] VIEWS IN O.R. [**2128-1-21**] 11:13 AM C-SPINE NON-TRAUMA [**3-5**] VIEWS I Reason: ANTERIOR CERVICAL FUSION HISTORY: Anterior cervical fusion. Three lateral views of the cervical spine were obtained. One view labeled 11:05 demonstrates a surgical device overlying the anterior aspect of the C3/4 disc, which is wider anteriorly. There is minimal C3/4 retrolisthesis. A second view, not labeled as to time, demonstrates anterior plate and screws and intervening fusion plug at C3/4, with minimal retrolisthesis of C3/4 and widening laterally. A third view labelled at 12:30 shows anterior plate and screws in place with a surgical device pointing towards the C5 spinous process. There is severe background osteopenia. CHEST (PORTABLE AP) [**2128-2-3**] 6:41 PM CHEST (PORTABLE AP) Reason: eval trach position [**Hospital 93**] MEDICAL CONDITION: 80 year old man s/p fall, cardiac history SOB REASON FOR THIS EXAMINATION: eval trach position INDICATION: Status post fall, cardiac history and shortness of breath. Evaluate tracheostomy position. COMPARISON: [**2128-2-1**]. SUPINE AP CHEST: In the interim since the prior study, the endotracheal tube has been removed and a tracheostomy tube has been placed. The tracheostomy tube tip is positioned at the thoracic inlet. A pacemaker overlies the left chest, the leads overlie the right atrium and right ventricle. Cardiac and mediastinal contours are unchanged. The lungs are clear. No pneumothorax or pleural effusion. Brief Hospital Course: Patient admitted to the trauma service. Neurosurgery was consulted who recommended frequent neurologic checks and Orthopedic Spine Surgery consult for Central Cord Syndrome. Steroid drip initiated at referring facility and was continued. After discussion with patient by Orthopedic Spine Surgery the decision was made to proceed with posterior cervical laminectomy C3-5 and anteriror fusion C3-4; patient to OR on [**1-20**] for this procedure. [**1-21**]- Patient reintubated in PACU and transferred to TSICU [**1-26**]- Patient extubated [**1-27**]- transferred to floor, dobhoff placed post pyloric, fell out overnight [**1-28**]- urinary retention foley placed, s/p fall OOB and c/o hip and knee pain; films of pelvis and R knee negative, bowel regimen, tightened SSI, sent sputum. [**1-29**]- void trial Sat, started flomax. increased Lopressor. sitter at night for pt safety. PT following patient. [**1-30**] dobhoff d/c'd b/c clogged, PPN written, IV lopressor and protonix written, sundowned and gave haldol, IR to place new dobhoff. Pt sundowned requiring Haldol c/b copius secretions and inability to protect airway caused desat's -> required re-intubation and transferred back to T-SICU [**2-1**] CE's negative [**2-3**]: Patient underwent trach/PEG [**2-5**]: Transferred to floor. [**2-6**]: G-tube study in Radiology secondary to high residuals Medications on Admission: [**Last Name (LF) **], [**First Name3 (LF) **], Plavix, Atenolol Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain: Give per G-tube. 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for HR <60 & SBP <110. Give per G-tube. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Docusate Sodium 50 mg/15 mL Syrup Sig: Two (2) PO twice a day: Give via G-tube. 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): Give via G-tube. 10. Insulin Sliding Scale Sig: One (1) four times a day: See attached sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: s/p Fall Cervical Spine Stenosis C3 C4 Central Cord Syndrome Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedic Spine and Trauma in [**4-3**] weeks. Follow up with your Primary Doctor after your discharge from rehab. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 363**], Orthopedic Spine Surgery in [**4-3**] weeks, call [**Telephone/Fax (1) 3573**] for an appointment. Follow up in Trauma Clinic in [**4-3**] weeks, call [**Telephone/Fax (1) 6439**] for an appointment. Completed by:[**2128-2-6**]

Admission Date: [**2139-4-14**] Discharge Date: [**2139-4-26**] Date of Birth: [**2139-4-14**] Sex: F Service: NB HISTORY: Baby Girl [**Known lastname **] is a 34 [**3-30**] week gestation age born to a 34 year old gravida I, para 0 mother with [**Name2 (NI) **] type A positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative and rubella immune female. The estimated date of confinement was [**2139-5-24**] . 1. The prenatal course was significant for cervical shortening at 24 3/7 weeks, and not a candidate for cerclage. 2. The patient remained in the hospital for observation. Preterm contractions were noted and patient was started on magnesium and received betamethasone. The contractions resolved after she was started on magnesium. She continued on observation in the hospital until 29 3/7 weeks and then was noted to have contractions again. Magnesium was restarted and the contractions resolved. The patient was sent home on bed rest. There was a maternal history of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 4585**]. Fetal bilateral intrarenal dilitation of the collecting systems was noted by ultrasound on [**2139-4-13**]. The mother on the day of delivery presented with contractions. The GBS status was positive but no maternal fever rupture of membranes was 9 hours prior to delivery. The patient was started on Clindamycin 5 1/2 hours prior to the deliver y. The infant was delivered on [**2139-4-14**] at 2:45 A.M., spontaneous vaginal delivery with Apgar scores of 9 and 9 at one and five minutes. The infant emerged active, good respiratory effort, pink, and was brought to the Neonatal Intensive Care Unit for issues of prematurity. Her birth weight was 2210 grams, length 17. 5 inches and head circumference 30.5 cm. Her weight , 80th percentile, head circumference at the 50th percentile. PHYSICAL EXAMINATION: Baby Girl [**Known lastname **] appeared pink with a nterior fontanelle open and flat. Her chest examination showed breath sounds clear and equal on auscultation. Her heart sounds were normal, S1 and S2 with no audible murmur. She had mild intercostal/subcostal retraction. Her abdomen was soft, nontender, nondistended. The extremities were well perfused and the tone was appropriate for gestational age. Her facial features include a flat nose with midline indentation, most probably due to the position prior to the delivery. She had a caput and normal female genitalia. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: The patient remained stable and continued to do well on room air. She did not require any intubation or oxygen supp ort during this period in the Neonatal Intensive Care Unit. 2. CARDIOVASCULAR SYSTEM: The patient remained hemodynamicall y stable. Her heart sounds were normal and no murmur was heard. 2. FLUIDS, ELECTROLYTES, NUTRITION: The patient remained n.p.o. with intravenous fluid D10W on day zero. She was started on feeds and was gradually advanced on breast milk, Special Care 20. Currently she is on total fluids of 150 cc per kg per day breast milk, or Neosure 22 cals/ounce Her discharge weight is 2390 grams. 3. GASTROINTESTINAL: Baby Girl [**Known lastname **] had a peak bilirubin of 6.5 and a direct component of 0.3 on day 2 of life. She did not receive phototherapy. 4. HEMATOLOGY: Her initial CBC showed a hematocrit of 39.9 an d a platelet count of 421. 5. INFECTIOUS DISEASE: Baby Girl [**Known lastname **] was started on ampicillin and gentamicin. Her initial CBC had shown WBC count of 15.7 with 0 bands. Her ampicillin and gentamicin were discontinued on day 2 of life at 48 hours. Her [**Known lastname **] cultures remained no growth to date. 6. SENSORY: Hearing screen prior to discharge was 7. RENAL: The patient had a renal ultrasound on [**4-16**] due to history of prenatal hydronephrosis. This showed mild pyelectasis of the right kidney, otherwise normal examination. 8. IMMUNIZATIONS: Hep B immunization given on [**2139-4-22**]. 9. PSYCHOSOCIAL: The [**Hospital1 69**] soc ial wor is involved with the family. The contact social worker can be reached at [**Telephone/Fax (1) **]. Her newborn screening was sent to the state laboratory on [**2139-4-17**]. DISCHARGE DIAGNOSIS: 1. Prematurity at 34 3/7 weeks. 2. Rule out sepsis. DISCHARGE PLANS; F/U within 5 days of discharge at [**Location (un) 2274**]/COP Dr.[**Last Name (STitle) **] [**Name (STitle) 269**] to visit home day post discharge. [**Last Name (LF) **], [**Name8 (MD) **] M.D. [**MD Number(1) 38370**] Dictated By:[**Name8 (MD) 58726**] MEDQUIST36 D: [**2139-4-20**] 14:34:28 T: [**2139-4-20**] 15:47:35 Job#: [**Job Number 61312**]

Admission Date: [**2149-10-3**] Discharge Date: [**2149-10-9**] Date of Birth: [**2116-3-25**] Sex: F Service: GYNECOLOGY ADMISSION DIAGNOSES: 1. Unwanted pregnancy. 2. Desires permanent sterilization. DISCHARGE DIAGNOSES: 1. Status post dilatation and evacuation. 2. Status post uterine perforation. 3. Status post uterine repair. 4. Status post sigmoid resection. 5. Status post end-to-end reanastomosis. 6. Status post tubal ligation. HISTORY OF PRESENT ILLNESS: This 33-year-old G6, P5 with last menstrual period of [**2149-7-17**] presented for a termination and permanent sterilization. PAST OBSTETRICAL HISTORY: G6, P5, status post five spontaneous vaginal deliveries, no complications. PAST GYNECOLOGY HISTORY: Normal menses, last menstrual period [**2149-7-17**]. Last pap within normal limits. PAST MEDICAL HISTORY: Mitral valve prolapse confirmed on an echocardiogram. PAST SURGICAL HISTORY: None. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco, ethanol or drugs. PHYSICAL EXAM ON ADMISSION: Blood pressure 100/60. Weight of 130. In general, no acute distress. Pulmonary: Clear to auscultation bilaterally. Cor: 1-2/6 systolic ejection murmur. Breasts: No masses. Abdomen: Soft, nontender, nondistended. Pelvic exam: Normal external genitalia. Good vaginal support. No cervical lesions. Uterus consistent with 12 weeks size. Adnexa: No masses or tenderness. Rectal exam: Within normal limits. Negative guaiac. HOSPITAL COURSE: On [**2149-10-3**], this 33-year-old G6, P5 underwent a dilatation and evacuation which was complicated by a uterine perforation and injury to the sigmoid mesentery. An intraoperative Surgery consult was obtained. The Surgery Team recommended a partial resection of the denuded bowel. The patient underwent a resection and an end-to-end reanastomosis. The patient also underwent a repair of the uterine perforation as well as a tubal ligation. Intraoperatively, the patient received a total of four units of packed red blood cells, two units of FFP and 1500 cc of hetastarch. Please see the full operative note for details. 1. Hematology: Intraoperatively, the patient's hematocrit nadired at 14. As previously stated, the patient received a total of four units of packed red blood cells and two units of FFP intraoperatively. After surgery the patient was transferred to the Surgical Intensive Care Unit where serial hematocrits were followed. The patient's laboratories were notable for a likely dilutional as well as consumptive coagulopathy. On the first night after surgery, the patient's hematocrit fell to 19.5. Her platelets were 84,000 and her INR was elevated at 1.5. On the first postoperative day, the patient received an additional two units of packed red blood cells, two units of FFP and four units of cryoprecipitate. On postoperative day number two, the patient received an additional two units of packed red blood cells so the total products she received were eight units of packed red blood cells, six units of FFP and four units of cryoprecipitate. Her hematocrit stabilized at 29 and her INR stabilized at 1.1. The patient's platelets slowly increased to 128,000 on discharge. The patient had no further problems with bleeding during the hospitalization. 2. Neurology: The patient was originally intubated and sedated and was given a morphine drip for pain. This was continued through postoperative day number one and the propofol was weaned on postoperative day number one and she was extubated later that day. The patient was started on a Dilaudid PCA for pain which she used until postoperative day number five. The patient was then changed to Percocet and Motrin which she tolerated well. The patient was discharged on Percocet and Motrin. 3. Pulmonary: As previously stated, the patient was intubated until postoperative day number one. During the first postoperative day, the patient had wheezing consistent with an underlying asthma. The patient was given albuterol with good response. The patient was extubated on postoperative day number one at which time incentive spirometry was encouraged. The patient had no further problems from a pulmonary prospective during the hospitalization. 4. Coronary: The patient was stable from a coronary prospective throughout the hospitalization. 5. Gastrointestinal: The patient initially was NPO with intravenous fluids and had an nasogastric tube placed. The nasogastric tube was removed on postoperative day number one. The patient was NPO until postoperative day number four. The patient began passing flatus at this time and began to take sips. The patient tolerated sips without a problem, was advanced to clears, and by postoperative day number six was tolerating solids. The patient was initially on intravenous Protonix for gastrointestinal prophylaxis which was stopped on postoperative day number four. On the evening of postoperative day number four, the patient complained of midsternal/epigastric pain. The patient was restarted on intravenous Protonix with good relief. An electrocardiogram was done at the time which was within normal limits. 6. Genitourinary: After the surgery, the patient received two doses of 1000 mcg of Cytotec per rectum for uterine atony. The patient was also started on Methergine .2 mg q. 6 hours times 48 hours. The patient's bleeding was appropriate and she did not require any further uterotonics. The patient had a Foley catheter until postoperative day number three. After the catheter was removed she had no difficulties voiding. 7. Infectious Disease: The patient was originally started on ampicillin, gentamicin and clindamycin. She received a total of 36 hours of these antibiotics. The patient was afebrile during the entire hospitalization. The patient was started on no further antibiotics. 8. Prophylaxis: The patient was on Pneumoboots beginning on postoperative day number zero. On postoperative day number two, the patient complained of some left thigh pain and swelling. Although the clinical suspicion was low, the patient underwent a bilateral lower extremity Dopplers to rule out deep vein thrombosis and the ultrasound was negative. The patient was also on intravenous Protonix for gastrointestinal prophylaxis. 9. Support: The patient was seen by Social Work during her admission and was encouraged to contact Dr. [**Name (NI) **] if she needs any additional support after discharge. The patient was discharged to home on postoperative day number six. The patient was instructed to follow-up with Dr. [**Name (NI) **] in one week and with Dr. [**Last Name (STitle) 1305**] from General Surgery in two weeks. The patient was discharged to home on Percocet 5/325, Motrin and Colace. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6721**] Dictated By:[**Doctor Last Name 95593**] MEDQUIST36 D: [**2149-10-15**] 18:19 T: [**2149-10-15**] 18:19 JOB#: [**Job Number 95594**]

Admission Date: [**2173-2-19**] Discharge Date: [**2173-3-1**] Date of Birth: [**2106-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5119**] Chief Complaint: Seizures, aphasia Major Surgical or Invasive Procedure: Intubation/Mechanical Ventilation History of Present Illness: 66 yo M with a remote hx of EEE resulting in a seizure disorder and EtOH use, transferred to medicine from neurology for management of hypoxic respiratory distress. Patient was initially presented to an OSH on [**2-19**] for evaluation of sudden onset aphasia that day, which was noted to occur in the past after seizures. On arrival to [**Hospital3 **], he was noted to be in status epilepticus with subtherapeutic dilantin level, so he was intubated, loaded with dilantin, given IV valium, and transferred to [**Hospital1 18**] neurology ICU service. He was re-started on Keppra, Dilantin, and Klonopin. No further episodes of status while in-house, although noted to have short episodes of seizures in lower extremities that would subside with Ativan. Hospital course complicated by NSTEMI with troponins to 0.9. Cardiology was consulted and thought NSTEMI due to demand ischemia likely related to peri-intubation hypotension (transiently required neo gtt in ICU). Patient on heparin from [**Date range (1) 80701**] and continued on cardioprotective medication. Also noted to have a PNA (fevers, leukocytosis, and RLL consolidation), started on Vancomycin and Zosyn on [**2-19**] at OSH, which have been continued to date. Patient self-extubated on [**2-21**], requiring BiPAP. Resiratory status stabilized, and patient was called out to neuro floor on [**12-14**]. Called out to a negative pressure [****] ?TB exposure (daughter's boyfriend died of TB). Was ?receiving fluids when noted to be having difficulty with respiration. Received 1 dose of solumedrol for wheezing on [**2-23**]. Med/[**Female First Name (un) 1634**] consult called for management of respiratory issues on [**2-24**], noted to be volume overloaded/with crackles on exam after getting maitenence fluids o/n. When evaluated by the primary team on the floor this afternoon, patient's breathing continued to be quite tachypneic/using accessory muscle to breathe despite being on 5 L O2 and 2 doses of lasix 40 mg IV, ipratroprium nebs, with -1 L diuresis in one hour. Repeat ABG shows increased hypoxia on same oxygen settings and worsening A-a gradient (570=>583, normal 19). Patient also appeared slightly more confused, pulling off oxygen mask frequently during nebulizer treatment and insisting a 'cap' was on the floor, although nothing was noted on the floor. Therefore, MICU resident monitoring patient on the floor recommended immediate ICU transfer. Past Medical History: seizure DO s/p EEE encephalitis # hx of etohism since [**2171**] # HTN # Hyperlipidemia # [**2173-2-19**] NSTEMI: echo [**2-20**] with EF 20% to 25% (in setting of recent MI) Social History: Lives with daughter. Daughter's boyfriend recently died of TB on [**2173-2-2**]. +EtOH. denies illicit drug use or smoking hx. Family History: Noncontributory Physical Exam: VS: 97.6 110/80 76 28 95-97% on 5 L NC BS 105 GA: middle aged M lying in bed, labored breathing, AOx2 (knows name and date) HEENT: PERRLA. MM dry. no LAD. unable to assess JVD. neck supple. Cards: distant HS heard. Pulm: +expiratory wheezes scattered throughout all lung fields. +crackles at bases. Abd: soft, obese, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes Neuro/Psych: CNs II-XII intact. 4/5 strength in U/L extremities. DTRs [**3-2**]+ BL (biceps, achilles). sensation grossly intact to LT. cerebellar fxn poor (unale to do FTN accurately). gait WNL. babinski upgoing bilaterally (R>L. Spelled world backward "dlow". Pertinent Results: Labs: [**2173-3-1**] 08:00AM BLOOD WBC-6.7 RBC-4.63 Hgb-14.5 Hct-39.6* MCV-86 MCH-31.3 MCHC-36.6* RDW-13.4 Plt Ct-362 [**2173-2-19**] 07:20PM BLOOD WBC-20.1* RBC-5.84 Hgb-18.3* Hct-48.4 MCV-83 MCH-31.3 MCHC-37.8* RDW-13.8 Plt Ct-339 [**2173-2-19**] 07:20PM BLOOD Neuts-79.5* Lymphs-14.6* Monos-5.5 Eos-0.1 Baso-0.2 [**2173-3-1**] 08:00AM BLOOD PT-13.8* PTT-22.4 INR(PT)-1.2* [**2173-3-1**] 08:00AM BLOOD Glucose-114* UreaN-14 Creat-1.0 Na-141 K-3.9 Cl-103 HCO3-30 AnGap-12 [**2173-2-19**] 07:20PM BLOOD Glucose-231* UreaN-14 Creat-0.9 Na-138 K-3.9 Cl-101 HCO3-23 AnGap-18 [**2173-2-20**] 05:30AM BLOOD ALT-18 AST-32 LD(LDH)-198 CK(CPK)-155 AlkPhos-101 TotBili-0.3 [**2173-2-20**] 12:20PM BLOOD CK(CPK)-161 [**2173-2-24**] 01:57PM BLOOD CK(CPK)-118 [**2173-2-19**] 10:47PM BLOOD CK-MB-15* MB Indx-12.4* cTropnT-0.91* [**2173-2-24**] 01:57PM BLOOD CK-MB-3 cTropnT-0.14* [**2173-3-1**] 08:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.4 [**2173-2-20**] 05:30AM BLOOD %HbA1c-5.9 [**2173-2-20**] 05:30AM BLOOD Triglyc-452* HDL-21 CHOL/HD-7.1 [**2173-2-20**] 05:30AM BLOOD TSH-5.3* [**2173-2-22**] 02:53AM BLOOD Free T4-0.99 [**2173-2-26**] 08:05AM BLOOD Phenyto-20.8* [**2173-2-19**] 07:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: CXRs ~ [**2173-2-19**]: Diffuse interstitial opacities are most likely due to pulmonary edema. Repeat radiography following appropriate diuresis is recommended to assess for underlying infection. ~ [**2173-2-20**]: In comparison with the earlier study of this date, the endotracheal tube has been removed. There is opacification at the left base silhouetting the hemidiaphragm. This most likely represents atelectasis and pleural effusion, though the possibility of supervening pneumonia cannot be definitely excluded. Pulmonary vascularity is now essentially within normal limits. ~ [**2173-2-23**]: Moderate cardiomegaly is exaggerated by lordotic positioning, but has probably increased consistent with an enlarging heart, and/or pericardial effusion. Azygos distention indicates worsening elevated central venous pressure. There is no pulmonary edema, but left lower lobe consolidation persists, either atelectasis or pneumonia. Left subclavian line tip projects over the junction of brachiocephalic veins. There is no pneumothorax. ~ [**2173-2-24**]: Since earlier today, lung volumes remain low. Left lower lobe consolidation, right basilar atelectasis, and small bilateral pleural effusions slightly improved. Effusion in the minor fissure is not present anymore. ECHO: ~[**2173-2-20**]: Severe left ventricular systolic dysfunction consistent with multivessel coronary artery disease or stress cardiomyopathy. ~[**2173-2-25**]: Moderate regional left ventricular systolic dysfunction. Mild pulmonary hypertension. MICRO: AFB smear neg x 3, cultures pending Urine and blood cultures neg Brief Hospital Course: Brief Hospital Summary: 66 yo M with seizure disorder after EEE infection and former EtOH abuser who was transferred from an OSH in status epilepticus. Intubated and admitted to the Neuro ICU service. Hospital course complicated by an NSTEMI resulting in depressed LV ejection fraction, ventilator associated pneumonia treated with 8 day course of Vancomycin and Zosyn, and hypoxic respiratory distress due to volume overload from depressed LV ejection fraction. Patient was also ruled out for TB due to a possible exposure within his family members. During this hospital course, patient was transferred to the Neurology ICU to the neurology floor to the medicine floor to the Medical ICU and finally back to the medicine floor. He was discharged home with physical therapy. Hospital Course by Problem: # Status Epilepticus: Patient initially presented to the Neuro ICU intubated in status epilepticus, likely in setting of subtherapeutic dilantin level. Mr. [**Known lastname 80702**] daughter reports that he typically has seizures every 4-6 months and that these occur in the context of low or high levels of dilantin. His level at the OSH was subtherapeutic. Unlikely meningitis given lack of nuchal rigidity. Unlikely alcohol withdrawal as patient reported he had not had EtOH use recently and his toxicology screen was negative for EtOH. His head CT from the OSH shows stable L frontal encephalomalacia. The patient while in the MICU became acutely agitated, attempted to leave the unit without any clothes, and a code purple was called. He received on dose of IV haldol 2mg and improved. His mental status exam eventually improved, and his seizure medications were changed to keppra 1500 mg PO BID, dilantin 300 mg PO QHS (with therapeutic dilantin levels), and klonopin 1.5 mg PO QHS on discharge. Given prn Ativan for seizures > 3min. No further seizure activity on discharge. # Hypoxia: Patient became acute hypoxic on the floor after being called out from the ICU, presumably in the setting of continous IVFs and decreased LV ejection fraction of 30%. Aspiration pneumonia may also have contributed to hypoxia. He was transferred to the MICU after remaining on the floor for 6 hours due to concern for hypoxic respiratory distress and aggressively diuresed with IV lasix and treated with standing nebulizers. He improved gradually and was transferred back to the floor. Transitioned to oral lasix. Continued beta-blocker and ACE-inhibitor. Continued albuterol and ipratroprum nebs as needed. Room air sats were 94% on RA at rest and xx% on ambulation. CXR showed stable L lobar opacities. He was discharged with home physical therapy. # Ventilator associated pneumonia: Patient noted to have leukocytosis and left lower lobe infiltrate on CXR, likely VAP versus aspiration PNA during seizures 9Could not distinguish between the two). Unable to obtain speciation on sputum culture, so treated with 8 day course of Vancomycin and Zosyn. Kept on aspiration precautions and diet per speech and swallow recommendations. # TB exposure: Recent exposure to family member who died of TB of [**2173-2-2**]. AFB sputum negative x3. Kept in negative pressure room until completely ruled out. # NSTEMI: Patient suffered an NSTEMI likely due to demand ischemia (hypotensive and tachycardic in the neuro ICU after intubation requiring transient neosynephrine gtt) versus Takatsubo/stress cardiomyopathy. Therefore, decision was made not to do cardiac catherization. Cardiac enzymes were cycled and were downtrending on discharge. Continued cardioprotective meds (ASA, statin, Beta-blocker, started low dose ACE-inhibitor). Patient will need a stress test as outpatient # Pump: Patient had pulmonary edema with poor EF% (20-25%) which improved to 30% on repeat TTE, likely due to recent myocardial insult. Patient was diuresed and treated with beta blocker and afterload reduced with ACE-inhibitor. He will need a repeat TTE in [**6-2**] weeks as outpatient. # Rhythm: No arrythmias noted on telemetry. Continued telemetry # EtOH use: No signs of withdrawal. Continue MVI, thiamine, folate Medications on Admission: - atenolol 25mg PO QD - folate 1 mg QD - MVI QD - simvastatin 40mg PO QD - Keppra 1500 mg PO BID - Klonopin 1mg Qam and 1.5 QHS PO - Amlodipine 5mg PO QD - dilantin 200mg PO QHS Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 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. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 7. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation twice a day as needed for shortness of breath or wheezing. 13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary: Status Epilepticus Non-ST Elevation Myocardial Infarction Ventilator Associated Pneumonia Acute Systolic Congestive Heart Failure Discharge Condition: Satting well on room air on discharge Discharge Instructions: You were admitted initially with a diagnosis of seizures (status epilepticus). In the course of your hospital stay, you suffered a heart attack that damaged the pumping function of your heart, a pneumonia that was treated with antibiotics, and volume overload and difficulty breathing. Due a possible TB exposure, you were also ruled out for TB with 3 sets of sputums that were negative for TB on special stains. You were satting well on room air off of oxygen on discharge. Please take your medications as directed. You were started on oral lasix 40 mg by mouth daily. Your seizure medications were increased to: Dilantin 300 mg by mouth at night Klonopin 1.5 mg by mouth at night Keppra 1500 mg by mouth twice a day Your atenolol was changed to metoprolol 37.5 mg by mouth twice a day. Lisinopril 2.5 mg by mouth was added to your medications to help with heart remodeling. Please weigh yourself daily and call your PcP if your weight gain is > 3 lbs in one day. Fluid restrict to < 2 L daily. Please return to the ED or call your PCP if you experience shortness of breath, chest pain, fevers > 101 F, swelling in your legs, weight gain greater than 3 lbs in one day, or any symptoms concerning enough to you to warrant physician [**Name Initial (PRE) 35843**]. Followup Instructions: Please schedule a follow up appointment with your PCP [**Name Initial (PRE) 176**] [**1-29**] weeks after discharge. If you have no PCP, [**Name10 (NameIs) **] call [**Telephone/Fax (1) 250**] to schedule an appt at [**Hospital1 18**]. Cardiology: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2173-3-9**] @ 1:00pm, [**Hospital1 18**] [**Hospital Ward Name 23**] Center [**Location (un) 436**]. [**Telephone/Fax (1) 62**]. You should have an ECHO repeated and stress test with Dr [**Last Name (STitle) **]. Please also follow up with your neurologist within 1-2 weeks after discharge. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2173-3-1**]

Admission Date: [**2133-2-12**] Discharge Date: [**2133-2-13**] Date of Birth: [**2051-11-13**] Sex: F Service: EMERGENCY Allergies: Aspirin Attending:[**First Name3 (LF) 2565**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 27772**] is an 81 yo female with PMH of trached since [**Month (only) **] stomach mass, trouble weaning. Much of the history is provided by her husband, who is her HCP, given her ventilatory status. She was initially intubated for resection of a gastric cardiac tumor, but had difficulty weaning from the vent with complications including pna. She spent 72 days at [**Hospital 10287**] for this. She was discharged to [**Hospital 100**] Rehab on [**1-6**], where she was slowly weaned. She underwent bronchoscopy and endoscopy at [**Hospital3 **] roughly one week ago which showed healed resection sites. She was at [**Hospital 100**] Rehab today when she noticed sudden onset dyspnea and tachycardia. . In the ED, initial vs were: T 100.6 P 117 in afib BP 128/52 (decreased to 91/41 upon signout) R 36 O2 sat 95% on 100% FiO2. She had no leukocytosis, HCT was 34, trop was 0.03 but CK was 36. Lactate was 2.9. CXR showed mild CHF, small bilateral effusions, and a retrocardiac opacity. CTA showed PE in his LUL pulm artery, right lung pna, and LLL collapse. UA was positive for > 50 WBCs. Patient was given diltiazem, levofloxacin 750mg, vancomycin 1g, ceftriaxone 1g, and started on heparin. 2 18 gage PIVs were placed. UCx and BCx were sent. . On arrival to the ICU, she is intubated. She is resting and comfortable. Denies abd pain, chest pain. She reports continued SOB, though it is better than upon presentation to the ED. Past Medical History: - stomach/esophageal CA of cardia s/p resection [**2133-10-18**] - herpes zoster in [**2093**] - MI [**2115**] treated at [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] in [**Location (un) 1110**], s/p heart - catheterization in [**Location (un) 47**] [**2115**], unknown details - hepatitis in [**2083**], ? medication induced - obesity - hypercholesterolemia - HTN . Social History: nonsmoker. no EtOH Family History: NC Physical Exam: Vitals: T: 99.7 BP: 147/68 P:112 R:22 99% on 100% FiO2 Vent: PSV 10/5 40% FiO2 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple. bounding carotid pulses. JVP not elevated, no LAD. TTP right neck. Fullness of right neck and supraclavicular area. Lungs: bronchial BS in left base. Rales in right base. CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM murmur at base. no rubs, gallops Abdomen: soft, non-distended, bowel sounds present. Diffuse TTP. no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: answers questions appropriately by nodding. CNs [**1-22**] intact grossly. Pertinent Results: Admit Labs: [**2133-2-11**] 07:40PM BLOOD WBC-9.7 RBC-3.53* Hgb-11.2* Hct-34.0* MCV-97 MCH-31.7 MCHC-32.8 RDW-16.3* Plt Ct-333 [**2133-2-11**] 07:40PM BLOOD Neuts-63.7 Lymphs-28.9 Monos-5.5 Eos-1.4 Baso-0.4 [**2133-2-11**] 07:40PM BLOOD PT-12.6 PTT-20.4* INR(PT)-1.1 [**2133-2-11**] 07:40PM BLOOD Glucose-128* UreaN-12 Creat-0.5 Na-134 K-4.1 Cl-93* HCO3-33* AnGap-12 [**2133-2-12**] 03:40AM BLOOD ALT-13 AST-29 LD(LDH)-320* CK(CPK)-40 AlkPhos-68 Amylase-5 TotBili-0.3 [**2133-2-11**] 07:40PM BLOOD CK(CPK)-36 [**2133-2-12**] 11:28AM BLOOD CK(CPK)-30 [**2133-2-11**] 07:40PM BLOOD cTropnT-0.03* [**2133-2-12**] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2133-2-12**] 11:28AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2133-2-12**] 03:40AM BLOOD Lipase-16 [**2133-2-11**] 07:40PM BLOOD Calcium-9.0 Phos-1.9* Mg-1.5* [**2133-2-11**] 07:51PM BLOOD Lactate-2.9* [**2133-2-12**] 04:40AM BLOOD Lactate-0.9 . Discharge Labs: [**2133-2-13**] 05:15AM BLOOD WBC-7.0 RBC-2.93* Hgb-9.6* Hct-28.4* MCV-97 MCH-32.9* MCHC-33.9 RDW-16.0* Plt Ct-267 [**2133-2-12**] 03:40AM BLOOD Neuts-72.0* Lymphs-20.5 Monos-5.6 Eos-1.3 Baso-0.5 [**2133-2-13**] 05:15AM BLOOD PT-15.6* PTT-62.5* INR(PT)-1.4* [**2133-2-13**] 05:15AM BLOOD Glucose-142* UreaN-9 Creat-0.4 Na-138 K-3.8 Cl-98 HCO3-35* AnGap-9 [**2133-2-13**] 05:15AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.8 [**2133-2-12**] 04:40AM BLOOD Lactate-0.9 . Studies: CXR AP [**2133-2-11**]: Mild CHF with small bilateral pleural effusions and retrocardiac opacity which may represent atelectasis and/or pneumonia. Would recommend followup post-diuresis. . CTA chest [**2133-2-11**]: Pulmonary artery filling defects, consistent with acute thrombus, begin at the origin of the right upper lobe pulmonary artery extending into segmental and subsegmental right upper lobe branches. Focal acute pulmonary embolism is noted in the right interlobar pulmonary aretery as well. Other pulmonary artery filling defects appear peripherally located within the vessel, perhaps representing recannulated arteries in the setting of chronic embolism (i.e. branches to the superior segment of the left lower lobe). . Breathing artifact obscures evaluation of subsegmental levels, particularly to the right lower lobe. No left sided pulmonary emboli are identified. There is no overt evidence of right- sided heart strain. Atherosclerotic calcifications involve the thoracic aorta and its branches including the coronary arteries. There is no evidence of pericardial effusion. Small scattered mediastinal lymph nodes are identified though they do not appear to meet CT criteria for pathologic enlargement. An tracheostomy tube appears appropriately positioned. Heterogeneous appearance of the thyroid with rim- calcified left thyroid nodules are partially imaged. Lung windows reveal extensive right lung peribronchovascular opacity throughout the upper, middle, and lower lobes. More consolidative changes at the right base are also noted. There is a small left pleural effusion with consolidation of the left lower lobe consistent with collapse. Secretions are noted in the left main stem bronchus extending into left lower lobe bronchi. Although this exam is not tailored to evaluate abdominal organs, limited evaluation of the upper abdomen is unremarkable. There are no bone findings of malignancy. Fracture deformity of the left seventh rib is old. Multilevel thoracolumbar bridging anterior osteophytosis is noted. IMPRESSION: 1. Pulmonary emboli including those beginning at the origin of the right upper lobe pulmonary artery extending into segmental and subsegmental vessels and another in the right interlobar artery. 2. Focal right basilar consolidation and diffuse right lung peribronchovascular opacity is most concerning for infection or aspiration, though the sequela of chronic emboli is in the differential. 3. Left lower lobe collapse with opacification of lower lobe bronchi, perhaps reflecting mucus impaction. Associated small left pleural effusion. . TTE [**2133-2-12**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild right ventricular systolic dysfunction. Preserved global left ventricular systolic function. No significant valvular disease seen. No pericardial effusion. . Bilateral LENI: No evidence of deep vein thrombosis in either leg. . CXR AP [**2133-2-13**]: In comparison with the study of [**2-11**], there are persistent low lung volumes in this patient with a tracheostomy tube in place. Opacification at the left base is consistent with pleural fluid and atelectasis, though superimposed pneumonia cannot be excluded in the absence of a lateral view. The pulmonary vasculature is essentially within normal limits. The cardiac silhouette is somewhat prominent, though much of this may reflect the poor inspiration. Opacification at the right base medially could reflect crowding of vessels or a possible consolidation in this area as well. . Brief Hospital Course: 81 year old lady was admitted with acute respiratory distress. Patient was found to have pulmonary emboli as mentioned above. She also had pneumonia. She was found to be in atrial fibrillation with rapid ventricular response on admission. . # Pulmonary emboli: She was started on heparin drip on admission. This was switched to lovenox bridge to coumadin on [**2133-2-13**]. Her respiratory status continued to improve and she was being weaned off the ventilator as tolerated. Her TTE showed RV free wall hypokinesis. Patient needs to be in therapeutic INR prior to discontinuing her lovenox shots. She had negative lower extremities for DVT. . # Pneumonia: Patient has trach. She was found to have pnuemonia on both CXR and CT. Final sputum culture is still pending but she was growing 4+ gram positive cocci. Patient will be treated with Vancomycin, levofloxacin and zosyn for a 8 day course to be completed on [**2133-2-19**]. Her sputum culture and sensitivities needs to be followed up. Patient initially had elevated lactate to 2.9 on admission which quickly trended down. . # Afib/aflutter: Patient was found to be in intermittent afib/aflutter, mostly in sinus with good rate control in ICU. She received IV diltiazem in ED. She was continued on home digoxin in ICU. Anticoagulation course as above. . # Abdominal pain: Found to have diffuse tenderness on admission which quickly resolved. Her LFTs and pancreatic labs were within normal limits. . # Urinary tract infection: Positive UA in ED. Cultures are pending at the time of discharge. She is already pancovered for pneumonia as above. . # HTN: Patient has a history of HTN on multiple antihypertensives at home. SBP ranging 100s to 140s in ICU. Her home medications were held due to active infection. Could gradually restart as she improves. . # DM: Her metformin was held in house and she was placed on sliding scale insulin. Could restart her metformin as out patient. . # Contacts: husband: [**Telephone/Fax (1) 80895**]. cell [**Telephone/Fax (1) 80896**]. . Medications on Admission: zofran 9mg [**Hospital1 **] KCl 20mEq [**Hospital1 **] spironolactone 25mg qday ambine 5mg qhs percocet 5/325 0.5 tab q 6 hrs prn pain tramadol 50mg q 6 hrs prn pain ativan 0.25mg PO prn anxiety reg insulin SSI lactobacillus lidocaine patch 5% TD qday losartan 75 qday metformin 500mg [**Hospital1 **] metoprolol tartrate 50mg TID mritazapine 7.5 mg qhs omeprazole 20mg [**Hospital1 **] albuterol/ipratropium 4 puffs qid amlodipine 5mg qday digoxine 0.25mg qday duloxetine 20mg [**Hospital1 **] lovenox 40mg qday (starting [**2-7**]) fentanyl patch 50mcg q3 day ferrous sulfate 325mg [**Hospital1 **] lasix 40mg qday hydralazine 25mg qid Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours): 8 day course to be completed on [**2133-2-19**]. 10. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours) for as directed below days: Patient should have therapeutic INR for atleast 3 days prior to discontinuing this medication. 14. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 15. Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for as directed below days: 8 day course to be completed on [**2133-2-19**]. . 16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 17. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 12H (Every 12 Hours): 8 day course to be completed on [**2133-2-19**]. Vancomycin trough levels should be checked after 3 doses and the dose should be adjusted accordingly (target level 15 to 20). 18. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Pulmonary embolism Pnuemonia . Sendary: Chronic vent dependence s/p trach Discharge Condition: Afebrile and hemodynamically stable. Discharge Instructions: You were admitted to [**Hospital1 69**] with acute respiratory distress. You were found to have pulmonary embolims (clot in lung arteries). You also have a pneumonia. You are being treated with anticoagulation for pulmonary embolism. You will have Lovenox shots in the next five days. You are started on coumadin. You need to be lovenox till you have appropriate blood thinning with coumadin. Your comadin levels (INR) need to be monitored daily and adjusted accordingly, with the target INR being 2 to 3. You will also need to be on antibiotics, Vancomycin, Levofloxacin and Zosyn for atleast 8 days ending on [**2133-2-19**]. . You need to be weaned off of the ventilator at [**Hospital1 10151**] facility. Please follow up the culture results at [**Hospital1 69**]. . Please take the medications as written. . Please keep all of the follow up appointments. . If you develop worsening breathing, chest pain or any other concerning symptoms, please call your primary care provider or come to the Emergency Department. Followup Instructions: Please follow up with your primary care provider early next week. Completed by:[**2133-2-14**]

Admission Date: [**2125-10-17**] Discharge Date: [**2125-10-26**] Date of Birth: [**2058-6-10**] Sex: M Service: MEDICINE Allergies: Ceftriaxone Attending:[**First Name3 (LF) 338**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Bronchoscopy, PICC line placement History of Present Illness: 67 year old man 1 month s/p AVR, MVR, and CABG x 3, now with fever to 100.7, WBC 18.7, and erythema at superior aspect of wound. Pt recently had a long hospitalization following CABG and MVR/AVR([**Date range (3) 83151**]), which was complicated by post-op CVA, aflutter/afib with unsuccessful cardioversion, and a HA-pna. The pt was discharged with a trach to [**Hospital3 **], due to his inability to manage secretions. The pt did well at rehab, until [**2125-10-4**], when he developed a low-grade fever and CXR showed a new left lung base consolidation. He continued to have temps to 99, and on [**10-14**] pt was started on ceftriaxone 1g q24h. On [**10-15**] the pt was also started on vancomycin 1g q12h. Per rehab reports the pt developed confusion and RR in the high 30's. The pt was thought to be in volume overload, and was given lasix 20mg IV once on [**10-17**]. Gram stain of sputum from [**10-14**] showed 1= GPCSputum culture from [**10-14**] grew 2+ E. coli that was pansensitive. Cdiff from that date was also negative. Blood cultures from [**10-15**] showed no growth on [**10-16**]. In the ED, the pt's triage VS were: T100.7, P71 BP 185/73, RR 20, 99%. Pt had a non-con CT Chest that showed: soft tissue stranding anterior to sternum, soft tissue stranding and fluid posteriorly (4cm x 07.cm) adjacent to pericardium which may be thickened. Tmax in ED 100.9, pt received tylenol. Pt was seen by CT [**Doctor First Name **] which thought that CT findings were post-op changes, and recommended continuing vanc/ctx for presumed pna versus cellulitis. Pt admitted to MICU for further eval. Past Medical History: Coronary artery disease s/p CABG - [**8-23**] Had NSTEMI, cath showed 3VD. - [**2125-9-12**] - CABGx3(Left internal mammary artery->Left anterior descending artery, Saphenous vein graft->Obtuse marginal artery, Saphenous vein graft->Posterior descending artery)/Aortic Valve Replacement(25mm [**Doctor Last Name **] Pericardial)/MV Repair(St. [**Male First Name (un) 923**] 32mm saddle ring) - hospital course c/b aflutter/afib, s/p cardioversion x2, coag pos staph and GNR in sputum, pt got 8 day course of vancomycin and zosyn stopped [**10-1**], [**9-13**] frontal CVA Mitral Regurgitation s/p mitral valve repair Aortic Insufficiency s/p AVR CVA: right frontal infarction [**9-13**] Atrial fibrillation/flutter Failed swallow with signs aspiration s/p [**2125-9-19**] PEG placement Inability to manage secretions s/p [**2125-9-26**] Tracheostomy #8 Portex Social History: Lives with sister. [**Name (NI) **] alcohol since [**2092**] though was a heavy drinker prior to this. He has smoked at least a pack a day for 50 years. Works in finance managing stock portfolios. Family History: [**Name (NI) 2320**] (Mother) Ca (grandparents) Physical Exam: VS: P73, BP 114/60, RR 13, POx 98% on A/C FiO2 50%, TV 500, RR14, PEEP 8 Gen: Elderly man with trach, in NAD HEENT: EOMI, PERRLA, fair dentition CV: RRR, 3/6 systolic murmur at apex Pulm: CTAB anteriorly, no wheeze, trying to cough, responds to suctioning Chest: Erythema over sternal notch, incision site well healed near clavicle, steri-strips in place along bottom of incision site. No e/o purulent discharge, no tenderness. Abd: Soft, NT/ND, no organomegaly, G-tube in place, minimal erythema surrounding tube site, no tenderness at tube site Extr: Warm, trace pedal edema, DP+ b/l, left forearm in brace, right UE PICC Neuro: A+Ox3, low volume d/t trach CN: EOMI, PERRLA, left lower facial droop Motor: 0/5 strength left UE and 3/5 strength in L LE, [**6-19**] strength R UE and LE. Pertinent Results: [**2125-10-17**] 02:44PM BLOOD WBC-18.7* RBC-3.29*# Hgb-10.0*# Hct-30.9* MCV-94 MCH-30.3 MCHC-32.2 RDW-14.9 Plt Ct-171 [**2125-10-24**] 04:25AM BLOOD WBC-12.8* RBC-2.81* Hgb-8.4* Hct-26.3* MCV-94 MCH-29.8 MCHC-31.9 RDW-15.2 Plt Ct-194 [**2125-10-17**] 02:44PM BLOOD PT-17.6* PTT-33.9 INR(PT)-1.6* [**2125-10-24**] 04:25AM BLOOD Plt Ct-194 PltClmp-1+ [**2125-10-24**] 04:25AM BLOOD PT-20.7* PTT-31.3 INR(PT)-1.9* [**2125-10-17**] 02:44PM BLOOD Glucose-138* UreaN-26* Creat-0.9 Na-138 K-4.3 Cl-100 HCO3-30 AnGap-12 [**2125-10-24**] 04:25AM BLOOD Glucose-128* UreaN-15 Creat-0.8 Na-135 K-4.8 Cl-100 HCO3-31 AnGap-9 [**2125-10-19**] 6:09 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2125-10-22**]** GRAM STAIN (Final [**2125-10-19**]): THIS IS A CORRECTED REPORT [**2125-10-20**]. >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. PREVIOUSLY REPORTED AS [**2125-10-19**]. >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (CC7D) ON [**2125-10-20**] AT 15:06. RESPIRATORY CULTURE (Final [**2125-10-22**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. ESCHERICHIA COLI. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- 16 I <=1 S CEFTAZIDIME----------- 16 I <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ 8 I <=1 S MEROPENEM------------- =>16 R <=0.25 S PIPERACILLIN---------- R <=4 S PIPERACILLIN/TAZO----- 64 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S CT Chest: IMPRESSION: 1. Post-surgical stranding in the anterior mediastinal space. No fluid collection. 2. Tracheostomy tube is 7.6 cm from the carina. 4. Right PICC loops superiorly, malpositioned; consider readjustment. 5. Mitral and aortic valve replacement. 6. Left moderate-sized pleural effusion and bibasal atelectasis. 7. Gynecomastia. CXR [**2125-10-24**] Portable AP chest radiograph was reviewed in comparison to [**2125-10-22**]. The tracheostomy tip is 6.5 cm above the carina. The cardiomediastinal silhouette is stable. The replaced mitral valve is in place. There is bilateral pleural effusion and right lower lobe opacity that might represent a combination of atelectasis and infectious process. The left retrocardiac atelectasis has also progressed and might represent an additional source of infection as well. Brief Hospital Course: 67 year old man 1 month s/p AVR, MVR, and CABG x 3, now with fever to 100.9, WBC 18.7 admitted with possible pneumonia and cellulitis, rule out mediastinitis. # Fever/Pseudomonal pneumonia: Pt had CT chest that indicated some stranding around sternum, but thoracic surgery did not think CT was consistent with mediastinitis, but that changes were characteristic of post-op changes. No evidence of cellulitis on exam, and although PICC line appeared normal, it was removed for concern for line infection. Pt found to have new ventilator-associated pneumonia, and had bronchoscopy that showed copious secretions. Sputum grew multi-drug resistant pseudomonas. During the admission the pt was thought to have had a ceftriaxone allergic reaction (morbilloform drug rash) and ceftriaxone was added to allergy list. Pt was discharged to rehab on tobramycin with plan to complete a 14 day course, that will be complete on [**2125-11-4**]. He will need his tobra level checked every 3 days to see if his dose needs adjustment. Renal function should be checked q3 days while on the tobra to ensure proper dosing. # Cardiovascular: EKG improved from prior. No chest pain. Continued amiodarone, coumadin, statin, aspirin and restarted beta blocker at a lower dose. # H/o CVA: Left hemiparesis improved as L LE now has some strength. He was continued on his statin, aspirin, and coumadin. # FEN/GI: Continue home Jevity. # GERD: was continued on home ranitidine # Access: new PICC line was placed during his admission, old PICC was removed and had a negative culture. # Communication: With sister [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 83152**], and patient # CODE STATUS: FULL CODE Was tranfered to rehab for continued care. Medications on Admission: Atorvastatin 80 mg daily Docusate Sodium 10mg [**Hospital1 **] Aspirin 81 mg daily Amiodarone 200 mg daily Lisinopril 10 mg DAILY Metoprolol Tartrate 50 mg TID Temazepam 15 mg HS as needed for insomnia. Norvasc 10 mg once a day Ranitidine HCl 15 mg/mL Syrup DAILY Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day): while mechanically ventilated. Regular insulin Sliding Scale Warfarin 2 mg Tablet Mucinex 600mg [**Hospital1 **] CTX 1 g q24 Day 1= [**10-14**] Vanco 1g q12 Day 1= [**10-15**] Lasix 20mg once MVI daily Tylenol 650 supp q6h prn fever Trazodone 50mg qhs prn Tylenol Elixir Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a day). 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for dyspnea, wheeze. 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for Apply to groin. 13. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dryness. 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for mucus. 17. 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. 18. 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. 19. Tobramycin Sulfate 40 mg/mL Solution Sig: Six Hundred (600) mg Injection Q24H (every 24 hours) for 10 days. 20. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 21. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 22. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomina. 23. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for pain/cramping. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary: Healthcare associated pneumonia Secondary: Coronary artery disease Atrial fibrillation on coumadin Hx of cerebrovascular accident Discharge Condition: Good, vital signs stable Discharge Instructions: You were admitted to the hospital with fevers and found to have a pneumonia. We started you on a two week course of antibiotics. You should complete your course of tobramycin on [**2125-11-4**]. Followup Instructions: Follow up with your primary care doctor in [**3-20**] weeks. Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2125-11-1**] 1:45

Admission Date: [**2141-12-25**] Discharge Date: [**2141-12-30**] Date of Birth: [**2061-5-16**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 443**] Chief Complaint: Hypertensive Emergency Major Surgical or Invasive Procedure: Cardiac Cath ([**12-26**]) Cardiac Cath ([**12-27**]) History of Present Illness: 80 yo female with pmh of DM and htn who was admitted with CP on [**12-25**]. The day prior to admisssion she had substernal CP, diaphroesis which occured for a few minutes. The next morning she had a repeat episode also with HA (which she has when her BP increases with anxiety. In the ED her BP was 232/95 upon presentation. She stated she had taken her BP meds. She was given lopressor. Head CT was negative. Her HA improved. Her EKG showed NSR in the 90s with no ST segment changes, however her Trop was 1.8. She was started on a nitro gtt, heparin gtt, and given ASA. . She was taken to cath today where she complained of chest pain. She became acutely anxious and agitated. Her SBP increased to the 240's with her LVEDP in the 30's even when given TNG 200 mcg/min IVD, furosemide 20 mg IV, 6 mg total of morphine, midazolam IV, labetalol IV bolus, nitroprusside IV infusion, and amlodipine 10 mg po. As the procdure continued she began complaining of SOB and worsening chest pain so the procedure was stopped. Her renal arteries where not visualized angiographically. Her SBP eventually fell to the 150s. . Here she is confused and only occasionally will answer questions. She does admit to continued chest pain, but denies shortness of breath. Past Medical History: Diabetes Mellitus Hypertension Osteoarthritis CAD/Stable angina Left breast lumpectomy HX of thyroidectomy in the past (for substernal thyroid) ?Nephrolithiasis CRF baseline creatinine 1.2-1.9 TAH Social History: Non smoker, unable to exercise, no EtOH Family History: Noncontributory Physical Exam: GENERAL: elderly female sitting in bed, pleasant HEENT: NCAT. Sclera anicteric. EOMI. CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. 8 cm JVD LUNGS: Patient is breathing comfortably, diffuse rhonchi. No rales or wheezes ABDOMEN: +BS soft, NTND. No HSM or tenderness. EXTREMITIES: no c/c/e SKIN: Hyperpigmented skin lesions on the lower legs with flaking skin. Neuro: aox4, cn 2-12 intact grossly Pertinent Results: [**2141-12-25**] 02:50PM GLUCOSE-41* UREA N-27* CREAT-1.5* SODIUM-138 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12 [**2141-12-25**] 02:50PM estGFR-Using this [**2141-12-25**] 02:50PM CK(CPK)-488* [**2141-12-25**] 02:50PM cTropnT-1.80* [**2141-12-25**] 02:50PM CK-MB-17* MB INDX-3.5 [**2141-12-25**] 02:50PM CALCIUM-9.7 PHOSPHATE-3.4 MAGNESIUM-2.5 [**2141-12-25**] 02:50PM WBC-10.3 RBC-4.53 HGB-12.4 HCT-37.8 MCV-83 MCH-27.3 MCHC-32.7 RDW-13.7 [**2141-12-25**] 02:50PM NEUTS-85.5* LYMPHS-8.9* MONOS-4.9 EOS-0.6 BASOS-0.1 [**2141-12-25**] 02:50PM PLT COUNT-238 [**12-25**] CT Head FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect or infarction. The ventricles and sulci are normal in caliber and configuration. No acute fractures are identified. There is hyperostosis frontalis. The paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No evidence for intracranial hemorrhage. [**12-26**] C Cath COMMENTS: 1. Selective coronary angiography of this right dominant system revealed 2 vessel obstructive coronary artery disease. There were dual ostia giving rise to the LD and LCX. The LAD had a tubular 65% stenosis in the proximal portion just before D1. The distal LAD wrapped around the apex. The LCX had a 95% subtotal occlusion in the AV groove segment immediately after OM1, which was a tortuous vessel. The [**Month/Day (2) 11641**] had a hazy proximal 70% stenosis followed by a mid 75% stenosis. The RCA tapered in the proximal to mid portion suggestive of moederated disease with diffuse plaquing througout. There was a large very tortuous AM and RPL. 2. Limited resting hemodyanmics demonstrated severe systemic systolic arterial hypertension with a SBP >200mm Hg. There was evidence of diastolic heart failure with an elevated LVEDP of 23. There was no transaortic valvular gradient on careful pullback of the catheter from the left ventricle to the aorta. 3. The patient became progressively uncomfortable, dysnpneic and agitated during the procedure, which was terminatned. Renal angiography was planned but not attempted. FINAL DIAGNOSIS: 1. Multivessel coronary artery disease involving LAD, [**Month/Day (2) 11641**], AV groove CX, with diffuse disease in the RCA. 2. Mild to moderate LV diastolic heart failure. 3. Severe systemic arterial hypertension. [**12-27**] C Cath COMMENTS: 1. Selective coronary angiography showed 2-vessel coronary artery disease. The LAD had a proximal tubular 70% stenosis. The LCx had a high OM1 with proximal and mid 60-70% stenoses. There was a 90% stenosis in the distal AV groove LCx that was of small caliber. The RCA was not injected. 2. Limited resting hemodynamics revealed moderate systemic arterial systolic hypertension with a central aortic pressure of 175/75 mmHg. 3. Successful direct stenting was performed in the proximal LAD using a 3.0x23mm Vision bare-metal stent. This was post-dilated using a 3.0mm NC [**Male First Name (un) **] balloon. Interim angiography showed normal flow, no apparent dissection, and no residual stenosis. 4. Successful PTCA was performed in the distal LCx using a 2.0x15mm Voyager balloon. Final angiography showed normal flow, no apparent dissection, and a 40% residual stenosis. 5. The right femoral arteriotomy was successfully closed using a Mynx device. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Moderate systemic arterial systolic hypertension. 3. Placement of a bare-metal stent in the proximal LAD. 4. PTCA of the distal LCx. [**12-27**] Echo There is moderate 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%). Diastolic function could not be assessed. 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. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2139-12-4**], the degree of mitral regurgitation has increased. Diastolic function cannot be determined on the current study. The other findings are similar. Brief Hospital Course: 80 yo female with pmh of htn and DM admitted with an [**Hospital 7792**] transferred to the CCU after an attempted cath due to a hypertensive emergency secondary to anxiety and agitation. She was taken to cath on [**12-25**] where she complained of chest pain. She became acutely anxious and agitated. Her SBP increased to the 240's with her LVEDP in the 30's even when given TNG 200 mcg/min IVD, furosemide 20 mg IV, 6 mg total of morphine, midazolam IV, labetalol IV bolus, nitroprusside IV infusion, and amlodipine 10 mg po. As the procdure continued she began complaining of SOB and worsening chest pain so the procedure was stopped. Her SBP eventually fell to the 150s when she was transferred to the CCU on a nitrogylcerin and nitroprusside drip. The two drips were weaned off overnight. Her CP resolved as her anxiety and agitation decreased. The heparin gtt was held given her recently elevated SBP due to the risk of hemorrahage. She had elevated BS in the 430's which remained elevated after 6 units of humalog x2, so she was started on an insulin gtt until the morning when she was weaned off and given 4 units of lantus and covered with SSI. She was delirious overnight and was given 5 mg of zyprexa x2 and 2.5 mg iv haldol x1 for agitation and required restraints to avoid her from climbing out of bed and pulling out her IVs. The cath from [**12-25**] showed multivessel CAD involving the LAD, [**Last Name (LF) 11641**], [**First Name3 (LF) **] grrovve Cx, and diffuse disease of the RCA. The option of CAGB was discussed, however given her age and how poorly she tolerated the cath, it was decided to take her back to cath again and place a stent in the major lesion. She was taken to cath on [**12-26**] where she had a bm stent placed to the LAD and POBA to the distal LCx. Her SBP rose to the 200's during the procedure again and she was started on a nitro gtt which was weaned off overnight as her blood pressue was better controlled with oral medications. Problem Based Hospital Course: # s/p NSTEMI: The patient had no prior history of CAD, but had positive Cardiac enzymes in the setting of hypertensive emergency. On cath, she was found to have multivessel CAD involving the LAD, [**Month/Day (2) 11641**], AV groove Cx, and diffuse disease in the RCA, however the major occlusion was a 95% subtotal occlusion of the AV groove Cx. She underwent a second cath [**12-27**] as the first was terminated due to agitation and hypertension. She had a bare metal stent placed to the LAD and PTCA to the distal LCx. - Continue ASA 325 mg daily. - Continue Atenolol 25mg daily, Lisinopril 20mg daily, simvastatin 80 mg daily - Continue plavix 75 mg daily - Patient to follow up with Dr. [**Last Name (STitle) 171**]. # Hypertensive Emergency: Blood pressues controlled in the 130s-140s on discharge. The patient had very labile blood pressures during admission and was placed transiently on a nitro drip. Patient was transitioned to a po regimen. - Continue Lisnopril 20mg daily, Atenolol 25mg daily, amlodipine 10mg daily # RHYTHM: The patient is in normal sinus rythm. - Will continue to follow on tele. # Diabetes: Patient was covered with Sliding scale during admission, will re-transition to Glipizide on discharge. # Chronic kidney disease Stage III: Patient with baseline Cr baseline 1.3-1.8. Patient had tranient elevation in Cr that improved with fluids, likely sec to dye load. Resolved on discharge with Cr 1.5. Note: Patient was dischaged without presciptions for blood pressure medications. Patient was contact[**Name (NI) **] on day of discharge at home and asked to resume Atenolol 25mg daily, Lisinopril 20mg daily, and Amlodipine 10mg daily. Amlodipine was called into the pharmacy. Medications on Admission: (patient is unable to confirm; [**Hospital1 778**] Pharmacy [**Telephone/Fax (1) 8613**] not currently open): Atenolol 25mg daily Lisinopril 20mg daily Nifedipine ER 90mg daily Atorvastatin 20mg daily--patient says she was switched to other statin Glipizide 5mg daily Omeprazole 20mg daily Tramadol 50mg Bacitracin-Polymyxin ointment Dorzolamide 2% drop OU TID Latanoprost 0.005% OU QHS Discharge Medications: 1. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: 0.5 Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. Patient was called Saturday Evening on day of discharge to resume the above medications and the following blood pressure medications Atenolol 25mg daily (patient has at home) Lisinopril 20mg daily (patient has at home) Amlodipine 10mg daily (this Medication called to [**Location (un) **] Pharmacy) Discharge Disposition: Home Discharge Diagnosis: Primary Two vessel coronary artery disease Hypertension Secondary Hypercholesterolemia Diabetes Mellitus Discharge Condition: Afebrile, vitals stable Discharge Instructions: You were hospitalized because you had heart attack. As a result, you had a stent placed in your one of your coronary arteries. Additionally, your blood pressure was significantly elevated during your hospitalization. It is now stable. You have been started on a new medication, Plavix that you must take to keep your coronary arteries open. Please take this medication daily and do no skip any doses. Aspirin has also been added to your regimen. Your blood pressure medications have also been adjusted. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet If you experience any chest pain, shortness of breath, chest pain, or any other concerning symptoms, please call your PCP or return to the ER. Followup Instructions: Call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Monday to schedule an appointment in two weeks Completed by:[**2142-1-10**]

Admission Date: [**2131-3-5**] Discharge Date: [**2131-3-19**] Date of Birth: [**2071-7-31**] Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: Anterior/posterior fusion with instrumentation T3-S1 History of Present Illness: Ms. [**Known lastname 13469**] has a long history of back pain due to scoliosis. She has attempted conservative therapy but continues to experience back pain. She now is electing to proceed with surgical intervention. Past Medical History: Scoliosis PM/SH: HTN depression/anxiety chronic back pain on opioid therapy Appy [**2115**] chole [**2128**] tubal ligation [**2102**] rotator cuff [**2127**] tonsils out as child Social History: Denies tobacco Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles Pertinent Results: [**2131-3-19**] 04:30AM BLOOD WBC-11.9* RBC-3.09* Hgb-9.5* Hct-28.1* MCV-91 MCH-30.8 MCHC-33.7 RDW-14.9 Plt Ct-1088* [**2131-3-18**] 09:00AM BLOOD WBC-12.0* RBC-3.12* Hgb-9.6* Hct-28.2* MCV-91 MCH-30.9 MCHC-34.1 RDW-14.8 Plt Ct-1019* [**2131-3-17**] 04:57AM BLOOD WBC-14.1* RBC-3.01* Hgb-9.2* Hct-27.1* MCV-90 MCH-30.4 MCHC-33.8 RDW-14.9 Plt Ct-806* [**2131-3-16**] 09:05AM BLOOD WBC-16.1* RBC-3.01* Hgb-9.1* Hct-27.6* MCV-92 MCH-30.4 MCHC-33.1 RDW-14.6 Plt Ct-672* [**2131-3-15**] 05:05AM BLOOD WBC-16.5* RBC-3.07* Hgb-9.4* Hct-28.5* MCV-93 MCH-30.6 MCHC-32.9 RDW-14.9 Plt Ct-652* [**2131-3-14**] 09:38AM BLOOD WBC-16.0* RBC-3.25* Hgb-9.9* Hct-29.9* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.9 Plt Ct-537* [**2131-3-13**] 07:35PM BLOOD WBC-14.6* RBC-3.25* Hgb-10.0* Hct-29.6* MCV-91 MCH-30.6 MCHC-33.7 RDW-14.8 Plt Ct-502* [**2131-3-13**] 05:30AM BLOOD WBC-14.7* RBC-3.27* Hgb-10.0* Hct-29.4* MCV-90 MCH-30.8 MCHC-34.2 RDW-14.9 Plt Ct-517* [**2131-3-12**] 04:20AM BLOOD WBC-11.5* RBC-3.25* Hgb-9.8* Hct-29.0* MCV-89 MCH-30.1 MCHC-33.8 RDW-14.7 Plt Ct-357 [**2131-3-11**] 01:45AM BLOOD WBC-10.3 RBC-2.97* Hgb-9.2* Hct-26.3* MCV-89 MCH-31.0 MCHC-35.0 RDW-14.8 Plt Ct-266 [**2131-3-10**] 09:46AM BLOOD WBC-9.4 RBC-3.18* Hgb-9.8* Hct-28.3* MCV-89 MCH-30.8 MCHC-34.7 RDW-15.1 Plt Ct-226 [**2131-3-9**] 02:14PM BLOOD WBC-9.6 RBC-3.07* Hgb-9.5* Hct-26.9* MCV-88 MCH-31.1 MCHC-35.5* RDW-15.3 Plt Ct-201 [**2131-3-16**] 09:05AM BLOOD Glucose-112* UreaN-5* Creat-0.4 Na-135 K-3.7 Cl-99 HCO3-29 AnGap-11 [**2131-3-12**] 04:20AM BLOOD Glucose-106* UreaN-6 Creat-0.4 Na-137 K-3.7 Cl-100 HCO3-31 AnGap-10 [**2131-3-11**] 01:45AM BLOOD Glucose-134* UreaN-6 Creat-0.3* Na-139 K-3.3 Cl-101 HCO3-32 AnGap-9 [**2131-3-10**] 02:12AM BLOOD Glucose-122* UreaN-9 Creat-0.3* Na-138 K-3.5 Cl-102 HCO3-33* AnGap-7* [**2131-3-9**] 03:52AM BLOOD Glucose-100 UreaN-13 Creat-0.4 Na-141 K-3.7 Cl-106 HCO3-29 AnGap-10 [**2131-3-15**] 05:05AM BLOOD ALT-34 AST-26 LD(LDH)-336* AlkPhos-152* TotBili-0.3 [**2131-3-16**] 09:05AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.9 [**2131-3-11**] 01:32PM BLOOD Calcium-7.8* Phos-2.1* Mg-2.0 [**2131-3-10**] 02:12AM BLOOD Calcium-7.6* Phos-1.4* Mg-1.9 [**2131-3-13**] 07:35PM BLOOD CRP-217.6* Brief Hospital Course: Ms. [**Known lastname 13469**] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2131-3-5**] and taken to the Operating Room for L3-S1 interbody fusion through an anterior approach. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#2 she returned to the operating room for a scheduled T11-L3 anterior fusion through a thoractomy. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the PACU in a stable condition. Postoperative HCT was stable. HD#3 she returned for a scheduled T4-S1 posterior fusion. Postoperative hematocrit was low and she was transfused multiple units of packed cells and platelets. She was transfered to the T/SICU from close monitoring. Her chest tube was removed POD2 from the third procedure. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop day one from the third procedure. She was kept NPO until bowel function returned then diet was advanced as tolerated. She developed a persistently elevated white count and a medical consult was obtained. A thorough workup was conducted but returned negative for a source. She remained afebrile and on HD#9 her leukocytosis decreased. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#3 from the third procedure. She was fitted with a lumbar warm-n-form brace for comfort. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: diltiazem alprazolam escitalopram Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*2* 3. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours). Disp:*90 Tablet Extended Release(s)* Refills:*0* 5. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO Q4H (every 4 hours) as needed for PRN Pain. Disp:*100 Tablet(s)* Refills:*0* 7. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety. 8. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Home with Service Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Scoliosis Acute post-op blood loss anemia Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/Lateral/ POSTERIOR Thoracolumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Activity as tolerated Thoracic lumbar spine: when OOB TLSO when OOB Treatment Frequency: Please continue to change the dressings daily with dry, sterile gauze. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days Completed by:[**2131-3-22**]

Admission Date: [**2112-5-15**] Discharge Date: [**2112-5-27**] Date of Birth: [**2039-10-8**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 72 year-old woman with long standing pulmonary fibrosis who was admitted with an acute exacerbation of her respiratory status. She was eventually intubated due to severe decompensation. She underwent a lung biopsy demonstrating advanced untreatable disease and she was eventually extubated in the hospital and then allowed to die with the family at her side. She was pronounced dead on [**2111-5-28**]. CONDITION ON DISCHARGE: Deceased. DISCHARGE STATUS: To the morgue. DISCHARGE DIAGNOSIS: Respiratory failure secondary to interstitial lung disease or pulmonary fibrosis. [**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) 8560**], M.D. [**MD Number(1) 8561**] Dictated By:[**Last Name (NamePattern4) 9931**] MEDQUIST36 D: [**2112-11-4**] 12:00 T: [**2112-11-9**] 09:43 JOB#: [**Job Number 93099**]

Admission Date: [**2107-7-7**] Discharge Date: [**2107-8-10**] Date of Birth: [**2107-7-7**] Sex: M Service: NEONATOLOG DATE OF ANTICIPATED DISCHARGE: [**2107-8-10**]. HISTORY OF THE PRESENT ILLNESS: Baby boy [**Known lastname 6624**] [**Known lastname 42632**] delivered at 28 and 4/7 weeks gestation 1105 grams, male twin #2, born by Cesarean section for intractable preterm labor and incompetent cervix to a 38-year-old G1, PO now one month. Pregnancy was complicated by several episodes of preterm labor at 20 weeks and 24 weeks. The patient received a course of betamethasone on [**6-7**]. Prenatal ultrasound was suggestive for right hydronephrosis and left renal dilatation. PRENATAL SCREENS: Blood type O positive, antibody negative, amnio negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative. DELIVERY ROOM: Infant emerged with good cry, given blow-by oxygen and transported to the Neonatal Intensive Care Unit. Apgars were 7 at 1 and 8 at 5 minutes. PHYSICAL EXAMINATION: Examination revealed the following: AGA male with extreme prematurity, inspiratory crackles bilaterally, otherwise, normal. Weight 1105 grams, (25th to 50th percentile), length 37.5 cm (25th to 50% percentile), head circumference 28 cm (50% to 75% percentile). HOSPITAL COURSE: (by systems) RESPIRATORY: Because of respiratory distress, the patient was intubated, given two doses of surfactant with good response. Extubated day of life #2; on CPAP from day of life #2 to #6. Failed trial on nasal cannula, continued on nasal CPAP until day of life #10. Transitioned to room air on day of life #27. The patient was treated with caffeine for apnea of prematurity, has one to two spells a day. CARDIOVASCULAR: The patient has been cardiovascularly stable. The patient was noted to have a murmur of day of life #20. Evaluation with echocardiogram revealed a small hemodynamically insignificant patent ductus arteriosus. Persistence of the murmur prompted repetition of the echocardiogram on day of life #26 at which time some peripheral pulmonary stenosis was diagnosed as well. A very small PDA persisted. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was initially started on IV fluids and feeds by day of life #3. The patient was gradually increased on the enteral intake and he has reached full feeds on day of life #12. Subsequently calories have been increased and he is currently feeding breast milk 30 with ProMod. He started to breastfeed and he is taking one additional bottle PO per day. Most recent nutritional labs were checked on [**2107-7-29**] and showed normal electrolytes, calcium of 9.9, phosphatase 5.5, albumin 3.3. GASTROINTESTINAL: The patient had an episode of periumbilical erythema, which was treated with ampicillin. HEMATOLOGY: The patient was started on phototherapy or hyperbilirubinemia of prematurity on day of life #2. Phototherapy was discontinued on day of life #9. Maximal bilirubin level has been 6.2 on day of life #7. Bilirubin on day of life #12 was 4.1. The patient has developed apnea of prematurity on day of life #22 on [**7-29**]. The hematocrit dropped to 25.2% with the reticulocyte count of 2.6%. At this point, Epogen was started along with vitamin E, iron, and folate. Repeat hematocrit on day of life #31 showed repeat hematocrit of 33.4% and retic of 9.8%. INFECTIOUS DISEASE: The patient was treated with ampicillin and gentamicin for rule out sepsis because of negative blood cultures. Treatment was discontinued at 48 hours. On day of life #4, the patient was noted to have periumbilical redness. Treatment with oxacillin was begun and maintained for a week. Umbilical venous line was discontinued. The patient did not exhibit any bandemia. Periumbilical redness has resolved. NEUROLOGICAL: The patient had the first head scan on day of life #7 and a repeat on day of life #27. Both ultrasounds were normal. SENSORY: The patient has not yet had a hearing screen. OPHTHALMOLOGY: The patient had his first eye examination on [**2107-8-10**] - this revealed immature vessels in Zone 3. FU is recommended in 2 weeks. PSYCHOSOCIAL: Parents are very involved with their sons' care and visit frequently. RENAL: Followup renal ultrasound was done on [**2107-8-8**] and showed a normal examination. No further followup was needed. CONDITION ON DISCHARGE: The patient's weight is 1850gm. He is in room air breathing comfortably. Chest was clear to auscultation; 2/6 systolic ejection murmur can be heard at the left sternal border, as well as in both axillae and over the back. Abdomen was soft, nontender, and nondistended with normal bowel sounds. Genitourinary examination is normal. Extremities have full range of motion. DISCHARGE DISPOSITION: The patient is to be transferred to [**Hospital **] Hospital for further care. PRIMARY PEDIATRICIAN: To be determined. CARE RECOMMENDATIONS: Feeds on discharge: Breast milk 30 with ProMod at 150ml/kg/d q.3h. to 4h by gavage and bottle. Breastfeeding should also continue to be encouraged when mother is available. Breast milk 30 is mixed with 4kcal/oz of HMF, 4 kcal/oz of MCT and 2 kcal/oz of Polycose. MEDICATIONS: 1. Fer-In-[**Male First Name (un) **] 2.45 cc PO pg q.d. 2. Folate 25 mcg PO pg q.d. 3. Caffeine citrate 10 mg PO pg q.d. 4. Vitamin E, 5 units PO pg q.d. 5. Epogen 300 units subcutaneously q. Monday, Wednesday, and Friday or until the end of next week. Car seat position screening has not yet been done. Newborn screen has been sent and normal except for a hemoglobin F and Hemoglobin [**Last Name (un) **](alpha-thalassemia) in addition to Hemoglobin A. Repeat sample was sent on [**2107-8-8**]. No immunizations have been given. DISCHARGE DIAGNOSES: 1. Extreme prematurity. 2. Respiratory distress syndrome. 3. Status post abdominal wall cellulitis. 4. Apnea of prematurity. 5. Hyperbilirubinemia of prematurity. 6. Anemia of prematurity. 7. Status post rule out sepsis. 8. Rule out alpha-thalassemia trait - FU sample pending with state lab. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**] Dictated By:[**Last Name (STitle) 42633**] MEDQUIST36 D: [**2107-8-8**] 17:07 T: [**2107-8-8**] 17:25 JOB#: [**Job Number **]

Admission Date: [**2103-12-12**] Discharge Date: [**2103-12-22**] Date of Birth: [**2049-8-10**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: DOE/Submassive PE Major Surgical or Invasive Procedure: Intensive Care Unit stay History of Present Illness: This is a 54 yo M with no significant past medical history who presented to an OSH with 3 days of progressive dyspnea on exertion. The patient noticed intermittent R calf swelling for 2-3 months prior to presentation. The patient thought that this was due to trauma from exercise and did not undergo further workup. Over the past three days, the patient noted increasing dyspnea on exertion. One day prior to admission, he noted that he was breathing harder at rest and he presented to OSH for further workup. At the OSH, the patient had a LE US that showed a RLE clot and a CTA that showed a sub-massive PE (unable to view reports yet). He was started on a heparin gtt and transfered to the [**Hospital1 18**] ED for further workup. For the last 2 weeks, the patient has noted chills, subjective fevers, myalgias, drneching night sweats, and fatigue. He has taken intermittent ibuprofen without much relief. He denies cough, rashes, sore throat, rhinorrhea, abd pain, N/V, diarrhea. The patient denies sick contacts. In the ED, initial VS were: 100 112 165/110 22 99% 3L. He was kept on heparin gtt. He had a bedside, portable US that showed ? septal bowing and R heart strain. His EKG did not have evidence of R strain, however. Vitals on transfer were 100, 102, 18, 106/63, 100% 3L. . On arrival to the MICU, the patient does not have increased work of breathing. He is not hypoxic on 3 L. He is comfortable. Past Medical History: None Social History: Social History: - Tobacco: None - Alcohol: Socially - Illicits: None Family History: Family History: No cancers, blood clots, hematological disorders noted Physical Exam: Admission exam Vitals: T: 101.5 BP: 116/71 P: 96 R: 18 O2: 96% 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear without exudates, EOMI, PERRL Neck: obese, supple, JVP not elevated to level of mandible, no discrete LAD but exquisitely tender below left mandible to palpation CV: Sinus tachycardia, RV heave, 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: RLE larger than left, no Homigs sign or palpable cords although slight increased erythema and warmth, TTP of posterior R calf Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Discharge exam Vitals: Tm: 97.7 BP: 124/80 P: 79 R: 18 O2: 97 RA General: Alert, oriented, NAD, speaking in full sentences Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, no accessory muscle use CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, no right heart heave. Abdomen: obese, soft, non-tender, non-distended, Ext: no right lower extremity edema, no left lower extremity edema, 2+ DP/PT pulses. Pertinent Results: Admission labs [**2103-12-12**] 09:30PM BLOOD WBC-11.2* RBC-4.76 Hgb-14.0 Hct-40.8 MCV-86 MCH-29.4 MCHC-34.3 RDW-12.0 Plt Ct-229 [**2103-12-12**] 09:30PM BLOOD Neuts-68.7 Lymphs-20.6 Monos-7.4 Eos-2.8 Baso-0.6 [**2103-12-13**] 03:44AM BLOOD PT-12.7* PTT-78.1* INR(PT)-1.2* [**2103-12-12**] 09:30PM BLOOD Glucose-100 UreaN-15 Creat-1.1 Na-139 K-4.7 Cl-102 HCO3-28 AnGap-14 [**2103-12-12**] 09:30PM BLOOD cTropnT-<0.01 [**2103-12-12**] 09:59PM BLOOD Lactate-1.3 Discharge labs: [**2103-12-21**] 06:16AM BLOOD WBC-9.6 RBC-4.74 Hgb-13.9* Hct-41.4 MCV-87 MCH-29.4 MCHC-33.6 RDW-12.1 Plt Ct-410 [**2103-12-22**] 06:40AM BLOOD PT-24.5* PTT-68.9* INR(PT)-2.3* [**2103-12-13**] 06:23AM BLOOD Glucose-121* UreaN-14 Creat-1.1 Na-141 K-4.4 Cl-106 HCO3-25 AnGap-14 Studies CXR [**2103-12-12**] Assessment of the lungs is more thoroughly performed on the outside hospital CT, though there is no focal consolidation, effusion, or pneumothorax seen. Cardiomediastinal silhouette appears normal. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: No pneumonia. TTE [**2103-12-13**] Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with borderline normal free wall function. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. No aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Moderately dilated right ventricle with borderline normal function and evidence of pressure/volume overload. Unable to determine pulmonary artery pressure on this exam. Normal left ventricular size and function. Brief Hospital Course: 54 yo M with no prior medical history who presents with RLE swelling and SOB, found to have deep venous thrombosis and submassive pulmonary embolism. Patient was placed on heparin drip and transitioned to coumadin. . # Pulmonary Embolism/DVT: Patient presented with several months of shortness of breath and worsening dyspnea on exertion. He also noted a 6 month history of swelling and pain in his right leg. He reported several 14 hour car trips to the midwest in the months leading up to his leg swelling. He was sent to an OSH by his PCP where [**Name Initial (PRE) **] saddle pulmonary embolism was seen on CTA. The patient was transferred to [**Hospital1 18**] and placed on a heparin drip. He was unable to bridge to coumadin with lovenox given his weight (>150 kg) outside of guidelines. He had a slow to respond INR and was discharged on 10 mg coumadin daily with INR of 2.3 at discharge after being therapeutic for >48 hours. He was discharged to follow up with his PCP regarding future INR checks and coumadin dosing over then 6 months. . Transitional issues # Should have age appropriate cancer screening (colonoscopy) if not already planned # Would recommend sleep study to assess for OSA # Would recommend fasting lipids if not reccently checked # Will need frequent INR checks until stable INR is achieved. Medications on Admission: None Discharge Medications: 1. Outpatient Lab Work INR with PT and PTT fax results to [**Telephone/Fax (1) 29683**] Care of: [**Last Name (LF) **],[**First Name3 (LF) **] B. [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES 2. Coumadin 2.5 mg Tablet Sig: Four (4) Tablet PO once a day: daily at 4 pm. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Pulmonary Embolism -Deep vein thrombosis SECONDARY: -obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted for evaluation of your leg swelling and shortness of breath. You were found to have both a large blood clot in your right leg as well as a large blood clot in your lungs. You were started on blood thinners and transitioned to an oral medicine called coumadin. On this drug you will bleed much more easily and will need be careful when shaving and using sharp objects. Your primary care doctor will help manage your blood levels. You will need to have regular blood checks done at [**Hospital3 4107**] and these results will be faxed to his office. The following changes were made to your medications: START -coumadin 10 mg daily at 4 pm (4 2.5 mg tablets) Followup Instructions: Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**] Appt: [**12-24**] at 1:45pm

Admission Date: [**2109-7-5**] Discharge Date: [**2109-7-10**] Date of Birth: [**2045-9-23**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old female with a history of rheumatic heart disease with mitral stenosis with a valve area of 0.75 to 0.9 cm squared and resulting pulmonary hypertension with PA pressures of 90 to 100 mmHg who was admitted to [**Hospital1 188**] for mitral valvuloplasty. Per the patient's daughter the patient has been short of breath and ultimately bedridden. For the past few months the patient has had severe dyspnea with even short trips out of her bed. PAST MEDICAL HISTORY: 1. Rheumatic heart disease and mitral stenosis. 2. Pulmonary hypertension. 3. Questionable asthma/chronic obstructive pulmonary disease. 4. Hypothyroidism. 5. Gastroesophageal reflux disease. 6. Depression/anxiety. PAST SURGICAL HISTORY: Status post cholecystectomy, status post knee surgery. MEDICATIONS: 1. Effexor. 2. Remeron. 3. Klonopin. 4. Levoxyl. 5. Nexium. 6. Vioxx. 7. Morphine. 8. Hydrochlorothiazide questionable dose. ALLERGIES: No known drug allergies. FAMILY HISTORY: No history of heart disease. HOSPITAL COURSE: 1. Cardiac: The patient has undergone a left heart catheterization, which showed clean coronaries. The patient had a TEE, which showed mean mitral valve gradient of 12 mmHg with moderate mitral stenosis, mild mitral leaflet thickening, good MC mobility, normal left ventricular function and severe pulmonary hypertension of more then 100 mmHg. The patient was taken to valvuloplasty, which improved mitral valve area of 2.6 cm squared by catheterization and 2.0 cm squared by TEE. The procedure was complicated by development of new pericardial effusion with increasing RA pressures to 22 mmHg. Pericardiocentesis yielded 350 cc of blood with improved RA pressures to 8. Hemopericardium was felt to be secondary to left atrial perforation, therefore the patient was transferred to the cardiac care unit for observation. The patient has done very well in the cardiac care unit. The patient's pericardial drain was discontinued the day following its placement. The patient's repeat echocardiogram has shown mild left atrial dilation, no effusion and normal left ventricular systolic function. The patient has had a repeated echocardiogram on [**2109-7-10**], which was unremarkable and unchanged. The patient was subsequently transferred to the regular medicine floor. The patient's home medications were restarted including Zebeta 5 mg, which was increased to 5 mg subsequently, Hydrochlorothiazide 12.5 mg as well as all of the patient's outpatient medications. The patient has done extremely well and was seen by physical therapy, but was shown to have decreased endurance, balance and gait due to prolonged bed rest prior to the hospitalization. As far as the status post mitral valvuloplasty the thought is the patient's pulmonary hypertension that she had on admission is likely to improve. The patient has had good systolic function. On telemetry the patient has had a few episodes of ventricular ectopy, which is thought to be due to pericardial irritation. The patient is to continue Zebeta at her current dose. 2. Pulmonary is stable. 3. Renal is stable. Stable creatinine, normal electrolytes, which were followed throughout the admission. 4. Infectious disease: One of the patient's blood cultures were positive for gram positive cocci in clusters. All subsequent blood cultures were negative for 42 hours. It was initially concerning since the patient has been persistently tachycardic with a rate in the 130s, but this was felt to be rebound tachycardia fro being off of beta blockers the patient has been use to taking at home and resolved once the patient's Zebeta was started at the outpatient dose. The patient has remained afebrile throughout the hospital stay and we opted not to administer antibiotic treatment. 5. Endocrine: Hypothyroidism, Levothyroxine was started at 25 mg po q day. The patient is to be followed by TSH and free T4 in four to six weeks by her primary care physician. [**Name10 (NameIs) **] patient has had borderline elevated fasting blood sugars during the hospitalization. The patient is to have hemoglobin A1C checked by her primary care physician. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home with VNA for nursing and physical therapy. DISCHARGE MEDICATIONS: 1. Zebeta 10 mg po q.d. 2. Hydrochlorothiazide 12.5 mg po q.d. 3. Clonazepam. 4. Remeron. 5. Venlafaxine. 6. Levothyroxine 25 mg po q.d. 7. Nitroglycerin sublingual prn. FOLLOW UP PLANS: The patient is to follow up with Dr. [**Last Name (STitle) **] in two weeks following discharge. The patient is also to follow up with her primary care physician in one week following discharge. The patient is to schedule this appointment. The patient is to return home with VNA for nursing and physical therapy. [**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**] Dictated By:[**Doctor Last Name 47849**] MEDQUIST36 D: [**2109-7-21**] 11:52 T: [**2109-7-26**] 12:15 JOB#: [**Job Number 47850**]

Admission Date: [**2108-4-16**] Discharge Date: [**2108-4-19**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 2186**] Chief Complaint: respiratory distress, slurred speech Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 19017**] is a 69-year-old male with past medical history significant for severe COPD on home oxygen at 4L, HTN, GERD, CAD (prior NSTEMI), hyperlipidemia, h/o resistant pseudomonas PNA and chronic back pain who was brought to ED via EMS after wife noticed he had worse confusion and altered mentation this evening. Patient denies recent cough, fevers, chills or increased/discolored sputum production. Of note, he had recent ED visit on [**4-5**] for worse weakness and depression and was seen by psychiatry and SW and discharged home. Much of history collected from wife given patient's AMS. In ED a fentanyl patch was noticed on his back and he was having some slurred speech so there was concern for narcotic induced hypercarbia after initial ABG showed pH 7.28, pCO2 116, pO2 56, HCO3 57. He is also taking Ativan and Percocet at home regularly for anxiety and low back pain. He complained of some generalized weakness along with 1 week of more focal right hand weakness. Therefore, neurology was called to evaluate him in ED and his exam was non-focal. A CT head was done which was unremarkable. Neuro recommended CTA head and neck. There was also concern for COPD flare up from possible infection as well but CXR was unremarkable for PNA. Initial vitals in ED were: T98.2F, HR 93, BP 137/77, RR 28 and O2 Saturation 99% on 6L. He was given albuterol nebs, ipratropium nebs, 125mg IV Solumedrol, 1g IV Ceftriaxone, 500mg IV Azithromycin and Naloxone .4mg x1 for presumed narcotic induced respiratory distress. He became quite agitated after Naloxone so he was given 2.5mg IV Haldol. Lactate was normal at 0.8 and he also had hyperkalemia to 5.4 range. WBC count was normal at 8.6 and Hct near baseline at 37.2. FSG was 184. Repeat ABG much improved s/p BIPAP with pH 7.36, pCO2 85, pO2 65, HCO3 50. On evaluation in the MICU, he appeared confused, somewhat agitated and was not cooperative with initial questions but then calmed down within minutes and was able to give a limited history. Speech somewhat garbled at baseline and patient was only oriented to place and year but did not know month or why exactly he was in ICU. REVIEW OF SYSTEMS: As per HPI. Limited ROS otherwise due to patient's AMS. Patient also endorses decreased appetite and wife also corroborates poor PO intake x 1 week. Past Medical History: 1. Severe COPD on 4 L O2 at home 2. History of VRE UTI 3. History of MRSA 4. CAD w/ NSTEMI ([**2101**]) (last cath in [**4-/2103**] w/o abnormalities. 5. Steroid induced hyperglycemia 6. Hypertension 7. Hyperlipidemia 8. Chronic low back pain after L1-2 laminectomy 9. Bilateral shoulder pain 10. Cataracts bilaterally - s/p surgery for both 11. GERD 12. BPH 13. History of resistant Pseduomonas PNA Social History: Lives in [**Location 686**] with his wife. [**Name (NI) **] was born in [**Country 7936**]. He has 4 adult children. He is a retired mechanic. History of alcoholism but only drinks rare glass of wine "every few weeks". Denies illicit drugs. Prior history of tobacco use. Family History: Noncontributory Physical Exam: Admit Exam: Vitals- T 99.3F, HR 100, BP 152/70, RR 22, oxygen sat 88% on 1.5L NC General: alert and oriented x 1, no acute distress, very cachectic HEENT: PERRLA, sclera anicteric, dry MM, oropharynx clear, poor dentition noted Neck: supple, JVP ~6cm, no LAD, no thyromegaly Lungs: mild bilateral wheezes at bases and mid-fields with end expiration, otherwise no crackles or rhonchi CVS: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, or gallops Abdomen: non-tender, non-distended, normoactive bowel sounds present, soft, no rebound, no guarding, no HSM. Neuro: CNs [**2-17**] in tact, sensation to light touch in tact, moving all extremities. Mild decreased right sided hand grasp. Downgoing toes. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Access: 2 PIVs in place Pertinent Results: Admission Labs [**2108-4-15**] 09:00PM BLOOD WBC-8.6 RBC-4.49* Hgb-11.1* Hct-37.2* MCV-83 MCH-24.6* MCHC-29.7* RDW-14.5 Plt Ct-296 [**2108-4-15**] 09:00PM BLOOD Neuts-88* Bands-0 Lymphs-8* Monos-3 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2108-4-15**] 09:00PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-OCCASIONAL Target-1+ [**2108-4-15**] 09:00PM BLOOD PT-11.5 PTT-30.3 INR(PT)-1.0 [**2108-4-15**] 09:00PM BLOOD Glucose-179* UreaN-17 Creat-0.7 Na-137 K-6.2* Cl-85* HCO3-48* AnGap-10 [**2108-4-15**] 09:00PM BLOOD Calcium-9.9 Phos-4.6* Mg-2.0 [**2108-4-15**] 09:00PM BLOOD cTropnT-<0.01 [**2108-4-15**] 11:44PM BLOOD Type-ART pO2-56* pCO2-116* pH-7.28* calTCO2-57* Base XS-21 Intubat-NOT INTUBA Most Recent Labs [**2108-4-17**] 05:45AM BLOOD WBC-11.6*# RBC-3.46* Hgb-8.6* Hct-28.6* MCV-83 MCH-24.9* MCHC-30.2* RDW-15.2 Plt Ct-279 [**2108-4-17**] 05:45AM BLOOD PT-11.2 PTT-28.8 INR(PT)-0.9 [**2108-4-17**] 05:45AM BLOOD Glucose-88 UreaN-17 Creat-0.6 Na-140 K-4.7 Cl-95* HCO3-37* AnGap-13 [**2108-4-16**] 06:13AM BLOOD ALT-12 AST-19 LD(LDH)-173 AlkPhos-73 TotBili-0.2 [**2108-4-17**] 05:45AM BLOOD Calcium-8.6 Phos-1.7* Mg-2.5 [**2108-4-16**] 05:23PM BLOOD Type-ART pO2-97 pCO2-74* pH-7.40 calTCO2-48* Base XS-16 Urine Studies [**2108-4-15**] 09:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2108-4-15**] 09:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2108-4-15**] 09:15PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0-2 [**2108-4-16**] 06:00PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2108-4-16**] 06:00PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-NEG [**2108-4-16**] 06:00PM URINE RBC-[**11-24**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-[**3-9**] ================================= MICROBIOLOGY: [**2108-4-16**] URINE CULTURE - NO GROWTH [**2108-4-15**] BLOOD CULTURE x 2 - NO GROWTH TO DATE (FINAL REPORT PENDING) ================================= IMAGING: CXR ([**2108-4-17**]) - FINDINGS: As compared to the previous radiograph, there is no evidence of newly appeared focal parenchymal opacity suggesting pneumonia. Unchanged hyperinflation of both lungs, the right lung base is better ventilated than on the previous examination. No pleural effusions. Normal size of the cardiac silhouette. Moderate tortuosity of the thoracic aorta. CXR ([**2108-4-15**]) - IMPRESSION: COPD. No definite signs of pneumonia. If needed, correlation with a lateral view may aid. CT Head ([**2108-4-15**]) - IMPRESSION: No acute intracranial process. Brief Hospital Course: 69-year-old male with severe COPD on home 4L NC, HTN, hyperlipidemia, CAD, GERD, depression and chronic back pain on multiple sedating pain medications and psychiatric medications who presented with AMS, hypercarbic respiratory distress. # Severe COPD & Hypercarbic Respiratory Distress: Initial desaturations and hypercarbia was felt to be related to narcotic- and benzodiazepine-induced respiratory depression. He is also a CO2-retainer at baseline. Patient had been taking fentanyl patches, percocet, and ativan at home. The patient had cultures with no growth, was afebrile, and had a clear CXR, making infection less likely. Moreover, he had no sputum changes or worse cough from usual baseline. He was initially treated as a COPD exacerbation with albuterol/ipratropium nebs, solumedrol, ceftriaxone, azithromycin. Ceftriaxone was ultimately stopped, and steroids were switched to oral prednisone. He was continued on a 5-day course of azithromycin. While he was in the MICU, meetings were held with the patient, his family, and the palliative care team. Given his advanced end stage COPD status and his wished to focus on his comfort, the patient was made CMO (comfort measures only). He was given the option of BiPAP to help with his breathing but did not like the way the BiPAP mask felt. Given his CMO status, his medication regimen was adjusted (see below). He was discharged to a [**Hospital1 1501**], with plans for eventual transition to hospice. # Altered Mental Status: As above, felt to be secondary to hypercarbia and narcotics. CT head negative for any acute process. Mental status improved over the [**Hospital 228**] hospital course. Pt was started on haloperidol and clonopin to help with anxiety and agitation. Pt's ativan was also increased from nightly PRN to q6hours PRN. # Coronary Artery Disease: Past medical history significant for prior NSTEMI in [**2101**]. On admission, he had no complaints of current chest pain or palpitations. After decision was made for comfort care, many of his cardiac medications were stopped, including lisinopril, pravastatin, and aspirin. # Chronic Back Pain: Given concern for decreased respirations and somnolence with hypercarbia, sedating narcotics were held on admission. He was started on [**Year (4 digits) 1988**] tylenol as well as lidoderm patches for pain control. At the time of discharge, the patient was not complaining of any pain. # Goals of Care: While the patient was in the ICU, meeting was held between the patient, his family, the ICU team, and the palliative care team. The decision was made to transition to comfort care. Many non-essential medications were stopped at that time (see medications section below). At discharge, he was started on morphine elixir for shortness of [**Year (4 digits) 1440**]. He was also started on haldol and klonopin for anxiety, as described above. He was discharged to a [**Hospital1 1501**], with plans for eventual transition to hospice. Medications on Admission: :(per OMR notes with PCP [**2108-4-5**]) Fentanyl 50 mcg/hr Patch One Patch Transdermal Q72H Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY Nitroglycerin 0.3 mg tablet, 1 tab prn chest pain: Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) Lorazepam 0.5 mg Tablet, 1 Tablet PO at bedtime as needed for anxiety: DO NOT TAKE MORE THAN AMOUNT DIRECTED Lactulose 10 gram/15 mL Syrup: 30 ML PO daily prn constipation Pantoprazole 40 mg Tablet po q24hr Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO Bedtime Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY Polyethylene Glycol 17 gram/dose PO DAILY prn constipation Trimethoprim-Sulfamethoxazole 160-800 mg Tablet PO 3X/WEEK Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID Senna 8.6 mg Tablet Sig: One Tablet PO BID prn constipation Calcium 600 + D(3) 600-400 mg-unit Tablet One PO once a day. Alendronate 70 mg Tablet One (1) Tablet PO q Monday. Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **] Tiotropium Bromide 18 mcg capsule daily Albuterol Sulfate 90 mcg 2 puff inh q6hours prn SOB/wheeze Albuterol Sulfate 2.5 mg /3 mL (0.083 %) neb q6 prn SOB Ipratropium Bromide 0.02 % Solution 1 inh q6 prn SOB/wheeze Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q6H prn pain Aspirin 81md daily Discharge Medications: 1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain : [**Month (only) 116**] repeat after 5 minutes if chest pain does not resolve. If pt still has chest pain after 3 doses (15 minutes), please notify MD. 2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: Do not take more than directed. 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a day as needed for constipation. 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dosr PO once a day as needed for constipation. 6. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for dyspnea. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for SOB. 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Do not exceed 4 grams in 24 hours. 14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back pain: leave on for 12 hours and then leave off for 12 hours. Adhesive Patch, Medicated(s) 16. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Course ends on [**2108-4-21**]. 19. Morphine 10 mg/5 mL Solution Sig: 2.5 - 5 mL PO q1h as needed for shortness of [**Date Range 1440**]. Disp:*1 500 mL bottle* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis -Altered mental status secondary to excessive narcotics -Severe chronic obstructive pulmonary disease Secondary Diagnosis -Anxiety -Hypertension -Chronic low back pain -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 were admitted to the hospital for altered mental status. It was felt that your mental status changes were likely related to an excess amount of pain medications as well as your underlying severe COPD. A meeting was held with you any your family while you were in the ICU and, according with your wishes, the decision was made that we would focus primarily on keeping you comfortable. Your medications were adjusted in keeping with these goals. You are now being discharged to an extended care facility with the ultimate goal of keeping you comfortable. CHANGES TO YOUR MEDICATIONS: - STOP Fentanyl Patch - STOP Finasteride - STOP Lisinopril - STOP Montelukast (Singulair) - STOP Pantoprazole - STOP Pramipexole - STOP Pravastatin - STOP Calcium/Vitamin D - STOP Alendronate (Fosamax) - STOP Percocet - STOP Aspirin - CHANGE your lorazepam (ativan) to 0.5 mg every 4 hours as needed for anxiety - INCREASE your albuterol nebs to every 4 hours as needed for shortness of [**Location (un) 1440**] / wheezing - START Tylenol 1 gram every 6 hours - START Prednisone 20 mg daily - START Lidoderm patch daily as needed for back pain - START Haldoperidol (Haldol) 1 mg twice a day - START Clonopin 0.5 mg twice a day - START Azithromycin 250 mg daily for 2 more days (ending [**2108-4-21**]) - START Morphine Elixir 5-10 mg PO every 1 hour as needed for shortness of [**Month/Day/Year 1440**] It was a pleasure taking part in your medical care. Followup Instructions: You should follow-up with the physicians at your long-term care facility.

Admission Date: [**2118-10-29**] Discharge Date: [**2118-12-23**] Date of Birth: [**2118-10-29**] Sex: M Service: Neonatology HISTORY: This is a 27-1/7 week infant who is now being transferred to [**Hospital3 1810**], 7 North for further care due to diagnosis of a colonic stricture following medical necrotizing enterocolitis. The infant was born to a 34 year-old gravida II, para I, now II mother with prenatal screens A positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, and group B strep unknown. Benign antepartum course until mother presented with vaginal bleeding and was admitted to the [**Hospital1 188**]. She was started on magnesium sulfate and given a complete course of betamethasone. Magnesium sulfate was discontinued and mother had further bleeding and concern for abruption. Due to this concern for abruption and mother's decreasing platelet count the infant was delivered by cesarean section on [**2118-10-29**] at 6:57 p.m., 20 minutes post onset of general anesthesia. Ruptured membranes at delivery for clear fluid, no maternal fever, no intrapartum antibiotics. The infant initially had decreased spontaneous respiratory effort likely secondary to general anesthesia. Heart rate about 60, received bag mask ventilation with improved heart rate to over 100 . Apgars of 2 at one minute, 6 at five and 7 at nine. [**Hospital **] transferred to the Neonatal Intensive Care Unit without incident. ADMISSION PHYSICAL EXAMINATION: Weight of 1110, which is 65th percentile. Length of 38 cm, which is 60th percentile. Head circumference of 26.5 cm, which is 65th percent. Anterior fontanelle open, flat. Palate deferred. Regular rate and rhythm without murmur. 2+ peripheral pulses including femorals. Breath sounds fairly clear with symmetric air entry. Abdomen benign without hepatosplenomegaly or masses. A 3 vessel cord was noted, normal male genitalia for gestational age with right testicle palpable high in the scrotum. Normal back and extremities. Skin pink and well perfused. Decreased spontaneous movement. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: [**Known lastname **] was initially intubated and required surfactant x2. He was extubated to CPAP on day of life #8 which was [**11-6**], after being loaded with caffeine citrate. He was then placed on CPAP of 6 with FIO2 30 to 40% and this continued until he developed medical necrotizing enterocolitis. Then [**Known lastname **] was taken off of CPAP and placed on nasal cannula on [**12-5**] and he has continued in nasal cannula up until this date. He had received maximum flow of 1 liter of room air humidified and now has weaned to today's nasal cannula setting of 100 cc on room air. He is currently breathing w/ respiratory rate of 30 to 60s and he continues on his caffeine citrate with 1 to 2 spells a day. 2. Cardiovascular: There was a murmur noted on day of life #2 and an initial echocardiogram showed a PDA. He received one course of indomethacin. A repeat echo on [**11-3**] showed a small PDA that was about 1 mm and a follow up on [**12-6**] at the time of his necrotizing enterolitis showed no ductus arteriosus. 3. Fluid, electrolytes and nutrition: Infant's birth weight was 1110. His most recent weight today is 2520 grams and his most recent head circumference on [**12-12**] was 30 cm and a length of 44 cm. Initially [**Known lastname **] had been n.p.o. with an umbilical arterial and an umbilical venous line in place. He was slowly started feedings on day of life #7 and slowly advanced to full feedings on day of life #10 and he was then advanced to breast milk 30 with beneprotein, was doing well without any intolerance until day of life #37 on [**12-5**] when he was noted to have grossly bloody stool. Please see GI system for rest of GI issues but he was made n.p.o. at that time and due to diagnosis of necrotizing enterocolitis remained n.p.o. until [**12-20**] and he was started slowly on feeds. He had been advanced to 30 cc per kilogram per day as of today and was noted to have abdominal distention. A KUB showed mildly dilated loops throughout the entire bowel. Continue to gastrointestinal for further information. 4. GI: As noted earlier, he presented with grossly bloody stool on [**12-5**], on day of life #37 and was made n.p.[**Initials (NamePattern5) **] [**Last Name (NamePattern5) 37079**] was placed to low wall suction. He had evidence of medical necrotizing enterocolitis with KUB showing multiple areas of pneumatosis over the next 1 to 2 days. Bowel wall appeared thickened in different locations. He never had any perforation. His CBC was significant for a bandemia with 25 bands that increased to 27 bands the following day and later normalized. His electrolytes remained stable throughout as well as his platelets which were not lower than 494 after he had the necrotizing enterocolitis. Today, in the setting of the increased abdominal distention on the KUB and his high risk for a stricture, he was sent over to [**Hospital1 **] radiology for a barium enema and a transverse colonic stricture was identified. 5. Hematology: He did receive phototherapy and had a peak bilirubin on day of life #1 of 4.5. His initial hematocrit was 45.5%. He did receive 1 blood transfusion on [**11-2**] for a hematocrit of 34. He did receive a second blood transfusion on the day of his diagnosis of medical necrotizing enterocolitis. His most recent hematocrit was on [**12-20**] of 26.6 % with a retic count of 3.2. His platelets have remained stable throughout the entire course and he has not received any platelet transfusions. 6. Endocrine: [**Known lastname **] had normal sugars in the first 2 weeks of life and on day of life 18 was noted to have a D-stick of 36 and he then continued over the next 1 to 2 weeks to have intermittent low D-sticks and endocrinology consult had been obtained and recommended sending an insulin level as well as growth hormone, urine for ketones, cortisol, and a blood gas if the blood D-stick was <50. However, this did not recur and these tests were never assessed. As a result of his previous history of low D-sticks which were presumed to be a period of hyperinsulinemia, we have not advanced his TPN glucose beyond 12.5 trying not to induce hyperinsulinemia as he was weaned off the PN with refeeding. 7. Infectious disease: He did receive an initial rule out sepsis in the first 48 hours. His initial white count was 5.8 with 11 polys and 0 bands with ANC of 638. His blood cultures were negative and antibiotics were discontinued after 48 hours. ON [**12-5**], he was started on vancomycin and gentamicin after he had grossly bloody stools with the significant bandemia of 27 bands. This was changed to Zosyn after initial blood cultures were negative and he continued on Zosyn to complete a total of 16 days, which was 2 days after the KUBs normalized. The Zosyn has been discontinued since [**2118-12-20**]. 8. Neurology: He has had 2 head ultrasounds, which have been normal ([**11-3**], [**11-29**]). He will need a third ultrasound at term corrected gestational age. 9. Ophthalmology: He had his initial eye examination on [**2118-11-28**]. It showed zone 2 immature. Follow up 2 weeks. On [**12-12**] he had a right stage 1, zone 2, 1 to 2 o'clock hours and left eye was immature with follow up in 1 week. On [**12-19**] he had right ROP stage 1, zone 2, 2 to 3 o'clock hours and the left was immature in zone 2 and follow up in 1 week. This follow up eye examination will need to be done at [**Hospital3 1810**] in the last week of [**Month (only) 1096**]. 10. Immunizations: He did receive 1 dose of hepatitis B vaccine on [**11-30**] and will be due to for his first set of immunizations over the next week. PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 45269**]. CONDITION AT TRANSFER: Critical. DISCHARGE DISPOSITION: To [**Hospital3 1810**] level 3 for surgical repair of the colonic stricture. CARE RECOMMENDATIONS AT DISCHARGE: 1. Feedings: N.p.o. 2. Medications: Caffeine 3. Car seat positioning has not been done as of yet but will need to be done prior to infant's discharge home. 4. Newborn state screen status: He has had multiple state screens with 11/11 state screen normal. A recent repeat state screen sent on [**2118-12-11**] is still pending at this time and will need to be followed. 5. Hearing screen status has not been done at this time but will need to be done prior to infant's discharge. 6. Immunizations received: As noted above, hepatitis B vaccine and infant will require first set of vaccinations within a week. 7. As noted above, will require a repeat HUS at term gestational age. 8. As noted above, repeat ophthalmologic exam is due next week. Discharge Diagnoses: 1) prematurity 2) s/p medical necrotizing enterocolitis 3) apnea of prematurity 4) s/p hypoglycemia 5) s/p PDA treated with indomethacin 6) s/p RDS requiring surfactant 7) anemia of prematurity 8) now with colonic stricture requiring transfer to [**Hospital3 18242**] 7N Surgical Service for repair. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**] Dictated By:[**Last Name (NamePattern4) 57175**] MEDQUIST36 D: [**2118-12-23**] 14:53:23 T: [**2118-12-23**] 16:37:32 Job#: [**Job Number **]

Admission Date: [**2117-8-4**] Discharge Date: [**2117-8-9**] Date of Birth: [**2048-6-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 492**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: [**2117-8-5**] Flexible bronchoscopy with narrow-band imaging and therapeutic aspiration. [**2117-8-6**] Flexible bronchoscopy with therapeutic aspiration. [**2117-8-6**]: Bronchial angiogram History of Present Illness: 69 yo transferred from [**Hospital2 **] [**Hospital3 6783**] hospital with a course of hemoptyis the began on the [**7-24**] for which he was admitted. At that time, he underwent bronchoscopy, and received bronchial artery embolization after a CT exam showed an increased density and bronchiectasis. Following this procedure and discharge, he continue to have a single episode of hemoptysis (teaspoon full). He was subsequently readmitted on [**8-1**] [**Hospital3 6783**] after a second episode of hemoptysis, [**2-16**] of a cup. Upper endoscopy showed a gastric ulcer in the fundus, 80% healed. During this hospitalization, he developed massive hemoptysis on [**8-3**], which was bright red blood with tissue, about 600 cc. He was unresponsive and was intubated. He was transfused 1 unit. Bronchoscopy was performed and showed no clots in the bronchus. Repeated upper endoscopy showed no change in the gastric ulcer. the patient subsequently self extubated himself on [**8-4**]. He was transferred to [**Hospital1 18**] for further work-up on [**8-4**] Past Medical History: Hypertension Dyslipidemia PVD, s/p fem-fem bypass Essential tremor Bladder Ca, s/p radical prostatetectomy and cystectomy w/ileal loop conduit [**2115**] Gastric ulcer w/negative biopsy and negative h.pylori AAA repair [**2105**] Bronchiectasis TIA w/left sided weakness Bilateral internal carotid stenosis Pulmonary AVM with coil embolization [**2105**] Hemoptysis Social History: Ex-smoker, stopped in [**2102**] Family History: No history of AVM Physical Exam: VS: Tm98.4 Tc97.4 HR62 BP124/60 RR20 94%RA Gen: No acute distress, AAO Card: RRR Lungs: CTA B/L Abd: +BS Pertinent Results: [**2117-8-4**] 11:54PM BLOOD WBC-8.8 RBC-3.36* Hgb-10.1* Hct-29.8* MCV-89 MCH-30.0 MCHC-33.7 RDW-15.6* Plt Ct-278 [**2117-8-7**] 03:23AM BLOOD WBC-5.5 RBC-3.10* Hgb-9.5* Hct-27.2* MCV-88 MCH-30.6 MCHC-34.8 RDW-15.0 Plt Ct-238 [**2117-8-8**] 07:00AM BLOOD WBC-6.0 RBC-3.36* Hgb-10.5* Hct-29.1* MCV-86 MCH-31.3 MCHC-36.3* RDW-14.7 Plt Ct-292 [**2117-8-4**] 11:54PM BLOOD PT-13.2 PTT-23.8 INR(PT)-1.1 [**2117-8-4**] 11:54PM BLOOD Plt Ct-278 [**2117-8-8**] 07:00AM BLOOD Plt Ct-292 [**2117-8-4**] 11:54PM BLOOD Glucose-101 UreaN-18 Creat-1.1 Na-145 K-3.8 Cl-110* HCO3-27 AnGap-12 [**2117-8-7**] 03:23AM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-140 K-4.0 Cl-105 HCO3-32 AnGap-7* [**2117-8-8**] 07:00AM BLOOD Glucose-106* UreaN-18 Creat-0.9 Na-140 K-3.8 Cl-103 HCO3-29 AnGap-12 [**2117-8-4**] 11:54PM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8 [**2117-8-7**] 03:23AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0 [**2117-8-8**] 07:00AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9 Brief Hospital Course: The patient was admitted on [**2117-8-4**] by the thoracic surgery service to the SICU for treatment and evaluation of massive hemoptysis. ENT evaluated the patient for bleeding sources: Fiberoptic exam revealed no source of blood from the nose, nasopharynx, oropharynx, oral cavity, hypopharynx or larynx; there were no supraglottic lesions. CTA on [**8-5**] showed a Left superior segment coiled AVM with an adjacent ground glass opacity. It was thought that this finding could represent intraparenchymal hemorrhage or it could represent aspiration, given the dependent consolidation seen in both lower lobes and the secretion seen in the right main bronchus. Imaging also revealed a question of a completely thrombosed aorta just distal to the origin of the renal arteries with extensive collaterals in the abdominal wall musculature. Due to this finding, ultrasound of the aorta was performed. While a suboptimal study due to bowel gas, arterial flow and normal waveforms was noted is seen in the right and left distal most external iliac arteries and common femoral arteries bilaterally consistent with a prior femoral-femoral bypass. On [**8-5**], flexible bronchoscopy with narrow-band imaging and therapeutic aspiration was performed. A fresh blood clot was identified in the right lower lobe lateral segment which was therapeutically aspirated. A clot was also identified left main-stem and this was emanating from the left lower lobe. There was evidence of possible pulmonary AVMs in the left main-stem medial segment; however, this was compounded somewhat by the traumatic appearance of the airways. Under white-light imaging, these areas appeared erythematous. No other definitive AVMs were noted under narrow-band imaging. On [**8-6**], a repeat flexible bronchoscopy was performed to isolate a source of bleeding.There was a small clot on the right main stem, however, there were no clots or active bleeding in the right upper lobe, right middle lobe, right lower lobe. The left main stem again had a questionable area of erythema, possible arteriovenous malformation in the medial aspect of the left main stem. The left upper lobe and lingula were free from clots or blood. There was an old blood clot emanating from left lower lobe, which was therapeutically aspirated. Upon examination, the anteromedial segment of the left lower lobe demonstrated a fresh clot with active oozing of blood, which was confirmed with a bronchial wash. The posterior and lateral segment of the left lower lobe were both washed and there was no active oozing. The final impression was that the Left lower lobe anteromedial segment is likely source of hemoptysis. The patient was taken to the angio suite on [**8-6**] for possible embolization. A preliminary report revealed: 1. Aortogram demonstrating no visualized bronchial artery branches. 2. Selective angiograms of intercostal arteries demonstrating no irregularity. 3. Subclavian arteriogram demonstrating no abnormality of the left internal mammary artery. No intervention was performed. The patient was transferred to the floor on [**8-7**], and kept for observation. The patient had several more episodes of hemoptysis on [**8-8**] - 2 tsp of bright red blood without clots - which resolved without intervention. On the evening of [**2034-8-7**], the patient had no episodes of hemopysis. The Interventional Pulmonology team, staff and patient agreed that is was appropriate to discharge the patient to home on [**8-9**] with follow as needed. The patient is being discharge stable, in good condition. Medications on Admission: zertec 10mg QD pletal 50mg [**Hospital1 **] Guaifenesin-Codeine 5-10mL PO q6h prn simvastatin 10mg po qhs lisinopril 10mg po qdaily nasonex 50mcg qam atenolol 50mg po qdaily qvar 80mcg 1-2 puffs Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: [**12-16**] puffs Inhalation 1-2 puffs [**Hospital1 **] (). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 10. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: HTN, Dyslipidemia, PVD, s/p fem-fem bypass, Essential tremor Bladder Ca, s/p radical prostatetectomy and cystectomy w/ileal loop conduit [**2115**], Gastric ulcer w/negative biopsy and negative h.pylori AAA repair [**2105**], Bronchiectasis, TIA w/left sided weakness, Bilateral internal carotid stenosis, Pulmonary AVM with coil embolization [**2105**] Hemoptysis Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 79205**] if you develop chest pain, shortness of breath, increased bloody sputum or any other symptoms that concern you. Followup Instructions: Call Dr.[**Doctor Last Name **] office [**Telephone/Fax (1) 10084**] for a follow up appointment. Follow up with your primary care doctor. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**] Completed by:[**2117-8-10**]