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Admission Date: [**2185-8-4**] Discharge Date: [**2185-8-17**] Date of Birth: [**2100-6-22**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: unresponsiveness, L sided weakness Major Surgical or Invasive Procedure: intubation/extubation History of Present Illness: Mr. [**Known lastname 112244**] is a 85-year-old right-handed man presenting with Intracerebral hemorrhage on a background of dementia, congestive heart failure, renal failure, prior pneumonia, prior "stroke" (not worked-up). He was asleep when his daughter arrived. [**Name2 (NI) **] refused to get up for breakfast at about 7:30 AM - this sometimes happens. He said goodbye to his other daughter. [**Name (NI) **] then got up around 10 or 10:30 AM, walking to the bathroom without his walker. At 11 AM he was back in bed and told his daughter to go away, he wanted to sleep - again normal for him. At about 11:30 his daughter tried to move him, noted that he wasn't moving his left side and was drooling. He was dysarthric, but able to speak and understand. 911 was called and they were taken to [**Hospital3 **], but there was no neurologist, per the patient's family. Head CT was performed showing a large hemorrhage. He was intubated and transferred to [**Hospital1 18**]. He just saw his Cardiologist and his blood pressure and otherwise stable - they were asked to come back in six months. Dementia had been diagnosed by PCP, [**Name10 (NameIs) **] an admission at [**Hospital3 **] for pneumonia also resulted in a daignosis of Alzheimer's disease. He also had an AMI while there (6/[**2184**]). He has otherwise been well, but is eating poorly - he doesn't get out of bed as much and seems less interested - but has eaten well for the last two weeks. Review of systems was negative except as above, per family. ROS with patient limited. Past Medical History: - Coronary artery disease - Dementia, provisionally Alzheimer's type - Pneumonia - 'TIA' - about five to six months ago, not worked up in full, but seems to have been TIA - fluent aphasia without other features, recovered over a few minutes. - Congestive heart disease, likely post-infarctive and in the setting of prerenal state and pneumonia, AMI - Hypertension - Hyperlipidemia - No prior surgery Social History: Smoking: Smoked in youth, per daughter. Alcohol: None. Drugs: No. Living Situation: Lives with daughter. Education and Language: English. Functional Baseline: Able to feed self, dress, and toilet indpendently. Dependent for other ADL's. Other: Retired mail handler. Family History: Mother had diabetes. Father unknown. Sibling with alcoholism. Physical Exam: Physical Exam on Admission: Vitals: T afebrile F; HR 52 BPM; BP 152/64 (had been SBP ~ 100) mmHg; O2Sat 100 % CMV 18 x 450, FiO2 0.5 General Appearance: Leaning to left, little spontaneous movement, but awake. HEENT: NC, ETT in place. Neck: Supple but reduced ROM. Lungs: Clear within limits of exam, vent sounds. Cardiac: Bradycardic regular. Normal S1/S2. Abdominal: Soft, NT, BS+. Extremities: No edema, cool (particularly right), delayed capillary refill and trophic changes in feet. Neurologic Examination: Mental status: Awake and attentive to events in room. Appropriate head shake or nod to simple questions. Only mild behavioral discomfort given ETT despite sedation being off. Tends to pay more attention to right. Cranial Nerves: I: Not tested. II: Pupils symmetric, round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation on right, not left. III, IV, VI: Extraocular movements conjugate and without nystagmus, difficult to get over to left. V, VII: Jaw midline, facial droop on left. VIII: Hearing intact to voice. IX, X: Not examinable. [**Doctor First Name 81**]: Not examinable. XII: Not examinable. Tone and Bulk: Tone is increased in legs, right arm flaccid. Power: Dense paresis of left arm, left leg moves to noxious stimulation of foot. Reflexes: B T Br Pa Ac R 2 1 2 0 0 L 3 2 2 1 0 Toes upgoing bilaterally. Sensation: Withdraws and increased arousal to painful stimulus to right, withdraws on right (foot, not hand). Coordination and Cerebellar Function: Not tested. Gait: Not tested. ***************** Physical Exam on Discharge: Expired Pertinent Results: [**2185-8-4**] 04:40PM TYPE-ART RATES-/16 TIDAL VOL-450 O2-100 PO2-412* PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1 AADO2-259 REQ O2-51 INTUBATED-INTUBATED [**2185-8-4**] 05:03PM GLUCOSE-147* LACTATE-2.0 NA+-136 K+-4.4 CL--102 TCO2-21 [**2185-8-4**] 05:04PM FIBRINOGE-263 [**2185-8-4**] 05:04PM PT-10.6 PTT-28.3 INR(PT)-1.0 [**2185-8-4**] 05:04PM PLT COUNT-205 [**2185-8-4**] 05:04PM WBC-8.8 RBC-4.04* HGB-12.8* HCT-38.3* MCV-95 MCH-31.7 MCHC-33.5 RDW-13.1 [**2185-8-4**] 05:04PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2185-8-4**] 05:04PM TSH-1.6 [**2185-8-4**] 05:04PM TRIGLYCER-149 HDL CHOL-42 CHOL/HDL-2.7 LDL(CALC)-41 [**2185-8-4**] 05:04PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-2.1 CHOLEST-113 [**2185-8-4**] 05:04PM CK-MB-2 cTropnT-<0.01 [**2185-8-4**] 05:04PM LIPASE-43 [**2185-8-4**] 05:04PM estGFR-Using this [**2185-8-4**] 05:04PM UREA N-19 CREAT-1.7* [**2185-8-4**] 05:15PM URINE HYALINE-1* [**2185-8-4**] 05:15PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2185-8-4**] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2185-8-4**] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2185-8-4**] 05:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG CT head [**8-4**]: IMPRESSION: 1. Large intraparenchymal hemorrhage involving mainly the right frontoparietal region with intraventricular extension, no significant change. Mass effect on the right lateral ventricle and unchanged midline shift to the left. 2. New increase in size of right temporal [**Doctor Last Name 534**] of the lateral ventricle likely due to trapping. 3. Stable subarachnoid blood in the right sylvian fissure and new subarachnoid blood now seen in the left temporal region. Brief Hospital Course: 85-year-old right-handed man with a hx of dementia, CHF, renal failure, prior stroke who was found unresponsive at home. CT head revealed large right lobar intraparenchymal hemorrhage with mass effect and intraventricular extension. He was admitted to the neuro ICU initially for close monitoring, then was later made CMO. Neuro: He was monitored closely with Q1hr neuro checks overnight. He was started on a nicardipine drip for BP control with a goal < 160. Aspirin and anticoagulants were held. Neurosurgery was consulted and declined acute surgical intervention. Per discussion with his daughters he was made DNR/DNI and was extubated on [**8-5**]. Palliative care was consulted and after further discussion he was made CMO. He was put on a morphine gtt and PRN ativan. He was transferred to the floor under inpatient hospice. Due to continued discomfort/agitation he was transitioned to a dilaudid drip on [**8-16**] and ativan was increased. He passed away peacefully at 12:40am on [**2185-8-17**]. Daughters were at the bedside and declined autopsy. Cardiovascular: He was maintained on telemetry monitoring. BP was monitored closely and controlled with nicardipine and metoprolol as above while in the ICU, but once made CMO his cardiac meds were withdrawn. PENDING LABS: None TRANSTIONAL CARE ISSUES: None, pt expired on [**2185-8-17**]. Medications on Admission: - Aricept 2.5 mg PO QD - Metoprolol succinate 50 mg PO QD - ASA 325 mg PO QD - Remeron 15 mg PO QHS - Lipitor 40 mg PO QHS - Trazodone 12.5 mg PO QHS - Vitamin D - Namenda 10 mg PO BID - Celexa 10 mg PO QD - Eye drops Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Right lobar intraparenchymal hemorrhage Discharge Condition: Expired Discharge Instructions: Mr. [**Known lastname **] was admitted to [**Hospital1 69**] on [**2185-8-4**] after he was found unresponsive at home. A CT scan of his head showed a large bleed in the right side of his brain. A breathing tube was placed and he was admitted to the neuro ICU. After discussion with his family the decision was made to remove the breathing tube the next day and not to pursue any further aggressive interventions. Palliative care was consulted and per his family's wishes he was made CMO on [**8-5**]. He was started on a morphine drip and transferred out of the ICU to inpatient hospice care. He passed away peacefully at 12:40am on [**2185-8-17**]. Followup Instructions: n/a [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Admission Date: [**2167-8-14**] Discharge Date: [**2167-8-15**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: 85 M s/p unwitnessed fall today - wife heard him fall, found him on his back on the living room floor - complained of a headache and nausea afterwards. No LOC, mild confusion and solmnent. Past Medical History: PMH: Hypertension MI last year s/p multiple falls, COPD, Anemia Pulmonary fibrosis polymyalgia rheumatica neck arthritis PSH: Cataract surgery TURP R colectomy Social History: SH: remote tob, no ETOH or drugs, retired salesman, lives in [**Location 583**] with wife Family History: FH: NC Physical Exam: PE: 97.9 90 161/96 16 95%3L NC Oriented to year, not month, oriented to state, mild confusion, somnolent Difficulty following commands and participated with physical exam Moves all extremities with good strength RRR CTAB soft NT.ND 2+ LE edema, swelling in hands Pertinent Results: Labs: Trop-T: 0.03 138 100 11 116 AGap=15 3.6 27 1.0 estGFR: 71 / >75 (click for details) CK: 81 MB: Notdone Ca: 9.0 Mg: 2.1 P: 2.6 5.8>33.9<242 Rads: CT Head: Acute right 16 mm SDH overlying cerebral convexity with shift to the left of 3 mm. Compression of the right lateral ventricle. Subdural blood also layers along the falx superiorly and along the tentorium bilaterally. Right parietal subgaleal hematoma. No fracture. CT C-spine: Slightly limited by motion. Mild anterior widening of the interspace at C2-3, C3-4, C4-[**5-11**] be chronic but acute ligamentous injury cannot be excluded. No fracture or subluxation. Mild septal thickening may reflect pulmonary edema. Brief Hospital Course: Patient was intubated for airway protection -repeat CT with shift - Dr. [**Last Name (STitle) 739**] thought if we were to proceed that this would need to be surgically evacuated and given pts comorbidities, worsening status, and being on aspirin and plavix he thought the prognosis was very grave. Upon discussion with his daughter and wife the decision was made that Mr. [**Known lastname 168**] would not have wanted to proceed and that he would be comfort measures only. He was extubated in ICU and keep him comfortable. He expired [**2167-8-15**]. Medications on Admission: [**Last Name (un) 1724**]: aspirin 325', B12, cymbalta 60', FeSO4 325', florinef 0.1 QOD, Lasix 20', Lipitor 80', Torprol 25', Plavix 75', Prednisone 5', Proscar 5', Protonix 40', senna, tylenol, tramadol', spriva, MiraLax Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: traumatic cerebral hemorrhage Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2167-10-13**]

Admission Date: [**2155-3-26**] Discharge Date: [**2155-6-10**] Date of Birth: [**2098-11-22**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Autologous BMT Major Surgical or Invasive Procedure: continuous renal replacement therapy hemodialysis intubation and mechanical ventilation tracheostomy paracentesis History of Present Illness: Mr. [**Known lastname **] is a 56-year-old male who was diagnosed with follicular lymphoma transitioning to a marginal zone lymphoma in 01/[**2154**]. He had a long preceding history of night sweats and dry cough, followed by the development of right leg swelling and a right inguinal mass. In [**2154-1-31**] he developed swelling in his right lower extremity and a mass in his inguinal area. CT scan of his abdomen and pelvis on [**2154-2-18**] revealed generalized lymphadenopathy beginning at the crural lymph nodes and extending inferiorly into the periaortic, mesenteric, celiac, pararenal, common iliac, and external iliac chains. In the right groin, there was a large lymph node mass approximately 6 x 5 x 6.6 cm. There was also a rounded low-density area just medial to the femoral artery which was felt to represent thrombosed femoral and external iliac veins. Overall, the findings were concerning for lymphoma. He was referred for a CT of his chest on [**2154-2-19**] which showed prominent adenopathy, principally in the left supraclavicular and left axillary regions, with the largest mass measuring 2.6 cm in his left axilla. Based on that, he was referred for excisional biopsy of the right inguinal adenopathy on [**2154-2-26**] which revealed follicular lymphoma with partial marginal zone differentiation, grade I-II by large cell quantitation. These cells were CD19 and CD20 positive and also co-expressed CD5 and CD10. They were also kappa light chain restricted. There was no expression of CD-23 or cyclin D1. Ki67 was 20-30%. His lymphoma was felt to represent a transitional state between follicular lymphoma and marginal zone B-cell lymphoma. He was then started on R-CVP. He tolerated therapy fairly well, but suffered from fatigue, hyperglycemia, flushing, and hypertension. His prednisone dose during treatment was eventually lowered from 200 mg daily to 100 mg daily. He received 2 days of neupogen after each cycle of chemotherapy. After three cycles of R-CVP, the vincristine was discontinued due to neuropathy. He underwent a PET scan on [**2154-5-1**] after the third cycle and this continued to show extensive FDG avid disease. However, his night sweats and leg swelling had improved. He continued on R-CVP for two additional cycles, but after the fifth cycle, he noticed the recurrence of right inguinal lymphadenopathy. He had also developed recurrent night sweats and cough. The lymphadenopathy grew quite quickly and became the size of a quarter over the span of 24 hours. He underwent a second PET scan on [**2154-6-12**] which showed little significant change, with hyperactive adenopathy at the left axilla and extensively below the diaphragm in the mesentery, para-aortic and pelvic regions. He underwent a second excisional biopsy on [**2154-7-2**] which again showed follicular lymphoma, grade I-II. The decision was made to hold on further R-CVP as his lymphoma was no longer responding to the current therapy. CYTOGENETICS CD19 and CD20 positive, also co-expressed CD5 and CD10, and kappa light chain restricted; no expression of CD-23 or cyclin D1; Ki67 was 20-30%. CHEMOTHERAPY HISTORY [**Date range (1) 83066**]: He received cyclophosphamide, vincristine, prednisolone plus rituximab (R-CVP) x 3 cycles; the vincristine was discontinued due to neuropathy. Night sweats and leg swelling improved. [**2154-5-1**]: PET Scan showing extensive FDG avid disease [**Date range (1) 83067**]: continued on R-CVP for two additional cycles, but after the fifth cycle, he noticed the recurrence of right inguinal lymphadenopathy. He had also developed recurrent night sweats and cough. [**2154-6-12**]: repeat PET - little interval change [**2154-7-2**]: repeat lesion biopsy - similar findings [**2154-8-5**]: transferred care to [**Hospital1 **], presented with bilateral inguinal lymphadenopathy; received 4 cyclyes R-Bendamustine by local oncologist at time of transfer; planned for two more cycles of R-bendamustine [**2155-1-22**]: Mobilization HiDAC, final cumulative CD-34 yield of 5.19 x 10e CD-34 cells/kg over three days, discharged on Cipro, Neupogen and Compazine. WBC at discharge 20.9. Two weeks later WBC 0.7 and one week later 0.5 w/ANC 0, asymptomatic. Started on Moxifloxacin and neupogen. Stem cell harvesting [**Date range (1) 83068**]. [**2155-2-25**]: W1 Rituxan/Zevalin: WBC 7.3, Hct 34.9, Plt 244. [**2155-3-4**]: W1 Rituxan/Zevalin: WBC 5.4, ANC 4560, Hct 32.5, Plt 292. Today he presents for admission for his BEAM autologous BMT. No current complaints. Denies headache, nausea, vomiting, diarrhea, abdominal pain, weakness, fevers, chills, recent night sweats, blurry vision, shortness of breath. Reports only mild ongoing cough significantly improved from prior and occasional fatigue when his counts get low. Past Medical History: Diagnosed with follicular lymphoma transitioning to a marginal zone lymphoma in [**1-/2154**] (These cells were CD19 and CD20 positive and also co-expressed CD5 and CD10. They were also kappa light chain restricted. There was no expression of CD-23 or cyclin D1. Ki67 was 20-30%.) Right thigh lymphedema (significantly improved, per patient) RLE DVT from compression (was on coumadin until [**2154-11-25**]) Mild diverticulitis s/p vasectomy, tonsillectomy Social History: Works in a management position at a metal fabrication plant overseeing production and quality control. He is married and has four children, ages [**8-17**]. He and his family live in Hooksett, [**Location (un) 3844**]. He denies any current tobacco use. He previously smoked but quit 15 years ago after a 20-pack-year history. He generally drinks several martinis a day but has decreased his drinking while on treatment. Family History: father - died at 80, lung cancer, Charcot-[**Doctor Last Name **]-Tooth disease, pulmonary embolism mother - alive at 80, diabetes and asthma three brothers - all in good health no family history of leukemia or lymphoma has 2 children from previous marriage and 2 children from his current marriage Physical Exam: ON ADMISSION: VS: 96.6 132/96 109 18 98/ra 195lbs 71" GENERAL: NAD HEENT: Sclerae are anicteric. PERRLA. EOMI. O/P clear. Neck: Supple. Lymph: No cervical, supraclavicular, or axillary lymphadenopathy; some left supraclavicular fullness; possible right inguinal lymphadenopathy although possibly just scar tissue from biopsy CARDIAC: RRR Normal S1/S2 No R/G/M LUNGS: CTAB ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds; no HSM EXTREMITIES: no edema . ON DISCHARGE: [**2155-6-10**] Tmax: 36.5 ??????C (97.7 ??????F) Tcurrent: 36.3 ??????C (97.3 ??????F) HR: 117 (109 - 117) bpm BP: 79/57(62) {64/40(48) - 93/59(68)} mmHg RR: 30 (21 - 30) insp/min SpO2: 95% Heart rhythm: ST (Sinus Tachycardia) Wgt (current): 80.3 kg (admission): 98.2 kg Height: 72 Inch 24 HR: SMN: Total In: 1,807 mL 722 mL PO: TF: 1,017 mL 602 mL IVF: Blood products: Total out: 0 mL 0 mL Urine: 0 mL 0 mL NG: Stool: Drains: Balance: 1,807 mL 722 mL Respiratory support: O2 Delivery Device: Trach mask 50% SpO2: 95% Physical Examination: General Appearance: Well nourished, No acute distress, Thin, Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Tracheostomy in place, NG tube in place Lymphatic: No Cervical or Supraclavicular adenopathy Cardiovascular: PMI Normal, S1: Normal, S2: Normal, No murmurs, rubs, gallops. Chest: Expansion: Symmetric Excursion, No Dullness, CTAB. Abdominal: Soft, Non-tender, Bowel sounds present, Distended, + fluid wave. Non-tender. Extremities: No edema, Cyanosis, Clubbing, 2+ Peripheral pulses. Musculoskeletal: Muscle wasting, Unable to stand, Skin: Warm, No Rash, No Jaundice Neurologic: Attentive, Follows commands, Responds to verbal stimuli, Oriented x3, Moving all extremeties equally, Strength [**4-2**] in UE & LE bilat, Dizzy if not in supine position, Moving all extremeties equally, sensation intact. Pertinent Results: LABS ON ADMISSION: [**2155-3-26**] 10:15AM BLOOD WBC-3.9* RBC-4.62 Hgb-13.8* Hct-41.5# MCV-90 MCH-29.9 MCHC-33.3 RDW-15.7* Plt Ct-144*# [**2155-3-26**] 10:15AM BLOOD Neuts-88.5* Lymphs-4.0* Monos-6.4 Eos-0.7 Baso-0.3 [**2155-3-26**] 10:15AM BLOOD PT-11.2 PTT-21.2* INR(PT)-0.9 [**2155-3-28**] 12:00AM BLOOD Gran Ct-4380 [**2155-3-26**] 10:15AM BLOOD UreaN-14 Creat-0.8 Na-141 K-4.6 Cl-102 HCO3-32 AnGap-12 [**2155-3-26**] 10:15AM BLOOD ALT-35 AST-33 LD(LDH)-157 AlkPhos-102 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2155-3-26**] 10:15AM BLOOD TotProt-7.0 Albumin-4.5 Globuln-2.5 Calcium-10.0 Phos-3.8 Mg-2.0 UricAcd-8.3* LAB TRENDS DURING ADMISSION: WBC: MAX 47.8 on [**2155-5-13**] --> 35.3 on [**2155-5-20**] --> 25.9 on [**2155-5-28**] -->18.9 on [**2155-6-3**] --> 15.5 on [**2155-6-10**] HCT: stable at 28-33 for past 2 weeks PLT: stable at 40-70 for past 2 weeks. COAGS: have been within normal limits. CHEM7: Patient on HD Tues, Thurs, Sat LFTS: AST: 1341 & ALT: 2472* MAX on [**2155-4-12**] trended down to AST: 59* ALT: 40 by [**2155-4-23**] and AST & ALT have been normal since [**2155-5-28**]. LDH: 1466 MAX on [**2155-4-12**] trended down to normal by [**2155-5-17**] ALK PHOS: 170 on [**2155-4-12**] trended up to MAX on 248 on [**2155-4-15**] and then down to 172 on [**2155-6-10**]. TBILI: 10.0 MAX on [**2155-4-12**] trended down to 2.9 on [**2155-6-10**] LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [**2155-5-8**] 08:46AM 173 196* 11 15.7 123 CORTISOL Stimulation Test: [**2155-5-25**] 03:30PM 29.4*1 [**2155-5-25**] 02:37PM 17.91 HEPATITIS HBsAg HBsAb HBcAb HAV Ab IgM HAV [**2155-4-10**] 03:46AM NEGATIVE POSITIVE NEGATIVE POSITIVE NEGATIVE HEPARIN DEPENDENT ANTIBODIES: Negative [**2155-5-27**] 12:00PM ASPERGILLUS ANTIGEN: 0.1 <0.5 considered to be negative [**2155-5-20**] B-GLUCAN: 65 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL LABS ON DISCHARGE: [**2155-6-10**] 04:21AM BLOOD WBC-15.5* RBC-2.61* Hgb-10.0* Hct-31.1* MCV-119* MCH-38.1* MCHC-32.0 RDW-19.6* Plt Ct-40* [**2155-6-10**] 04:21AM BLOOD PT-12.8 PTT-25.9 INR(PT)-1.1 [**2155-6-10**] 04:21AM BLOOD Plt Ct-40* [**2155-6-10**] 04:21AM BLOOD Glucose-140* UreaN-54* Creat-5.0* Na-139 K-5.5* Cl-103 HCO3-23 AnGap-19 ****PRIOR TO HD TODAY***** [**2155-6-10**] 04:21AM BLOOD ALT-27 AST-34 AlkPhos-172* TotBili-2.9* IMAGING: RUQ ULTRASOUND [**2155-4-8**]. IMPRESSION: 1. Apparent reversed flow in the main portal vein with normal flow direction in the left and right portal veins. These findings are discrepant and do not appear to be artifactual in nature. Given that the etiology of these findings is unclear, whether there is true portal vein reversal or possibly more proximal thrombus, we would recommend focused MRI of the abdomen including 2D time-of-flight sequences (with saturation bands to determine directionality of flow) through the portal vein to clarify this issue. 2. Cholelithiasis but no other evidence of acute cholecystitis. 3. Small amount of ascites. MRI Abdomen. [**2155-4-9**]. IMPRESSION: 1. Reversal of flow within the main portal vein, both on breath-hold imaging and free breathing. 2. Reversal of flow within the right anterior portal vein on breath-hold imaging. 3. Suggestion of reversed flow within the right posterior portal vein during breath-hold, but antegrade flow during free breathing. This may reverse depending on phasicity of respiration. 4. Directionality of flow within the left portal vein is not clearly demonstrated on this examination. 5. Interval increase in ascites since yesterday's examination. 6. No evidence of focal hepatic lesion or hepatic or portal vein thrombus. 7. Suggestion of siderosis within the spleen. Possibility of iron deposition within the liver cannot be excluded without dual-echo gradient-echo images (omitted in this abbreviated examination due to patient intolerance of examination). 8. Cholelithiasis. No biliary abnormalities noted. MR HEAD W/O CONTRAST Study Date of [**2155-5-2**] 12:31 PM IMPRESSION: 1. Hyperintense subarachnoid material, involving the sulci of both cerebral hemispheres, most likely representing subarachnoid hemorrhage, less likely proteinaceous material as seen in meningitis. Oxygen therapy can also have this appearance. 2. No evidence of masses, mass effect or infarction. ECHO: [**2155-5-23**] at 3:47:46 PM Conclusions: The left atrium and right atrium are normal in cavity 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 (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2155-4-21**], the findings are similar. CT TORSO: [**2155-5-23**] 1:53 PM CHEST CT: Bilateral small pleural effusions, on the left increased as compared to the prior study and the right slightly increased as compared to the prior study. Linear atelectasis in the right lower lobe and left lower lobe accompanied by small patchy consolidations in the left lower lobe. This is new as compared to the previous study. Small amount of pericardial effusion is noted (series 2, image 34). Central line catheter is noted with its tip in the right atrium. Tracheostomy. Nasogastric tube with its tip in the stomach. ABDOMINAL CT: Small-to-moderate amount of ascites is demonstrated. Limited evaluation of the liver due to lack of i.v. contrast and artifacts. There is no evidence of intrahepatic or extrahepatic bile duct dilatation. The pancreas is within normal limits. Gallbladder is nondistended. Adrenals are unremarkable bilaterally. Spleen is of normal size and attenuation on this non-contrast scan. Visualized small bowel demonstrate diffuse mucosal thickening without evidence of dilatation. The findings may caused by ascites or GVHD. Retroperitoneal and mesenteric lymphadenopathy, small but numerous, measuring up to 1 cm in mesentery and 1.4 cm in the retroperitoneum. PELVIC CT: Moderate amount of fluid is seen in the pelvis. Urinary bladder is not distended. Rectal tube is seen in the rectum. OSSEOUS STRUCTURES: Degenerative changes in the lumbar and sacral vertebra. IMPRESSION: 1. Bilateral small pleural effusions, slightly larger as compared to the prior study. 2. Linear atelectasis in the right lower lobe and left lower lobe and left lower lobe patchy consolidation which is new as compared to the prior study. 3. Moderate amount of ascites. 4. Limited evaluation of the liver due to artifacts. CXR: [**2155-6-6**] FINDINGS: Indwelling support and monitoring devices are similar in position, and cardiomediastinal contours are unchanged. There is a suggestion of increasing layering effusions on this semi-upright projection. Persistent left retrocardiac opacity is probably due to atelectasis. Patchy opacities in right mid and right lower lung could be due to either atelectasis or early sites of pneumonia, and followup radiographs may be helpful in this regard. Brief Hospital Course: This is a 56 year old male with PMH of follicular lymphoma transitioning to a marginal zone lymphoma s/p R-CVP admitted for BEAM auto-SCT (C1D1 ([**2155-3-26**]) and as per BMT protocol, initiated carmustine day -7, followed by etoposide/cytarabine on days -6 to -3, then melphalan on day -2 ([**2155-3-31**]). He then underwent Autologus stem cell transplant on [**2155-4-2**]. Post-transplant course was complicated by mucositis, diarrhea, febrile neutropenia, and transient hyperuricemia that responded to 1 dose of allopurinol. On [**2155-4-11**], the patient was transferred to the ICU for respiratory distress, altered mental status, renal failure, and transaminitis secondary to [**Last Name (un) **]-occlusive disease. 1. Respiratory distress - The patient was tachypneic to the 40s on admission to the ICU and had an increasing oxygen requirement, thought to represent attempted compensation for metabolic acidosis and low lung volumes with atelectasis. The patient failed a trial of bipap and was intubated and placed on A/C mechanical ventilation. He had no evidence of pneumonia but was noted to be >7L fluid positive on admission, with increasing ascites secondary to his hepatic complications. Serial CXRs over course of his ICU stay demonstrated reduced lung volumes with small amounts of atelectasis but no new consolidation, effusion, or intravascular congestion. Patient remained intubated in the [**Hospital Unit Name 153**] for a) impaired mental status and b) restrictive physiology [**3-4**] increased intra-abdominal pressure. The patient remained on the ventilator for approximately three weeks; his respiratory status remained relatively stable but his mental status precluded extubation. He did experience an episode of leukocytosis, detailed below, and was treated for a pseudomonas ventilator associated pneumonia with improvement in his leukocytosis. The patient eventually received a tracheostomy and was subsequently weaned down to trach collar, which coincided with an improvement in his mental status. 2. Hypotension - The etiology was initially thought to be a combination of a) intravascular volume depletion [**3-4**] decreased effective circulating volume and splanchnic vasodilation from liver failure, and b) sedation. Sepsis thought to be a contributing factor as well, but he was maintained on broad-spectrum antimicrobial coverage, with no infectious source identified for the majority of his hospitalization. CT imaging was unremarkable for an infectious source. The patient was initiated on levophed [**4-12**] and had a prolonged ongoing pressor requirement without an obvious cause for hypotension. Although cortisol levels were normal, suggesting against adrenal insufficiency, the patient was trialed on a three day course of steroids, which temporarily improved his pressures and removed his pressor requirement. Following the conclusion of the steroid trial, the patient again required vasopressor support to maintain his blood pressure. A cortisol stimulation test was performed to better assess for impaired adrenal response, did not reveal any significant abnormal findings. Ultimately, vasopressin was started and levophed was weaned. After his CVVH was stopped, the patient had an episode of symptomatic hypotension, for which vasopressin was briefly restarted. For the rest of his ICU course, the patient was maintained off of pressors and perfusion was monitored by assessing mental status. He was initiated on HD, and tolerated this well without ultrafiltration. His hypotension may be related to his liver disease in addition to severe deconditioning. He is persistently orthostatic which has somewhat improved with restarting midodrine. He mentates well with a blood pressure of 60s systolic. Please continue to encourage thigh high compression stockings to increase peripheral resistance. Please elevate head of bed as patient tolerates and continue passive motion in bed. Autonomics was consulted prior to discharge and feels like hypotension is not likely related to dysautonomia given his hypotension even while supine. Autonomics recommended continuation of midodrine and a trial of florinef to be started at rehabilitation. Florinef will be started at low dose (0.1 mg daily) and can be uptitrated based on patient response to a maximum of 0.4 mg daily. It is felt that the hypotension is likely related to deconditioning and aggressive PT should be pursued. 3. Leukocytosis - Elevated WBC count beginning [**4-13**] with persistent hypotension. Filgrastim discontinued [**4-12**]; therefore, this could not account for the persistent leukocytosis. Patient was at high risk for nosocomial infection (critically ill, ascites, multiple tubes/lines) with difficult-to-interpret fever curve on CVVH. He was empirically started on broad spectrum antibiotics with a mild improvement in his leukocytosis but with no obvious source on cultures. Multiple paracenteses were negative for SBP. Much later in the [**Hospital 228**] hospital course, a re-elevation in his white blood cell count corresponded with a new positive sputum culture for Pseudomonas. The patient was treated with seven days of ceftazidime per infectious disease recommendations, after which his leukocytosis improved but still remained dramatically elevated. A large volume paracentesis was performed with fluid sent for cytology and flow cytometry, which was not revealing. Ultimately, only his CVVH catheter tip grew out the same strain of pseudomonas on [**6-4**] that was in his sputum on [**5-12**]. It is felt that this was a colonizer only as surveillance blood cultures were negative. No other infectious sources were identified. His antibiotics were ultimately all discontinued and he did well. He should no longer be on precautions as he has no active infections. His leukocytosis continues to improve, but does remain elevated. A component of this elevation may be due to auto splenectomy that appears to have occurred during this hospitalization. 4. Transaminitis/Hepatic Failure - Right upper quadrant ultrasound and abdominal MRI demonstrated reversal of flow through portal vein, suggestive of cirrhosis. On admission to the intensive care unit, he was noted to have new significant ascites. Rising INR and worsening mental status were suggestive of progression to hepatic failure. Liver biopsy confirmed a diagnosis of [**Last Name (un) **]-occlusive disease. Infectious workup of hepatitis was negative. Per Hepatology, patient would not be a candidate for liver transplant. The patient was then started on a defibrotide treatment protocol on [**2155-4-9**] with close monitoring of coags, plts, hct, fibrinogen due to concern of bleeding (goal INR < 1.5, plts > 30, Hct > 30, Fibrinogen > 150). LFTs peaked [**Date range (1) 14806**] with TBili 10, then trended down gradually. After 25 days of treatment for defibrotide, a head MRI revealed a subarachnoid hemorrhage, which necessitated discontinuation of the treatment. The patient subsequently continued to show gradual, mild improvement in functional status, but continued to have large ascites on exam requiring periodic taps. Currently he is requiring paracentesis every 10-14 days and his ascites should continue to be monitored and tapped PRN. Through his ICU course, his LFTs gradually improved; however, his bilirubin did remain elevated at 2.9 on discharge. He should have liver clinic follow-up with Dr. [**Last Name (STitle) 497**] within one month after discharge. 5. Depression: The patient appears to be extremely frustrated and depressed about his current state. He was started on low dose amphetamine salts at 5mg [**Hospital1 **] to increase his energy and blood pressure. His cardiac status should be monitored closely as well as his mood on this new medication. It can also be titrated up slowly in an attempt to increase his energy. 6. Thrombocytopenia: His platelets have fallen dramatically during his hospitalization. They have remained stable around 50. There was initial concern for HIT, but antibody returned negative on [**5-28**]. Platelets should be transfused only if the patient is actively bleeding. Caution should be used with blood thinners due to his low platelet level. 7. Ileus - Attributed to critical illness with ascites and opioid -based sedation. Abdominal x-ray and CT scan were negative for obstruction. The patient was started on reglan and an aggressive bowel regimen. Following withdrawal of sedation as patient's respiratory status improved, his ileus improved as well. Lactulose was continued less frequently as prophylaxis against hepatic encephalopathy and was eventually discontinued. The reglan was stopped. He developed loose stools/ diarrhea that was treated as below. 8. Diarrhea - Patient has had continued loose stools ever since his ileus resolved. His stool frequency has improved after stopping lactulose but have continued to remain loose. C diff. toxin has been checked multiple times and has remained negative. It is likely that the diarrhea is related to tube feeds and banana flakes have been added recently with subsequent improvement in diarrhea. 9. Altered mental status - Attributed to hepatic encephalopathy in addition to sedating meds for treatment of his abdominal pain. Standing lactulose was started for therapy of hepatic encephalopathy and was also given broad spectrum antibiotics for treatment of possible infections. Patient had a protracted hospital course with minimal improvement in mental status but began to show dramatic improvement in mid [**Month (only) 547**], approximately one month after initiation of defibrotide. His mental status continued to improve throughout his ICU course and he is now able to interact appropriately. His antibiotics and lactulose were ultimately discontinued. 10. Renal failure - The patient was found to have new renal failure that began on [**2155-4-10**]. Per renal, the etiology was most consistent with ischemic ATN. His initial hypotensive insult was likely secondary to hepatorenal syndrome. The patient was started on CVVH on [**2155-4-12**] for worsening metabolic acidosis. He continued to be severely oliguric throughout his admission with no restoration in renal function. The patient's severe volume overload was corrected gradually via CVVH while he continued to have an ongoing pressor requirement. Midodrine was started in an effort to improve the patient's blood pressures so that he could be transitioned to HD. He was eventually transitioned to HD without ultrafiltration, and has tolerated it well. 11. EKG Changes: The patient had subtle ST depressions at the beginning of [**Month (only) 116**] in the setting of decreased mentation and hypotension. He was ruled out for an MI and these depressions have since resolved. It was likely related to demand in setting of hypotension. 12. Neutropenic fevers - On admission, patient was kept on broad spectrum antibiotics for neutropenic fevers (vancomycin/cefepime/ganciclovir/micafungin). Infectious disease was consulted. Patient was culture negative and no source of infection was identified. Antibiotics were stopped [**4-12**] following recovery of his neutrophil counts. He was treated later in his hospital course for a pseudomonas pneumonia (see above). 13. Hyperglycemia: Patient with blood sugars persistently between 200-300. Regular insulin was added to the TPN, and the patient was placed on a Regular Insulin SS. This may represent diabetes. He will need ongoing monitoring and upon discharge from rehabilitation center follow-up with his primary care provider. 14. Follicular Lymphoma: Patient is status post BEAM Auto SCT on [**2155-4-2**]. Patient engrafted. Received IV solumedrol x1 for anti-inflammatory effect. Received filgrastim until ANC>1000 (discontinued [**2155-4-12**]). He was continued on atovaquone prophylaxis for PCP but there was concern that it was not being absorbed as it appeared to be present in his diarrhea. He was given one dose of inhaled pentamidine on [**2155-6-9**] and will be continued on atovaquone. If his diarrhea continues to improve, he can remain on atovaquone and will likely not need another dose of inhaled pentamidine one month from [**2155-6-9**]. He also remains on Acyclovir prophylaxis. 15. Deep Vein Thombosis Prophylaxis: Patient not started on heparin due to low platelets. Patient repeatedly offered pneumoboots, but usually declined to wear the pneumoboots. Encourage aggressive physical therapy. Medications on Admission: Multivitamin No other current medications Discharge Medications: 1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 2. Midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): give every day, on dialysis days give daily dose after dialysis. 4. 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. 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 7. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 8. Insulin Regular Human 100 unit/mL Solution Sig: per scale Injection ASDIR (AS DIRECTED). 9. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO DAILY (Daily). 10. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): uptitrate as tolerated. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: - Follicular Lymphoma - Renal Failure, Acute tubular necrosis, now requiring hemodialysis. - Respiratory Failure - Hepatic Failure Secondary to Venous Occlusive Disease - Hypotension - Multi-Drug Resistant Pseudomonal Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Blood pressure: SBPs 50-80s with good mentation. If concerned about blood pressure, monitor for change in mental status. Patient tolerating very low blood pressures attributed to deconditioning. Discharge Instructions: You were admitted for bone marrow transplant. You had a prolonged hospital course that was complicated by liver failure, infection, persistent low blood pressure, kidney failure, and respiratory failure that ultimately required trach tube placement. Your clinical status ultimately improved. You are now being discharged to a rehab facility for further care. You were started on many different medications during your hospital course. You should follow the medication list provided at the time of discharge. It was a pleasure taking part in your medical care. Followup Instructions: You will need to see the following providers within the timeframe below. We are working to schedule appointments for you, please call the following offices in [**2-1**] days time to get the appointment information: PROVIDER: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD SPECIALTY: HEMATOLOGY/ONCOLOGY TELEPHONE: ([**Telephone/Fax (1) 3936**] TIMEFRAME: within 2-4 weeks PROVIDER: [**Name10 (NameIs) **] [**Name8 (MD) **], MD SPECIALTY: LIVER TELEPHONE: ([**Telephone/Fax (1) 1582**] TIMEFRAME: within 2-4 weeks. You will need to see you primary care doctor within 2 weeks after discharge from the rehab facilty. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Admission Date: [**2182-8-1**] [**Month/Day/Year **] Date: [**2182-8-23**] Date of Birth: [**2103-1-20**] Sex: M Service: MEDICINE Allergies: Penicillins / ciprofloxacin / Cephalosporins Attending:[**First Name3 (LF) 3063**] Chief Complaint: Weakness/Fluid Overload Major Surgical or Invasive Procedure: drainage of pericardial effusion drainage of plerual effusion pleacement and removal of temporary dialysis catheter placement of tunneled dialysis catheter History of Present Illness: 79M with PHX h/o A Fib on Coumadin, moderate to severe AI s/p AVR [**2182-6-27**], reccently readmitted [**7-15**] for BRBPR likely [**1-17**] anticoagulation and diverticulosis and was discharged [**7-23**] to [**Hospital1 100**] Home, now readmitted for worsening weakness and fluid overload. Patient states that since he was sent to [**Hospital 100**] Rehab, he has gotten worse, not better. He can participate in the physical therapy, but he is not able to walk with his walker as well as before. His breathing is not much worse than baseline- he mostly feels weak. He was seen by Dr [**Last Name (STitle) 911**] in office [**7-31**] who found the patient to be in fluid overload and he is admitted for monitoring of his fluid status in house with likely IV diuresis. While in house previous admission, Aspirin was stoppd and coumadin continued. Patient was also complaining of new stool incontinence, was found to be c. diff positive per PCR and was started on 2 weeks of metronidazole to be completed on [**2182-8-2**]. On the same admission patient had TTE's on [**7-19**] and [**7-22**] which demonstarted moderate pericardial effusion without signs of tamponade (likely [**1-17**] recent CT surgery). Admission was c/b initially difficult to control Afib/RVR which was finally controled with diltiazem CD 120 mg po daily and metoprolol tartrate 75 mg po daily; also had fluid over load (known CHF with LVEF 45%) which was treated with IV diureis. He was discharged to [**Hospital 100**] Rehab on [**7-23**]. . On arrival to the floor, patient is comfortable with no complaints. REVIEW OF SYSTEMS On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, or hemoptysis. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, syncope or presyncope. The patient does have occasional PND, [**1-18**] pillow orthopnea, occasional palpitations from his A Fib, and sometimes trouble breathing on exertion. Past Medical History: - Moderate-to-severe aortic insufficiency with dilated LV (LVEF 50-55%), s/p bioprosthetic AVR on [**2182-6-27**] - Recent cardiac catheterization showing no obstructive coronary artery disease, however, found to have elevated filling pressures, requiring diuresis - Atrial fibrillation, currently on Coumadin for thromboembolic prophylaxis - Hypertension - Kidney transplant in [**2155**] due to PCKD, the baseline creatinine approximately 1.6 - Hyperlipidemia - Peripheral neuropathy - Diverticulitis - Pseudogout - Osteoporosis Social History: Patient previously worked as an engineer for channel 5. He currently lives in a house himself. His wife passed away 9 years ago. Prior history of 3 ppd X 20 years, quitting 34 years ago. Occasional ETOH (few beers per week). No illicits. His daughters ([**Doctor First Name **] (daughter) - ([**Telephone/Fax (1) 101330**], [**Female First Name (un) **] (daughter) [**0-0-**]) are very involved. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION VS- T=98.1 BP=103/69 HR=101 RR=18 O2 sat=97RA Pulsus-10mmHg GENERAL- in mild resp distress. Oriented x3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- Supple with JVP of 16 cm. CARDIAC- PMI located in 5th intercostal space, midclavicular line. irregularly irregular, normal S1, S2. No murmurs appreciated. No thrills, lifts. No S3 or S4. LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp were somewhat labored, [**Month (only) **] breath sounds b/l bases ABDOMEN- Soft, NTND. No HSM or tenderness, mild ascites percussed, Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES- warm, pulses not well palpated, 3+ pitting edema distal LE up to lower knee b/l SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. Back- 2+ pitting sacral edema [**Month (only) 894**] VITAL SIGNS: 98.0. 85. 140/76. 24. 98% RA GENERAL: A&Ox3. NAD. HEENT: Sclera anicteric. PERRL, EOMI, MMM. JVP not elevated. CARDIAC: irregularly irregular, nl S1, S2. III/VI systolic ejection murmur. LUNGS: Decreased breath sounds bilaterally at bases. ABDOMEN: +BS, soft, NTND. No HSM. EXTREMITIES: 1+ lower ext edema bilaterally to ankles. SKIN: large ecchymosis on left leg and small ecchmyosis around tunneled cath site. ACCESS: tunneled catheter in place. Pertinent Results: ON ADMISSION [**2182-8-1**] 07:30PM GLUCOSE-150* UREA N-57* CREAT-1.8* SODIUM-141 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 [**2182-8-1**] 07:30PM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.7 [**2182-8-1**] 07:30PM WBC-5.5 RBC-3.65* HGB-11.3* HCT-36.7* MCV-101* MCH-31.0 MCHC-30.8* RDW-19.4* [**2182-8-1**] 07:30PM PLT COUNT-162 [**2182-8-1**] 07:30PM PT-40.4* INR(PT)-4.0* OTHER LABS: [**2182-8-23**] 06:07AM BLOOD WBC-6.6 RBC-2.60* Hgb-7.9* Hct-25.7* MCV-99* MCH-30.5 MCHC-30.9* RDW-19.7* Plt Ct-169 [**2182-8-23**] 06:07AM BLOOD PT-33.8* PTT-36.0 INR(PT)-3.3* [**2182-8-22**] 05:51AM BLOOD PT-27.4* PTT-34.1 INR(PT)-2.6* [**2182-8-21**] 07:10AM BLOOD PT-23.5* PTT-32.9 INR(PT)-2.2* [**2182-8-20**] 06:00AM BLOOD PT-22.1* INR(PT)-2.1* [**2182-8-18**] 05:58AM BLOOD PT-17.3* PTT-31.2 INR(PT)-1.6* [**2182-8-17**] 06:39AM BLOOD PT-15.5* PTT-31.8 INR(PT)-1.5* [**2182-8-15**] 02:51AM BLOOD PT-16.5* PTT-99.3* INR(PT)-1.6* [**2182-8-14**] 05:19AM BLOOD PT-17.5* PTT-32.2 INR(PT)-1.6* [**2182-8-13**] 05:05AM BLOOD PT-17.3* PTT-34.4 INR(PT)-1.6* [**2182-8-23**] 06:07AM BLOOD Glucose-76 UreaN-33* Creat-3.2* Na-135 K-4.8 Cl-97 HCO3-26 AnGap-17 [**2182-8-13**] 05:05AM BLOOD ALT-13 AST-23 AlkPhos-283* TotBili-0.8 [**2182-8-23**] 06:07AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1 [**2182-8-18**] 05:58AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2 Iron-37* [**2182-8-18**] 05:58AM BLOOD calTIBC-131* Ferritn-748* TRF-101* [**2182-8-11**] 06:07AM BLOOD Hapto-173 [**2182-8-1**] 07:30PM BLOOD TSH-2.3 [**2182-8-13**] 03:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE PERICARDIAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS. PLEURAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS. Paucicellular specimen with scattered mesothelial cells, histiocytes, and predominantly blood. [**2182-8-2**] 5:15 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [**2182-8-2**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2182-8-5**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2182-8-8**]): NO GROWTH. FUNGAL CULTURE (Final [**2182-8-16**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2182-8-3**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2182-8-4**] 10:55 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT [**2182-8-10**]** Blood Culture, Routine (Final [**2182-8-10**]): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES STRAIN 2. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES STRAIN 3. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | KLEBSIELLA PNEUMONIAE | | | AMPICILLIN/SULBACTAM-- 4 S 8 S 4 S CEFAZOLIN------------- <=4 S <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S S S TOBRAMYCIN------------ <=1 S <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S Anaerobic Bottle Gram Stain (Final [**2182-8-5**]): Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 101334**] ON [**2182-8-5**] AT 0530. GRAM NEGATIVE ROD(S). [**2182-8-4**] 10:54 am URINE Source: Catheter. **FINAL REPORT [**2182-8-6**]** URINE CULTURE (Final [**2182-8-6**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 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-------- 128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final [**2182-8-4**]): Test performed only on suprapubic and kidney aspirates received in a syringe. TEST CANCELLED, PATIENT CREDITED. [**2182-8-7**] 6:09 pm PLEURAL FLUID PLEURAL FLUID. **FINAL REPORT [**2182-8-13**]** GRAM STAIN (Final [**2182-8-7**]): 2+ (1-5 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 [**2182-8-10**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2182-8-13**]): NO GROWTH. [**2182-8-6**] 11:38 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2182-8-12**]** Blood Culture, Routine (Final [**2182-8-12**]): NO GROWTH. [**2182-8-6**] 2:52 am CATHETER TIP-IV Source: left picc line. **FINAL REPORT [**2182-8-8**]** WOUND CULTURE (Final [**2182-8-8**]): No significant growth. [**2182-8-5**] 10:10 am BLOOD CULTURE Source: Line-white port PICC. **FINAL REPORT [**2182-8-11**]** Blood Culture, Routine (Final [**2182-8-11**]): NO GROWTH. Echo [**2182-8-2**] There is moderate global left ventricular hypokinesis (LVEF = 35%). Right ventricular chamber size is normal. with moderate global free wall hypokinesis. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis cannot be adequately assessed. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is a large pericardial effusion. The effusion appears circumferential. No right ventricular diastolic collapse is seen. IMPRESSION: Large circumferential pericardial effusion. No echocardiographic signs of tamponade. Right ventricular hypertrophy and enlargement raise suspicion of underlying pulmonary hypertension (not confirmed on this study), which may limit the sensitivity of echocardiographic evaluation for tamponade. CXR [**2182-8-1**]: Large right pleural effusion has markedly increased. Moderate cardiomegaly is partially obscured by the right pleural effusion. There are atelectasis in the lower lobes bilaterally, right greater than left, and in the right upper lobes. There is probably a small left pleural effusion. There is no pulmonary edema. Sternal wires are aligned. IMPRESSION: Markedly increase in size in large right pleural effusion. CXR [**2182-8-14**]: Small-to-moderate bilateral pleural effusions have decreased substantially. Although the cardiac silhouette remains enlarged, there is less distention of mediastinal veins and previous mild pulmonary edema has largely cleared. Left lower lobe remains collapsed. A supraclavicular central venous dual-channel catheter has replaced a small-bore catheter, ending in the mid-to-low SVC. TTE [**2182-8-5**]: Left ventricular wall thicknesses and cavity size are normal. There is a very small (<0.5cm) pericardial effusion along the basal inferolateral wall, basal lateral, and apical lateral wall. There is no evidence for hemodynamic compromise. IMPRESSION: Very small pericardial effusion without evidence of hemodynamnic compromise RENAL ULTRASOUND [**2182-8-9**]: 1. Persistent though improved high resistance waveforms throughout the arterial system including intrarenal and main renal arteries. 2. Irregularly irregular waveforms suggests arrhythmia. 3. Stable large rounded calcifications are of unclear etiology. Predominantly pyramidal location is suggestive of medullary nephrocalcinosis; however, the scattered cortical calcifications are not consistive with this diagnosis. No hydronephrosis. RIGHT AND LEFT CARDIAC CATH [**2182-8-12**]: 1. Resting hemodynamics revealed markedly elevated left and right-sided filling pressure consistent with severe diastolic heart failure. There was also moderate pulmonary arterial hypertension. 2. The cardiac output and cardiac index were preserved. FINAL DIAGNOSIS: 1. Severely elevated filling pressures consistent with diastolic heart failure. 2. Preserved cardiac output and cardiac index. Brief Hospital Course: 79 yo M with a PMHx of moderate to severe AI with decreased EF s/p bioprosthetic AVR [**2182-6-27**], recently admitted [**Date range (1) 57819**] for BRBPR, now presenting with weakness and fluid overload, cardiac echo significant for worsening pericardial effusion, going for pericardiocentesis on the day of admission, with hospitalization complicated by renal failure requiring dialysis, klebsiella urosepsis, atrial fibrillation with RVR. #Acute on Diastolic Heart Failure: Patient presented to Dr. [**Name (NI) 39743**] office weighing 15 lbs more than previous [**Name (NI) **] and was edemetous on exam. He was admitted to [**Hospital1 1516**] for diuresis. He was transferred to the CCU following pericardial drainage for aggressive diuresis. He was started on a Lasix ggt with moderate UOP. He was below goal of 2L daily and metolazone was added with minimal improvement. Diuresis was eventually held in the setting of rising creatinine and poor UOP and ultimately dialysis was initiated for removal of fluid (see below). It was believed that symtoms might be secondary to a constrictive cardiomyopathy. Cath [**8-12**] showed elevated R and L-sided pressures but preserved CI and CO. Due to progressive renal failure of his renal graft, he commenced HD via temporary catheter and had a tunnelled line placed for more durable access. With volume removal during HD, his respiratory status and peripheral edeam improved. #Moderate Pericardial Effusion: Previously visualized but increased based on echo done this admission. Small amount of RV diastolic collapse. Pulsus 10mmHg, ECG shows mild electrical alternans. Voltage unchanged from prior ECG. Pt had bloody pericardial drainage with drain placement, felt to be [**1-17**] high INR (4). Repeat echo showed resolution of the effusion. #Respiratory distress: When pt was admitted he required several liters of 02 via face mask to maintain saturations in the low 90's. CXR was consistent with pulmonary edema. Oxygen saturations improved following pericardial drainage and diuresis. He continued to have SOB and and an O2 requirement and a right sided thoracentesis was performed which drained 2L of exudate with many RBCs. With diuresis and later HD, his volume overload and oxygen requirement likewise improved. #Klebsiella sepsis: Pt had a positive blood culture and urine culture for Klebsiella, with the blood growing three pan-sensitive strains. He was febrile and hypotensive at time of diagnosis and treated broadly with vanc/cefepime prior to narrowing to ceftriaxone. Pt remained afebrile and normotensive following initiation of abx. Pt's PICC line was removed as (+) BC was drawn from it. He completed a total 2 week course of CTX ending [**2182-8-18**]. #Atrial Fibrillation with RVR: CHADS2 score of 3, on coumadin at home. Coumadin was held intially as INR was supratherapeutic on admission, but resumed prior to d/c. Prior to admission, pt was rate-controlled with metoprolol 75mg [**Hospital1 **] and 120mg daily of diltiazem. His dilt was held briefly to allow pt to tolerate HD, but resumed after the first few HD sessions. On [**Hospital1 **], doses adjusted to toprol xl 100mg daily and diltiazem CR 180mg daily. He does occasionally have RVR to 110-120 if he is late for his doses, but responds quickly to oral meds. His INR was 3.3 on [**Hospital1 **] and had been increasing slowly over the past few days of hospitalization despite decreasing warfarin. Will need 1mg daily with daily INR checks until stabilized. Nutritional optimization will be necessary. #Renal Failure: He is s/p renal transplant 25 years ago for PKD and has a baseline creatinine of 1.6. He was initally kept on home cyclosporine and prednisone for immunosupression. Renal transplant service followed pt throughout admission. Pt's Cr continued to trend up with diuresis to 3.9. The etiology was initially felt to be ATN, but given lack of renal recovery, the eitology became unclear. Further diuresis was held at as pt was believed to be pre-renally intravascularly depleted despite being fluid overloaded. he did not respond to albumin and ultimately became oliguric. Given anasarca and lack of response to diuretics, HD was initiated. He received a tunnelled HD line on [**8-20**] for durable access. His CSA was discontinued initially but was restarted on [**Month/Day (4) **] to attempt a 2 week trial course to rescue his graft. He will continue 100mg daily. If no urine output increase noted over 2 weeks, he probably will discontinue cyclosporin. but the prednisone was continued at 5mg daily. He may regain some renal function, but remains oligo-anuric at [**Month/Day (4) **]. If anuric x24hr or greater, please bladder scan to rule out obstruction/retention. Will need HD MWF at LTAC, followup with renal and transplant surgery. #Recent GI Bleed: H/H was monitored. He recieved 1 unit pRBCs this admission for anemia felt to be [**1-17**] decreased epo in the setting of renal failure and phelbotomy. He had marroon stools for about 5 days without signfiicant HCT drop in the setting of heparin gtt, likely diverticular. GI was consulted and no intervention taken. Will f/u with GI as outpatient. #Delirium: Felt to be multifactorial, ICU delerium as well as uremia. Pt's mental status improved with HD. He was not aggitated but rather endorsed delusions of grandeur and hypoactivity. Care was taken to maintaine sleep-wake cycle. #Hyperlipidemia: Patient was maintained on home on atorvastatin 20mg daily. #Depression: SW provided support to the pt and his famiyl during his hospital stay. He was maintained on home SSRI. #Gout: Febuxostat was changed to renally-dosed allopurinol in the setting of renal failure #depression: started citalopram 10mg daily, will need titratrion up if depressive symptoms continue over next several weeks. # Code status: Pt had intially been full code on admission. As he became mroe ill in the setting of his renal failure, he expressed wishing to die but also endorsed wanting things done that could prolong his life. Multiple conversations were had with the pt and his family, particularly prior to starting HD. Ultimately, the pt endorsed wanting to be DNR/DNI and, given episodes of delerium, the pt's daughters felt this was consistant with their father's wishes. All were in agreement with going forward with HD. # dysphagia: diet advanced to regular at time of discharge1. PO diet: thin liquid and regular consistency solids. 2. Meds whole with thin liquid or applesauce. Transitional Issues: - will need titration of warfarin for INR goal [**1-18**] - f/u with renal and transplant surgery - f/u with cardiology and CHF for volume management - HD MWF - Trial of cyclosporin 100mg daily for roughly 2 weeks. Check 24hr trough in one week with level goal of <100. If oliguria persists in 2 weeks, likely will stop cyclosporin. . MEDICATIONS STARTED Allopurinol 150 mg PO EVERY OTHER DAY . MEDICATIONS CHANGED Diltiazem ER increased from 120mg daily to 180 mg daily Metoprolol Tartrate 75 mg PO BID to Metoprolol Succinate XL 100 mg PO DAILY Warfarin 2.5mg to 1mg daily . MEDICATIONS STOPPED: Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **] Flagyl course completed Furosemide Febuxostat . Pending tests at [**Hospital1 **]: -none Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Ascorbic Acid 500 mg PO TID 3. Calcium Carbonate 1000 mg PO DAILY 4. Cholestyramine 4 gm PO DAILY 5. CycloSPORINE (Sandimmune) 100 mg PO Q24H 6. Diltiazem Extended-Release 120 mg PO DAILY 7. Febuxostat 40 mg PO DAILY 8. Ferrous Sulfate 325 mg PO TID 9. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **] 10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 11. Furosemide 40 mg PO BID 12. Lovastatin *NF* 20 mg ORAL DAILY Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 13. Metoprolol Tartrate 75 mg PO BID 14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 15. Multivitamins 1 TAB PO DAILY 16. Omeprazole 40 mg PO DAILY 17. PredniSONE 5 mg PO DAILY 18. Vitamin D 800 UNIT PO DAILY 19. Warfarin 2.5 mg PO DAILY16 [**Hospital1 **] Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Allopurinol 150 mg PO EVERY OTHER DAY 3. Citalopram 10 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Nephrocaps 1 CAP PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 7. Senna 1 TAB PO BID:PRN constipation 8. Ascorbic Acid 500 mg PO TID 9. Calcium Carbonate 1000 mg PO DAILY 10. Ferrous Sulfate 325 mg PO TID 11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 12. PredniSONE 5 mg PO DAILY 13. Vitamin D 800 UNIT PO DAILY 14. Lovastatin *NF* 20 mg ORAL DAILY Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 15. Omeprazole 40 mg PO DAILY 16. Diltiazem Extended-Release 180 mg PO DAILY hold for SBP < 100, HR < 60. 17. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **] 18. Cholestyramine 4 gm PO DAILY 19. Metoprolol Succinate XL 100 mg PO DAILY hold for SBP < 100, HR < 60 20. Warfarin 1 mg PO DAILY16 21. CycloSPORINE (Sandimmune) 100 mg PO Q24H [**Hospital1 **] Disposition: Extended Care Facility: [**Hospital **] rehab macu [**Hospital **] Diagnosis: primary: pericardial effusion with tamponade s/p drainage renal failure . secondary: Klebsiella UTI and bacteremia atrial fibrilation acute on chronic dialstolic heart failure [**Hospital **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. [**Hospital **] Instructions: Mr. [**Known lastname 57554**], . It was a pleasure taking care of you at [**Hospital1 **]. You were admitted to the hospital after you were found to have too much fluid on your body in clinic. You were found to have fluid around your heart, which was drained. Unfortunately, while you were here, your kidney failed and you were started on dialysis. We also treated you for an infection in your blood and urine while you were here. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . You will need to continue your dialysis on Monday, Wednesdays and Fridays. You will also need to follow up with your cardiologist as an outpatient. You had some mild bleeding of your intestines, we will have you see a GI doctor as an outpatient. You will also see a heart failure specialist as an outpatient. You will now spend time getting stronger in rehab with more physical therapy. Many changes were made to your medications and are explained on the following sheet. We wish you the best of luck, Mr. [**Known lastname 57554**]! Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2182-8-28**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2182-9-5**] at 3:00 PM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Congestive Heart Failure Clinic [**2182-9-10**] at 1pm with Dr. [**Last Name (STitle) **] [**Location (un) 436**] [**Hospital Ward Name **] center, [**Hospital Ward Name **] Phone: ([**Telephone/Fax (1) 2037**] Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2182-8-27**] at 2:00 PM With: [**Doctor First Name 23138**] [**First Name8 (NamePattern2) 23139**] [**Name8 (MD) 815**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Completed by:[**2182-8-25**]

Admission Date: [**2109-3-28**] Discharge Date: [**2109-4-4**] Date of Birth: [**2032-2-8**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: SOB with exertion Major Surgical or Invasive Procedure: CABG X 3 (LIMA > LAD, SVG>OM, SVG>PDA), AVR (tissue) on [**2109-3-28**] History of Present Illness: Ms. [**Known lastname **] is a 77 ywar old male who presented with DOE, he underwent a stress test which was positive, he was then referred for cardiac catheterization which showed severe thre vessel disease and aortic stenosis. Past Medical History: Hypercholesterolemia AS Anemia Bilateral knee arthritis s/p TURP s/p appy Social History: pipe smoker, no etoh. Works as director of a research center Family History: Father deceased from MI at 72 Mother deceased from MI at 76 Physical Exam: On admission: NAD HEENT unremarkable Lungs CTAB RRR with 3/6 systolic murmur Abd benign no edema Neuro intact Carotids with transmitted bruits Pertinent Results: [**2109-4-3**] 06:23AM BLOOD Hct-25.0* [**2109-4-2**] 06:23AM BLOOD Hct-25.6* [**2109-3-31**] 05:55AM BLOOD WBC-11.4* RBC-3.56* Hgb-10.1* Hct-29.1* MCV-82 MCH-28.5 MCHC-34.9 RDW-18.2* Plt Ct-155 [**2109-4-4**] 06:32AM BLOOD PT-19.9* PTT-60.5* INR(PT)-1.9* [**2109-4-3**] 06:23AM BLOOD UreaN-28* Creat-1.1 K-3.9 Brief Hospital Course: Mr. [**Known lastname **] was admitted the morning of surgery, he was taken to the operating room on [**2109-3-28**] where he underwent a CABG x 3 (LIMA->LAD, SVG->OM & PDA) and AVR with a 25 mm CE pericardial valve. He wsa transferred to the intensive care unit in critical but stable condition. Postoperatively he was noted to have a right pneumothorax for which a chest tube was placed with near total resolution of the pneumothorax. He ws extubated on POD 0, His invasive lines and mediastinal drains were discontinued on POD 1. He did have multiple episodes of atrial fibrillation for which he ws treated with amiodarone and anticoagulated with heparin and coumadin. His INR on [**4-4**] was 1.9 and he was ready for discharge to home. Dr.[**Name (NI) 5765**] office was contact[**Name (NI) **] to follow his INR after discharge. Medications on Admission: Lipitor Toprol ASA FeSo4 Glucosamine Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: 400 mg(2 tablets) once daily for 1 week, then 200 mg(1 tablet) daily until d/c'd by Dr. [**Last Name (STitle) **]. Disp:*90 Tablet(s)* Refills:*0* 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: Check INR [**4-5**] with results called to Dr. [**Last Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CAD AS hypercholesterolemia arthritis post-op AFib Discharge Condition: good Discharge Instructions: no lifting > 10# for 10 weeks may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. [**Last Name (NamePattern4) 2138**]p Instructions: with Dr. [**Last Name (STitle) **] in [**12-28**] weeks with Dr. [**Last Name (STitle) **] in [**12-28**] weeks and for INR check and coumadin dosing with Dr. [**Last Name (Prefixes) **] in 4 weeks Completed by:[**2109-4-4**]

Admission Date: [**2154-1-7**] Discharge Date: [**2154-1-17**] Date of Birth: [**2090-2-7**] Sex: F Service: CARDIOTHORACIC Allergies: Latex Attending:[**First Name3 (LF) 2969**] Chief Complaint: Esophageal cancer. Major Surgical or Invasive Procedure: [**2154-1-7**]: Transhiatal esophagectomy, placement of a jejunostomy tube, pyloroplasty, umbilical hernia repair. History of Present Illness: The patient is a 63-year-old lady who presented with a nine-month history of voice change. Despite her medical history, she had an excellent performance status preoperatively. Upon her daughter's request, she underwent an upper endoscopy in [**2153-9-26**] that showed a nodule in the gastroesophageal junction that was biopsied. Pathology of that specimen indicated high-grade dysplasia. However, repeat pathologic evaluation of the specimen that was obtained at [**Hospital1 24300**] Hospital confirmed presence of an intramucosal carcinoma in the setting of high-grade dysplasia. Endoscopy, EUS and PET scan were all performed suggesting T1a, N0, stage I esophageal carcinoma. With this operative indication, the patient was brought to the operating room for transhiatal esophagectomy. Past Medical History: Non-insulin dependent diabetes Hypertension Hypercholesterolemia Rheumatic fever Glaucoma Diverticulosis Roscea PSH: lap chole [**2151**] right tigger finger [**Doctor First Name **] [**2152**], L rotator cuff repair [**2149**], C4-6 laminectomy and foraminotomy [**2147**], facial resurfacing [**2149**], b/l glaucoma [**Doctor First Name **], left LE vein striping Social History: Married, lives with family. Tobacco quit 34 years ago, ETOH occasional Family History: Father- throat ca died 60yrs [**Name (NI) 82040**] sister died [**Name2 (NI) 499**] ca [**2128**] Physical Exam: VS: T: 98.8 HR: 95-100 SR BP: 110-120/60-70 Sats: 96% RA Wt: 77.1 kg General: sitting up in chair in no apparent distress Card: RRR Resp: diminished breath sounds at bases otherwise clear GI: bowel sounds positive, abdomen soft. J-tube in place site clean no erythema Extr: warm 1+ bilateral edema Incision: neck incision clean, dry intact with steri-strips, abdominal clean dry intact with staples Neuro: non-focal Pertinent Results: [**2154-1-14**] WBC-6.3 RBC-3.07* Hgb-9.0* Hct-26.4* Plt Ct-304 [**2154-1-12**] WBC-7.5 RBC-2.79* Hgb-8.1* Hct-23.5* Plt Ct-254 [**2154-1-11**] WBC-7.2 RBC-2.78* Hgb-8.2* Hct-23.4* Plt Ct-217 [**2154-1-7**] WBC-5.6 RBC-3.51* Hgb-10.3*# Hct-28.9* Plt Ct-227 [**2154-1-17**] Glucose-250* UreaN-18 Creat-0.6 Na-135 K-4.9 Cl-94* HCO3-33* [**2154-1-16**] Glucose-244* UreaN-24* Creat-0.7 Na-134 K-3.9 Cl-97 HCO3-29 [**2154-1-15**] Glucose-235* UreaN-29* Creat-0.7 Na-139 K-4.2 Cl-103 HCO3-27 [**2154-1-15**] Glucose-235* UreaN-29* Creat-0.7 Na-139 K-4.2 Cl-103 HCO3-27 [**2154-1-14**] Glucose-257* UreaN-30* Creat-0.7 Na-141 K-4.0 Cl-107 HCO3-22 [**2154-1-13**] Glucose-139* UreaN-27* Creat-0.8 Na-143 K-3.4 Cl-110* HCO3-23 [**2154-1-12**] Glucose-116* UreaN-21* Creat-0.7 Na-142 K-4.5 Cl-112* HCO3-21* [**2154-1-8**] Glucose-183* UreaN-8 Creat-0.6 Na-138 K-4.5 Cl-106 HCO3-24 [**2154-1-7**] Glucose-120* UreaN-11 Creat-0.7 Na-139 K-3.1* Cl-104 HCO3-25 AnGa [**2154-1-9**] ALT-74* AST-69* LD(LDH)-257* AlkPhos-57 Amylase-41 TotBili-0.8 [**2154-1-15**] Calcium-8.8 Phos-2.4* Mg-1.8 Culture: Blood cultures [**2154-1-9**]: NO growth x2, Urine Culture No growth CXR: [**2154-1-16**]: There is significant interval improvement within right subpulmonic effusion, which is now small in size. There is persistent bibasilar atelectasis. The lungs are otherwise clear with no signs of pneumonia or congestive heart failure. Cardiomediastinal silhouette is stable with moderate cardiomegaly and tortuosity of the aorta. [**2154-1-13**]: 1. No pneumothorax following chest tube removal. 2. Slight worsening right lower lobe atelectasis with adjacent pleural effusion. No substantial change in left lower lobe atelectasis. [**2154-1-10**]: There has been improvement of the left small pleural effusion and atelectasis, however progression of the small right pleural effusion and atelectasis. Lines and tubes remain in similar position. The cardiomediastinal silhouette is stable with a tiny amount of mediastinal air consistent with post-esophagectomy changes [**2154-1-7**]: Interval placement of ET tube, NG tube, left chest tube, and epidural catheter in appropriate positions. Interval left pleural effusion and bibasilar atelectasis. Brief Hospital Course: Mrs. [**Known lastname 4886**] was admitted on [**2154-1-7**] for Transhiatal esophagectomy, placement of a jejunostomy tube, pyloroplasty, umbilical hernia repair. She was transferred to the ICU intubated in stable condition with a left chest tube to suction, NGT to low-wall suction, foley, neck JP, and a Bupivacaine/Dilaudid epidural for pain control. On POD1 she was extubed. She was found to be hypotensive and the epidural was titrated down and administered a fluid bolus with a good result. On POD2 she was out bed to chair transferred to the Floor but returned to the ICU for respiratory distress, atelectasis and hypoxemia. She spiked a fever, pan cultured which grew no organism. She was very sensitive to narcotics and the epidural was removed. Her pain was managed with Tylenol and Toradol. Beta-blockers were started for tachycardia. On POD3 her pain was under better control, she was gently diuresed and pulmonary toileting was continued. On POD4 the chest film showed a right lower lobe effusion/atelectasis. A right lower lobe ultrasound showed minimal effusion. She was started on trophic tube feeds. She continued to improve and transferred out of the ICU on POD5. On POD6 The chest-tube and NGT were removed. Her activity increased with increase in discomfor and was started on Roxicet with good control. She was seen by physical therapy who recommended STR. Her bowel function returned and the tube feeds were increased. Nutrition was consulted who recommended Fibersource HN Goal rate 55 cc/hr. On POD7 [**Hospital **] clinic was consulted for better management of her diabetes. She was started on insulin. A grape juice challenge was given with no obvious anastomoses leak. She was started on a clear liquid diet advanced to fulls. On POD8 the JP was removed. Her insulin was titrated for elevated blood sugars. Her medications were converted to PO meds. On POD 9 she required gentle diuresing. Her electrolytes were replete. She continued to make steady progress and was transferred to rehab. She will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Lisinopril 40mg qAM, Lipitor 20mg qHS, metformin 500mg [**Hospital1 **], Avandia 4mg [**Hospital1 **], glyburide 5mg [**Hospital1 **], Aspirin 81mg daily, vitamin 2 AM, 2PM, Calcium 600mg +VitD 1 AM, 1PM, HCTZ 25mg qAM, doxycycline 100mg [**Hospital1 **], omeprazole 20mg qAM, Lunigan drop 1 drop each eye qHS Discharge Medications: 1. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Five (5) PO BID (2 times a day). 3. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 4. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 6. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 7. Nutren Pulmonary Full strength; Tube Feeds via J-tube Cycle 70 ml/hr x 15 hrs or 8. Ibuprofen 100 mg/5 mL Suspension [**Last Name (STitle) **]: One (1) PO Q8H (every 8 hours) as needed. 9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY (Daily). 10. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) MMML PO Q4H (every 4 hours) as needed for pain. 11. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) ML PO every six (6) hours as needed for pain. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: Three (3) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: Three (3) ML Inhalation Q6H (every 6 hours). 14. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Thirty Two (32) Units Subcutaneous Dinner time. 15. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: please titrate as blood pressure tolerates. Home dose 20mg daily. 16. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 17. Regular Insulin Sliding Scale 71-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 2 Units 2 Units 2 Units 0 Units 141-160 mg/dL 4 Units 4 Units 4 Units 0 Units 161-180 mg/dL 6 Units 6 Units 6 Units 0 Units 181-200 mg/dL 8 Units 8 Units 8 Units 4 Units 201-220 mg/dL 10 Units 10 Units 10 Units 6 Units 221-240 mg/dL 12 Units 12 Units 12 Units 10 Units 241-260 mg/dL 14 Units 14 Units 14 Units 12 Units 261-280 mg/dL 16 Units 16 Units 16 Units 14 Units 281-300 mg/dL 18 Units 18 Units 18 Units 16 Units 301-320 mg/dL 20 Units 20 Units 20 Units 18 Units Discharge Disposition: Extended Care Facility: [**Hospital 671**] Healthcare Center Discharge Diagnosis: Non-insulin dependent diabetes Hypertension Hypercholesterolemia Rheumatic fever Glaucoma Diverticulosis Roscea PSH: lap chole [**2151**] right tigger finger [**Doctor First Name **] [**2152**], L rotator cuff repair [**2149**], C4-6 laminectomy and foraminotomy [**2147**], facial resurfacing [**2149**], b/l glaucoma [**Doctor First Name **], left LE vein striping Discharge Condition: stable Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience: -Fever > 101 or chills. -Increased shortness of breath, cough or sputum production -Chest pain -Difficulty or painful swallowing, abdominal pain, diarrhea -Incision develops drainage -HOB elevated 30 degree or more indefinitely Feeding tube sutures become loose or break, please tape tube securely and call the office [**Telephone/Fax (1) 4741**]. If your feeding tube falls out, save the tube, call the office immediately [**Telephone/Fax (1) 4741**]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Do not put any medication down the tube unless they are in liquid form. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4741**] [**1-31**] at 2:00 pm on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**] Report to the [**Location (un) 861**] Radiology Department for a Barium Swallow before your appointment. Completed by:[**2154-1-17**]

Admission Date: [**2118-7-18**] Discharge Date: [**2118-7-22**] Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 458**] Chief Complaint: Ventricular Tachycardia Major Surgical or Invasive Procedure: Cardiac Catheterization EP study History of Present Illness: 86 y/o man w/ hitory of CAD s/p 4vessel CABG [**2096**], CHF EF 35%, Atrial Flutter (not anticoagulated) and chronic renal insufficiency who was sent to the [**Location (un) **] ED when an outpatient stress test revealed inssesant non-sustained ventricular tachycardia. He was asymptomatic and hemodynamically stable. He was given a dose of lidocaine and transfered to the [**Hospital1 18**] ED. . @ [**Hospital1 18**] ED he was started on lidocaine drip and seen by EP. Preliminary plans are for a possible EP study and VT ablation. ROS is posative for dyspnea on excertion which has been stable, with no history of synope or presyncope. Past Medical History: CAD s/p CABG [**2096**] with 4v disease CRI severe COPD ([**9-24**] FEV1 0.91, FVC 1.76, decreased TLC, nl DLCO) HTN Hyperlipidemia subclavian stenosis aflutter on sotalol prostate CA Social History: Social: Patient lives with son, non-[**Name2 (NI) 1818**], no etoh or illicits. Ballroom dancing a few times per week. Family History: Family: no family history of premature heart disease Physical Exam: VS - 96.6 129/86 86 20 Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 8cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were slightly unlabored, no accessory muscle use. Lungs with crackles @ bases bialterally, rhonchi and diffuse soft wheezing. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: LABS ON ADMISSION: [**2118-7-18**] 06:55PM CK-MB-NotDone cTropnT-<0.01 [**2118-7-18**] 01:00PM GLUCOSE-107* UREA N-33* CREAT-1.7* SODIUM-140 POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-26 ANION GAP-16 [**2118-7-18**] 01:00PM WBC-11.1* RBC-4.38* HGB-14.6 HCT-43.9 MCV-100* MCH-33.3* MCHC-33.3 RDW-13.7 [**2118-7-18**] 01:00PM CK-MB-NotDone cTropnT-0.01 . CARDIAC CATH: 1. Three vessel native coronary artery disease with LMCA disease. 2. Patent LIMA, SVG to Diaganol, and SVG to OM. SVG to PDA with moderate stenosis. 3. Moderate in-stent restenosis of left subclavian artery stent. 4. Severe distal subclavian artery stenosis proximal to the LIMA. 5. Severe pulmonary arterial hypertension. 6. Moderate systemic arterial hypertension. 7. Severe left ventricular diastolic heart failure. . Brief Hospital Course: 86 yo male with CAD s/p 4v CABG [**2097**], CHF with EF 35%, atrial flutter/fib, CRI who presented to [**Hospital1 18**] with stable sustained VT. . #Sustained VT / Rhythm He was taken to the EP lab for a VT ablation which was successful. VT terminated and primary rhythym was atrial fibrillation post procedure. Post-procedure, he was also noticed to have a blue toe in the PACU. He was transfered for further care to the CCU. His arterial and venous sheaths were pulled and blood flow returned to his foot. DP pulses were present w/ doppler bilaterally. He was re-started on his home dose sotalol [**2118-7-20**] and resumed normal sinus rhythm on [**2118-7-21**] around 10am. A 6 point hct drop was noted along with continued bleeding from groin, and a CT abdomen was performed which ruled out a retroperitoneal bleed. A right groin ultrasound was also performed to rule out pseudoaneurysm and was normal. Subsequently patient was started on heparin gtts to bridge to coumadin therapy for goal inr [**1-22**] with lovenox 80 mg daily for permanent atrial fibrillation. . #CAD Patient also underwent L + R cardiac catheterization. LIMA and other grafts were intact and patent. No angioplasty was performed nor were stents placed. He was continued on ASA 325 mg, moexepril 7.5 mg daily, sotalol 80 mg daily. Atorvastatin 10 mg daily was changed to simvistatin 40 mg daily since LDL was 101 (above goal 70). . #COPD Patient was continued on home medications of atrovent and albuterol. Ipratroprium albuterol nebulizer was added on final hospital day. He was discharged on home medication advair + combivent. Right cardiac catheterization showed severe pulmonary hypertension. . #Subclavian stenosis The patient was admitted to the [**Hospital Ward Name 121**] 6 cardiology service. He was taken to the cath lab [**7-19**] which showed proximal L subclavian disease (60-70% stenosis), but it was not intervened upon due to technical factors. . #CHF He was continued on home medications of sotalol, moexepril. Lasix was initially held due to low blood pressures. Pressures remained in systolic 80-90's; on [**7-21**] he also experienced one episode of bradycardia and hypotension with a likely junctional rhythm after dosage of sotalol so home sotalol was reduced to 80 mg once daily and moexepril was decreased to 7.5 mg daily. Blood pressures remained subsequently in sbp's 90-110s and maps 60-70's. He was discharged on sotalol 80 mg daily and moexepril 7.5 mg daily. . #Incidentaloma Renal cysts were found bilaterally during CT abdomen exam. A renal ultrasound was performed which only showed simple renal cysts bilaterally. . Mr. [**Known lastname 25699**] remained afebrile during entire hospitalization. He remained hemodynamically stable in the 24 hrs prior to discharge. His home dose sotalol was decreased to 80 mg daily and moexepril decreased to 7.5 mg daily. His atorvastatin was stopped and converted to 40 mg daily simvistatin. ASA 325 mg daily was initiated and coumadin therapy was started 5 mg daily for persistent atrial fibrillation. Home dose medications advair was continued and started on combivent. Lovenox 80 mg daily should be given for 4 days and coumadin 5 mg for 5 days. INR should be checked Sunday [**2118-7-24**] and the dose of warfarin should be adjusted accordingly. Medications on Admission: sotalol 80 mg [**Hospital1 **] lasix 20 mg daily lipitor 10 mg daily univasc 15 mg daily advair 250/50 1 puff [**Hospital1 **] flonase Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Moexipril 7.5 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. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). Disp:*1 vial* Refills:*2* 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day): rinse mouth after use. Disp:*60 puff* Refills:*2* 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs inhaler* Refills:*2* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: This dose will change based on your INR. . Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Location (un) **] geriatric Discharge Diagnosis: Primary Stable vtac s/p VT ablation atrial fibrillation CAD s/p catherization without intervention Secondary HTN severe COPD subclavian stenosis Discharge Condition: HD stable and afebrile. Discharge Instructions: You were admitted with an irregular rhythm called Ventricular tacchycardia and went to the catherization lab and electrophysiology lab where you had an ablation of the abnormal rhythm. Your heart rhythm is still irregular and you will need to be on coumadin to thin your blood. Please take all medications as directed. We changed some of your medications. We decreased your sotalol from 80 mg twice daily to once daily. We also decreased your moexipril from 15 mg daily to 7.5 mg daily. We also added coumadin 5 mg daily. Please follow-up with all outpatient appointments. Please return to the hospital or call your doctor if you experience fever, dizziness, chest pain, trouble breathing, abdominal pain or any other concerning symptoms. Followup Instructions: Please follow-up with your cardiologist, Dr. [**Last Name (STitle) **]. You have an appointment with him on Thursday [**8-18**] at 1:30 pm in [**Location (un) 620**]. . Please follow up with your PCP when you are discharged from rehab.

Admission Date: [**2199-7-3**] Discharge Date: [**2199-7-5**] Date of Birth: [**2138-4-19**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5893**] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 61-year-old gentleman with a history of gastric cancer s/p resection years ago, hypertension, presenting with several days of palpitations, which he describeds as a "fluttering" sensation. Denies chest pain or dyspnea. Says he has has these episodes every once in a great while, but cannot give specific frequency. When he has these symptoms, they typically resolve on their own in a matter of seconds. Today, however, his symptoms persisted for several minutes, and he decided to come to the ED. Of note, he has also reported left leg swelling since [**5-11**], when he sustained a fall while crossing the street. . In the ED, initial vs were: 97 133 135/102 18 99%, with ECG revealing atrial flutter. He was given ASA 325 mg and diltiazem 20 mg IV x1, which transiently brought his heart rate down to the 80s, then subsequently increased to the 120s. D-dimer + to the 800s. CTA chest revealed no pulmonary embolism or dissection, but was significant for LLL pneumonia. LENIs negative for DVT. Lactate was 4.7, which decreased to 2.2 after four liters of IV fluids. . In the ICU the patient denies any respiratory symptoms of any kind. He is no longer feeling the fluttering sensation. Denies fevers, chills, chest pain, dyspnea, cough. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria. . Review of sytems: (+) Per HPI. Also endorses dark urine when he drinks alcohol. (-) Denies recent weight loss or gain. Denies headache or congestion. Denied arthralgias or myalgias. Past Medical History: -Gastric cancer s/p gastrectomy in [**2175**], at [**Hospital1 112**] -Thyroid nodules -S/p quadriceps tendon rupture [**2196**] -Hypertension -Self-reported hx of WPW -Etoh abuse (Last drink earlier today, in the morning. Denies ever needing medical care for withdrawal symptoms, but admits to having drinks in the morning to get rid of "the shakes") Social History: Lives by himself. Divorced. Several grown children and grandchildren. Former chef, no longer working. Drinks several drinks per day, with etoh history as above. Reports smoking [**2-9**] cigarettes/month, but earlier told RN he smokes daily. Denies illicit drug use. Family History: Mother's family with "circulatory problems." Mother had non-fatal MI in her 60s. Mother's relatives (unspecified) with strokes. Physical Exam: Vitals: T:98.3 BP:149/99 P:64 R:12 O2:99% 2 liters General: Alert, oriented, NAD HEENT: Sclera anicteric, MMM, OP clear. Poor dentition. Neck: supple, no JVD or LAD Lungs: CTAB. No wheezes, rales, rhonchi. Good inspiratory effort and air movement throughout. CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, NT/ND, bowel sounds present, no rebound tenderness or guarding, no organomegaly or pulsatile masses. Well healed midline vertical incision scar GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAO x3, speech fluent, thought process generally clear. Sensation grossly intact throughout. 5/5 strength bilateral upper extremities and right lower extremities. Left LE: Can extend knee from 90 to 45 degrees. Pertinent Results: [**2199-7-3**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2199-7-3**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2199-7-3**] 08:56PM LACTATE-2.2* [**2199-7-3**] 06:35PM GLUCOSE-53* LACTATE-4.7* [**2199-7-3**] 03:17PM GLUCOSE-68* UREA N-12 CREAT-1.0 SODIUM-139 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-21* ANION GAP-24* [**2199-7-3**] 03:17PM ALT(SGPT)-29 AST(SGOT)-61* ALK PHOS-84 TOT BILI-0.4 [**2199-7-3**] 03:17PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-1.9 [**2199-7-3**] 03:17PM D-DIMER-826* [**2199-7-3**] 03:17PM WBC-5.3 RBC-4.02* HGB-12.8* HCT-38.5* MCV-96 MCH-31.7 MCHC-33.2 RDW-14.3 [**2199-7-3**] 03:17PM NEUTS-67.3 LYMPHS-26.4 MONOS-5.6 EOS-0.5 BASOS-0.3 [**2199-7-3**] 03:17PM PLT COUNT-164 [**2199-7-3**] 03:17PM PT-12.6 PTT-25.7 INR(PT)-1.1 LENI [**7-3**]: No evidence for DVT in the left lower extremity. CTA [**7-3**]: 1. Early left lower lobe pneumonia. 2. No evidence of pulmonary embolism or acute aortic process. 3. Severe coronary artery disease. 4. Fatty liver. 5. Thyroid nodularity for which clinical correlation is advised. Brief Hospital Course: This is a 61-year-old gentleman with history of gastric adenocarcinoma s/p remote surgical resection, hypertension, and likely regular significant ETOH intake, who presents with palpations. EKG concerning for atrial flutter and CTA concerning for PNA. # ATRIAL FLUTTER: EKG in ED showed atrial flutter with rates in the 130s. Unclear whether this is chronic however, patient has undergone holter monitoring in the past without evidence of sustained dysrhythmias. Patient also relates history of WPW as a child; he was seen by EP in [**2191**] who saw no evidence of active bypass tract. Not currently on any rate control as outpatient. Possible triggers for episode may include hypoxia from pneumonia or ETOH use. Mr. [**Known lastname **] [**Last Name (Titles) 35325**] diltiazem in ED and rate slowed into the 80s. In the ICU, patient was monitored on telemetry and no further rate control was necessary. EP was consulted who recommended patient follow-up in 1 month with Dr. [**Last Name (STitle) **]. A beta-blocker was not started as patient's HR's were continually in the 40s-50s. Cardiology also recommended obtaining an ECHO as an outpatient as patient had a right parasternal heave on exam. Atrial flutter likely exacerbated by some intrinsic lung process, and may be amenable to ablation. # LUNG INFILTRATE: Mild opacity in left lower lobe reported as possible early pneumonia on CTA. No clinical symptoms or signs of pneumonia--not hypoxic or febrile, no cough or dyspnea, no leukocytosis. Although Mr. [**Name13 (STitle) **] received ceftriaxone and azithromycin in the ED, these were not continued in the ED as suspicion for true PNA was low. # HYPERTENSION: BP of high 140s/high 90s upon arrival in [**Hospital Unit Name 153**]. Patient states that he has not been taking his anti-hypertensives for the past several days. Patient was continued on HCTZ and lisinopril was increased to 20mg QD. His pressures were monitored closely, especially as he was at risk for ETOH withdrawal as below. # ETOH ABUSE: Upon arrival in [**Hospital Unit Name 153**], patient gave different histories to different interviewers. Admits to having a drink before presenting to the ED in order to "get rid of the shakes." Patient was put on a CIWA scale but did not require benzos throught [**Hospital Unit Name 153**] stay. A social work consult was put in for addiction counseling. # CAD: CTA shows evidence of severe CAD. Patient has risk factors for CAD including sex, age, hypertension, and ETOH abuse. It is important for him to see cardiology as an outpatient for further work-up of this issue. He would likely benefit from ASA therapy or beta-blocker (if heart rate tolerates). He also needs counseling on reducing CAD risk factors. # ELEVATED ANION GAP: Elevated lactate on admission, which resolved with IV fluid administration. Gap closed on first morning of admission. Ketonuria may be due to starvation/ETOH ketoacidosis. # LEFT LOWER EXTREMITY SWELLING: Possibly from site of previous trauma. US negative for DVT. Patient was instructed to follow-up with orthopedics. Medications on Admission: -Lisinopril 10 mg daily -HCTZ 25 mg daily -Folate 1 mg daily Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Coarse atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you on this admission. You came to the hospital because you were experiencing palpitations. You were seen by the cardiologist who thought that you had a condition called atrial flutter. You should see Dr. [**Last Name (STitle) **] as an outpatient for evaluation and treatment of your atrial flutter. The following changes were made to your medications: 1. Increase lisinopril to 20mg QD Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Return to the hospital if you develop chest pain, shortness of breath, continuing palpitations, severe headache, nausea, vomiting, diarrhea, pain with urination, cough, fever, increased swelling in your legs, or any other concerning signs or symptoms. Followup Instructions: PCP/NP [**First Name9 (NamePattern2) 83923**] [**Doctor Last Name 122**]/ Dr. [**Last Name (STitle) **] at [**Hospital3 26956**] on [**7-16**] at 2pm Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2199-9-4**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2199-7-30**] 1:20 [**Hospital Ward Name 23**] [**Location (un) **]

Admission Date: [**2123-8-25**] Discharge Date: [**2123-9-2**] Date of Birth: [**2042-6-1**] Sex: M Service: CARDIOTHORACIC Allergies: Atenolol Attending:[**First Name3 (LF) 2969**] Chief Complaint: Lung Cancer Major Surgical or Invasive Procedure: Left lower lobe non-small cell lung cancer, Left vocal cord paralysis 7/5 L VATS pleuroscopy & mediastinoscopy (neg med nodes) 7/12 L thoracotomy/LLL lobectomy, L chest wall resect with gortex mesh repair, LUL wedge resect History of Present Illness: Mr. [**Known lastname 14859**] is an 81-year-old gentleman with a biopsy proven carcinoma of the left lower lobe, which by imaging abuts the chest wall. On his prior visit, he underwent a staging operation which showed no nodes involved and a pleural effusion negative for malignancy, with negative pleural biopsies. He had adequate reserve to tolerate resection and was surprisingly asymptomatic regarding the tumor, which was clearly adherent if not invading the chest wall. We recommended left lower lobectomy with en bloc chest wall resection and he agreed to proceed. Past Medical History: - A.fib s/p ablation and pacemenaker [**2123-5-28**] - Chronic obstructive pulmonary disease - +TOBacco - Perihilar lung mass Social History: Married with one grown daughter. Used to be in the army, studied physical education. TOB+ x >50 yrs, quit 2 months ago. ETOH 1 x per week. Family History: NC Physical Exam: LYMPHATICS: He has no adenopathy in the neck region or supraclavicular fossa. HEENT: His sclerae are muddy but nonicteric. He has no thyromegaly, and I can appreciate no carotid bruits. HEART: Irregular rhythm with a controlled rate. LUNGS: There is no focal wheezing in the lungs. EXTREMITIES: He has no peripheral edema. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2123-8-28**] 05:34AM 11.1* 3.11* 9.0* 26.3* 85 28.9 34.1 15.9* 228 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2123-8-25**] 09:00PM 84.8* 9.7* 3.9 1.1 0.5 NO RED TOP RECEIVED FOR MG RED CELL MORPHOLOGY Anisocy Poiklo Microcy [**2123-8-25**] 09:00PM 1+ 1+ 1+ NO RED TOP RECEIVED FOR MG BASIC COAGULATION (PT, PTT, PLT, INR) PT Plt Ct INR(PT) [**2123-8-28**] 05:34AM 228 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2123-9-1**] 04:05PM 116* 15 1.0 138 4.31 100 25 17 SLIGHTLY HEMOLYZED 1 HEMOLYSIS FALSELY ELEVATES K HEMOLYZED, SLIGHTLY CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2123-9-1**] 04:05PM 8.8 3.0 2.11 RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2123-9-1**] 1:13 PM Reason: eval for interval change/ptx s/p last Ct d/c [**Hospital 93**] MEDICAL CONDITION: 81 year old man s/p LLL lobectomy, left chest wall resection w/mesh, LUL wedge; had L CT d/c now REASON FOR THIS EXAMINATION: eval for interval change/ptx s/p last Ct d/c PA and lateral chest, [**9-1**]. HISTORY: Left lower lobectomy and chest wall repair, left upper lobe wedge resection. Chest tube discontinued. IMPRESSION: PA and lateral chest compared to [**8-30**]: Left posterior air and fluid collection in the region of chest wall resection has increased in size, predominantly in the anteroposterior dimension from roughly 31 to 39 mm in diameter, still between 10.5 and 12 cm in length, and now contains a large component of fluid. There is no appreciable layering left pleural effusion or significant pneumothorax along the other pleural margins. Subcutaneous emphysema in the left supraclavicular soft tissues has diminished. Small right pleural effusion is stable. Right lung is clear. Heart is top normal size and remains shifted slightly to the left. Transvenous pacer lead in standard position. RADIOLOGY Final Report VIDEO OROPHARYNGEAL SWALLOW [**2123-8-31**] 11:13 AM Reason: eval for swallow prophiciency. [**Hospital 93**] MEDICAL CONDITION: 81 year old man with left vocal cord paralysis per ENT [**8-30**] s./p Thoracic surgery, meds/ lobectomy. REASON FOR THIS EXAMINATION: eval for swallow prophiciency. INDICATIONS: 81-year-old man with left vocal cord paralysis following thoracic surgery. TECHNIQUE: Videotaped oropharyngeal swallowing study. FINDINGS: The study was performed in conjunction with the speech and swallow pathologist. Various consistencies of barium were administered under videofluoroscopy. Due to poor bolus control, premature spillover was observed into the piriform sinuses with thin liquids. Laryngeal valve closure was mildly impaired, and the left vocal cord showed paralysis. Residue in the piriform sinuses and valleculae could be cleared with multiple swallows. Pharyngeal contraction was symmetric. Mild penetration with sips of thin liquids was observed with spillover, but throat clearing was effective. A moderate amount of silent aspiration was observed with multiple sips of thin liquids, related to spillover, and cough was not effective at clearance. Also, there was reduced sensation with a lack of spontaneous cough. This aspiration occurred with larger boluses only. With smaller boluses of thin liquids via straw, only trace penetration was observed. IMPRESSION: Moderate aspiration with larger boluses of thin liquids, with only penetration into the vestibules seen at smaller boluses. Paralysis of left vocal cord. SUMMARY: Pt presents with a mild oropharyngeal dysphagia. He demonstrated aspiration and penetration with thin liquids during the examination, however, small bolus sizes were effective at preventing aspiration when pt was focused on the swallowing task. Pt also demonstrated deep penetration with small straw sips of thin liquids. In consideration of pt's left vocal cord paresis, it is very likely that this is the cause of his poor valve closure and thus compromising his airway protection with larger boluses. Therefore, based on this examination, it is recommended that pt continue with a regular PO diet with thin liquids while taking small sips of thin liquids and NO STRAWS. Pt demonstrated a good understanding of the instructions given after the evaluation. We will follow-up with the pt to ensure that these instructions are being followed at meals. RECOMMENDATIONS: 1. recommend that pt continue on regular PO diet with thin liquids and PO meds 2. pt should take small sips of thin liquids 3. Pt should not use straws Pathology Examination SPECIMEN SUBMITTED: LIPOMA, LATERAL CHEST WALL MARGIN, NEW LATERAL CHEST WALL MARGIN, LEFT LOWER LOBE AND CHEST WALL, L10 LYMPH NODE, L11 LYMPH NODE Procedure date Tissue received Report Date Diagnosed by [**2123-8-25**] [**2123-8-26**] [**2123-8-30**] DR. [**Last Name (STitle) **]. BROWN/lfb Previous biopsies: [**-7/2603**] LT PARIETAL PLEURA, 4 R, LOWER PARATRACHEAL, 4 L LOWER DIAGNOSIS: 1. Excision, central back: lipoma. 2. Lung, left lower lobe and chest wall: Squamous cell carcinoma, see synoptic report. 3. Margin, lateral chest wall: Squamous cell carcinoma. 4. New margin, lateral chest wall: Skeletal muscle, no carcinoma seen. 5. L10 nodes: No carcinoma seen. 6. L11 nodes: No carcinoma seen. Lung Cancer Synopsis MACROSCOPIC Specimen Type: Lobectomy. Laterality: Left. Tumor Site: Lower lobe. Tumor Size Greatest dimension: 7 cm. MICROSCOPIC Histologic Type: Squamous cell carcinoma. Histologic Grade: G2: Moderately to poorly differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor of any size that directly invades any of the following: chest wall, diaphragm, mediastinal pleura, parietal pericardium; or tumor of any size in the main bronchus less than 2 cm distal to the carina but without involvement of the carina; or tumor of any size associated atelectasis or obstructive pneumonitis of the entire lung. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Location: T 10. Number examined: Multiple fragments Number involved: 0. Location: T 11. Number examined: Multiple fragments Number involved: 0. Location: Hilar . Number examined: 6. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins: Tumor is focally present adjacent to the inked lateral chest wall margin in the lobectomy/chest wall resection specimen. Direct extension of tumor: Chest wall. Venous invasion (V): Indeterminate. Lymphatic Invasion (L): Indeterminate. Clinical: Left lower lobe lung cancer. Gross: Specimen submitted: 1. central back soft tissue, lipoma, 2. lateral chest wall margins, 3. new lateral chest wall margins, 4. left lower lobe and chest wall, 5. L10 lymph node, 6. L11 lymph node. The specimen is received fresh in six parts each labeled with the patient's name, "[**Known lastname 14859**], [**Known firstname **]" and with the medical record number. Part 1 is additionally labeled "central back soft tissue lipoma" and consists of a 6 x 6 x 2.5 cm portion of fatty tissue. The specimen is sectioned to reveal unremarkable fatty cut surfaces. The specimen is submitted in cassettes A-C. Part 2 is additionally labeled "lateral chest wall margin" and consists of a 1.5 x 1.0 x 0.5 cm fragment of soft tissue, which is entirely submitted for frozen section diagnosis. Frozen section diagnosis by Dr. [**First Name8 (NamePattern2) 32953**] [**Name (STitle) 10165**] is as follows: "lateral chest wall margin: positive for non small cell carcinoma." The specimen is entirely submitted as follows: D=frozen section remnant. Part 3 is additionally labeled "new lateral chest wall margin" and consists of a 2 x 2 x 1.5 cm portion of soft tissue, with a stitch indicating the new margin. The margin is shaved, and submitted for frozen section diagnosis. Frozen section diagnosis by Dr. [**Last Name (STitle) **] is as follows: "new lateral chest wall margin, negative for carcinoma." This specimen is represented as follows: E=frozen section remnant, F=portions of soft tissue. Part 4 is additionally labeled "left lower lobe with attached chest wall" and consists of a left lower lobe of lung, portion of upper lobe, and chest wall. The portion of the upper lobe measures 6 x 3 x 2 cm, the lower lobe measures 12 x 7 x 6 cm, the chest wall measures 14 x 9.5 x 2 cm. The specimen has been oriented with a white suture at the superior posterior aspect of the chest wall. There is additionally a black suture located on the lateral surface of the chest wall located just inferior to the 5th rib. The bronchial margin is shaved and submitted for frozen section diagnosis. Frozen section diagnosis by Dr. [**Last Name (STitle) **] is as follows: "negative for carcinoma." The specimen is sectioned to reveal a largely necrotic tumor mass within the left lobe of the lung with extension into the soft tissue. The mass overall measures 7 x 7 x 6 cm. It comes to within less than 1 mm of the soft tissue margin, within 0.5 cm of the stapled upper lobe margin, and to within 1 cm of the bronchial and vascular resection margin. The mass does not appear to involve the chest wall between ribs 4 and 5, however between ribs 5 and 6 it extends between the bones to the soft tissue. Additionally, on the posterior internal surface of the 6th rib there is a small 0.5 cm nodule which may represent tumor, may represent lymph node. This specimen is represented as follows: G=bronchial margins frozen section remnants. H=vascular margin, I=stapled upper lobe margin, with adjacent nodule, J=hilar lymph nodes, K=soft tissue margin between ribs 5 and 6, L=soft tissue margin between 6 and 7, M=soft tissue margin between 6 and 7, N=soft tissue margin internal to rib 6, posteriorly on the pleural surface, O=tumor in relationship to normal lung and pleura, P=tumor with necrosis with relationship to vessels. X,Y = 6th rib margin, Z,AA = 7th rib margin, AB = cross section of rib. Portions of this specimen are submitted for decalcification. Part 5 is additionally labeled "L10 lymph nodes" and consists of a 1.5 x 0.4 cm anthracotic lymph node, which is bisected and entirely submitted in cassette Q. Part 6 is additionally labeled "L11 lymph nodes" and consists of multiple anthracotic lymph nodes measuring in aggregate 2.5 x 1 x 1 cm. The largest is bisected and submitted in R. The remainder is entirely submitted in cassette S. Brief Hospital Course: [**8-25**]: Patient admitted for surgery (L thoracotomy, LLL lobectomy, L chest wall resection with gortex mesh repair, LUL wedge resection. Post-operatively, the patient was transferred to the ICU. [**8-26**]: Patient was extubated in the ICU. Patient's pacemaker was interrogated for abnormal rhythms and found to be normal. [**8-27**]: Patient's L IJ CVL (3 lumen) was withdrawn 2cm because of improper placement ,patient became hoarse shortly thereafter. [**8-28**]: Patient transferred to floor. [**8-30**]: Patient's chest tube dislogded accidentally while in radiology early in am. Patient seen by ENT for c/o hoarseness, discovered L Vocal cord paralysis. [**8-31**]: Patient had speech and swallow evaluation for c/o hoarseness.see report for detail. [**9-1**]: Patient's chest tube was removed. ENT recommended outpatient follow up in two weeks. [**9-2**] Pt stable overnight and pain controlled on po rx. Pt stable for discharge to home in company of wife. [**Name (NI) 269**] services w/ [**Location (un) **] [**Location (un) 269**].Coumadin to restart at home. Medications on Admission: Coumadin 2.5qd, Lasix 40qd,fluticasone, azatioprine, tictropium 1 puff qd, mucinex, prednisone Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-15**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 1* Refills:*0* 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 1* Refills:*1* 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH). 5. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO q12 (). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*80 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Left lower lobe lung 9cm massNSCLC, L vocal cord paralysis 7/5 L VATS pleuroscopy & mediastinoscopy (neg med nodes) Atrial fibrillation s/p ablation/pacer [**5-20**], Chronic obstructive pulmonary disease, Left lower lobe lung 9cm mass, bullous pemphigoid Discharge Condition: good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**]/Thoracic Surgery office [**Telephone/Fax (1) 170**] if you experience chest pain, shortness of breath, fever, chills, pain not relieved with oral pain medication. Take medications as previous to surgery. Take new medications as directed on discharge instructions. You may shower in 2 days, then remove dressing at chest tube site and change daily as needed. No driving if taking narcotic pain medication. Ambulation as much as possible. Take bowel medication for regularity. Followup Instructions: Dr.[**Name (NI) **] office will contact you regarding your follow up appointment Follow up with ENT, Dr. [**Last Name (STitle) 1837**] ([**Telephone/Fax (1) 26719**]) in 2 weeks. Completed by:[**2123-9-2**]

Admission Date: [**2128-10-28**] Discharge Date: [**2128-11-4**] Date of Birth: [**2054-7-23**] Sex: M Service: MEDICINE Allergies: Penicillins / Olanzapine Attending:[**First Name3 (LF) 1711**] Chief Complaint: AFIB CHF exacerbation Major Surgical or Invasive Procedure: Cardioversion Right Internal Jugular catheter History of Present Illness: This is a 74 year old man with history of CHF who was intially admitted to [**Hospital **] Hospital with atrial fibrillation and CHF exacerabtion and is now transfered to [**Hospital1 18**] for further management. History was obtained from patient and medical records since the patient could not address many aspects of his presentation. On [**2128-10-7**] he presented to his PCP with shortness of breath and weight gain. At the time his weight was 251 lb (aproximately 25 lb increase) and he was noted to have worsened lower extremity edema. On this visit he was also noted to be in atrial fibrilation with a ventricular rate of 130 bpm (most recent ECG in [**12/2124**] is reported as sinus). At that time he was on diltiazem 240 mg daily, furosemide 40 mg daily and lisinorpil 20 mg daily. His furosemide was increased to 40 mg twice daily and he was started on metoprolol succinate 50 mg daily. For unclear reasons his lisinopril was discontinued. On [**2128-10-14**] he presented to his PCPs office again with symptoms of shortness of breath and was found to have atrial fibrillation with a rate of 150. He was refered for admission at [**Hospital **] Hospital. There he was initially treated with diltiazem, metoprolol, digoxin and heparin ggt. ACS was ruled out with cardiac enzymes and ECG. He was also given intravenous furosemide boluses for management of his CHF exacerabtion. On [**2128-10-16**] he desaturated and he developed rapid ventricular response. A code was called without CPR administration. The patient was transfered to the ICU. He was intubated and placed on furosemide ggt. He was started on digoxin and his diltiazem ggt was continued. Acetazolamide was also started. He was extubated on [**2128-10-25**] and he has done well on 4L NC since then (02 sat 98%). His [**Location (un) **] admission weight was 279 lb, which improved to 250 lb with diuresis. A TTE on [**2128-10-16**] showed EF55% with septal hypokinesis as well as severe MR (with limited windows). Repeat TTE on [**2128-10-20**] confirmed severe MR with two separate jets tracking up. LENIs were negative bilaterally. His urine output ranged from 100 to 300 ml/hr??. His hospitalization course at [**Location (un) **] has been complicated by delirium with disorientation and combativeness. He developed hypokalemia in the setting of diuresis and although sputum cultures grew GNR (? E. Coli) he has been afebrile without CXR changes suggesting PNA. . On arrival to the CCU, he reported only intermittent cough that is non-productive and buttock pain at the site of his sacral ulcerations. He denied shortness of breath, chest pain, nausea, vomiting, diarrhea, fevers, chills. He is a poor historian and could not comment further on prior history. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: HTN CHF COPD ?CVA obesity Social History: -Tobacco history: quit 40 yrs ago -ETOH: no -Illicit drugs: no -wife deceased, former truck driver, lives alone . Family History: NC Physical Exam: admission PE: VS: T=99.8 BP=125/56 HR=110 RR=22 O2 sat= 94% on 15L FM GENERAL: obese male in NAD. Oriented x2, drowsy but arousable. Mood, affect appropriate. Inattentive on questioning. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: RIJ in place, CVP transduced at 15. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Tachy, irreg, irreg, normal S1, S2. Unable to appreciate m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased BS b/l with few inspiratory crackles at the bases. ABDOMEN: Obese, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. No sacral edema. SKIN: 4 sacral decubitus/periscrotal ulcers - stage two, two unstagable. No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [**2128-10-28**] 04:01PM GLUCOSE-104 UREA N-21* CREAT-1.1 SODIUM-141 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-34* ANION GAP-11 [**2128-10-28**] 04:01PM estGFR-Using this [**2128-10-28**] 04:01PM CALCIUM-9.0 MAGNESIUM-2.9* [**2128-10-28**] 04:01PM VIT B12-845 FOLATE-17.1 [**2128-10-28**] 04:01PM %HbA1c-5.9 [**2128-10-28**] 04:01PM DIGOXIN-1.2 [**2128-10-28**] 04:01PM HCT-38.0* [**2128-10-28**] 04:01PM PTT-74.9* [**2128-11-2**] 08:19AM BLOOD WBC-9.0 RBC-4.64 Hgb-13.3* Hct-39.9* MCV-86 MCH-28.6 MCHC-33.4 RDW-14.7 Plt Ct-304 [**2128-11-2**] 08:19AM BLOOD Plt Ct-304 [**2128-11-2**] 08:19AM BLOOD PT-13.0 PTT-27.4 INR(PT)-1.1 [**2128-11-2**] 08:19AM BLOOD Glucose-98 UreaN-13 Creat-0.8 Na-144 K-4.6 Cl-103 HCO3-35* AnGap-11 [**2128-10-29**] 05:17AM BLOOD ALT-28 AST-22 LD(LDH)-226 AlkPhos-75 TotBili-0.5 [**2128-11-2**] 08:19AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.3 [**2128-10-28**] 04:01PM BLOOD VitB12-845 Folate-17.1 [**2128-10-30**] 02:20PM BLOOD %HbA1c-5.9 [**2128-10-30**] 12:25AM BLOOD Triglyc-192* HDL-23 CHOL/HD-8.3 LDLcalc-129 [**2128-11-2**] 02:30PM BLOOD Type-ART pO2-64* pCO2-63* pH-7.38 calTCO2-39* Base XS-8 [**2128-11-2**] 02:30PM BLOOD Lactate-1.4 [**2128-11-4**]: INR 1.1 CXR - [**11-2**]: FINDINGS: In comparison with the study of [**10-31**], there is little overall change. Continued moderate cardiomegaly with mild engorgement of pulmonary vessels. Progressive clearing of the left basilar atelectasis and effusion. Elevation of the right hemidiaphragm persists with atelectatic streaks in the right lower zone. ECHO: [**10-28**]: 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. There is normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. There is moderate/severe mitral valve prolapse. There is partial mitral leaflet flail. An eccentric, anteriorly directed jet of severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: Atrial fibrillation: Apparently new onset since [**2128-10-14**], however his most recent ECG prior to this was in [**2119**]. Also pt is a poor historian. This was likely precipited by his CHF exacerbation. After a TEE revealed no clot, he was DC cardioverted. He was rhythm control with an amiodarone load and rate controlled with metoprolol. He was anticoagulated with heparin gtt (CHADS 2, note unclear h/o CVA), and once he was determined not to be a current surgical candidate bridging with warfarin was undertaken. Titrate to INR 2.0 - 3.0. . Decompensated diastolic/systolic LV dysfunction: On presentation at OSH, nearly euvolemic here. The exact etiology of the exacerbation was not known. The most concerning precipitant is worsening mitral regurgitation, although may be precipitated by dietary or medication noncompliance or gut edema and poor absorbtion. TTE showed preserved systolic function. Given his severe MR there is a component of systolic dysfunction as well given his EF<60. No baseline TTE was available to determine progression of his LV dysfunction. His weight decreased by aprx 30 lb with furosemide gtt, and he was stabilized on his diuresis regimen with furosemide 60mg po QD. Afterload reduction with a goal SBP<120 was acheived with BB and ACEI (lisinopril). There was some element of Co2 retention with sedation, normalized now. As goal O2 sat is 88-90%, pt was weaned off O2 on day of discharge. . Mitral regurgitation: Most likely this is a chronic process. A history of RHD is not reported. No evidence of ischemic disease at OSH to suggest acute MR [**First Name (Titles) 767**] [**Last Name (Titles) 8546**] mm rupture, but he has not been evaluated in past. TEE shows no intracardiac thrombus. TEE revealed partial posterior mitral leaflet with severe eccentric mitral regurgitation. Patient was seen by CT surgery and deemed not to be a candidate at this time given AMS, hypercarbia, deconditioning. Dr. [**First Name (STitle) **] was contact[**Name (NI) **] and he decided to postpone Cardiac Catheterization until a time more proximal to his surgery. We will look into the mitral valve clip placement trial as a possible therapeutic alternative, though this was not immediately obvious as an option. . Preventative Medicine- His Lipid panel revealed(TC-190, LDL-130, TG-192, HDL??????23) His A1C-5.9 was. . Delirium: Most evenings Mr [**Known lastname 12667**] became disoriented and occasionally combative in the setting of acute illness. Likely ICU delirium vs. toxic metabolic cause exacerbated by sundowing. Mr [**Known lastname 12667**] [**Last Name (Titles) 53183**] poorly to zydis. Per sister, patient is independent at baseline. We attempted to regulate his sleep and wake cycle with seroquel QHS. RPR, B12, folate were all WNL. . Medications on Admission: home meds confirmed with outpt pharmacy: metoprolol succinate 50 mg daily furosemide 40 mg twice daily diltiazem 240 mg daily 20 meq KCL Po daily - on transfer amio ggt 20cc/hr lopressor 5 mg q4 IV heparin gtt lasix 20 mg gtt digoxin 250mcg IV daily aspirin 325mg po acetazolamide 250 [**Hospital1 **] colace 100mg [**Hospital1 **] omeprazole 40mg daily Potassium miconazole topical TID insulin SS albuterol/ipratropium nebs QID reglan prn Ativan prn bisacodyl prn Discharge Medications: 1. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day. 2. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Heparin (Porcine) in D5W Intravenous 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: TITRATE TO INR 2.0 - 3.0. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Lamisil AT 1 % Cream Sig: One (1) Topical twice a day. 8. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day. 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for aggitation. 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. vial 16. Outpatient Lab Work Please check INR daily until > 2.0 Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Acute on Chronic Diastolic congestive Heart Failure Atrial fibrillation with rapid ventricular response Acute Delerium Mitral Regurgitation Chronic Obstructive Pulmonary Disease Onychomycosis and Tinea Pedis Hypertension Discharge Condition: Alert, oriented x2, delerium is clearing 1 assist to chair, able to take a few steps. Discharge Instructions: You had an acute exacerbation of your congestive heart failure and needed to be treated with Furosemide intravenously and with increased pill doses. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet. You also had atrial fibrillation, an irregular heart rhythm that increases your risk of stroke. You were started on coumadin to prevent strokes and will stay on a heparin IV drip until the coumadin is therapeutic. You also became delerious in the hospital because you were sick. This should clear slowly once you get better. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 8577**] Date/Time: Please make an appt after you get out of rehabilitation . Cardiology: [**Last Name (LF) **],[**First Name3 (LF) **] A. Phone: [**Telephone/Fax (1) 23882**] Date/Time: Monday [**12-13**] at 10:30am. Completed by:[**2128-11-4**]

Admission Date: [**2132-10-7**] Discharge Date: [**2132-10-14**] Date of Birth: [**2054-12-31**] Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**First Name3 (LF) 2782**] Chief Complaint: sudden onset dyspnea Major Surgical or Invasive Procedure: Intubation x2 days; History of Present Illness: Mr. [**Known lastname 5057**] is a 77yo M with HTN, HL, COPD, and newly diagnosed NSCLC , now s/p his first round of chemotherapy. He was transferred to the [**Hospital1 18**] ED in the midst of a RBC transfusion when he developed sudden shortness of breath that was interpreted as a possible transfusion reaction. . He appears to have severe COPD caused by an extensive smoking history. He has poor exercise tolerance which has only worsened in the preceding months. Any exertion, including walking down the street, can cause increased RR and profound SOB. Albuterol can help stop these episodes. He has been pursed-lip breathing for years. He recently underwent TTE evaluation of his exercise intolerance, at which point a relatively large pericardial effusion with tamponade physiology was seen. He was admitted to the CCU [**9-2**]- [**9-6**] and underwent pericardiocentesis, which revealed malignant cells. He recently underwent his first chemo session with taxol for NSCLC. His oncologist is Dr. [**Last Name (STitle) 349**] at [**Location (un) 2274**]. . His fatigue and poor exercise tolerance persisted. He was found to be anemic to 25 and subsequently was brought to 7 [**Hospital Ward Name 1826**] for blood transfusion. Midway through the transfusion, he developed worsening SOB and increased RR. He thinks this episode was similar to his usual bouts of breathlessness, and he admittedly was upset with how long the transfusion was taking. Fearing a transfusion reaction, he was brought to the [**Hospital1 18**] ED for further evaluation. . In the ED, he was found to be tachycardic and tachypneic. Received 20mg IV lasix and underwent BiPAP trial, which was poorly tolerated. Of note, he continued to saturate in the upper90s on 3-4LNC, though remained tachypneic. A bedside echo was done which showed no pericardial effusion per the ED read. He was transferred to the MICU for concern of increased WOB. VS prior to transfer were 97.9 108 150/80 36 99/4L. . On arrival to the MICU, his intial VS were 96.5, 107, 153/63, 95 3LNC. He continues to purse-lip breath. He describes frequent episodes similar to his breathlessness on transfusion, which often pass after coughing or spitting. He otherwise feels well aside from fatigue. He notes no recent couging or cold-like smpyotms, no sore throat, fevers, chills, chest pains or pressure. He has lower extremity edema but no PND, orthopnea. No recent F/C. In the midst of our interview, he had the urge to urinate and abruptly stood to use his urinal- he developed respiratory distress with saturations dipping to the 80s and tachypnea to 50. This episode resolved with supplemental 02. He felt it was similar to the events surrounding his infusion. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Non-small cell lung cancer - squamous cell carcinoma, s/p MOHS - colonic polyps, last colonoscopy 1 year ago - COPD - gastritis - h/o gout - h/o nephrolithiasis - hypertension - Hyperlipidemia Social History: Lives with his wife in [**Location (un) **]. Retired hardware store owner. Has two boys, both live in [**State **], and one grandson. - Tobacco history: 97.5 pack-year history, still smokes 1.5 ppd - ETOH: 1 glass of wine/night - Illicit drugs: denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death - Mother: chronic leukemia, died at age 89 - Father: h/o MI, pancreatic cancer, died at age 69 Physical Exam: Admission Exam: Vitals: 96.5, 107, 153/63, 95 3LNC General: Alert, oriented, pursed-lip breathing in the 30s HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: diffuse wheezing heard throughout anterior and posterior lung fields. Fair air movement. No crackles or rhonchi. CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Abdominal musculature used in exhalation. GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema At the time of his discharge, the patient's vital signs were stable and he had O2 sats of 96% on 2L NC. While he continued to have wheezes with fair air movement on lung exam, there were no basilar crackles. THere was no edema or elevation of the JVP. The Foley had been removed. Pertinent Results: Admission Labs: [**2132-10-7**] 08:23PM URINE HOURS-RANDOM UREA N-679 CREAT-97 SODIUM-71 POTASSIUM-81 CHLORIDE-86 [**2132-10-7**] 08:23PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2132-10-7**] 08:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2132-10-7**] 08:23PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2132-10-7**] 08:23PM URINE GRANULAR-2* HYALINE-14* [**2132-10-7**] 08:23PM URINE MUCOUS-RARE [**2132-10-7**] 06:36PM LACTATE-1.3 [**2132-10-7**] 06:30PM GLUCOSE-124* UREA N-30* CREAT-1.5* SODIUM-141 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17 [**2132-10-7**] 06:30PM estGFR-Using this [**2132-10-7**] 06:30PM LD(LDH)-395* CK(CPK)-115 TOT BILI-0.8 [**2132-10-7**] 06:30PM cTropnT-1.00* [**2132-10-7**] 06:30PM CK-MB-5 proBNP-[**Numeric Identifier 91421**]* [**2132-10-7**] 06:30PM IRON-83 [**2132-10-7**] 06:30PM WBC-3.2*# RBC-2.79*# HGB-9.1*# HCT-25.2*# MCV-90# MCH-32.7* MCHC-36.2* RDW-20.8* [**2132-10-7**] 06:30PM NEUTS-22* BANDS-2 LYMPHS-47* MONOS-19* EOS-7* BASOS-1 ATYPS-0 METAS-0 MYELOS-2* NUC RBCS-3* [**2132-10-7**] 06:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-1+ SCHISTOCY-2+ BITE-1+ ACANTHOCY-1+ [**2132-10-7**] 06:30PM PLT SMR-LOW PLT COUNT-132* [**2132-10-7**] 06:30PM PT-17.8* PTT-26.5 INR(PT)-1.6* Notable Labs: [**2132-10-9**] 05:15AM BLOOD FDP-40-80* [**2132-10-7**] 06:30PM BLOOD cTropnT-1.00* [**2132-10-8**] 04:41AM BLOOD CK-MB-6 cTropnT-0.99* [**2132-10-8**] 05:24PM BLOOD CK-MB-5 cTropnT-0.65* [**2132-10-7**] 06:30PM BLOOD calTIBC-257* Hapto-<5* Ferritn-590* TRF-198* [**2132-10-7**] 06:36PM BLOOD Lactate-1.3 EKG [**2132-10-7**]: Sinus tachycardia. Left axis deviation. Right bundle-branch block. Probable small R waves in leads II, III and aVF but consider prior inferior myocardial infarction. ST-T wave abnormalities. Low precordial voltage. Compared to the previous tracing of [**2132-9-3**] the rate is faster. ST-T wave abnormalities are more prominent. Precordial voltage is less prominent. Clinical correlation is suggested CXR [**2132-10-7**]: 1. Moderate enlargement of the cardiac silhouette, similar compared to the prior PET-CT. 2. Dilated and tortuous ascending thoracic aorta. 3. Patchy opacities within the lung bases, which could reflect atelectasis, infection, or aspiration. 4. Known spiculated nodule in the right upper lobe is better appreciated on the recent PET CT. TTE [**2132-10-8**]: The left atrium is elongated. The right atrium is markedly dilated. The estimated right atrial pressure is 5-10 mmHg. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 40-45 %). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-13**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-13**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Mild global left and right ventricular hypokinesis. Mild to moderate mitral regurgitation. Mild to moderate aortic regurgitation. Very small pericardial effusion. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2132-9-6**], biventricular function is now impaired. Valvular regurgitation is now apparent (previous study was focused). Pulmonary hypertension is identified. . Labs on Discharge: [**2132-10-14**] 09:45AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.8* Hct-31.2* MCV-99* MCH-31.2 MCHC-31.6 RDW-20.8* Plt Ct-135* [**2132-10-14**] 09:45AM BLOOD Plt Ct-135* [**2132-10-14**] 09:45AM BLOOD Glucose-131* UreaN-45* Creat-1.3* Na-143 K-3.7 Cl-99 HCO3-34* AnGap-14 [**2132-10-14**] 09:45AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8 Brief Hospital Course: Mr. [**Known lastname 5057**] is a 77yoM with COPD, HTN, HLD, and a recent hospitalization for cardiac tamponade who presents from [**Hospital Ward Name **] 7 transfusion unit with acute SOB during transfusion. 1. ACUTE HYPOXIC RESPIRATORY FAILURE: --PNEUMONIA and ACUTE SYSTOLIC CHF: He developed acute shortness of breath early into his blood transfusion which he was receiving for anemia. Transfusion reaction/TRALI was initially suspected though he lacked severe pulmonary edema or hypoxia to support this diagnosis. He was admitted to the MICU due to apparent increased WOB, and was briefly tried on BiPAP in the ED despite normal saturations. Tamponade was ruled out with US in ED. He initially was stable on room air with saturations in the 90s upon admission to the ICU. He related numerous similar episodes of shortness of breath at home and related a progressive worsening of his overall respiratory status and exercise stamina over the preceding months. His CXR showed mild edema and RLL haziness. Widespread wheezing prompted treatment for COPD exacerbation. He decompensated quickly in the unit after getting agitated during a foley adjustment. He desaturated to the 70s-80s and had an increased WOB refractory to nebs, lasix, and NRB. He was urgently intubated. The cause of his decompensation was felt to be multifactorial. He had a trop of 1.00 on admission with flat CK/MB, but new LAD-distributed TWI on EKG, and new onset systolic dysfunction with EF to 40-45% on TTE (new since last month). A cardiac event could have potentially caused his deterioration and CHF exacerbation. Pneumonia was possible based on his RLL infiltrate, and he was treated for HCAP with vanco/cefepime/levaquin. Sputum culture revealed commensal resp flora and sparse GNR. He was started on nebs and steroids for possible COPD exacerbation as well,though these were quickly tapered due to suspicion for more of a CHF etiology. He was aggressively diuresed. He was extubated on [**2132-10-9**] and transfered to the floor on [**2132-10-10**]. . On the floor he was initially saturating in the 90's on 4L NC. He continued to be diuresed gently with PO and occasional IV lasix. His oxygen was weaned as tolerated with a goal of 02 sat of 92%. His steroids were discontinued on [**2132-10-13**] as the etiology of his SOB was thought to be related to pulmonary edema and a possible pneumonia rather than a COPD exacerbation. His vancomycin was discontinued based on sputum data and cefepime and levaquin were continued until further speciation was available. His nebulizers were continued throughout his hospital stay. On the day prior to discharge, cefipime was discontinued as the patient had remained afebrile and without leukocytosis; prednisone was also discontinued since COPD flare appears to not have been the primary etiology of SOB and his symptoms were resolving. PT was consulted and worked with the patient on improving functional status. He was discharged home with home PT services, home 02, and cardiac telemonitoring. . 2)NSTEMI: His troponin elevation to 1.00 is without any similar MB or CK elevation. He had some nonspecific lateral T wave changes, but no chst pain or pressure to suggest ACS. TTE revealed new onset systolic dysfunction with EF 45-50%. Cardiology was consulted, who felt that the chemotherapy (taxol/cisplatin) is not likely to blame and that he had a recent MI. Based on EKG and echo data, there was a possible partial occlusion in the LAD and that the patient may benefit from elective cathetrization. However, based on the absence of symptoms and the comorbidities in the patient, oncology, medicine and the patient's family were in agreement with medical management. On [**2132-10-12**] the patient had an 8 beat run of v-tach. An EKG was essentially unchanged and troponins showed a continued downward trend. . 3. ANEMIA: HCT to 25 of unclear source, though inflammatory disease from malignancy or myelosupression from chemo are both possible. Though his hematrocrit trended downwards in the days prior to discharge, a transfusion was not thought to be necessary by cardiology (goal 25). . 4. NON SMALL CELL LUNG CANCER: currently undergoing taxol chemo; will resume as outpatient. Atrius oncology service followed while the patient was in house. 5. HYPERTENSION: The patient had recently been taken off his dose of 20 mg linisnopril QAM due to low blood pressures. Based on his new diagnosis of CHF, lisinopril was restarted at a dose of 10 mg QAM; his blood pressures remained stable with systolics greater than 110 while in house. . 6. GOUT: Allopurinol and colchicine were continued, this was not an active issue on this admission. Medications on Admission: 1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation q4-6 hours as needed for SOB, wheezing. 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Spray Inhalation twice a day. 4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation once a day. Disp:*30 capsules* Refills:*2* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-13**] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Home Oxygen 1-4 liters per minute continuous oxygen via nasal cannula [**Male First Name (un) **]: 99 months Diagnosis: COPD 11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 1 doses. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Congestive Heart Failure, Possible Pneumonia, COPD, Non-Small Cell Lung Cancer, Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker). Discharge Instructions: Dear Mr. [**Known lastname 5057**], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the medical ICU after presenting to the emergency department for acute onset shortness of breath during a blood transfusion. A reaction to the blood transfusion itself was ruled out. A chest xray showed possible signs of a pneumomia and you were started on broad spectrum antibiotics. It is possible that yoru COPD was contributing to your shortness of breath and you were also given a steroid as well as your usual inhalers. In the MICU you had a second acute episode of shortness of breath that was not responsive to oxygen. Because of your worsening respiratory status you were intubated (given a breathing tube). Laboratory results and an EKG suggested that you may have had a heart attack prior to the hospitalization. An echo cardiogram showed that you had a new onset of congestive heart failure (CHF). It is likely that your shortness of breath was due to too much volume backing up in your lungs. You were given lasix to help reduce the volume in your lungs and your respiratory status improved to the point that you were extubated (breathing tube was removed) two days after you were intubated. Cardiology was consulted to help with your care and suggested the possibility of a cardiac cathetrization to look at the vessels of your heart. However, along with your oncolgy team, it was determined to be best to try to manage your heart disease with medical management. Due to your continued improvement you were transferred to the general medical floor where we continued to monitor your respiratory status and give you lasix to manage your fluid balance. Your steroids were stopped on the medical floor and the medicines for your pneumonia were narrowed to treat the most likely organism. Your regular inhalers were continued. We followed your blood counts throughout your stay and it was not deemed necessary to transfuse additional blood at this time. You will return home with home nursing, oxygen, and physical therapy services. You should keep your oxygen saturation bewteen 88-92% and should use 3L of oxygen when active. You will also have cardiac telemonitoring to assist with monitoring your daily weights and blood pressures. The results of this will automitically be sent to Dr.[**Name (NI) 17793**] office. You should resume the medicines you were previously taking at home with the following changes: START: lisinopril 10 mg QD (daily) START: lasix 20 mg PO (by mouth) QD START: atorvastatin 80 PO QD START: Spiriva 1 puff [**Hospital1 **] (twice daily) CONTINUE: Levofloxacin 750 mg x1 dose ([**10-16**]) Followup Instructions: Please follow up with the appointments below after your discharge from the hospital: Name: [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **], NP Specialty: Internal Medicine When: Tuesday [**10-21**] at 9:30am Location: [**Location (un) 2274**]-[**University/College **] Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**] Phone: [**Telephone/Fax (1) 17530**] Dr. [**Last Name (STitle) **] is out of the office next week so you will see his nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **] at this visit. Name: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**], MD Specialty: Hematology/Oncology When: Thursday [**10-23**] at 1:30p Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] Name: [**Doctor First Name 30513**] [**Doctor First Name 88276**], PA Specialty: Cardiology When: Wednesday [**10-29**] at 11:30am Location: [**Hospital1 641**] Address: [**Hospital1 **], [**University/College **], [**Numeric Identifier **] Phone: [**Telephone/Fax (1) 72622**] You will see Dr. [**Last Name (STitle) 91422**] physicians assistant [**First Name5 (NamePattern1) 30513**] [**Last Name (NamePattern1) 88276**] at this visit. Completed by:[**2132-10-15**]

Admission Date: [**2141-2-23**] Discharge Date: [**2141-3-2**] Date of Birth: [**2063-3-10**] Sex: M Service: CARDIOTHOR The anticipated date of discharge is [**2141-3-3**]. This dictation is done for the Cardiothoracic Service. REASON FOR ADMISSION: The patient is a postoperative admit directly to the Operating Room on [**2-24**] for an aortic valve replacement and coronary artery bypass graft. The patient was seen on [**12-16**] during a hospital admission for a cardiac catheterization by the Cardiothoracic Surgery Service and his surgery was scheduled for [**2-24**] at that time. At the time that the patient was initially seen, his history and physical is as follows: CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: Asked by Dr. [**Last Name (STitle) **] to see this 77 year old man with a history of aortic stenosis. The patient is morbidly obese with long standing hypertension and a history of only mild dyspnea on exertion without chest pain. No rest symptoms. The patient with severe bilateral venous stasis currently on diuretics. No history of congestive heart failure per the patient. Recently, he stopped his diuretics. Serial echocardiograms have shown increasing severity of aortic stenosis. He was admitted to [**Hospital1 190**] in [**2140-1-13**] for a cardiac catheterization. PAST MEDICAL HISTORY: 1. Hypertension. 2. Aortic stenosis. 3. Morbid obesity. 4. Tobacco use. 5. Venous stasis ulcers. PAST SURGICAL HISTORY: 1. Status post left cataract surgery. 2. Status post tonsillectomy. 3. Status post varicocele surgery. MEDICATIONS: 1. Lisinopril 40 mg q. day. 2. Spironolactone 25 mg q. day versus twice a day. ALLERGIES: Norvasc, which causes increasing lower extremity edema. SOCIAL HISTORY: Tobacco use is remote; discontinued 40 years ago. Positive ETOH use; decreased per report by wife over the last four years. PHYSICAL EXAMINATION: Height is 5'[**47**]"; weight 310 pounds. Heart rate 68 and in sinus rhythm; blood pressure 146/60; respiratory rate 20; O2 saturation 99% on room air. In general, an obese man with severely draining venous stasis ulcers in no acute distress. HEENT: Anicteric, noninjected. Extraocular movements intact. Neck is supple with no jugular venous distention, no lymphadenopathy and no bruits. Oropharynx is clear. Cardiovascular is regular rate and rhythm with a III/VI perisystolic murmur at the left sternal border. Lungs clear to auscultation bilaterally. Abdomen is soft, obese, nontender. Bilateral tinea of the groins. Extremities with bilateral venous stasis changes to just below the knees. Ulcers with clear to green drainage on the lateral right and medial left. Pulses: Carotids two plus bilaterally, radial two plus bilaterally, femoral - left is the catheterization site; the right is two plus. Popliteal two plus bilaterally dorsalis pedis and posterior tibial, both two plus bilaterally. Neurological: Motor and sensory is grossly intact. Cranial nerves II through XII grossly intact. LABORATORY: Data is white blood cell count 9.3, hematocrit 33.9, platelets 288. Sodium 136, potassium 4.7, chloride 100, carbon dioxide 30, BUN 23, creatinine 1.1. INR was 1.3. EKG was sinus rhythm with left ventricular hypertrophy, nonspecific ST-T wave changes in leads 5 and 6. Echocardiogram with concentric left ventricular hypertrophy, severely dilated left atrium with an ejection fraction of 75%. Mild resting LVOT obstruction. Catheterization showed 50% left main, 20% ostial right coronary artery, 40% diagonal, aortic valve area 1.3 centimeters squared. The patient was discharged to home following his catheterization for further treatment of his venous stasis ulcers and an appointment with Vascular Surgery for follow-up regarding lower extremity ulcers. HOSPITAL COURSE: He returned on [**2-23**] where he was admitted directly to the Operating Room. At that time, he underwent an aortic valve replacement with a #23 tissue valve and coronary artery bypass graft times one with the left internal mammary artery to the left anterior descending. Please see the Operating Room report for full details. The patient tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had a heart rate of 91. He was a-paced with a mean arterial pressure of 65 and a central venous pressure of 10. He had Levophed at 0.12 mics per kg per minute and Propofol at 20 mics per kg per minute. In the immediate postoperative period, the patient experienced a labile blood pressure. A transesophageal echocardiogram was performed at the bedside which showed some systolic anterior motion. His Levophed and Neo-Synephrine were weaned to off and he was given volume. The patient did well hemodynamically following these maneuvers. Then, his anesthesia was reversed. He was weaned from the ventilator and successfully extubated. He remained hemodynamically stable throughout the night of his surgery and on postoperative day one DICTATION ENDS [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2141-3-2**] 18:39 T: [**2141-3-2**] 21:01 JOB#: [**Job Number 22266**]

Admission Date: [**2152-5-3**] Discharge Date: [**2152-5-25**] Date of Birth: [**2086-8-10**] Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin / Iodine-Iodine Containing / Coreg / Rosuvastatin / metronidazole / alendronate sodium / simvastatin / Ezetimibe / risedronate sodium / Vitamin D Attending:[**Last Name (NamePattern1) 1572**] Chief Complaint: Anticoagulation with heparin for colonoscopy Major Surgical or Invasive Procedure: Elective colonoscopy on [**2152-5-5**] (with MAC) Colonoscopy on [**2152-5-9**] Colonoscopy on [**2152-5-12**] History of Present Illness: 65 yo F pt with hx of rheumatic heart disease s/p mitral valve replacement ([**Doctor Last Name 1395**]-[**Doctor Last Name **] metallic prosthesis) [**2104**], complicated by diastolic dysfunction, mild stenosis,paravalvular leak prone to occasional heart failure and mild hypotension admitted for an elective colonoscopy with need for MAC anestheisa and heparin bridging. Pt has never had a colonoscopy. She recently had a (+) blood test for colon cancer last week, done by Quest (Colovantage). Patient denies any recent weight loss, night sweats, fevers, chills, melena, BRBPR, diarrhea, constipation. Patient has mild SOB at baseline. GI are planning to perform colonscopy on [**Year (4 digits) 2974**]. Pt's last dose of coumadin was Sunday. She will also need SBE prophylaxis as per her primary cardiologst (although guidelines don't say it is necessary, he recognizes this and would like to err on the side of caution). . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, chest pain or tightness, palpitations. Denied nausea, vomiting, or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. . Past Medical History: 1. Rheumatic heart disease status post mitral valve replacement with a [**Doctor Last Name 1395**]-[**Doctor Last Name **] metallic prosthesis in [**2104**]. 2. Congestive heart failure - ECHO in [**6-28**] EF 50-55% mitral insuffiency 3. Chronic atrial fibrillation. 4. Hypertension 4. HLD 5. Carotid stenosis 6. Vitamin D deficiency 7. Borderline diabetes, not on medications. 8. Anemia, on iron supplements. 9. Spontaneous hemarthroses in right knee in [**2150-7-21**], [**2150-8-19**], [**10-27**] 10. Osteoarthritis of the knees 11. Migraine headaches 12. Allergic rhinitis . Past Surgical History: 1. Mitral valve replacement [**2104**] 2. CCY for gallstones [**2108**] 3. Tubal ligation in [**2110**] Social History: The patient lives with her husband. She is a nonsmoker (she quit smoking in [**2114**]). She does not drink alcohol. Denies IVDU. Family History: FHx negative for premature coronary artery disease or sudden cardiac death. She does mention that one of her uncles had a heart condition at an older age as well as her mother who had a valve problem in her 50s, but she eventually passed away at the age of 96. Physical Exam: Physical Exam: Vitals: T: 96.3 BP: 119/62 P: 80 irreg irreg; R: 22 O2: 96 RA General: Alert, oriented, no acute distress. Pleasant woman. HEENT: Sclera anicteric, MMM, oropharynx clear skin warm smooth and dry. Neck: supple, JVP elevated with prominent V wave height 12.5 cm. Carotids 2+ equal without bruit. Chest: Clear to auscultation bilaterally, no wheezes, fine dry atelectatic rales at both bases about 1/4 up.Left parascapular thoracotomy scar. CV: Irregularly irregular rate and rhythm, normal S1 + S2, Gr [**1-23**] hololsystolic murmur loudest in midaxillary line 5th ICS, Gr 2/6 SEM at RUSB, no rubs or gallops, prominent parasternal RV lift. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, 13 cm liver, 3 FB's below the costal margin, pulsatile. Cholecystectomy scar. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+ pedal medial malleolar and some pretibial edema. Neuro: Normal muscle tone, moves all extremities bilaterally, reflexes 2+ UE and LE bilaterally, toes downgoing bilaterally. CNI: not tested, CNII: PERRLA 4mm to 2mm bilaterally. CNIII, IV, VI: EOMI. CN VII: Facial muscles intact. CN VIII: Intact bilaterally CNIX,X: Palate elevates symmetrically. CNXI: Intact CNXII: Tongue protrudes midline. Gait: normal. Pertinent Results: Admission labs: [**2152-5-3**] 09:45PM WBC-3.2* RBC-4.03* HGB-11.6* HCT-34.8* MCV-87 MCH-28.9 MCHC-33.4 RDW-14.4 [**2152-5-3**] 09:45PM PT-21.1* PTT-150* INR(PT)-1.9* [**2152-5-4**] 05:15AM BLOOD Glucose-86 UreaN-38* Creat-1.2* Na-142 K-4.3 Cl-106 HCO3-26 AnGap-14 [**2152-5-4**] 05:15AM BLOOD ALT-31 AST-52* LD(LDH)-340* AlkPhos-117* TotBili-1.0 [**2152-5-4**] 02:55AM BLOOD proBNP-2791* [**2152-5-4**] 05:15AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9 Iron-112 [**2152-5-4**] 05:15AM BLOOD calTIBC-295 VitB12-1741* Folate-GREATER TH Hapto-<5* Ferritn-117 TRF-227 . Imaging: ECHO [**2152-5-4**]: IMPRESSION: Normal left ventricular function. Ball and cage mitral prosthesis with normal gradient and at least mild mitral regurgitation. Dilated and hypokinetic right ventricle with severe tricuspid regurgitation and moderate pulmonary hypertension. Mild aortic regurgitation. Biatrial dilatation with the right atrium being markedly dilated. . Splenic US [**2152-5-5**]: FINDINGS: Transverse and sagittal images were obtained of the spleen. The spleen is enlarged measuring 16.2 cm. The splenic appearance is unremarkable. No ascites is seen in the left upper quadrant. IMPRESSION: Splenomegaly. . Colonoscopy [**2152-5-5**]: Impression: Polyp in the proximal ascending colon (polypectomy) Otherwise normal colonoscopy to cecum. . Colonoscopy [**2152-5-9**]: Impression: There was blood throughout the colon making visualization difficult. The mucosa was not examined. There was a large blood clot in the proximal ascending colon at the site of prior polypectomy. There was a clip buried within the clot. The area was washed extensively but the clot could not be removed. Biopsy forceps were used to try to remove the clot but this was not successful. There was erythema and active oozing seen at the superior aspect of the clot. (endoclip, injection) . Colonoscopy [**2152-5-12**]: Impression:Blood in the colon The polypectomy site was identified by presence of clips. An adherent clot was noted adjacent to the clips. Fresh bleeding was noted from the base. The clot was removed by wash and suction. A small visible vessel was noted. Three clips were applied with successful hemostasis. 5 cc of epinephrine was injected into the mucosa for hemostasis. The rest of the colon was not fully examined. Otherwise normal colonoscopy to cecum. Polyp described as serrated adenoma requiring repeat colonoscopy in 5 years given increased risk of finding of serrated polyp. Discharge Labs: Brief Hospital Course: 65 yo F pt with hx of rheumatic heart disease at age 7, s/p mitral valve replacement ([**Doctor Last Name 1395**]-[**Doctor Last Name **] mechanical prosthesis) [**2104**], complicated by mitral insufficiency, ? ball variance/and or paravalvular leak, pulmonary hypertension and RV failure,tricuspid insufficiency and normal LV function, admitted for an elective colonoscopy with need for MAC anesthesia and heparin bridging. . # Positive Colovantage test: Patient has not undergone routine screening colonoscopy however she underwent the Colovantage testing which came back as positive on [**2152-4-12**], indicating that she has increased likelihood of colorectal cancer. She was admitted for IV heparin bridge due to her mechanical valve (pt must be anticoagulated; at high risk for thrombus) starting [**12-23**] days after discontinuing her coumadin (stopped on [**4-30**]). Colonoscopy performed on [**5-5**] under MAC anesthesia with removal of a single sessile polyp in the ascending colon. Post procedure her stay was complicated by bleeding, see below. . #Loose bloody stools: On [**5-7**], patient experienced loose stools mixed with blood. Her coumadin was held, heparin initially continued. Hct started to fall on [**5-8**] to 25 and she was given 2 units RBCs. Heparin was stopped and she was reprepped for a colonscopy (#2). She remained hemodynamically stable. On [**5-9**], a large clot was visualized at the polypectomy site which could not be evacuated, so additional clips were placed along with epinephrine. Heparin was restarted after procedure. However, on [**2152-5-11**], patient's hct dropped to 28 and patient experienced increased bloody stools. Patient received one more unit RBCs and heparin was dc'd for 6 hrs. She was repreped for a repeat scope that was done on [**2152-5-12**]. The clot was removed and more clips were placed and epi injected. Post procedure her hct remained stable. . # Mechanical Mitral Valve: Patient is s/p mitral valve replacement ([**Doctor Last Name 1395**] [**Doctor Last Name **] valve) for mitral stenosis/atrial fibrillation in [**2104**]. Patient was admitted for heparin bridge for her procedure. She was given SBE prophylaxis (clindamycin 600mg IV) with her procedures. Her home coumadin was initially restarted on [**5-5**], but it was dc'd on [**5-7**] due to bloody bowel movements. For her bleeding episodes as stated above her heparin was stopped at given intervals. Her coumadin was restarted on [**2152-5-15**]. She had increasing warfarin requirement from her usual dose of 5.5 mg with slow rise in INR until therapeutic plateau (2.3) was reached with 8 mg of warfarin Q PM likely related to increase in PO nutrients supplemented with Boost. She may need less warfarin as she returns to her usual home diet. She was bridged with heparin until [**2152-5-25**]. . # CHF: Patient had an ECHO in [**2151-6-20**] with a EF of 50-55% and moderate to severe tricuspid regurgitation and pulm artery htn noted. CXR on [**2152-4-12**] performed by her cardiologist revealed probable small left pleural effusion, no evidence of CHF; BNP was 218 on [**2152-4-12**]. Patient presents volume overloaded with systolic ejection murmur; repeat ECHO essentially unchanged from [**6-/2151**], worsening pulm htn. Pro-BNP elevated to 2791 on [**5-4**]. Her home medications, including nebivolol, valsartan, and diltiazem were discontinued in setting of bleed so that symptoms of blood loss would not be masked. Transfusions were performed slowly over 4 hours in order to not fluid overload. Patient was without an oxygen requirement and clear lungs throughout the hospitalization. In the ICU, home diltiazem was restarted and tolerated well. . #Splenomegaly/pancytopenia: Patient presented with thrombocytopenia on admission labs (plts 79); unclear etiology (heme had low suspicion for HIT). Per outpt cardiology records, patient's platelets were 129 on [**2152-4-12**]. Patient's anemia [**12-22**] hemolysis from mechanical valve (LDH elevated, low haptoglobin). Splenic ultrasound shows splenomegaly; heme will likely perform outpt BM bx. Valsartan can be associated with leukopenia; further investigation revealed that pt had a cough with ace-inhibitor. No ACE or [**Last Name (un) **] was rx'd pending consultation i f/u with Dr. [**Last Name (STitle) **]. Will also follow up with heme-onc as outpatient. . #Atrial fibrillation: Patient is rate controlled with diltiazem, nebivolol; anticoagulated with heparin (was on coumadin) while in house. During colonoscopy, pt had episode of AFib with RVR, and required a dose of esmolol. She was transferred to the ICU for overnight monitoring. In the ICU, home regimen of diltiazem was restarted. On a dose of Dilt ER without beta blocker her ambulatory HR was 120-130. Dilt ER was increased to 180 PO daily with excellent rate control, never greater than 90. While febrile to 99.6 on the day of discharge peak rate over 12 hrs was 114. Patient was successfully bridged back to coumadin with discharge INR of 2.3. . #Fever: the day prior to discharge, [**2152-5-24**], the patient had a low-grade temperature to 100.4. She felt well, without cough, diarrhea, abdominal pain or dysuria. A urinalysis was negative. Abdomen was benign on exam and she was eating and drinking normally. The day of disharge she had a temperature of 99.6 at 12pm. She was counseled to continue monitoring her temperature at home and call her primary care doctor with any new symptoms. No antibiotics were started. She has close follow-up with Dr. [**Last Name (STitle) **]. . #Difficult to crossmatch blood: Patient required several transfusions and was difficult to crossmatch. Further investigation by the blood bank revealed a new clinically significant alloantibody, anti-E. The patient was notified of this new finding and is to carry this information with her. A card describing this finding will be issued by pathology. . # HTN: Patient is stable on her home medications. No hypertension was recorded. . #Transition of care: She will need close monitoring of her INR after discharge and follow up for blood loss. She should have a hematocrit checked after discharge. She should also have heart failure medications re-evaluated and restarted. Unclear why she is on nebivolol rather than carvedilol. Some concern as to whether Valsartan is causing pancytopenia and may want to consider restarting ACE inhibitor instead of Valsartan. She has a hematology/oncology appointment to evaluate her pancytopenia. Medications on Admission: Home Medications (reconciled with Dr. [**Last Name (STitle) **]: Valsartan 160 mg once daily Diltiazem 120mg once daily Furosemide 20mg once daily Coumadin 5.5mg daily Nebivolol 10mg 1 tablet once daily Iron 325 mg 1 tablet twice a day Calcium citrate 600mg +400 iu 1 tablet twice a day Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). Disp:*30 Capsule, Extended Release(s)* Refills:*2* 3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 5. warfarin 8 mg PO once a day: Dose to be adjusted per Dr. [**Last Name (STitle) **]. 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Elective colonoscopy Secondary Diagnosis: s/p mitral valve replacement [**Doctor Last Name 1395**] [**Doctor Last Name **] mechanical prosthesis diastolic CHF RV failure secondary to Pulmonary Hypertension Mitral insufficiency Atrial fibrillation,chronic Transfusion reaction alloantibody Anti E. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a planned colonoscopy to follow up a positive Colovantage colon cancer screen. You required heparin while you were not taking Coumadin because of your mechanical mitral valve. During your colonoscopy on [**2152-5-5**] a polyp was removed and you started to bleed from your colon. This required two additional colonoscopies [**2152-5-9**] and [**2152-5-12**] to stop the bleeding. After the bleeding stopped, you were able to start your Coumadin again [**2152-5-15**] to get you back close to your goal INR 2.5-3.5. You were very patient and we were able to get you close to you goal INR 2.3 with your Coumadin before leaving the hospital. You will need to have you INR closely followed. You should have your INR checked [**2152-5-26**] at 1pm with Dr. [**Last Name (STitle) **] and continue follow up with him. Your temperature was slightly elevated at 100.4 on [**2152-5-25**], but you had no symptoms of feeling unwell. It will be important for you to continue to check your temperature. If you begin to feel unwell please follow up with your primary care doctor or nearest emergency department. . Please go to all your follow up appointments. If you see any evidence of bleeding please contact your primary care physician immediately or go to your nearest ED. Also you have congestive heart failure that causes you to hold on to water in your legs. If you notice increased swelling in your legs or an increase in your weight please contact your primary care doctor or cardiologist. You nebivolol and valsartan were stopped. Please discuss with your cardiologist what medications you should resume for your congestive heart failure. Please follow-up with hematology for follow-up of your low blood counts and possible bone marrow biopsy. . Changes were made to your medications. Please: - STOP Bystolic (nebivolol) - increase diltiazem to 180mg daily - increase warfarin (Coumadin) to 8mg daily (4 x 2mg tablets) - STOP valsartan for now. Dr. [**Last Name (STitle) **] may want to restart this medication in the future. Followup Instructions: Name: [**Last Name (LF) 7726**],[**First Name3 (LF) 177**] A. Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 7728**] Appt: [**Last Name (LF) 2974**], [**4-26**] at 1pm Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2152-6-7**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], 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 Completed by:[**2152-5-25**]

Admission Date: [**2154-11-14**] Discharge Date: [**2154-11-24**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Erythromycin Base / Lactose Intolerance Attending:[**First Name3 (LF) 11217**] Chief Complaint: fever and cough Major Surgical or Invasive Procedure: Left Midline placed [**11-22**] History of Present Illness: Ms. [**Known lastname 31102**] is a [**Age over 90 **] yo with h/o COPD and aspiration pneumonia who was noted to have a cough over past several weeks. She saw her PCP and was started on mucinex and robitussin. She was doing well until day of admission at 1 pm when she had the onset of nonbloody nonbilious emesis x 3. Her home nurse noted a fever to 101.2, HR of 140, and that the patient's "lungs weren't so good" today. For this reason, the patient was brought in by ambulance. Here, the patient was found to be satting 97%4L and low 90s on 2 L. Her baseline is 93% on 2L). CXR showed RLL infiltrate. Of note, she has been at baseline wit her activities, helping with cooking even on the day prior to admission. . In the ED, the patient was given Ipratropium Neb, Albuterol 0.083% Neb, CefTRIAXone 1g, Metronidazole 500mg, and MethylPREDNISolone 125mg for ? COPD. Blood and urine cultures were obtained. . ROS: no chest pain, dysuria, or frequency. + weight loss Past Medical History: 1) Diabetes mellitus (Hgb A1C 5.8% in [**2-8**]) 2) Frequent UTI 3) Gastroesophageal reflux disease 4) S/p CVA w/residual mild R hemiparesis 5) Osteoporosis 6) Mild cognitive impairment 7) Depression/Anxiety 8) Osteoarthritis 9) Hypothyroidism (last TSH 2.8 in [**11-7**]) 10) Chronic diarrhea 11) COPD, on night O2 at home (FEV1 0.88 (73% pred), FVC 1.2, elevated EV1/VC ratio in [**1-6**]), no prior intubations, was placed on steroid taper at last admission in [**3-11**]. Social History: Smoked 2ppd until [**2131**]. [**2-4**] glass of wine 3-4x/week. Worked as a secretary. Independent with ADLs, not IADL. Has 24 hour caretaker. [**Name (NI) **] (daughter) is the Healthcare proxy. Pt confirmed FULL CODE. Family History: non-contributory Physical Exam: Vitals: T96 BP 150-180/62-69 P 68-73 R 20 sat 97%RA, 93%4LNC Gen: elderly cachectic female sitting in bed at 60 degrees, sleepy but awakens with difficulty, NAD HEENT: NCAT, sclerae anicteric/noninjected, EOMI, PERRL, OP clear, uvula midline, dry MM Neck: JVP 8 cm, no HJR, no LAD, no thyromegaly, no carotid bruits CV: distant heart sounds, nl S1/S2, no m/r/g noted Lungs: decreased breath sounds at the bases, otherwise CTA Ab: soft, NTND, NABS, no HSM by percussion, no rebound or guarding Extrem: wwp, no c/c/e Neuro: MAFE Skin: no rashes Pertinent Results: [**2154-11-14**] 08:25PM BLOOD WBC-24.5*# RBC-3.75* Hgb-12.6 Hct-36.8 MCV-98 MCH-33.6* MCHC-34.3 RDW-14.9 Plt Ct-350 [**2154-11-17**] 04:11AM BLOOD WBC-10.6 RBC-3.19* Hgb-10.6* Hct-31.4* MCV-99* MCH-33.1* MCHC-33.6 RDW-15.1 Plt Ct-257 [**2154-11-22**] 08:45AM BLOOD WBC-13.5* RBC-3.86* Hgb-12.5 Hct-37.9 MCV-98 MCH-32.5* MCHC-33.1 RDW-15.4 Plt Ct-349 [**2154-11-14**] 08:25PM BLOOD Neuts-88* Bands-0 Lymphs-7* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2154-11-16**] 06:25AM BLOOD Neuts-93.5* Bands-0 Lymphs-4.8* Monos-1.4* Eos-0.1 Baso-0.1 [**2154-11-16**] 06:25AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-OCCASIONAL Burr-1+ Stipple-1+ Tear Dr[**Last Name (STitle) **]1+ [**2154-11-14**] 09:15PM BLOOD Glucose-210* UreaN-35* Creat-1.4* Na-140 K-5.1 Cl-105 HCO3-23 AnGap-17 [**2154-11-18**] 03:33AM BLOOD Glucose-53* UreaN-41* Creat-0.9 Na-152* K-3.7 Cl-119* HCO3-23 AnGap-14 [**2154-11-21**] 05:20AM BLOOD Glucose-60* UreaN-31* Creat-0.9 Na-142 K-3.9 Cl-105 HCO3-25 AnGap-16 [**2154-11-15**] 11:25AM BLOOD ALT-36 AST-30 LD(LDH)-204 AlkPhos-109 Amylase-55 TotBili-0.3 [**2154-11-15**] 11:25AM BLOOD Lipase-12 [**2154-11-18**] 08:09PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2154-11-19**] 03:35AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2154-11-19**] 02:38PM BLOOD cTropnT-<0.01 [**2154-11-17**] 04:11AM BLOOD Calcium-7.6* Phos-1.6* Mg-2.8* [**2154-11-15**] 12:11PM BLOOD Type-ART pO2-53* pCO2-28* pH-7.48* calTCO2-21 Base XS-0 Intubat-NOT INTUBA [**2154-11-18**] 12:13PM BLOOD freeCa-1.16 . Micro: Urine culture [**11-16**], [**11-17**] Negative Stool culture [**11-17**] negative Blood cultures: 10/12 [**2-6**] + Strep Pneumo sensitive to ceftriaxone, all others negative or NGTD . CXR: [**11-18**] FINDINGS: There is dense consolidation in the right lower lobe. No pleural effusions are identified. The pulmonary vasculature is normal. The heart and mediastinal contours are stable. Soft tissue and osseous structures are remarkable for scoliosis. Surgical staples are present in the right upper quadrant. IMPRESSION: Right lower lobe pneumonia. . CXR: [**11-21**] The heart size is normal. The aorta is unfolded. There is a small improved right-sided layering pleural effusion. Right basilar consolidation may represent atelectasis or aspiration pneumonitis. Left lung field is clear. No pneumothorax. IMPRESSION: Small stable right effusion with right basilar consolidation which may represent either atelectasis or pneumonia. . CXR: [**11-23**] FINDINGS: There is a small right apical pneumothorax, which has decreased in size in the interval from approximately 18 mm to 11 mm of maximal visceral and parietal pleural separation. There is no tracheal deviation or other findings suggestive of tension physiology. There is interval clearing of a right lower lobe opacity previously described. No further consolidation is identified. There is no superimposed edema. A mildly tortuous atherosclerotic aorta is again noted. The cardiac silhouette is within normal limits for size with a mild left ventricular configuration. There is no definite effusion. There is a levoconcave curvature of the thoracic spine. Surgical clips are identified in the right upper quadrant. IMPRESSION: Right apical pneumothorax decreased in size. No evidence of underlying tension Brief Hospital Course: Patient is a 90-year old female with MMP admitted for fevers and cough, initially on the floor, transferred to the unit, and transferred back to the floor prior to discharge. # Cough: The patient had a history of aspiration pneumonia and also had a history of COPD and is oxygen dependent. Due to the location of the infiltrate on radiographs and the quick decompensation, the clinical picture seemed to fit an aspiration pneumonia. Blood cultures, [**2-8**], returned positive for strep pneumoniae sensitive to ceftriaxone. She was begun on a 14-day treatmet regimen of ceftriaxone, 1g IV to treat the pneumonia. As regards to the COPD element of the clinical presention, the patient was continued on advair, ipratropium, albuterol, and PO steroids with a taper. Her steroid taper was completed on [**11-23**]. It was also noted that the patient had a small right apical pneumothorax on CXR noted on [**11-22**] amenable to monitoring. This was likely secondary to a bleb bursting from her ICU stay. She was otherwise asymptomatic. Follow up CXR showed marked improvement in the size on [**11-23**]. She will need follow up CXR in [**6-9**] days to assess for resolution The day prior to discharge, the patient's white count showed a mild elevation. A UA and urine culture were sent to ensure no urinary tract infection was the cause. Consideration was given to restarting an additional abx, possibly flagyl, to cover for possible aspiration pneumonia. The urine was negative for UTI. Blood cultures were NGTD. The patient's WBC stabilized at 14. She remained entirely asymptomatic with no localizing signs. However, given a low threshold for an aspiration component, we started Flagyl 500mg PO TID x 10days ([**12-3**]). Her steroids may also have contributed to her lymphocytosis . # UTI: The patient had no urinary complaints, but the UA was positive for a UTI and her urine culture grew E-Coli, sensitive to ceftriaxone. She is being treated appropriately for this. . # ARF: Initially, the patient's renal function was impaired with a slight elevation in her creatinine level, which was up from baseline. These levels resolved with some fluid boluses and remained steady throughout her stay. . # Hypothyroidism: The patient was continued was continued on her levothyroxine. . # Psych: As per the daughter, the patient has history of depression and anxiety. During this stay, the patient showed period of somnolence, including on her second stay on the floor, which her daughter stated was somewhat normal. The patient was continued on mirtazapine and fluoxetine and lorazepam PRN. . # HTN: Patient has history of hypertension, but had below normal levels during this stay, often remaining in the high 80s and 90s despite fluid boluses. Her ace inhibitor and beta blockade were held initially, but when her SBPs tolerated, they were added to her regimen. . # CHF: Initially, due to her underlying diastolic cardiac dysfunction and her hypovolemic status initially, diuresis was implemented. But once the patient's vital signs stabilized and the her clinical illness began to improve, gentle diuresis was attempted to help with her respiratory status. She can continued to be diuresed gently as needed at rehab. . # TIA history: Not a clinical issue during this stay, but the patient was continued on her aspirin. . # FEN/aspiration risk: Patient was placed on a nectar thickened liquid diet for aspiration risk. Medications on Admission: Ipratropium Bromide Neb 1 NEB IH Q8H Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **] Aspirin 81 mg PO DAILY Fluoxetine HCl 20 mg PO DAILY GlipiZIDE 2.5 mg PO DAILY Metoprolol 12.5 mg PO BID Mirtazapine 30 mg PO HS Levothyroxine Sodium 50 mcg PO DAILY Lisinopril 2.5 mg PO QD Lorazepam 0.5 mg PO QD Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation q6hrs:prn. 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation q4-6hrs:prn. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for perineal redness. 14. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 3 days: [**11-28**] last dose. 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO qd:prn. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO prn as needed for fluid overload: Will need to be assessed daily. 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) INJ Injection TID (3 times a day). 19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days: To complete 10 day course (last day [**12-3**]) for empiric coverage against possible aspiration component of pneumonia. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: 1. Pneumonia 2. COPD 3. Pontine stroke 4. Hypothyroidism 5. Depression and anxiety requiring hospitalization 6. Hypertension 7. Diabetes mellitus II 8. CHF Discharge Condition: Patient was discharged to the rehab facility in stable condition, requiring oxygen for adeqaute saturations, tolerating PO feeds, and without fever. Discharge Instructions: Patient advised to return to the emergency department if she acquires chest pain, shortness of breath, nausea, vomiting, fevers, chills, or pain that is out of the ordinary for her. Patient is advised to keep all follow-up appointments as assigned. Followup Instructions: 1. PCP [**Name Initial (PRE) 176**] 1 week. Please call for this appointment. 2. Will need to have Midline removed after assessment by a physician and after antibiotic regimen is completed. 3. Will need follow up Chest X-Ray to re-assess for resolution of infectious processes/pneumothorax

Admission Date: [**2116-3-8**] Discharge Date: [**2116-3-26**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Infected Pacemaker Major Surgical or Invasive Procedure: Screw-in pacer wire placement ([**2116-3-12**]) PICC line placement ([**2116-3-13**]) TEE Removal of pacemaker History of Present Illness: Patient is an 86 year old female patient with PMHx significant for mechanical aortic valve, CHB s/p PM that was complicated by large hematoma requiring evacuation who presents from OSH after found to have abscess at previous hematoma site. . Patient was recently discharged from [**Hospital1 18**] during which she was found to be in complete heart block. Patient had pacemaker placed however developed large chest hematoma in setting of being anticoagulated for mechanical valve. Patient required 9 units of PRBC and had hematoma evacuated. . She was discharged to nursing home on [**2-13**] and then was found to have infected PM with abscess at previous hematoma site. At NH her incision under her clavicle began to open and start draining while she was having temps of 104. At OSH, she had a WBC of [**Numeric Identifier 71077**] (69% PMNs, 17% Bands) pacemaker was removed by local surgeon and patient was started on vanc and gent (per an ID consult). She continues to spike temperatures and prelimanary wound and blood cultures at OSH are growing gram + cocci in clusters. Patient was also found to be tachycardic with HR ranging from 114-140s. She was transferred to [**Hospital1 18**] for further management. Past Medical History: CAD s/p 2-vessel CABG [**2104**] CHB s/p PM complicated by large hematoma and evacuation s/p [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] in [**2104**] for AS CHF HTN Diabetes Hypothyroidism Dementia, mild-moderate s/p appy s/p TAH Social History: Recently living in nursing home after previous discharge from [**Hospital1 18**] non-smoker non-drinker Family History: unable to obatin from patient due to dementia Physical Exam: T 99.2 BP 123/55 HR 77 RR 20 Sat 95% on 5L nc Gen: moaning, NAD HEENT: OP clear, no scleral icterus Neck: no carotid bruits, prominent a-waves , JVP 7cm Chest: 5cm x 3cm x 1.5cm incision on left upper chest extending into pectoral muscle tissue without any frank drainage or erythema; lungs with bibasilar rales CV: irregular, II/VI systolic murmur across precordium with mechanical S2 Abd: mildly distended, nontender, soft, normal bowel sounds, no HSM Extr: 2+ DP pulses, no edema, cool Neuro: alert, conversant, oriented to self only Pertinent Results: TTE ([**2116-3-11**]): There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. A mechanical aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. No masses or vegetations are seen on the aortic valve but cannot be excluded. Significant aortic regurgitation is present, but cannot be quantified. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is mild mitral stenosis (area 1.5-2.0cm2). Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Labs: [**2116-3-8**] 01:51AM BLOOD WBC-28.0*# RBC-3.53* Hgb-10.8* Hct-31.3* MCV-89 MCH-30.6 MCHC-34.5 RDW-17.0* Plt Ct-271 [**2116-3-24**] 03:41AM BLOOD WBC-11.2* RBC-3.26* Hgb-10.2* Hct-29.8* MCV-92 MCH-31.2 MCHC-34.1 RDW-16.5* Plt Ct-352 [**2116-3-8**] 01:51AM BLOOD Neuts-75* Bands-15* Lymphs-2* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2116-3-21**] 01:11PM BLOOD Neuts-92.9* Bands-0 Lymphs-4.2* Monos-2.9 Eos-0.1 Baso-0 [**2116-3-24**] 03:41AM BLOOD Plt Ct-352 [**2116-3-24**] 03:41AM BLOOD PT-80.0* PTT-52.8* INR(PT)-10.5* [**2116-3-8**] 01:51AM BLOOD PT-22.2* PTT-39.7* INR(PT)-2.2* [**2116-3-24**] 09:00AM BLOOD FDP-10-40 [**2116-3-24**] 09:00AM BLOOD Fibrino-410* D-Dimer-[**2125**]* [**2116-3-21**] 01:11PM BLOOD Ret Aut-4.3* [**2116-3-24**] 03:41AM BLOOD Glucose-165* UreaN-24* Creat-2.1* Na-133 K-3.5 Cl-104 HCO3-17* AnGap-16 [**2116-3-8**] 01:51AM BLOOD Glucose-190* UreaN-22* Creat-0.8 Na-139 K-4.0 Cl-105 HCO3-23 AnGap-15 [**2116-3-21**] 01:11PM BLOOD LD(LDH)-336* CK(CPK)-126 [**2116-3-23**] 02:33AM BLOOD TSH-6.0* [**2116-3-23**] 02:33AM BLOOD T4-2.9* T3-53* [**2116-3-23**] 02:56AM BLOOD Type-ART Temp-37.7 pO2-76* pCO2-30* pH-7.39 calTCO2-19* Base XS--5 . [**3-15**] CT Head FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect, hydrocephalus, or shift of normally midline structures. There remain large areas of periventricular white matter hypodensity consistent with chronic small vessel infarction. A right thalamic lacune is again seen. There is a fluid level in the sphenoid sinus. The soft tissues are unchanged. IMPRESSION: No evidence of intracranial hemorrhage or mass effect. . [**3-20**] TTE Conclusions: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic prosthesis appears well seated, with normal leaflet/disc motion. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**1-21**]+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2116-3-20**] there is no significant change. . [**3-23**] CT Head FINDINGS: The study is significantly motion degraded at the lower and mid levels. Allowing for this deficiency, no acute intracranial hemorrhage is appreciated. There is diffuse cerebral periventricular white matter hypodensity consistent with chronic small vessel infarction. Chronic lacunar infarcts in the left basal ganglia and right thalamus are stable. No evidence to suggest acute major vascular territorial infarction is seen. Sphenoid sinus air- fluid level is noted. Carotid vascular calcification is seen. IMPRESSION: Motion limited study; allowing for this limitation, no acute intracranial hemorrhage seen. Sphenoid sinus air-fluid level (are there symptoms of sinusitis?). . [**3-24**] CT Head FINDINGS: As was the case yesterday, a number of the images are degraded by patient motion. Allowing for this deficiency, there is no definite interval change identified. Once again, there is a chronic lacunar infarct noted within the right thalamic region, as well as more generalized bilateral cerebral periventricular white matter hypodensity, consistent with chronic small vessel infarction. There is no sign for the presence of an intracranial hemorrhage. There is heavy atherosclerotic calcification of the distal vertebral arteries and cavernous carotid arteries. The surrounding osseous and soft tissue structures are remarkable for redemonstration of the sphenoid sinus air-fluid level. As was stated yesterday, the finding suggests possible acute sinusitis but requires clinical correlation, as sinus drainage could be impeded by the presence of a nasogastric tube. CONCLUSION: No intracranial hemorrhage. Brief Hospital Course: Assessment/Plan: 86 yo woman with abscess surrounding pacemaker site, s/p surgical pacemaker removal and in NSR, but had a 9 second period of asystole, treated with temporary external pacer and plan for permenant pacer once course of Abx completed. Her pacer infection seemed to be resolving but on [**3-20**] she had another TEE to eval for endocarditis. Her mental status never seemed to improve after that and her po intake was very poor. On [**3-21**], she had a hypotensive episode that required pressors and intubation. It appeared to have been from [**Month (only) **] po and inability to mount a tachycardic response [**2-21**] heart block. She was quickly weaned off pressors and off the vent but her mental status never improved. CT scans did not show an acute intracranial event. Her daughter then made the decision to make her CMO, which was consistent with the patient's stated wishes. She passed away two days later. . Hospital course complicated by: . ## Wound abscess/bacteremia: Wound grew VRE and MRSA . ## Hematoma: recurred at pacer site, s/p 1uPRBC's with appropriate hct increase, but no further bleeding. - U/S of area just showed a small cystic structure which we did not aspirated . ## Delerium: Continues with waxing and [**Doctor Last Name 688**] mental status. Likely related to infection, pacer, hematoma, hospitalization, underlying dementia. Head CT without bleed [**3-15**], [**3-23**], [**3-24**]. Became acutely hypotensive on [**3-21**] requiring intubation and has not recovered mental status after that. Unclear etiology but likely multifactorial and from episodes of hypotension. . ## Valves: s/p St. [**Male First Name (un) 1525**] aortic valve placement in [**2104**]; also has moderate MS (valve area 1.0-1.5cm^2), [**1-21**]+ MR, 2+ TR on recent TTE - TTE and TEE were negative for vegetations - INR intermittently high and then low so was on heparin gtt off and on with fluctuating doses of coumadin . ## Rhythm: history of recent CHB - due to episode of 9 second asystole, EP screwed in pacer wires on [**3-12**] with external device. - telemetry - resumed beta blockade now that pacer is in place . ## Coronaries: s/p 2-v CABG at OSH in [**2104**] (anatomy unknown) - cont aspirin, statin; continue beta-blockade . ## Pump: diastolic CHF with LVEF of 70-75% on [**1-/2116**] TTE; - cont home dose of PO Lasix . ## HTN - resumed beta blockade now that pacer wires in place - on Lisinopril 80 - hydral added on [**3-19**] . ## Hyperlipidemia - atorvastatin per outpatient dose . ## Dementia - held psychotropics given altered mental status . ## Hypothyroidism - cont thyroid replacement . ## DM2 - hold sulfonylurea; cover with RISS . ## COPD - cont Spiriva; prn ipratropium nebs . ## FEN: now with NGT [**2-21**] po getting tube feeds - cardiac/purreed diet, encourage pos - trend lytes; replete prn . ## Prophylaxis - bowel regimen; on heparin gtt . ## Code: DNR/DNI /CMO. - appreciate palliative care consult . ## Access: L PICC placed by IR . Medications on Admission: Meds on transfer: Vancomycin 1gm [**Hospital1 **] Gentamycin 100mg qd synthroid 0.1mg daily Protonix 40mg IV qam . Outpt meds: glyburide, metoprolol, lipitor, coumadin, lexapro, diovan, risperdal, lasix, amlodopine Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Cardiopulmary arrest 2. Sepsis 3. Infected hematoma 4. Pacemaker removal Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: None

Admission Date: [**2146-8-7**] Discharge Date: [**2146-8-20**] Date of Birth: [**2066-7-17**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2836**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Intubation on [**2146-8-7**] History of Present Illness: Mr. [**Known lastname 32913**] is an 80-year-old male who presented from rehabwith respiratory distress. This was in the setting of recent hospitalization ([**141-12-2**]) during which he was treated for a florid urinary tract infection, acute kidney injury, J-tube clogging, severe fluid imbalances, and intubation for respiratory distress in the context of a LLL PNA which grew out E.coli. All this took place after a duodenal perforation s/p a laparoscopic cholecystectomy at an OSH on [**2146-6-2**], after which he was brought to [**Hospital1 18**] for repair of duodenal injury, placement of lateral duodenostomy tube, feeding jejunostomy tube, and PTBD (6/[**2146**]). Past Medical History: Past Medical History: HTN, prostate CA, duodenal ulcer Past Surgical History: partial gastrectomy with BII reconstruction, prostatectomy with bilateral inguinal node dissection, laparoscopic cholecystectomy Social History: He lives in a long term care facility. He does not drink alcohol, and has not smoked for 20 years. Family History: non-contributory Physical Exam: ADMIT EXAM: Vitals: T =100.4, HR = 109, RR = 20, O2Sat = 100% NRB, BP = 132/74 General: Sedated, intubated, thin and ill appearing white male HEENT: Sclera anicteric,Pupils of 5 minimally reactive, moving eyes around, not blinking very much but blinks to light shinning in the, Neck: supple, JVP not elevated when recumbent at 0 deg no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse breathsounds at the left base compared to the right Abdomen: soft, midline scar is well healed. Drains on left appear to be intact, with multiple bags full of dark yellow/[**Location (un) 2452**] fluid. No erythema of the skin surrounding them. Hypoactive bowel sounds but normal pitch. Ext: warm, well perfused, 2+ pulses DP pulses bilaterally no clubbing, cyanosis or edema Neuro: Unable to assess as patient is sedated and intubated DISCHARGE EXAM: Vitals: 98.2 97.8 89 113/56 16 99%RA General: In no distress, thin appearing male, interactive upon stimulation HEENT: anicteric sclera, PERRLA CV: RRR, +S1/S2, no m/r/g Lungs: Sparse coarse breath sounds diffusely, otherwise CTAB Abdomen: soft, well-healed incision. Drains x4 intact. +BS, NT, ND, no r/r/g Ext: warm, well perfused, 2+ distal pulses Pertinent Results: IMAGING: 1) CHEST (PORTABLE AP) ([**2146-8-7**]): An endotracheal tube is positioned 4.2 cm above the level of the carina. A nasoenteric catheter courses below the diaphragm with the tip in the stomach. A left PICC is in unchanged position terminating in the mid SVC. There is consolidation within the left lung base. which appears similar to prior examination and likely reflects atelectasis or resolving pneumonia. No new confluent opacity is identified. There is no pneumothorax. Blunting of the bilateral costophrenic angles is unchanged from prior and likely suggests possible small effusions. There is no overt interstitial edema. Cardiomediastinal and hilar contours are within normal limits. IMPRESSION: Expected position of support devices. No pneumothorax. Persistent retrocardiac opacity possible atelectasis or resolving pneumonia. Probable small bilateral pleural effusions. 2) BILAT LOWER EXT VEINS ([**2146-8-7**]): [**Doctor Last Name **]-scale and color Doppler images of bilateral common femoral, superficial femoral, deep femoral, popliteal and calf veins demonstrate normal flow, compressibility and response to augmentation. IMPRESSION: No evidence of deep venous thrombosis in bilateral lower extremities. 3) CT HEAD W/O CONTRAST ([**2146-8-7**]): There is no evidence of hemorrhage, edema, mass effect or infarction. Prominence of the ventricles and sulci is compatible with age-related global atrophy, unchanged. There is mild left cavernous carotid artery calcification. No osseous lesions are seen. There are mucosal retention cysts and mucosal thickening within the maxillary sinuses. A small amount of aerosolized secretions are seen within the left sphenoid sinus. The mastoid air cells are grossly clear. IMPRESSION: Age appropriate volume loss and mild carotid calcification. Otherwise normal study. No evidence of acute intracranial process. 4) CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST ([**2146-8-7**]): Wet read- bibasilar atelectasis, left greater than right. given history, an aspiration is certainly possible. dense atherosclerotic calcifications. hypodense vascular space consistent with anemia. unchanged right upper lobe pulmonary nodules. known multiple biliary drains and stent from prior procedure with bile leak. scattered free fluid however no focal collection or evidence of abscess. MICRO/PATH: GRAM STAIN (Final [**2146-8-7**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2146-8-7**]): TEST CANCELLED, PATIENT CREDITED. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended ADMIT LABS: [**2146-8-7**] 12:25PM BLOOD WBC-16.2* RBC-3.03* Hgb-9.0* Hct-29.5* MCV-97 MCH-29.8 MCHC-30.6* RDW-16.8* Plt Ct-738* [**2146-8-7**] 12:25PM BLOOD Neuts-66.5 Lymphs-22.6 Monos-2.4 Eos-7.8* Baso-0.7 [**2146-8-7**] 12:25PM BLOOD PT-11.5 PTT-30.5 INR(PT)-1.1 [**2146-8-7**] 12:25PM BLOOD Plt Ct-738* [**2146-8-7**] 12:25PM BLOOD Glucose-890* UreaN-68* Creat-2.3* Na-134 K-5.6* Cl-105 HCO3-18* AnGap-17 [**2146-8-7**] 12:25PM BLOOD ALT-12 AST-29 AlkPhos-196* TotBili-0.5 [**2146-8-7**] 12:25PM BLOOD Albumin-2.6* [**2146-8-7**] 03:04PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9 [**2146-8-7**] 02:17PM BLOOD Type-ART Temp-38.0 Tidal V-450 FiO2-100 pO2-159* pCO2-41 pH-7.28* calTCO2-20* Base XS--6 AADO2-513 REQ O2-86 Intubat-INTUBATED [**2146-8-7**] 12:31PM BLOOD Lactate-1.0 DISCHARGE LABS: [**2146-8-18**] 05:39AM BLOOD WBC-9.4 RBC-2.63* Hgb-8.2* Hct-24.5* MCV-93 MCH-31.0 MCHC-33.2 RDW-17.1* Plt Ct-628* [**2146-8-18**] 05:39AM BLOOD Plt Ct-628* [**2146-8-18**] 05:39AM BLOOD Glucose-108* UreaN-69* Creat-1.5* Na-131* K-4.1 Cl-105 HCO3-18* AnGap-12 [**2146-8-18**] 05:39AM BLOOD ALT-13 AST-36 AlkPhos-313* TotBili-0.4 DirBili-0.2 IndBili-0.2 [**2146-8-18**] 12:50PM BLOOD Vanco-19.2 Brief Hospital Course: 80 year old male s/p CCY complicated by duodenal perforation with multiple drains in place and recently discharged after prolonged hospital course where he was treated for pan sensitive Ecoli pneumonia to rehab who presents with acute respiratory distress and leukocytosis. On [**2146-8-7**]: The patient was tachypnic on admission and hypoxemic with increased oxygen requirement. He was intubated, and his CXR post-intubation revealed stable infiltrates bilaterally. He was admitted to the medical ICU. ABG revealed a non-anion gap acidosis without appropriate respiratory compensation. CT Chest revealed on PNA, and LE ultrasound revealed no DVT. He was continued on TPN. He was started on vancomycin, cefipime, and flagyl empirically given a leukocytosis without a left shift and no obvious initial course. Blood and urine cultures were obtained. CT abdomen and CT head were obtained. On [**2146-8-8**]: The patient remained intubated and sedated, on CMV/Assist settings. His care was transferred to the Surgical ICU team. He was continued on TPN, and remained NPO, with nothing but medication by J tube. Antibiotics as stated above, were continued. On [**2146-8-9**]: The patient's ventilator settings were adjusted to CPAP/PS. He was continued on TPN, kept NPO, with nothing but medication by J tube. Antibiotics were continued, but adjusted to include only vancomycin and cefipime. On [**2146-8-10**]: The patient was successfully extubated on this day. He was continued on TPN, and kept NPO, with nothing by medication by J tube. On this day, he was able to spend much time sitting in a chair, and was noted to be conversational and interactive. Antibiotics were continued. Planning was begun to transfer him to the regular floor. On [**2146-8-11**]: The patient was kept NPO, and continued on TPN. On this day, he was transferred back to the floor for his continued recovery. He continued to look well. Antibiotics were continued. On [**2146-8-12**]: The patient was kept NPO, on TPN, with foley catheter and PTBD, T Tube, [**Doctor Last Name 406**] drain in place. Physical Therapy continued to work with the patient. He was continued on antibiotics (vancomycin and cefepime). On [**2146-8-13**]: The patient was kept NPO, on TPN, with all catheters and drains in place, and antibiotics runing. On [**2146-8-14**]: All prior drains were maintained. The patient remained NPO, on TPN. He continued to work with physical therapy. Dispo planing to rehab was initiated. On [**2146-8-15**]: All drains as above (PTBD, T Tube, foley, [**Doctor Last Name 406**] drain) were maintained. The patient remained NPO, on TPN, and antibiotics. Thereafter, the patient continued to recover well, with no remarkable events. His drains were all maintained, and he remained NPO, on TPN, and the above stated antibiotics. These antibiotics are to be continued until [**2146-8-21**]. The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. The patient's complete blood count was examined routinely. he patient's white blood count and fever curves were closely watched for signs of infection. The patient received subcutaneous heparin and venodyne boots were used during this stay; he was seen by and worked with Physical Therapy. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was on TPN, with nothing by J tube except medication. He is to receive IV antibiotics (cefipime and vancomycin) until [**2146-8-21**]. Discharge planning to an extended care facility was made, and thorough follow-up instructions were provided. Medications on Admission: 1. Acetaminophen IV 1000 mg IV Q6H:PRN pain 2. Carbidopa-Levodopa (25-100) 1 TAB NG TID please crush and give via j-tube with 60cc water to avoid j-tube clogging 3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 5. Heparin 5000 UNIT SC TID 6. Insulin SC Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 8. Pantoprazole 40 mg IV Q24H Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. Carbidopa-Levodopa (25-100) 1 TAB PO TID via j-tube 3. CefePIME 2 g IV Q24H 4. Heparin 5000 UNIT SC TID 5. Insulin SC Sliding Scale Fingerstick Q4h Insulin SC Sliding Scale using REG Insulin 6. Octreotide Acetate 200 mcg SC Q8H 7. Ondansetron 4 mg IV Q8H:PRN nausea 8. Pantoprazole 40 mg IV Q24H 9. Senna 1 TAB PO BID:PRN constipation 10. Vancomycin 750 mg IV Q 24H 11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 13. Heparin Flush (10 units/ml) 10 mL IV PRN PICC Flush 14. 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. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 16. 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. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Respiratory distress, in setting of recent hospitalization ([**2146-7-14**]) during which he was treated for a florid urinary tract infection, acute kidney injury, J-tube clogging, severe fluid imbalances, and intubation for respiratory distress in the context of a LLL PNA which grew out E.coli. All this took place after a duodenal perforation s/p a laparoscopic cholecystectomy at an OSH on [**2146-6-2**], after which he was brought to [**Hospital1 18**] for repair of duodenal injury, placement of lateral duodenostomy tube, feeding jejunostomy tube, and PTBD (6/[**2146**]). Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [**Known lastname 32913**] was admitted to the surgery service at [**Hospital1 18**] for evaluation and management of respiratory distress. He has recovered well, and is now safe to return to an extended care facility to complete his recovery with the following instructions: Please resume all regular medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please allow patient to get plenty of rest, continue to ambulate as tolerated, and continue TPN. Please do NOT administer any tube feesd, the patient is to receive only CRUSHED Cinemet by J tube. Please follow-up with surgeon and Primary Care Provider (PCP) as advised. Care for Drains: *Please look at the sites every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb drains, and allow the bag-drains to hang to gravity. *Note color, consistency, and amount of fluid in the drain. Call the doctor or nurse practitioner if the amount increases significantly or changes in character. *Be sure to empty the drains frequently. Record the output, if instructed to do so. *The patient may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge in water. *Make sure to keep the drain attached securely to the patient's body to prevent pulling or dislocation. Please call the doctor or nurse practitioner if the patient experiences the following: *New chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *Vomiting and cannot keep down fluids or medications. *Dehydration due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *Blood or dark/black material in vomit or bowel movement. *Burning on urination, blood in urine, or discharge. *Shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in symptoms, or any new symptoms that concern you. Followup Instructions: Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office as needed at [**Telephone/Fax (1) 2998**] as needed. Appointment:- Department: SURGICAL SPECIALTIES When: FRIDAY [**2146-9-9**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2146-8-18**]

Admission Date: [**2150-5-1**] Discharge Date: [**2150-5-10**] Date of Birth: [**2098-2-21**] Sex: F Service: MICU The patient was admitted to the Medical Intensive Care Unit Service on [**5-1**] and was transferred from the Intensive Care Unit service to the [**Hospital1 139**] Service on [**2150-5-6**], and planned for discharge on [**2150-5-12**]. CHIEF COMPLAINT: Altered mental status. HISTORY OF PRESENT ILLNESS: This is a 52 year old woman with a history of insulin dependent diabetes mellitus and a history of self-induced hypoglycemic episodes, who presented on [**2150-5-1**], to [**Hospital1 69**] with agitation and altered mental status. The EMS checked her fingerstick which was about 102 at that time. She was brought to [**Hospital1 69**] Emergency Room for evaluation. In the Emergency Department, her fingerstick was about 400. She was given Ativan, Versed and Haldol, 7 mg of Droperidol and insulin 10 units. She underwent a lumbar puncture at that time with her cerebral spinal fluid showing 24 white blood cells, 350 red blood cells, 70 protein, 152 glucose with 81% neutrophils, 1% band and 14% lymphocytes. She got dexamethasone 10 mg intravenously, Ceftriaxone 2 grams intravenously, Vancomycin 1 gram intravenously, Acyclovir 500 mg intravenously and Toradol. After getting all this medication, she dropped her systolic blood pressure to the 90s and received several liters of intravenous fluid and was thought to have aspirated. She also got Dilantin due to a question of some seizures. She was transferred to the Medical Intensive Care Unit on the night of [**5-1**] and early morning of [**5-2**]. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus for 13 years with multiple episodes of self-induced hypoglycemia as attention seeking behavior. 2. Migraine headaches relieved with Fioricet. 3. Depression. 4. Dementia with memory difficulties that have been progressing through recent years. Her primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7516**] at [**Hospital 8503**]. ALLERGIES: No known drug allergies. HOME MEDICATIONS: 1. Insulin. 2. Fioricet. SOCIAL HISTORY: She is divorced with two children. Her son is in [**Doctor First Name 1191**] for heroin abuse. She has one other son who is very involved in her care. She lives alone. She smokes one pack per day. FAMILY HISTORY: Son has heroin abuse; otherwise unknown. While in the Medical Intensive Care Unit she was treated presumptively with Vancomycin, Ceftriaxone and Acyclovir for meningitis, encephalitis and aspiration pneumonia. The patient became hypoxic. Chest x-ray showed congestive heart failure and left retrocardiac opacity. Bronchoscopy was performed but was unrevealing. The patient self-extubated after bronchoscopy and remained stable, however, still requiring oxygen via face mask. She was eventually weaned off the face mask onto nasal cannula. A repeat lumbar puncture was performed on [**5-5**] showing one white blood cell, eight red blood cells. At that time, the culture from the first lumbar puncture came back negative. The Vancomycin and Ceftriaxone were discontinued. Levofloxacin was started for treatment of pneumonia. Acyclovir was continued for herpes simplex virus encephalitis/meningitis. Herpes simplex virus PCR was sent on the second sample of cerebrospinal fluid from the [**5-5**] lumbar puncture. It eventually came back negative. The patient received a ten day course of Acyclovir which was then discontinued due to the negative PCR. While in the Medical Intensive Care Unit she was also given intravenous Lasix for effective diuresis with improvement in her O2 saturation. She was evaluated by Psychiatric who recommended adding multivitamins, thiamine, and folate to her medication regimen given concern for alcohol use. They also recommended Haldol for her agitation and further medical work-up. She was also seen by Neurology, whose impression was that this was encephalitis and to continue treating and also to rule out other metabolic etiology such as myocardial infarction, adrenal insufficiency, thyroid disease. They agreed with the thiamine and folate supplementation. LABORATORY: Data on admission was white blood cell count of 20.4, hematocrit 37.6 with 91% neutrophils, 7% lymphocytes. Platelet count was 333. INR 1.1, PTT 29.1. Urinalysis showed 250 glucose, 50 ketones. Serum sodium of 143, potassium 3.8, chloride 107, bicarbonate 23, BUN 12, creatinine 0.6, glucose 122, calcium 7.8, phosphate 2.3, magnesium 1.7. ALT was 40, AST was 68, which increased slightly. LDH was 278, alkaline phosphatase was 93. Total bilirubin was 0.4. Due to the increase in ALT and AST, hepatitis panel was done. Hepatitis C virus antibodies was negative. Hepatitis B surface antigen and surface antibodies were both negative. ANCA was negative. [**Doctor First Name **] was positive with 1:80 titer. HIV antibodies was negative. Vitamin B12 came back at 1071. Folate was normal at 10.2. Thyroid stimulating hormone was 0.96. Free T4 level was 1.2. Cortisol stimulation test pre-stimulation was 9.0, at 30 minutes was 26.7; at 60 minutes was 36.6. Serum toxicology screen and urine toxicology screen were both positive for barbiturates due to the Fioricet for her headaches. RPR was negative. CK and troponin were sent off as well and the patient had a troponin leak of 8.2, which subsequently decreased to less than 0.3. Cardiology consultation was obtained. They recommended a transthoracic echocardiogram which showed normal left ventricular wall thickness and cavity sizes. Due to sub-optimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal, greater than 55% ejection fraction. Right ventricular chamber size and free wall motion were normal. Aortic valve leaflets were mildly thickened. No masses or vegetations were seen. No aortic valve stenosis or regurgitation. The echocardiogram was essentially normal. They recommended continuing with aspirin and continuing to follow troponin. They recommended outpatient follow-up for cardiac issues in one month. The patient remained asymptomatic without chest pain or hemodynamic instability. Her mental status improved throughout the Intensive Care Unit stay. Herpes simplex virus two antibodies were negative. Herpes simplex virus one IgG was positive, showing previous exposures. EEG showed encephalopathy but no seizure activity. Influenza B was negative. RSV antigen was negative. BAL cultures were negative. Urine cultures were negative times two. Blood cultures were negative. Legionella urinary antigen was negative. Insulin A was negative. MRI of the head was negative. CT scan of the head was negative. Bartonella IgG and IgM were sent off which were still pending at the time of this dictation. The patient was transferred to the Floor and continued to improve, although her mental status did not get back to her baseline. The patient had very poor insight into her illness. She remained not oriented to month and day and demanded to go home. She was deemed not competent and incapable of taking care of herself given her cognitive deficits and the fact that she lives home alone. The patient refused to consider any other options. She finished a ten day course of antibiotics including ceftriaxone, Vancomycin and Levofloxacin for presumed pneumonia. Her congestive heart failure resolved with stable O2 saturation on room air. She was evaluated by Physical Therapy who felt that she had no physical therapy issues. She was also evaluated by Occupational Therapy who felt that she had cognitive deficits that would prevent her from taking care of herself at home. [**Last Name (un) **] consultation was obtained who gave their input in formulating an insulin regimen for the patient. A family meeting was scheduled for [**2150-5-11**] to determine the safest disposition for the patient. The patient's discharge condition, medications, and plan will be dictated in an addendum by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**]. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Name8 (MD) 6371**] MEDQUIST36 D: [**2150-5-10**] 20:50 T: [**2150-5-10**] 21:20 JOB#: [**Job Number 25485**]

Admission Date: [**2103-8-8**] Discharge Date: [**2103-8-16**] Date of Birth: [**2034-12-3**] Sex: F Service: VASCULAR CHIEF COMPLAINT: Cold foot with pain progressive over the last three days prior to admission. Information was obtained from the patient and transfer of records. The patient was transferred from [**Hospital6 18346**]. HISTORY OF PRESENT ILLNESS: The patient is a 68 year-old black female well known to our service status post abdominal aortic repair with an aorta bifemoral status post right ABF limb removal with interposition saphenous vein graft secondary to infection, status post left fem [**Doctor Last Name **] with jump graft to fem [**Doctor Last Name **] to tibial peroneal artery with vein presents with a three day history of left foot pain with onset of coldness and numbness within the last 24 hours. She was seen at [**Hospital3 22439**] and was diagnosed with acute ischemic foot. IV heparin 5000 unit bolus and a 1000 units per hour was started at 1600. It was discontinued at 1820 for transfer to the main land. REVIEW OF SYSTEMS: Positive for numbness, coolness and pain. She denies any other interval changes since last hospitalization in [**Month (only) 547**] of this year secondary to left thigh abscess. She denies chest pain, shortness of breath. She is nondiabetic. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: Coronary artery disease, hypertension, hypercholesterolemia, peripheral vascular disease, history of MRSA, sacroiliitis, infected right ABF limb secondary to MRSA, status post removal. PAST SURGICAL HISTORY: Abdominal aortic aneurysm repair with an aorta bifemoral in [**2092**], right ABF limb with removal with interposition graft in [**2102-6-8**], left fem [**Doctor Last Name **] in [**2098**], left jump graft from fem [**Doctor Last Name **] to [**Doctor First Name **] peroneal artery in [**2102-8-8**], right breast biopsy in [**2099**], I&D of left thigh abscess in [**2103-4-8**]. MEDICATIONS ON TRANSFER: Lipitor 20 mg q day, Colace 100 mg b.i.d., Lopressor 25 mg b.i.d., ferrous sulfate 325 mg q day, aspirin 81 mg q.d. SOCIAL HISTORY: The patient lives with her son. The remaining review of systems is unremarkable. PHYSICAL EXAMINATION: The patient was afebrile. This is an alert black female complaining of left foot pain. HEENT examination was unremarkable. Pulse examination shows an intact carotid, brachial and radial pulses bilaterally with bilateral carotid bruits. Femoral pulses were 2+ on the right and absent on the left by palpation of doppler. There were no bruits. Popliteal pulses were absent bilaterally. On the right, the DP was dopplerable. The PT was absent by palpation and doppler. The pedal pulses and popliteal pulses on the left were absent by palpation and doppler. Chest was clear to auscultation bilaterally. Heart was a regular rate and rhythm. Normal S1 and S2. There were no murmurs, rubs or gallops. Abdomen was benign. There was no bruits, masses or organomegaly. Right foot toes were cool. The left foot was cold to the ankle and cool from the ankle to mid calf. The foot was modeled. There was no capillary refill. The foot had diminished dorsiflexion and plantar flexion. The left first toe strength was [**4-12**] and the left foot strength was [**4-12**]. The left leg had moderate amount of weakness of [**4-12**] with elevation on off bed. Neurological examination except for the motor sensory on extremities were unremarkable. HOSPITAL COURSE: The patient was admitted to the Vascular Service. She was made NPO, IV hydration normal saline at 80 cc per hour was begun. Interventional Radiology was requested to see the patient for anticipated intervention. The patient's admitting laboratories were white count 15.8, hematocrit 33.9, platelets 456, electrolytes 137, 4.6, 103, 19, 22 and 0.7. PT/INR were normal. PTT 26.7. The patient was taken to angio. Initial arteriogram demonstrated hydronephrotic obstructed right kidney. Left limb graft open. Has stenosis at the aorta anastimosis. This was dilated 6 mm with a 15 mm residual gradient clot in the fem [**Doctor Last Name **] graft. Tissue plasminogen activator was continued. Follow up thrombolysis arteriogram demonstrates successful recanalization of the left common femoral with access of the catheter to the fem [**Doctor Last Name **] graft injection of the AT at the level of the distal anastomosis demonstrated complete occlusion. They were not able to identify the distal run off. The catheter was removed at this point. At this time the patient became hypoxic, hypertensive and tachycardic. Emergency head CT was obtained to rule out intracranial hemorrhage, which was negative. The patient was transferred to the SICU for continued monitoring and care. The patient was given 1 gram of vancomycin prior to any interventional work on the night of admission. Infectious disease was consulted regarding antibiotic coverage for positive blood cultures from the sheath. She had been started on Ceptaz 1 gram q 8 hours and Gentamycin 80 IV q 8 hours. Vancomycin 1 gram q 12 hours was continued. Blood cultures obtained on the second 2/2 bottles grew gram negative rods, anaerobic bottle growing gram positive cocci. Identifications and speciation pending. Infectious disease recommended continued antibiotics as they were for both a history of MRSA and enterococcus infection. The abdominal pelvic CT was reviewed and they felt that the graft could be a possible site of infection along with a right hydronephrosis. At this point was consulted. Urology felt this was a chronic hydronephrosis and had not changed from previous abdominal CT. The urine cultures were pending. Urinalysis showed only 0 to 2 white blood cells. They felt at this point given this picture that the hydronephrosis was not the etiology of her bacteremia. Urine culture on [**8-10**] was negative and urine specimen from the right kidney gram stain showed no bacteria and no polys. The white count peaked at 25.5. The patient did require intubation at the time of her hypertension, tachycardia and was extubated on SICU day three. Blood cultures were poly microbial and predominantly GI flora, Flagyl was added to the antibiotic regimen on [**2103-8-12**]. A right nephrostomy tube was placed on [**3-11**]. This was removed after urine cultures were proven to be negative. The patient returned to angio on retrieval of foreign body at the time of line change and loss of guidewire. The guidewire was removed from the inferior vena cava with a snare and a IJ triple lumen catheter was placed and continued to show improvement with diminished white count of 17.0, hematocrit was 23.8 and no transfusion was given secondary to patient's Jehovah's witness beliefs. She was transferred to the VICU for continued monitoring and care. The left foot was stable and showed some improvement with diminishment in pain, but not complete relief of pain. The patient was beginning to wiggle her toes. The patient continued to show clinical improvement and was transferred to the regular nursing floor on hospital day number seven. IV heparin and coumadinization were continued. Abdominal CT and pelvic and upper left leg were obtained, which showed a diminished collection in the inguinal area. No discreet collection noted. Multiple diverticuli, no free fluid in the pelvis. White count continued to defervesce. Her renal numbers remained stable. Her heparin was adjusted for PTT of 60 to 80. Her Lopressor was adjusted for her persistent tachycardia. Physical therapy was requested to see the patient and begin ambulation and case management was requested to see the patient regarding rehabilitation screening. Her Flagyl was discontinued on [**2103-8-15**]. She is continued on her Ceptaz 1 gram q 8 hours, Gentamycin 80 mg q 12 hours, Vancomycin 1 gram q 12 hours. Her cultures are as follows, 8/2 cultures blood grew enterococcus cloacae, Klebsiella, pneumonia, MRSA and enterobacter buccalis. The Enterobacter was sensitive to Ceptaz, Ceftriaxone, Gentamycin, _______, Penicillin, Tobra and Bactrim. The enterococcus was sensitive to Ampicillin, Gentamycin, Penicillin, Vanco. Resistant to streptomycin and Cipro. The staph aureus MRSA was sensitive to Gent, Rifampin, Tetracycline and Vanco. Klebsiella was pan sensitive. Repeat cultures on [**8-9**] grew the same organisms and on [**8-12**] blood cultures were no growth. At the time of dictation her white count was 16.7 with hematocrit of 25.0 and platelets 339. Her BUN was 9, creatinine 0.7, K 4.0, Gentamycin levels on [**8-14**] peak was 5.9, trough 2.6. Final recommendations regarding antibiotic course of therapy will be determined just prior to discharge from Infectious Disease. The patient's heparin drip was discontinued on [**2103-8-16**]. Coumadin 5 mg q day was begun. Lopresor was adjusted to 50 mg t.i.d. DISCHARGE MEDICATIONS: Coumadin 5 mg q.d. goal INR is 2.0 to 3.0, Gentamycin 100 mg IV q 12 hours, this was begun on [**2103-8-15**] and a trough and peak were pending after the third dose. Lopressor 50 mg t.i.d., Colace 100 mg b.i.d., antibiotics are Ceftazidime 1 gram q 8 hours and Vancomycin 1 gram q 12 hours. Percocet tablets 5/325 one q 4 to 6 hours prn for pain, Zantac 150 mg b.i.d., Procrit 40,000 units subQ q week. Dressings include nephrostomy dressing, which should be changed on a daily basis. Ambulation as tolerated, full weight bearing, essential distances with healing sandal. PT/INR should be checked on a daily basis until the patient is therapeutic with an INR between 2.0 and 3.0. No heparin, so no PTT. The patient should follow up with Dr. [**Last Name (STitle) 1391**] in two to three weeks or post discharge from rehab or prn as needed. DISCHARGE DIAGNOSES: 1. Left foot ischemia status post tissue plasminogen activator with improvement. 2. Right hydronephrosis etiology unknown status post right nephrostomy tube. 3. Polymicrobial bacteremia treated. 4. Hypertension controlled. 5. Peripheral vascular disease. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2103-8-16**] 09:01 T: [**2103-8-16**] 10:26 JOB#: [**Job Number 31666**]

Admission Date: [**2147-8-1**] Discharge Date: [**2147-8-8**] Date of Birth: [**2107-7-7**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Chocolate Flavor Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2147-8-1**] - Mitral valve replacement (27mm St. [**Male First Name (un) 923**] Mechanical Valve)and Tricuspid Valve Repair with MC3 Annuloplasty system. History of Present Illness: 40 year-old woman, known to our service, who presented to [**Hospital **] Hospital in [**Month (only) 205**] after waking up with shortness of breath. She reported that was the first time she has had such an episode, but in retrospect she probably has had increasing dyspnea on exertion. A chest CT was done and ruled out PE. An echocardiogram revealed severe mitral valve regurgitation and significant pulmonary hypertension. She was referred for surgical evaluation. Past Medical History: severe mitral regurgitation hypertension pulmonary hypertension cardiomegaly anemia depression Social History: Occupation: on disability Last Dental Exam >1 year Lives with: children Race: Tobacco: smoked for 20 years, quit 5 years ago ETOH: rarely Family History: non-contributory Physical Exam: Pulse: 96 Resp: 16 O2 sat: 97% RA BP: 150/90 Height: 5'4" Weight: 115.1 kg General: WDWN female in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: SEM III/VI Crisp valve snap Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: - Left:- Pertinent Results: [**2147-8-1**] ECHO Pre-bypass: No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve shows characteristic rheumatic deformity. There is moderate thickening of the mitral valve chordae. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Moderate to severe (3+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. Post-bypass: At the time of post-bypass exam, the patient is receiving norepinephrine at 0.08 mcg/kg/min. There is a mitral valve mechanical prothesis well-seated without paravalvular regurgitation. Both mechanical leaflets are opening appropriately and there are small regurgitant "washing" jets.The mean gradient across the mitral valve is 7 mm hg with a heart rate of 90. The tricuspid valve has a minimal transvalvular gradient of 4 mm Hg. There is no tricuspid stenosis and mild tricuspid regurgitation. Ventricular function is similar to prebypass findings. The aorta is intact post decannulation. All findings communicated with [**Month/Day/Year 5059**] at time of exam. [**2147-8-4**] WBC-23.2* RBC-3.70* Hgb-8.6* Hct-28.5* RDW-19.4* Plt Ct-185 [**2147-8-5**] WBC-21.0* RBC-3.94* Hgb-9.6* Hct-31.2* RDW-19.0* Plt Ct-227 [**2147-8-6**] WBC-13.5* RBC-3.70* Hgb-8.4* Hct-28.6* RDW-19.6* Plt Ct-223 [**2147-8-7**] WBC-10.0 RBC-3.69* Hgb-8.8* Hct-29.0* RDW-18.9* Plt Ct-297 [**2147-8-8**] WBC-9.2 RBC-3.78* Hgb-9.0* Hct-29.6* RDW-18.9* Plt Ct-346 Warfarin dosing: [**2147-8-3**]: 5mg [**2147-8-4**]: 4mg [**2147-8-5**]: 5mg [**2147-8-6**]: 5mg [**2147-8-7**]: 2mg [**2147-8-8**]: 4mg - discharge dose PT/INR Results: [**2147-8-4**] PT-20.9* INR(PT)-1.9* [**2147-8-5**] PT-23.4* PTT-31.4 INR(PT)-2.2* [**2147-8-6**] PT-29.0* PTT-48.5* INR(PT)-2.9* [**2147-8-7**] PT-38.3* PTT-39.3* INR(PT)-4.0* [**2147-8-8**] PT-38.4* INR(PT)-4.0* [**2147-8-4**] Glucose-97 UreaN-16 Creat-0.7 Na-135 K-3.7 Cl-102 HCO3-25 AnGap-12 [**2147-8-5**] Glucose-87 UreaN-20 Creat-0.7 Na-139 K-3.6 Cl-105 HCO3-25 AnGap-13 [**2147-8-6**] Glucose-93 UreaN-18 Creat-0.6 Na-136 K-3.5 Cl-105 HCO3-24 AnGap-11 [**2147-8-7**] Glucose-82 UreaN-15 Creat-0.8 Na-138 K-3.9 Cl-105 HCO3-24 AnGap-13 [**2147-8-8**] UreaN-14 Creat-0.8 K-4.2 Brief Hospital Course: Ms. [**Known lastname 82901**] was admitted to the [**Hospital1 18**] on [**2147-8-1**] for surgical management of her valvular heart disease. She was taken to the operating room where she underwent a mitral valve replacement using a St. [**Male First Name (un) 923**] mechanical valve and a tricuspid valve repair using a MC3 annuloplasty system. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. On postoperative day one, she awoke neurologically intact and was extubated. She was weaned from her pressors. Her chest tubes and epicardial wires were removed and she was transferred to the step down floor. There she experienced copious diarrhea and was found to be c.dif positive, so oral Vancomycin was begun. Coumadin and heparin were initiated for her mechanical mitral valve. Warfarin was monitored daily and dosed for a goal INR between 3.0 - 3.5. Heparin was eventually discontinued once her INR reached above 2.0. The remainder of her postoperative course was uneventful. Over several days she continued to make clinical improvements with diuresis and was medically cleared for discharge to home on postoperative day seven. INR at discharge was 4.0. Prior to discharge, arrangements were made and confirmed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17466**] for management of Warfarin dosing as an outpatient. Medications on Admission: Zestril 30mg qd Nifedipine ER 60 qd Metoprolol XL 50 qd Ativan prn Tylenol Discharge Medications: 1. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: take 2 tabs(4mg) daily...daily dose may vary according to INR..use as directed by local MD. [**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2* 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: then drop to 1tab(40mg) daily for seven days then discontinue. [**Last Name (Titles) **]:*21 Tablet(s)* Refills:*0* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days: then drop to 1 tab(20mEq) daily for seven days then discontinue. [**Last Name (Titles) **]:*21 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 7 days. [**Last Name (Titles) **]:*28 Capsule(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Mitral and Tricuspid Valve Regurgitation Possible Rheumatic Valvular Heart Disease Hypertension Pulmonary Hypertension Anemia C. difficile Colitis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) You should wash incision daily with soap and water. No lotions creams or powders to incision until it has healed. No bathing or swimming for 6 weeks. 5) No lifting more then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month from date of surgery. 7) Take Warfarin as directed for goal INR between 3.0 - 3.5. Please check PT/INR on [**8-10**] call results to Dr [**Last Name (STitle) **],[**First Name3 (LF) **] @ [**Telephone/Fax (1) 50485**]. 8) Take Lasix and KCl as directed for two weeks then stop 9) Complete one week course of PO Vancomycin as directed 10) Please call with any questions or concerns Followup Instructions: [**Hospital 409**] clinic in 2 weeks Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 17466**] in [**12-27**] weeks. [**Telephone/Fax (1) 50485**] Please follow-up with Dr. [**Last Name (STitle) 2603**] in 3 weeks. please call to schedule all appointments Completed by:[**2147-8-8**]

Admission Date: [**2162-1-7**] Discharge Date: [**2162-1-20**] Date of Birth: [**2107-9-8**] Sex: M Service: CA [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: This is a 54 -year-old gentleman with multiple medical problems, including diabetes, hypertension, hyperlipidemia, and peripheral vascular disease, status post bilateral femoral popliteal bypasses, presenting with unstable angina and increased shortness of breath. Cardiac catheterization showed three vessel disease and an ejection fraction was moderately depressed. The patient was admitted to the Medical service and referred to Cardiac Surgery for surgical revascularization. PAST MEDICAL HISTORY: Coronary artery disease, status post percutaneous transluminal coronary angioplasty times one, peripheral vascular disease, status post bilateral femoral popliteal bypasses, hypertension, hyperlipidemia, peripheral neuropathy, diabetes insulin dependent. ADMITTING MEDICATIONS: Include Lipitor 20 mg q HS, Actos 45 mg a day, Celebrex 200 mg a day, Neurontin 300 mg a day, Atenolol 25 mg a day, Monopril 20 mg a day, and NPH 90 units subcutaneous q AM and 60 units subcutaneous q PM. Ciprofloxacin and clindamycin started during his medical admission. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On admission, alert and oriented male in no acute distress. Head and neck examination is unremarkable. Cardiovascular examination: regular rate and rhythm without murmurs. Lungs were clear to auscultation bilaterally. Extremity examination was significant for bilateral healed femoral popliteal incisions. In the left lower extremity there is a demarcated area of erythema and edema / induration. There were no palpable distal pulses and the patient had pain in the left shoulder upon abduction. The abdomen was mildly distended, but soft and nontender. ADMISSION LABORATORY DATA: White count on admission was 7.6, hematocrit 26, platelets 288,000. HOSPITAL COURSE: Prior to surgery, the patient was seen by Dermatology for his left lower extremity edema and erythema. Diagnosis of elephantiasis nostra verrucosa. Treatment was topical MetroGel to affected area [**Hospital1 **]. The patient also had an area of erythema on his right pretibial area which was diagnosed as necrobiosis lipoidica diabeticorum. This was just followed with plan for treatment on an outpatient basis. Infectious Disease was consulted and they placed the patient on clindamycin and ciprofloxacin for his presumed left lower extremity cellulitis. Th[**Last Name (STitle) 1050**] was brought to the Operating Room on [**2162-1-11**] for coronary artery bypass graft times three by Dr. [**Last Name (Prefixes) **]. The patient tolerated the procedure well and there were no complications. The patient was transferred to the Cardiac Intensive Care Unit postoperatively for hemodynamic monitoring. He remained hemodynamically stable and afebrile, was extubated on postoperative day zero. The patient was transferred to the floor on postoperative day one and he did well. Chest tube, pacing wires, central line, and Foley catheter were removed without any problems. The patient worked with Physical Therapy and was able to achieve level 5 ambulation. The patient's postoperative course was complicated only by sternal drainage which he developed several days after surgery. The patient's white count remained normal and he remained afebrile throughout the postoperative course. Cultures were sent of the fluid which had no organisms on gram stain and culture showed only sparse growth of gram positive cocci, believed to be contaminant from the skin. The skin remained healthy appearing and the sternum remained stable. The patient was watched several extra days at the hospital for this sternal drainage and he remained without any sign of infection. [**Last Name (un) **] Diabetes service was consulted to manage his insulin regimen. Finally, on postoperative day nine, the patient was felt to be safe to go home with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 11197**] the wound on a daily basis with dressing changes. DISPOSITION: The patient was discharged on [**2162-1-20**]. He had completed his course of ciprofloxacin and clindamycin as per Infectious Disease for a complete two week course. DISCHARGE MEDICATIONS: Include Lopressor 100 mg po bid, NPH insulin 100 units subcutaneous q AM, 50 units subcutaneous q HS, Lasix 20 mg po q day times seven days, potassium chloride 20 mEq po q day times seven days, aspirin 81 mg po q day, Percocet one to two tablets po q four to six hours prn, Colace 100 mg po bid, Zantac 150 mg po bid, Actos 45 mg po q day, and Lipitor 20 mg po q HS, MetroGel 1% [**Hospital1 **] to left lower extremity. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft times three. 2. Left lower extremity cellulitis. DISCHARGE STATUS: The patient was discharged home with [**Hospital6 407**] services as previously mentioned. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 33441**] MEDQUIST36 D: [**2162-1-20**] 10:10 T: [**2162-1-20**] 10:21 JOB#: [**Job Number 34542**]

[**Numeric Identifier 38710**] Admission Date: [**2118-3-12**] Discharge Date: [**2118-3-15**] Date of Birth: [**2118-3-12**] Sex: F Service: NEONATOLOGY HISTORY: Baby Girl [**Known lastname 38711**] [**Known lastname 38712**], twin number one, was delivered at 34 3/7 weeks gestation, weighing 2350 grams and was admitted to the Intensive Care Nursery from Labor and Delivery for management of prematurity. Mother is a 33-year-old gravida III, para I now III woman, with estimated date of confinement of [**2118-4-20**]. Prenatal screens included blood type A positive, antibody screen negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, and group B strep unknown. Pregnancy by in [**Last Name (un) 5153**] fertilization conception, with diamniotic dichorionic twin gestation. The mother was admitted to [**Hospital1 69**] at 28 weeks gestation with cervical shortening. She received betamethasone at that time, and was discharged home on bed rest. She presented on [**2118-3-11**] with pre-term labor and progressed to vaginal delivery under epidural anesthesia. Rupture of membranes four and a half hours prior to delivery. Received intrapartum antibiotics five and a half hours prior to delivery for unknown group B strep and prematurity. No maternal fever. This twin emerged with a spontaneous cry. Was dried and bulb suctioned. Apgar scores were 8 and 9 at one and five minutes respectively. PHYSICAL EXAMINATION: On admission, weight 2350 grams (50th percentile), length 45 cm (45th percentile), head circumference 31.5 cm (30th percentile). In general, an active, alert, pink premature female infant. Skin without rashes. Anterior fontanel open, flat, sutures mobile. Eyes with red reflex bilaterally. Palate intact. Breath sounds bilaterally equal, clear, with easy work of breathing. Regular rate and rhythm, without murmur. Normal pulses. Abdomen soft, without hepatosplenomegaly, no masses. Genitalia normal pre-term female external genitalia, anus patent. Spine straight and intact. Extremities normal, no hip clicks. Normal reflexes and tone for gestational age. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: No respiratory distress. Has remained in room air since admission, with oxygen saturations in the high 90s. Is comfortable breathing 30 to 50 times per minute. No apnea. 2. Cardiovascular: Soft murmur heard during first 12 hours of life, that has resolved. Has been hemodynamically stable since admission. Recent blood pressure 65/29 with a mean of 41. 3. Fluids, electrolytes and nutrition: Started ad lib feeds with formula shortly after admission. Received intravenous D-10-W for about 12 hours to maintain glucose above 40. Since intravenous discontinued, has maintained glucose in the 60s before feeds. Discharge weight 2345 grams. 4. Gastrointestinal: Has mild jaundice at time of discharge. Bilirubin level on [**3-14**] was 9.8. Follow-up bilirubin level on [**3-15**] was 9.7. 5. Hematology: Hematocrit on admission 43.6%. 6. Infectious Disease: Received 48 hours of ampicillin and gentamicin for rule out sepsis. 7. Neurology: Examination age appropriate. Head ultrasound not indicated. 8. Sensory: Hearing screening was performed with automated auditory brain stem response and she passed for both ears. CONDITION ON DISCHARGE: Stable pre-term infant, feeding well, with mild jaundice. DISCHARGE DISPOSITION: Discharged home with parents. NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38713**], M.D., telephone number [**Telephone/Fax (1) 38714**], fax number [**Telephone/Fax (1) 38715**]. CARE RECOMMENDATIONS: 1. Feeds: Ad lib breast or bottle feeding every three to four hours. Monitor for weight. 2. Monitor jaundice. 3. Medications: None. 4. Car seat position screening - infant was unable to maintain saturations while positioned in car. Repeat screening done in car bed. She remained well saturated throughout the test. Recommend travel in car bed. 5. State newborn screen drawn prior to discharge, and is pending. 6. Immunizations received: Received hepatitis B immunization and Synagis on [**2118-3-13**]. 7. Immunizations recommended: Synagis respiratory syncytial virus prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks gestation; (2) Born between 32 and 35 weeks, with plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; or (3) With chronic lung disease. 8. Follow-up appointments: a. The parents will make follow-up appointment with pediatrician at discharge. DISCHARGE DIAGNOSIS: 1. AGA pre-term female 2. Rule out sepsis 3. Physiologic jaundice [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**] Dictated By:[**Last Name (NamePattern1) 36138**] MEDQUIST36 D: [**2118-3-14**] 00:22 T: [**2118-3-14**] 01:00 JOB#: [**Job Number 38716**]

Admission Date: [**2192-6-17**] Discharge Date: [**2192-7-6**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Found down Major Surgical or Invasive Procedure: PEG History of Present Illness: Pt. is an 88 year old with a history of HTN and bilateral hip replacement who is brought in by EMS today after being found down. History is per daughter and per EMS report. Daughter reports that pt. is very active at baseline, lives independantly, does her own shopping, takes care of a grandchild 2 days a week. She was last seen well yesterday afternoon by a friend. [**Name (NI) **] friend was expecting her at church this morning but she did not arrive. She went over to her house afterwards and tried to knock but pt. did not answer. Her friend became concerned and called EMS. EMS found her lying on the floor of her bathroom, with a puddle of cleaning fluid around her. They describe her as being awake but not oriented. She was unable to state how long she had been on the floor. Her BP was 200/110 on the scene. Here she has been noted to be in A fib, with a rate in the 70s-80s. Pt. has no complaints at presents, denies pain, weakness. Does not know where she is or why she is here. Past Medical History: Hypertension Bilateral Hip replacement Bilateral cataract repair, daughter reports she has anisocoria at baseline No history of arrhythmia or stroke that daughter is aware of Social History: Lives alone in [**Hospital3 28354**], daughter, who is an Ob/Gyn at [**Hospital1 **], lives in the area. No tobacco, occ social EtOH. Very active and independant at baseline. Daughter, [**Name (NI) **] [**Name (NI) **], HCP [**Name (NI) **] at [**Hospital1 **]), H [**Telephone/Fax (1) 73415**], C [**Telephone/Fax (1) 73416**], Bp [**Telephone/Fax (2) 73417**] Family History: Father -> Aortic Stenosis Mother -> Alzheimer's, ? stroke Brother -> MI Physical Exam: T- 97.8 BP- 210/151 HR- 78 RR- 18 O2Sat- 96% on RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa, + racoon eyes bilaterally Neck: in C collar CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert. Cannot say where she is, or what the month or year are, says first name when asked (not last name). Speech is non-fluent, says a few words only (says her name, answers simple Y/N questions, when asked her last name and where she is says something unintelligible, paucity of spontaneous speech); follows simple commands (stick out tongue, wiggle toes, raise arm). No dysarthria. + R sided neglect. Cranial Nerves: R pupil 6 mm, irregular, NR. L pupil 2.5 mm, minimally reactive. R NLF flattening. Tongue midline. Blinks to threat on L, not R. Crosses midline to R, but does not bury sclera, burys sclera on L gaze. L gaze preference. Motor: Decreased bulk throughout. Tone normal. No observed myoclonus or tremor. Holds L arm anti-gravity x 10 sec with no drift. Holds R arm anti-gravity x 10 sec with some drift and some motor impersistance. Holds R leg briefly anti-gravity, but quickly drifts to bed. Holds L leg anti-gravity x 5 sec. Sensation: Withdraws to pain all 4 extremities. Reflexes: +2 and symmetric throughout. Toes upgoing on R, down on L Pertinent Results: [**2192-6-17**] 03:19PM BLOOD ALT-41* AST-73* CK(CPK)-923* AlkPhos-141* Amylase-47 TotBili-1.4 [**2192-6-18**] 04:35AM BLOOD CK-MB-14* MB Indx-3.3 cTropnT-0.04* [**2192-6-17**] 10:30PM BLOOD CK-MB-23* MB Indx-3.7 cTropnT-0.04* [**2192-6-17**] 03:19PM BLOOD cTropnT-0.04* [**2192-6-25**] 06:30AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.4* [**2192-6-24**] 05:55PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.6 [**2192-6-21**] 07:25AM BLOOD Calcium-9.2 Phos-2.2* Mg-1.9 [**2192-6-18**] 08:55PM BLOOD %HbA1c-6.0* [**2192-6-23**] 12:35AM BLOOD Triglyc-72 HDL-52 CHOL/HD-3.1 LDLcalc-94 [**2192-6-25**] 12:55PM BLOOD Osmolal-257* [**2192-6-19**] 02:59PM BLOOD Osmolal-266* [**2192-6-24**] 05:55PM BLOOD TSH-7.7* [**2192-6-17**] 03:19PM BLOOD TSH-3.9 [**2192-6-24**] 05:55PM BLOOD Cortsol-23.8* [**2192-6-25**] 06:30AM BLOOD T3-74* Free T4-1.2 [**2192-6-17**] 03:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2192-6-17**] 03:31PM BLOOD Lactate-4.1* Head CT: 1. Left early subacute infarct with hemorrhagic transformation in the posterior cerebral artery territory involving the left posterior corona radiata, thalamus, temporal lobe, and occipital lobe. 2. Right frontal lobe late subacute infarct Echo: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2), but the valve area may have been slightly DERestimated, because of the technically suboptimal acquisition of LVOT velocities. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a physiologic pericardial effusion. MRA/MRI: FINDINGS: The carotid and vertebral arteries are visualized from their origins to their intracranial courses. There is no evidence of stenosis or occlusion. There are mild atherosclerotic changes identified. The distal cervical internal carotid arteries measure 4.3 mm diameter on the left and 4.5 mm diameter on the right following NASCET criteria. CONCLUSION: Mild atherosclerotic changes of the cervical arterial vessels. Otherwise, no evidence of stenosis or occlusion. Brief Hospital Course: Ms. [**Known lastname 39540**] is a 89-year-old woman with a history of hypertension who presented after being found down. Her hospital course by problem is as follows: 1. Neuro: STROKE. Ms. [**Known lastname 39540**] was admitted to the stroke service for further evaluation. An MRI of the brain showed the left subacute infarct of the posterior corona radiata, thalamus, temporal lobe, and occipital lobe, as well as a right frontal lobe infarct. As these appeared to be the result of multiple emboli and as she was discovered to have atrial fibrillation (previously unknown), she was started on a Heparin drip. The next morning, she was found to be excessively somnolent; stat Head CT showed hemorrhagic transformation of her ischemic strokes. The ICH and heparin was discussed with her daughter who is the medical decision maker. The daughter decided to continue with the heparin despite the risk of worsening ICH. She was transferred to the step-down for closer monitoring. Her blood pressure was controlled with IV prn BB initally; ultimately it was controlled with oral lisinopril and metoprolol. She was maintained euglycemic and normothermic. She was continued on Heparin with goal PTT 40-60 and started on Coumadin. After several days of low INRs, her INR was found to be 10.6 on [**7-4**]; she was given 5 mg of Vitamin K subcutaneously and 5 mg orally, and 2 units of FFP. She was then resumed on the Heparin drip while her INR was again sub-therapeutic; she was restarted on a lower dose of warfarin. Her goal INR is [**1-7**]. Her exam improved somewhat so that she is fully awake and alert and moving her left side well; she is hemiparetic on the right but does have some movement in the R LE. 2. Hypercholesterolemia. LDL was found to be 94; as her goal will be < 70, she was started on Lipitor 10. 3. DENS fracture. She was found to have a Dens fracture on CT due to her initial fall. She was evaluated by the spine service who recommended to keep the C-collar for 3 months (through [**2192-9-17**]). 4. Atrial fibrillation. She was rate controlled with metoprolol and anti-coagulated as above. 5. ID. She had mild temperature bumps for which she was pan-cultured. She was empirically started on vanco and zosyn and her leukocytosis improved. No infectious source was found, and she remained afebrile after the completion of these antibiotics. 6. Hyponatremia. This was thought to be due to a combination of cerebral salt wasting and SIADH. The renal service was consulted. After fluid restriction failed to improve the sodium, they recommended using 3% saline. This improved her Na, and once her PEG was in place, her sodium was maintained with salt tabs. 7. Subclinical hypothyroidism. She was found to have elevated TSH with a normal free T4 (1.2) and low T3 (73). This was not clinically significant at this point, but should be followed as an outpatient in the future. 8. Nutrition. She was evaluated by speech and swallow on several occasions but failed her feeding trial. A PEG was therefore placed for further feeding. 9. Airway edema. After being electively intubated for the PEG placement, she was found to have significant epiglottal edema preventing extubation. She was given 3 days of prednisone, but bronchoscopic evaluation after these 3 days revealed persistent edema. In consultation with her daughter, it was decided that she should receive a tracheotomy. 10. CODE: She is DNR; intubated electively as above. 11. Dispo: She was discharged to a rehab facility. Medications on Admission: Lisinopril Atenolol Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever: per PEG. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Per PEG. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Per PEG. 5. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3 times a day): Per PEG. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed): Per PEG. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: Per PEG. 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Per PEG. 9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Per PEG. 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Per PEG. 11. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet Sig: Two (2) packets PO once a day for 1 doses: Please give once per PEG at 8 pm [**2192-7-6**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Stroke 2. Intracranial hemorrhage 3. Atrial fibrillation 4. Pneumonia 5. Hyponatremia Discharge Condition: Stable. On neurological examination, the patient is awake and alert, but aphasic, without speech. She has findings consistent with a right homonymous hemianopsia. Right pupil is surgical and the left reactive. Her left arm and leg are consistently anti-gravity (3+). However, her right arm and leg are generally weaker and have often fluctuated during the hospital course, ranging between a 1+ and a 3+. On day of discharge her right side was [**12-6**]+. Discharge Instructions: Please take your medications as prescribed and follow up with your appointments as scheduled. If you have new, worsening, or concerning symptoms, please call your phyician or return to the nearest emergency room. The patient is to contune to wear her cervical collar for 3 months until her follow up appointment with the orthopedic clinic at that time. Please follow up the INR daily, as the paient is on coumadin with a history of atrial fibrillation. Her goal INR is [**1-7**]. Given her history of hyponatremia, please check a chemistry (including soudium) and a CBC at least weekly. Please aim for a systolic blood pressure in the 120's to 130's if possible. Lisinopril was added just prior to discharge. Followup Instructions: 1. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2192-8-21**] 3:30 2. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2192-9-27**] 10:40 Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2192-9-27**] 11:00 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2192-7-6**]

Admission Date: [**2154-2-4**] Discharge Date: [**2154-2-20**] Date of Birth: [**2099-5-31**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient complained of chest tightness, dyspnea and palpitations for the past month. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gout. 3. L4 through L5 and S1 through S2 herniated disks. 4. Pin implant in the left fifth finger. PAST SURGICAL HISTORY: Status post cholecystectomy. SOCIAL HISTORY: The patient is a previous smoker but quit 20 years ago. MEDICATIONS AT HOME: 1. Aspirin 325 q. day. 2. Lisinopril 10 mg q. day. ALLERGIES: The patient has no known drug allergies. REVIEW OF SYSTEMS: Negative for myocardial infarction, transient ischemic attack, cerebrovascular accident, claudication, orthopnea, hepatitis or peptic ulcer disease. PHYSICAL EXAMINATION: Vital signs were heart rate 70s in sinus rhythm, blood pressure 110/70. The patient was alert and oriented x 3. There was no jugular venous distension, no bruits. Chest was clear to auscultation. Cardiovascular examination was regular rate and rhythm, S1 and S2, no S3 or S4 and a 3/6 systolic ejection murmur. Abdomen had positive bowel sounds, nontender, nondistended. Extremities had no cyanosis, clubbing or edema. An echocardiogram done in [**2153-12-15**] showed an ejection fraction of 60%, severe atrial fibrillation, mild mitral regurgitation, mild aortic insufficiency and left ventricular hypertrophy. Cardiac catheterization on [**2154-2-4**] showed preserved left ventricular ejection fraction, left anterior descending 60% mid vessel, obtuse marginal #1 40%, no mitral regurgitation, moderate aortic stenosis with an aortic valve area of 0.7 cm. LABORATORY DATA: White blood cell count was 11.6, hematocrit 44.6, platelet count 200, BUN 21, creatinine 1.0, liver function tests within normal limits and a negative urinalysis. HOSPITAL COURSE: The patient was admitted on [**2154-2-4**] and taken to the operating room on [**2154-2-5**] for an aortic valve replacement with a [**Street Address(2) 11688**]. [**Male First Name (un) 923**] mechanical valve and a coronary artery bypass grafting x 1 with left internal mammary artery to the left anterior descending coronary artery. Anesthesia was reversed and the patient was transferred to the intensive care unit where he was successfully weaned from vasopressors and was extubated on postoperative day one. Chest tubes and pacing wires were discontinued on postoperative day three and he was transferred to the floor for continued recovery and rehabilitation. He was placed on heparin and Coumadin for anticoagulation. On postoperative day four he began experiencing significant dyspnea with diaphoresis and decreased blood pressure as well as tachycardia. He was transferred back to the CSRU. Chest x-ray revealed hematoma in the left middle lobe. A chest CT was also done and showed no evidence of a PE. A large pericardial effusion was present as well as moderate-sized bilateral pleural effusions and a loculated effusion on the left. The patient was aggressively diuresed and respiratory status improved. He was also transfused with two units of packed red blood cells for a 6% hematocrit drop. The Coumadin and heparin were discontinued. Renal was consulted for increasing creatinine as well as decreased urinary output. An echocardiogram was done and showed left ventricular ejection fraction of 55% and mildly dilated left atrium. The patient remained in the intensive care unit for the next several days. He had remitting episodes of shortness of breath that responded well to diuresis. Chest x-ray remained stable. On postoperative day six creatinine was trending downward and urine output was improving. He was started on levofloxacin for a positive urinalysis. Culture was pending. The patient began experiencing decreased appetite with some slight abdominal distention. Liver function tests were trending upward. GI was consulted. They believed this to be due to a low flow state. On postoperative day seven hematology was consulted for continued decreasing hemoglobin and hematocrit despite no evidence of real bleeding. On postoperative day eight the patient began improving with decreased liver function tests, increased appetite, decreased creatinine. Urine output was stable. Respiratory status was improving and hematocrit remained stable. On postoperative day nine he was transferred back to the floor. Physical therapy was involved with rehabilitation and anticoagulation was resumed. On postoperative day 10 the patient had some episodes of sinus tachycardia with bursts of wide complex tachycardia. Beta blocker was increased. No further episodes were noted. On postoperative day 12 the patient complained of right ankle pain and increased white blood cell count. Rheumatology was consulted. The joint was aspirated and fluid sent for culture. The results are still pending. Fluid analysis was consistent with pseudogout. He was treated with colchicine and intra-articular steroid injection with good pain relief. On postoperative day 13 the patient continued to have episodes of supraventricular tachycardia without a wide complex tachycardia. Cardiology was consulted. Beta blocker was changed from Lopressor to sotalol with no further episodes of supraventricular tachycardia noted. The patient continued to have the presence of bilateral pleural effusions. A right thoracentesis was performed and drained about 1.5 liters of bloody fluid. Culture was sent and was still pending, and a left thoracentesis was also performed and that drained about one liter of bloody fluid. At this point on postoperative day 15 the patient's respiratory status continues to improve. He is ambulating independently in the hallways. He is eating well, making sufficient urine and is continuing to recover nicely. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 17400**] MEDQUIST36 D: [**2154-2-20**] 10:03 T: [**2154-2-20**] 10:17 JOB#: [**Job Number 49602**]

Admission Date: [**2106-10-23**] Discharge Date: [**2106-10-27**] Date of Birth: [**2052-3-29**] Sex: M Service: MEDICINE Allergies: Tylenol-Codeine #3 Attending:[**First Name3 (LF) 7651**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: - Percutaneous Coronary Intervention w/ Drug-Eluting Stent Placement (x2) in Right Coronary Artery. History of Present Illness: 54 year old male with PMH of hypercholesterolemia admitted with chief complaint of chest pain. Pt reports that this afternoon he had substernal chest pain and diaphoresis. Previously he was in good health and denies any h/o angina. . In the ED EKG revealed STE in inferior leads and in V5/V6. Pt was loaded with 600mg of plavix, given 325 ASA and given heparin bolus. . Cath revealed 70% mid-RCA lesion and occlusion of PDA. Thrombectomy of RCA and PCI placed in RCA and PDA lesions. Was given fentanyl for CP. . On transfer to CCU pt was in sinus rhythm, SBP 160 and vitals were otherwise unremarkable. Venous sheath was still in place. Pt still complaining of chest pain and STE have not yet resolved, but improved. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia. 2. CARDIAC HISTORY: Unremarkable. 3. OTHER PAST MEDICAL HISTORY: Left Inguinal Hernia. Social History: Works as skilled metal worker. Lives with fiance in [**Location (un) 6151**] but stays every night with his mother in [**Name (NI) 86**]. Primary caretaker of mother, has limited support from siblings. - Tobacco history: no - ETOH: no - Illicit drugs: no Family History: Father died of MI Mother s/p quadruple bypass Physical Exam: VS: T=afebrile (Tmax=99.7, Range=97-99.7 x 24 hrs) BP=91-114/59-79 HR=80-104 RR=16-20 O2-Sat= 95-97% GENERAL: NAD. Oriented x3. HEENT: Sclera anicteric, non-injected. PERRL, EOMI. NECK: Supple. No lymphadenopathy or asymmetry noted. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No m/r/g or S3/S4 noted. No thrills, lifts. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Venous sheath in place 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+ . Exam at Discharge: GENERAL:54 yo M in no acute distress HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP non elevated CHEST: CTABL no wheezes, no rales, no rhonchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. Pos hernia. EXT: wwp, no edema. DPs, PTs 2+. NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. Gait WNL. SKIN: no rash PSYCH: A/O , calm, appropriate Pertinent Results: ADMISSION AND HOSPITAL COURSE LABS [**2106-10-23**] 10:22PM PLT COUNT-227 [**2106-10-23**] 10:22PM NEUTS-55.7 LYMPHS-37.0 MONOS-5.2 EOS-1.4 BASOS-0.7 [**2106-10-23**] 10:22PM WBC-8.3 RBC-5.00 HGB-15.5 HCT-42.0 MCV-84 MCH-31.0 MCHC-36.8* RDW-13.5 [**2106-10-23**] 10:22PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.1 [**2106-10-23**] 10:22PM GLUCOSE-160* UREA N-15 CREAT-0.7 SODIUM-142 POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-19* ANION GAP-17 [**2106-10-23**] 10:30PM PT-17.9* INR(PT)-1.6* [**2106-10-23**] 10:22PM BLOOD cTropnT-<0.01 [**2106-10-24**] 04:51AM BLOOD CK-MB-261* MB Indx-8.1* cTropnT-7.56* [**2106-10-24**] 01:22PM BLOOD CK-MB-209* MB Indx-7.2* [**2106-10-25**] 05:12AM BLOOD CK-MB-83* MB Indx-5.1 [**2106-10-23**] 10:22PM BLOOD CK(CPK)-106 [**2106-10-24**] 04:51AM BLOOD CK(CPK)-3224* [**2106-10-24**] 01:22PM BLOOD CK(CPK)-2917* [**2106-10-25**] 05:12AM BLOOD CK(CPK)-1614* [**2106-10-24**] 04:51AM BLOOD Triglyc-155* HDL-34 CHOL/HD-6.3 LDLcalc-150* . DISCHARGE LABS [**2106-10-27**] 07:15AM BLOOD WBC-8.0 RBC-4.70 Hgb-14.6 Hct-40.6 MCV-86 MCH-31.0 MCHC-35.9* RDW-13.4 Plt Ct-201 [**2106-10-25**] 05:12AM BLOOD PT-14.9* PTT-36.4* INR(PT)-1.3* [**2106-10-27**] 07:15AM BLOOD Glucose-134* UreaN-19 Creat-0.8 Na-141 K-4.1 Cl-104 HCO3-28 AnGap-13 . IMAGING [**2106-10-23**] Cardiac Cath: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated two vessel coronary artery disease. The LMCA was normal. The LAD was patent. The LCx had less than 50% stenosis. The RCA had a 70% mid-vessel lesion and a subtotal occlusion before the bifurcation with complete occlusion of the PDA. 2. Limited resting hemodynamics revealed systolic and diastolic arterial hypertension. 3. Successful aspiration thrombectomy, PTCA and stenting of the distal RCA into the PDA with a 3.0 x 18 mm Promus DES (see PTCA comments). 4. Successful direct stenting of the mid RCA with a 3.5 x 28 mm Promus DES (see PTCA comments). 5. Successful RFA AngioSeal (see PTCA comments) FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Normal ventricular function. 3. Successful aspiration thrombectomy and PCI fo the distal RCA into the PDA with a 3.0 x 18 mm Promus DES. 4. Successful PCI of the mid RCA with a 3.5 x 28 mm Promus DES. [**2106-10-24**] TTE: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal 2/3rds of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40-45 %). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal with focal basal free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional biventricular systolic dysfunction c/w CAD (prox/mid RCA distribution). Mild pulmonary artery systolic hypertension. Brief Hospital Course: Mr. [**Known lastname **] is a 54 yo male with PMH of hyperlipidemia who presented with chest pain and found to have STEMI s/p 2 drug-eluting stent placement. . # Acute Inferior Myocardial Infarction (STEMI): Initial EKG showed ST elevation in II, III, aVF, V5 and V6, as well as ST depression in I, aVL, aVR, V1 and V2. Pt underwent emergent catheterization, which revealed 70% stenosis of RCA, and 100% occlusion of PDA. Aspiration thrombectomy was performed, and 2 Drug-Eluting Stents were placed (distal-RCA into PDA, mid-RCA). Post-PCI echocardiogram performed on HD 2 was notable for mild LV dysfunction, w/ EF of 40-45%, and severe hypokinesis of basal [**3-4**] inferior/inferolateral walls and mild pulmonary hypertension. His post-cath course was complicated by right groin hematoma at the site of access on HD 2, but resolved without intervention. He also developed low-grade temps to Tmax of 100.5, but was without other concerning signs or symptoms for infection or acute thromboembolic event. He was started Aspirin, Plavix, Atorvastatin, Lisinopril, and Metoprolol. He tolerated these medications well, and at time of discharge, pt had experienced no observed arrhythmias on telemetry, and was asymptomatic, feeling well and ready to go home. . # Hypertension: Pt was previously on HCTZ/lisinopril, stopped secondary to side-effects (lightheadedness). He was started on Metropolol and Lisinopril for long-term improved cardiac outcome. . # Hyperlipidemia: At time of admission, pt was not on any lipid-lowering medications, and lipid panel on this admission revealed LDL of 150, borderline low HDL and TG 155. As pt is status-post acute myocardial infarction, he was started on atorvastatin, which will require long-term continuation. . TRANSITIONAL ISSUES: - Will have follow-up with NP [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 67876**] on [**2106-11-4**], previous outpatient Cardiology (Dr. [**Last Name (STitle) **] on [**2106-11-23**], and Dr. [**Last Name (STitle) **] on [**2106-12-21**] - Will recommend CBC + BMP check-up at first outpatient consultation. - Dry weight estimated at 89kg. Will aim for healthy weight reduction via low-salt/low-fat cardiac diet. Medications on Admission: None. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 6. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Disp:*25 tablets* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ST Elevation myocardial infarction Acute Systolic dysfunction Dyslipidemia Discharge Condition: Medically Stable. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were admitted because you had a heart attack. Images of your heart (catheterization) showed that critical vessels that supply blood to your heart were blocked, and so 2 stents (drug-eluting) were placed in order to keep the blood vessels open. Echocardiogram (which is an ultrasound of your heart) after the catheterization procedure showed impaired heart function. These findings predispose you to future heart problems, including fluid backup in your lower extremities and lungs. Please START taking the following medications in addition to your home medications: 1. Metoprolol - to lower your heart rate, control your blood pressure and help your heart pump better. 2. Atorvastatin - to lower your cholesterol and prevent future plaque build-up in your heart's arteries. 3. Plavix - to prevent re-occlusion of your stented arteries or blockage of the drug-eluting stent that was placed. 4. Aspirin - to prevent platelet blockage of the drug-eluting stent that was placed. 5. Lisinopril - to control your blood pressure and help your heart pump better. 6. Nitroglycerin - to alleviate heart-related chest pain. Please take this medication if you have chest pain at home that is similar to the chest pain that brought you to the hospital. Take one tablet, wait 5 minutes, then take another tablet. Please call 911 if you still have chest pain after 2 tablets, and please call Dr. [**Last Name (STitle) **] if you use nitroglyerin at all. It is very important that you are compliant with these medications, especially Plavix (Clopidogrel) and Aspirin. Skipping or changing doses of these medications can result in life-threatening blockage of the arteries that were blocked during this heart attack. Do not stop unless your cardiologist, Dr. [**Last Name (STitle) **], tells you that it is ok. In addition, please: 1. Weigh yourself every morning, and call your primary care physician if your weight goes up by more than 3 lbs (total). 2. Continue the exercise plan that the physical therapist discussed with you during this admission. 3. Involve your family and friends in your lifestyle modifications (including low-salt/low-fat diet, aerobic exercise and new medication regimen) in order to facilitate the long-term maintenance of this care. Thank you for entrusting your health to our staff. Please contact the [**Name (NI) 91659**] ([**Telephone/Fax (1) 10339**]) if you have chest pain again or any other concerning symptoms. Followup Instructions: Name: [**Last Name (LF) **], [**Name8 (MD) **] NP Location: [**Hospital **] MEDICAL ASSOCIATES, P.C. Address: [**Street Address(2) 75807**], STES 3A, B, [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 54268**] Appointment: THURSDAY [**11-4**] AT 10:45AM Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **] MD Specialty: CARDIOLOGY Address: [**Street Address(2) 75807**],STE 2C, [**Location (un) **],[**Numeric Identifier 23881**] Phone: [**Telephone/Fax (1) 44655**] Appointment: TUESDAY [**11-23**] AT 10:30AM Department: CARDIAC SERVICES When: TUESDAY [**2106-12-21**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2106-10-27**]

Admission Date: [**2124-12-20**] Discharge Date: [**2124-12-26**] Date of Birth: [**2046-8-3**] Sex: F Service: SURGERY Allergies: Sulfonamides / Lasix Attending:[**First Name3 (LF) 17683**] Chief Complaint: fever, lethargy, swelling under chin, respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: Pt is 78 yo NH resident found to have fever (102.3) for 3 days and cellulitis of the chin. Presented to the [**Hospital1 18**] ED on [**2124-12-20**] with the above complaints. Also lethargic. Was intubated in the ED for stidor and respiratory distress. Past Medical History: * Diabetes * Hypercholesterolemia * CHF: EF> 60% with LAE, 1+ MR [**First Name (Titles) **] [**Last Name (Titles) **] [**2-8**]; prior admissions for overload * hx of sacral decubitus ulcer * hx of gastric ulcer * osteomyelitis of the L4-L5 s/p laminectomy * Cryptogenic Cirrhosis * osteoarthritis * Hypertension * CAD (details unknown) * h/o spontaneous PTX (with CT placement) * nutritional deficiency * hx of MRSA Social History: lives in [**Location **] x 3 years, daughter and son visit everyday. Former 25 pack-year smoking hx. No alcohol. Retired [**Last Name (un) 104638**] in schools. Family History: Sister and Daughter with cryptogenic cirrhosis Physical Exam: 100.1, 97.8, 65, 91/38, 12 99% intubated Vent AC FiO2 50% PEEOP 5 CTA RRR Abd: soft, NT, ND Neck: Swollen, erythematous, no crepitous HEENT: MMM, no obvious abscess or cellulitis Pertinent Results: [**2124-12-20**] 10:50AM BLOOD WBC-8.6 RBC-2.82* Hgb-9.8* Hct-27.4* MCV-97 MCH-34.9*# MCHC-35.9*# RDW-13.6 Plt Ct-106* [**2124-12-20**] 10:50AM BLOOD Neuts-80* Bands-2 Lymphs-6* Monos-11 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2124-12-20**] 10:50AM BLOOD PT-14.0* PTT-24.8 INR(PT)-1.3 [**2124-12-20**] 10:50AM BLOOD Glucose-212* UreaN-16 Creat-0.7 Na-134 K-4.6 Cl-100 HCO3-20* AnGap-19 [**2124-12-20**] 10:50AM BLOOD ALT-26 AST-41* CK(CPK)-32 AlkPhos-139* Amylase-45 TotBili-2.5* [**2124-12-20**] 10:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 . RADIOLOGY Final Report CT NECK W/CONTRAST (EG:PAROTIDS) [**2124-12-20**] 1:02 PM CT OF THE NECK WITH CONTRAST: The subcutaneous soft tissues of the anterior neck are swollen with diffuse fat stranding thickening and ill defined imaging of the fasical planes. The process extends from the level of the clavicular heads to the angle of mandible, and is more prominent on the right side. Blurring of the fat planes between the anterior strap muscles with increased asymmetric soft tissue infiltration both anterior and posterior to the hyoid bone is noted, again largely right sided Some suggestion of small ~1 cm fluid collections posterior to the right submandibular gland and adjacent to the right portion of the hyoid bone are found. Soft tissue stranding extends to the right carotid sheath, blurring the fat plane. However, both the internal jugular and carotid vasculature within the neck enhance normally, with no evidence of filling defects or irregularity. The patient is intubated, likely accounting for a large amount of fluid secretions within the nasopharynx, oropharynx, nasal cavity, and right inferior maxillary sinus. The base of the brain is unremarkable. No suspicious bone lesions are found. Lung apices are clear. IMPRESSION: Marked edema and stranding of the soft tissues of the anterior neck as described, more prominent on the right side, most consistent with cellulitis/fasciitis in light of the provided history of infectious signs and symptoms. Possible small, early fluid loculations adjacent to the right submandiblaur gland and right portion of the hyoid bone. . RADIOLOGY Final Report NECK,SOFT TISSUE US PORT [**2124-12-21**] 12:48 PM COMPARISON: CT scan from [**2124-12-10**]. ULTRASOUND OF THE SOFT TISSUES OF THE NECK: There is edema of the strap muscles, which is slightly more conspicuous deep neck soft tissues above the hyoid, without any discrete fluid collections. IMPRESSION: Edematous changes within the strap muscles in the soft tissues of the right neck, without any discrete fluid collections. Results were discussed with the covering resident after the study was performed. . Brief Hospital Course: The patient was admited to the General Surgery service under Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and placed in the SICU. IV Antibiotics were started (Vanco, Zosyn, Clindamycin). ENT was consulted who agreed with IV Abx and following the patient wihtout surgery if unless her condition worsened. ON HD 2 the cellulitis was improved and vent weaning began. On [**12-22**] decadron was started to help with laryngeal swelling per the reccommendation of ENT; NG tube placement was unsuccessful. There continued to be improvement in the neck swelling/erythema and airwayu swelling. Pt was extubated on [**12-23**] without event. On [**2124-12-24**] the patient was started on a full liquid diet and transfered to the floor with continued improvement of her clinical course. The antibiotics were continued. A PICC line was placed on [**2124-12-24**]. The morning of [**2124-12-25**] the patient was found to be in rate controlled AFib. Given her rate control, multiple comorbidities, and return to NSR, we opted not to anticoagulate. There was worsening of the patients baseline anemia (HCT lowest 22.4). This anemia of acute disease was observed; given no signs of hypovolemia, we opted not to transfuse. On [**2124-12-26**] the patient was tolerating a regular diet, was afebrile, and had no signs of cellulitis. She was discharged to back to her Nursing Home to finish a 14-day course of Vanco/Zosyn. Clindamycin was stopped [**2124-12-25**] per ID recommendations. Medications on Admission: Tylenol, aldactone, insulin, doxepin, benadryl, nirtofuratone, protonix, reglan, albuterol Discharge Medications: 1. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 8 days. Disp:*24 Recon Soln(s)* Refills:*0* 2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 8 days. Disp:*8 1gm/200ml* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital1 10283**] Center - [**Location (un) **] Discharge Diagnosis: neck cellulitis Discharge Condition: good Discharge Instructions: Restart you home medications as usual. Regular diet. You may resume activity as tolerated. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Return of erythema/swelling of neck * Other symptoms concerning to you Followup Instructions: Call Dr.[**Name (NI) 22019**] office for a follow-up appointment ([**Telephone/Fax (1) 25089**] [**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]

Admission Date: [**2131-10-2**] Discharge Date: [**2131-10-12**] Date of Birth: [**2074-8-16**] Sex: M Service: SURGERY Allergies: Cellcept Attending:[**First Name3 (LF) 371**] Chief Complaint: Trauma- MVC Major Surgical or Invasive Procedure: 1. Intubation 2. Open reduction internal fixation right distal radius History of Present Illness: PI: The patient is a 57 yo male s/p renal transplant, HTN, IDDM who was airlifted from OSH following MVA. History mainly obtained from records as patient was intubated. Earlier tonight patient had MVA car versus tree accident with moderate damage. He was unrestrained, airbag worked. According to the notes, he was able to ambulate at the scene and it is not clear whether the patient lost consiousness. FSBS at scene was 52, for which he received an amp of D50. He was brought to OSH. He had laceraration to his head and periorbital ecchymoses. A CT head showed small SAH (R-frontal and temporal) and focal, punctate hemorrhage in R basal ganglia as well as small vessel disease. He was transferred to [**Hospital1 18**], where he was intubated in the OR with fiberoptics as he had a raspy voice (according to his daughter this is his baseline). Injuries include L-rib fractures ([**2-17**]), C1 fracture (minimally displaced), widened mediastinum. A head CT was repeated. Past Medical History: 1. Insulin dependent diabetes mellitus 2. Cerebral vascular event 3. Hypertension 4. Laproscopic cholecystectomy 5. Renal transplant x 2 Social History: n/a Family History: n/a Physical Exam: A&Ox2 PERRLA left 2-->1mm Right periorbital hematoma and multiple lacerations CTA bilaterally RRR Abd soft, ntnd, foley in place Rectal nml tone, heme negative C spine ttp, no step off Pertinent Results: [**2131-10-2**] 10:47PM BLOOD WBC-16.9* RBC-4.09* Hgb-13.3* Hct-37.9* MCV-93 MCH-32.5* MCHC-35.1* RDW-14.1 Plt Ct-147* [**2131-10-3**] 02:50AM BLOOD WBC-11.1* RBC-3.44* Hgb-10.9* Hct-31.7* MCV-92 MCH-31.7 MCHC-34.5 RDW-14.1 Plt Ct-136* [**2131-10-3**] 04:13PM BLOOD WBC-14.2* RBC-3.16* Hgb-10.4* Hct-29.6* MCV-94 MCH-33.0* MCHC-35.2* RDW-14.2 Plt Ct-127* [**2131-10-4**] 01:53AM BLOOD WBC-13.4* RBC-3.03* Hgb-9.7* Hct-28.7* MCV-95 MCH-31.8 MCHC-33.6 RDW-14.3 Plt Ct-137* [**2131-10-5**] 02:09AM BLOOD WBC-10.4 RBC-2.77* Hgb-8.8* Hct-25.5* MCV-92 MCH-31.9 MCHC-34.7 RDW-14.0 Plt Ct-120* [**2131-10-5**] 11:10AM BLOOD WBC-11.5* RBC-2.82* Hgb-9.1* Hct-26.1* MCV-93 MCH-32.4* MCHC-34.9 RDW-14.0 Plt Ct-121* [**2131-10-6**] 02:46AM BLOOD WBC-11.5* RBC-2.91* Hgb-9.1* Hct-26.7* MCV-92 MCH-31.3 MCHC-34.1 RDW-13.8 Plt Ct-173 [**2131-10-7**] 03:09AM BLOOD WBC-7.9 RBC-2.68* Hgb-8.6* Hct-24.2* MCV-90 MCH-32.1* MCHC-35.7* RDW-13.8 Plt Ct-170 [**2131-10-11**] 04:55AM BLOOD WBC-7.6 RBC-3.28* Hgb-10.2* Hct-29.9* MCV-91 MCH-31.2 MCHC-34.2 RDW-14.0 Plt Ct-530* [**2131-10-2**] 10:47PM BLOOD PT-13.6* PTT-20.8* INR(PT)-1.2 [**2131-10-2**] 10:47PM BLOOD Plt Ct-147* [**2131-10-3**] 02:50AM BLOOD PT-13.8* PTT-23.6 INR(PT)-1.3 [**2131-10-3**] 02:50AM BLOOD Plt Ct-136* [**2131-10-3**] 04:13PM BLOOD Plt Ct-127* [**2131-10-5**] 02:09AM BLOOD Plt Ct-120* [**2131-10-5**] 11:10AM BLOOD Plt Ct-121* [**2131-10-6**] 02:46AM BLOOD Plt Ct-173 [**2131-10-10**] 01:52AM BLOOD Plt Ct-423# [**2131-10-11**] 04:55AM BLOOD Plt Ct-530* [**2131-10-2**] 10:47PM BLOOD Fibrino-369 [**2131-10-6**] 10:50AM BLOOD Parst S-NEGATIVE [**2131-10-3**] 02:50AM BLOOD Glucose-230* UreaN-17 Creat-0.8 Na-138 K-4.4 Cl-105 HCO3-26 AnGap-11 [**2131-10-3**] 04:13PM BLOOD Glucose-142* UreaN-16 Creat-0.8 Na-137 K-4.4 Cl-104 HCO3-26 AnGap-11 [**2131-10-4**] 01:53AM BLOOD Glucose-210* UreaN-15 Creat-0.8 Na-138 K-4.5 Cl-106 HCO3-24 AnGap-13 [**2131-10-5**] 02:09AM BLOOD Glucose-68* UreaN-11 Creat-0.8 Na-141 K-3.9 Cl-108 HCO3-26 AnGap-11 [**2131-10-5**] 11:10AM BLOOD Glucose-181* UreaN-15 Creat-0.9 Na-140 K-4.0 Cl-106 HCO3-24 AnGap-14 [**2131-10-7**] 03:09AM BLOOD Glucose-141* UreaN-19 Creat-0.8 Na-136 K-4.3 Cl-103 HCO3-25 AnGap-12 [**2131-10-8**] 01:52AM BLOOD Glucose-229* UreaN-21* Creat-0.8 Na-137 K-4.4 Cl-104 HCO3-25 AnGap-12 [**2131-10-11**] 04:55AM BLOOD Glucose-51* UreaN-16 Creat-0.9 Na-136 K-5.0 Cl-103 HCO3-21* AnGap-17 [**2131-10-2**] 10:47PM BLOOD Amylase-71 [**2131-10-3**] 02:50AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.5* [**2131-10-11**] 04:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0 [**2131-10-7**] 08:57AM BLOOD Vanco-6.7* [**2131-10-4**] 01:53AM BLOOD Phenyto-9.0* [**2131-10-5**] 02:09AM BLOOD Phenyto-7.0* [**2131-10-2**] 10:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2131-10-5**] 12:14PM BLOOD FK506-LESS THAN [**2131-10-6**] 02:46AM BLOOD FK506-7.8 [**2131-10-11**] 10:03AM BLOOD FK506-PND [**2131-10-3**] 12:16AM BLOOD Type-ART pO2-166* pCO2-42 pH-7.41 calHCO3-28 Base XS-2 [**2131-10-7**] 07:21PM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-129* pCO2-38 pH-7.46* calHCO3-28 Base XS-3 Brief Hospital Course: Admitted to trauma service T-SICU. Intubated and sedated. Seen by orthopedics for radius fracture and unltimately ORIF ([**10-5**]) of radius without complication. Evaluated by Orthopedic spine service- recommended continued hard cervical collar. Transplant nephrology followed throughout his hopsitalization. Patient was febrile through his stay in the SICU and treated with Vancomycin and Zosyn empirically. Video swallow study on HD6 revealed mild oral and mild to moderate pharyngeal dysphagia [**1-17**] tongue weakness. This resulted in recommendation for ground consistency diet with thin liquids Patient extubated on HD 4 ([**10-4**]) HD 11: Patient with continued waxing and [**Doctor Last Name 688**] baseline confusion (oriented to person and intermittently to time). Repeat Head CT revealed decreased intracranial bleed. CT Sinus revealed nondisplaced posterior wall fracture of the maxillary sinus with fluid ni the left maxillary and bilateral ethmoid sinuses. CT cervical spine revealed know right C1 lateral mass fracture. Continued on immunosuppressive therapy for transplant. Medications on Admission: See admission H & P Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. Disp:*30 Tablet(s)* Refills:*0* 3. Albuterol Sulfate 0.083 % Solution Sig: [**12-17**] Inhalation Q6H (every 6 hours) as needed. Disp:*1 1* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Prednisone 5 mg Tablet Sig: 1.5 tabs Tablets PO at bedtime: TOTAL DOSE 7.5 mg PO QD. Disp:*60 Tablet(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Azathioprine 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*20 * Refills:*2* 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*1 1* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: 1. Right subarachnoid hemorrhage 2. Thalamic contusion 3. 1st cervical vertebrae lateral mass fracture 4. Right distal radius fracture 5. Left sided rib fractures (Rib 1, [**2-20**]) 6. Pulmonary contusion Discharge Condition: Stable Discharge Instructions: 1. Wear cervical collar at ALL TIMES 2. Physical therapy, occupational therapy, speech therapy 3. Neuro rehab per protocols of accepting facility 4. Follow daily tacrolimus (FK05) levels Followup Instructions: 1. Trauma clinic in 2 weeks [**Telephone/Fax (1) 24689**] 2. [**Hospital **] clinic [**Telephone/Fax (1) 9769**] 3. Orthopedic spine clinic in 6 weeks. Call [**Telephone/Fax (1) 54028**] 4. Follow up with your transplant doctor within 1-2 weeks

Admission Date: [**2200-11-27**] Discharge Date: [**2201-2-10**] Date of Birth: [**2142-2-13**] Sex: M Service: MEDICINE Allergies: Dofetilide / Lipitor / Haldol / Reglan Attending:[**First Name3 (LF) 759**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: multiple ET intubation during 3 MICU admissions (now extubated) right IJ [**2200-12-10**] (removed) right PICC line placement [**2201-1-5**] (removed) NGT placement [**2201-1-7**] (removed) left PICC line placement [**2201-1-27**] (still in place) NGT placement [**2201-1-30**] (removed) 2 units of pRBC transfusion ([**2201-1-31**] and [**2200-12-24**]) 1 unit of plate transfusion ([**2201-1-30**]) History of Present Illness: The patient is a 58 year old male with severe cardiomyopathy (EF ~20%) who was seen in ED in [**Month (only) **] and treated for a pneumonia. He now presents with progressive symptoms including sinus pain, cough, rhinorrhea, headache and mild shortness of breath. He describes his cough as productive of pink sputum. He denies any lower extremity edema. The patient first presented to the ED on [**2200-11-5**] and was evaluated in the emergency department and found to have a RML pneumonia. He was discharged with a Z-pack but this was later changed to levofloxacin given concern for a possible interaction with amiodarone. He completed a 7 day course of levofloxacin with great improvement in his symptoms. Approximately six days prior to this presentation, he began to have recurrence of his symptoms. He took three days of amoxicillin 500 mg, which he had left over from a previous dental procedure. This has made him feel somewhat better. On [**11-24**], he presented to his PCP. [**Name10 (NameIs) **] that time a repeat CXR showed "probable partial resolution of a right-sided pneumonia." His symptoms continued to worsen over the next three days and his PCP ultimately advised him to come to the emergency department. . In the ED, vital signs were T 100.5, HR 69, BP 98/66, RR 20, O2 sat 97%. He received 500 mg levofloxacin and was admitted to the floor. Past Medical History: 1. Dilated cardiomyopathy of unclear etiology (EF=20 percent) 2. 3+ MR (s/p repair [**8-29**] at [**Hospital1 112**]) 3. AF (s/p maze procedure [**8-29**], AV paced, on coumadin and amiodarone) 4. COPD: PFT [**5-30**](FVC=2.86, FEV1=2.28, MMF=2.09, FEV1/FVC=80) 5. Hypercholesterolemia 6. AICD with pacer placement in [**12-28**] following an episode of NSVT 7. Polymorphic ventricular tachycardia [**2-27**] dofetilide therapy 8. CAD s/p IMI in [**2189**] LAD stent in [**12-28**] (patent on cath [**8-29**]), s/p SVG to OM1 9. Depression/anxiety Social History: He has a 20pk/yr smoking history but quit over 10yr ago. Denies any intravenous drug use or alcohol use. Lives in [**Hospital1 392**] w/ his girlfriend and has a 11yr old son who does not live with him. Does not work but used to work for a security company and a catering company. Family History: Noncontributory Physical Exam: VS - T 100.5, BP 106/69, HR 69, RR 20, O2 sat 93% on RA GEN - well appearing male, lying in bed in NAD, occastionally coughing HEENT - no LAD, sclera anicteric, no conjunctival palor CV - rrr, III-IV/VI systolic murmur, best heard at apex with radiation to axilla PULM - crackles at left base and right middle areas; good inspiratory effort ABD - soft, non-tender, non-distended EXT - warm, no edema Pertinent Results: Admission Labs: [**2200-11-27**] 02:07PM LACTATE-2.2* [**2200-11-27**] 02:00PM UREA N-13 CREAT-1.1 SODIUM-138 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 [**2200-11-27**] 02:00PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-2.0 [**2200-11-27**] 02:00PM WBC-13.0* RBC-4.41* HGB-14.3 HCT-45.4 MCV-103* MCH-32.5* MCHC-31.6 RDW-13.7 [**2200-11-27**] 02:00PM NEUTS-83.1* LYMPHS-9.5* MONOS-6.3 EOS-0.4 BASOS-0.8 [**2200-11-27**] 02:00PM PLT COUNT-161 [**2200-11-27**] 02:00PM PT-21.0* PTT-29.3 INR(PT)-2.0* MICU Admission Labs: [**2200-11-30**] 01:59PM BLOOD WBC-23.8*# RBC-4.24* Hgb-14.4 Hct-44.0 MCV-104* MCH-34.0* MCHC-32.7 RDW-14.1 Plt Ct-147* [**2200-11-30**] 05:30AM BLOOD Neuts-76* Bands-2 Lymphs-9* Monos-5 Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2200-12-2**] 11:50AM BLOOD PT-53.5* PTT-42.9* INR(PT)-6.4* [**2200-12-2**] 11:50AM BLOOD Fibrino-746* D-Dimer-3362* [**2200-11-30**] 01:59PM BLOOD Glucose-138* UreaN-44* Creat-2.5* Na-134 K-5.4* Cl-97 HCO3-16* AnGap-26* [**2200-11-30**] 01:59PM BLOOD ALT-50* AST-110* LD(LDH)-848* CK(CPK)-49 AlkPhos-74 [**2200-11-30**] 05:30AM BLOOD proBNP-6548* [**2200-12-1**] 03:17PM BLOOD Cortsol-27.0* [**2200-12-1**] 05:29PM BLOOD Cortsol-36.9* [**2200-12-2**] 11:50AM BLOOD ANCA-NEGATIVE B [**2200-11-30**] 02:09PM BLOOD Lactate-10.9* K-5.3 [**2200-11-30**] 04:00PM BLOOD O2 Sat-74 . Discharge labs: [**2201-2-10**] 06:04AM BLOOD WBC-10.0 RBC-2.71* Hgb-9.2* Hct-29.7* MCV-110* MCH-33.9* MCHC-30.8* RDW-21.5* Plt Ct-67* [**2201-2-10**] 06:04AM BLOOD PT-11.4 PTT-26.5 INR(PT)-1.0 [**2201-2-10**] 06:04AM BLOOD Glucose-119* UreaN-36* Creat-0.3* Na-143 K-3.8 Cl-112* HCO3-25 AnGap-10 [**2201-2-10**] 06:04AM BLOOD ALT-75* AST-49* LD(LDH)-546* CK(CPK)-25* AlkPhos-325* TotBili-2.3* [**2201-2-10**] 06:04AM BLOOD Albumin-1.9* Calcium-7.9* Phos-3.0 Mg-2.1 Other Labs: [**2200-12-2**] 11:50AM BLOOD ESR-66* [**2200-12-24**] 03:36AM BLOOD Parst S-NEG [**2201-1-3**] 04:34AM BLOOD LAP-154* [**2200-11-30**] 01:59PM BLOOD CK-MB-3 cTropnT-0.05* [**2200-11-30**] 10:49PM BLOOD CK-MB-5 cTropnT-0.08* [**2200-12-1**] 04:23AM BLOOD CK-MB-NotDone cTropnT-0.08* [**2200-12-22**] 03:28PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2200-12-23**] 02:45AM BLOOD CK-MB-NotDone cTropnT-0.11* [**2201-1-24**] 09:40PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2201-2-6**] 02:54PM BLOOD CK-MB-NotDone cTropnT-0.18* [**2201-2-7**] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.13* [**2201-2-7**] 07:09AM BLOOD CK-MB-NotDone cTropnT-0.12* [**2201-2-9**] 06:36AM BLOOD CK-MB-7 cTropnT-0.06* [**2201-2-9**] 12:08PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2201-2-10**] 06:04AM BLOOD cTropnT-0.08* [**2201-1-20**] 03:59AM BLOOD Triglyc-539* [**2201-2-8**] 08:26AM BLOOD Triglyc-278* HDL-17 CHOL/HD-12.7 LDLcalc-143* [**2200-12-22**] 03:28PM BLOOD T3-125 Free T4-GREATER TH [**2200-12-23**] 02:45AM BLOOD T4-22.2* calcTBG-0.31* TUptake-3.23* T4Index-71.7* [**2200-12-24**] 03:36AM BLOOD T4-20.2* T3-105 Free T4-6.2* [**2200-12-25**] 03:50AM BLOOD T4-20.8* T3-97 Free T4-7.3* [**2200-12-26**] 04:20AM BLOOD T4-20.4* T3-93 Free T4-6.1* [**2200-12-27**] 04:56AM BLOOD T4-18.5* T3-88 [**2200-12-28**] 02:57AM BLOOD T4-15.7* T3-82 [**2200-12-29**] 03:23AM BLOOD T4-13.5* T3-74* [**2200-12-29**] 10:31AM BLOOD T4-16.0* calcTBG-0.53* TUptake-1.89* T4Index-30.2* [**2200-12-30**] 05:15AM BLOOD T4-15.2* T3-69* [**2201-1-6**] 05:13AM BLOOD T4-19.3* T3-99 Free T4-6.2* [**2201-1-7**] 04:15PM BLOOD T4-GREATER TH T3-116 calcTBG-0.31* TUptake-3.23* [**2201-1-9**] 05:34AM BLOOD T4-24.6* T3-115 calcTBG-0.28* TUptake-3.57* T4Index-87.8* [**2201-1-11**] 04:30AM BLOOD T4-24.3* T3-113 calcTBG-0.33* TUptake-3.03* T4Index-73.6* [**2201-1-13**] 05:41AM BLOOD T4-18.4* T3-88 calcTBG-0.48* TUptake-2.08* T4Index-38.3* [**2201-1-21**] 03:08AM BLOOD T4-11.4 T3-47* calcTBG-0.72* TUptake-1.39* T4Index-15.8* [**2201-2-3**] 03:29AM BLOOD T4-7.9 T3-45* Free T4-1.7 . Microbiology: [**2200-11-28**] Urine Legionella - negative [**2200-11-29**] Blood cultures - NGTD [**2200-11-30**] Viral antigen panel - negative, cultures pending [**2200-11-30**] Urine culture - negative [**2200-11-30**] BAL - 4+ polys, gram stain negative, PCP neg, AFB neg, cultures negative [**2200-12-1**] Blood cultures, urine cultures - negative [**2200-12-3**] Blood cultures, urine cultures - negative [**2200-12-3**] Sputum cultures - 2+ yeast [**2200-12-3**] Stool - C. diff negative [**2200-12-5**] Blood, urine cultures - NGTD [**2200-12-5**] Sputum cultures - yeast [**2200-12-7**] Blood, urine cultures - NGTD [**2200-12-8**] Stool - C. diff negative [**2200-12-9**] Blood, urine cultures - NGTD . Imaging and studies: CXR ([**2200-11-27**]) Comparison is made with the prior chest x-ray of [**11-24**]. Since that time, there has been increase in density in the right mid zone. The heart remains enlarged. The costophrenic angles are sharp. These findings suggest [**Month (only) 9140**] of the right-sided pneumonia which probably lies in the apical segment of the right lower [**Month (only) 3630**]. . TTE [**2200-12-1**]: The left atrium is moderately dilated. No definite intracardiac shunt identified. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with severe global hypokinesis and septal dysynchrony. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened with mildly restrained leaflets. The annuloplasty ring is well seated but with increased gradient c/w mild functional mitral stenosis. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2200-9-11**], the severity of mitral regurgitation is lower (may be related to acoustic shadowing). The transmitral gradient has increased (previously 5mmHg mean) and the estimated mitral valve area is smaller (prior P1/2 time 95ms). Left ventricular systolic function is more depressed (global) -EF 20%. CXR [**1-24**]: [**Month/Year (2) **] air space disease bilaterally, right greater than left. Complement of superimposed failure may be present but lack of distention of the pulmonary vessels and persistent sharp features of the costophrenic sulci suggest otherwise. . Thyroid U/s ([**2200-12-11**]) IMPRESSION: This is a normal EEG recording during stage II sleep. No epileptiform features or focal slowing were noted. However, only a very brief period of wakefulness was recorded, precluding a full evaluation for possible encephalopathy. If clinical suspicion for encephalopathy remains, a repeat study during wakefulness could be considered. . [**Month/Day/Year **] ([**2200-12-29**]) Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with moderate regional systolic dysfunction with near akinesis of the inferior and inferolateral walls and mild hypokinesis of remaining segments. Right ventricular cavity size is normal with mild global free wall hypokinesis. There is abnormal septal motion/position. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. A mitral valve annuloplasty ring is present. There is a minimally increased gradient consistent with trivial mitral stenosis. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be quanitified.There is no pericardial [**Month/Day/Year 17838**]. . EEG ([**2201-1-18**]) IMPRESSION: This is a normal EEG recording during stage II sleep. No epileptiform features or focal slowing were noted. However, only a very brief period of wakefulness was recorded, precluding a full evaluation for possible encephalopathy. If clinical suspicion for encephalopathy remains, a repeat study during wakefulness could be considered. CT [**1-22**]: 1. Abnormal markedly distended urinary bladder with mild hydroureter and hydronephrosis bilaterally in the setting of well positioned Foley catheter. This likely is due to obstruction of the catheter system and flushing or replacement is recommended. No other cause for lower quadrant intraabdominal pain identified. 2. Nonspecific opacities within the right middle [**Month/Year (2) 3630**] and left lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] represent resolving pneumonia, however acute infectious process or chronic interstitial process (especially within the lower [**First Name3 (LF) 3630**]) cannot be excluded. Moderate right-sided pleural [**First Name3 (LF) 17838**] and compression atelectasis. 3. Cholelithiasis without evidence of acute cholecystitis. 4. Simple right renal cyst. 5. Mild amount of intraabdominal and pelvic free fluid. . Abd U/S ([**2201-1-31**]): RIGHT UPPER QUADRANT ULTRASOUND: Limited evaluation of the liver shows no evidence of biliary ductal dilatation. A gallstone is noted in the fundus of the gallbladder. The gallbladder wall is normal with no gallbladder distention or pericholecystic fluid. There is no extrahepatic biliary ductal dilatation with the common duct measuring 4 mm. IMPRESSION: Cholelithiasis, without evidence of biliary ductal obstruction or cholecystitis. . CXR ([**2201-2-1**]) The previously seen Dobbhoff tube in the right mainstem bronchus has been removed. There is a feeding tube with the distal tip beyond the pylorus. There is a left-sided AICD, unchanged. There are again noted diffuse airspace opacities bilaterally with relative sparing in the left upper lung zone. This may be secondary to underlying pulmonary edema versus multifocal pneumonia. There are streaky densities at the left base consistent with subsegmental atelectasis. There is a small right-sided pleural [**Month/Day/Year 17838**]. . CT abd ([**2201-2-7**]) IMPRESSION: 1. Persistent linear opacities at the left lung base. Interval change in configuration of opacities in the right middle [**Month/Day/Year 3630**] with an appearance of nodular density. Decrease in size of right-sided pleural [**Month/Day/Year 17838**] with persistent compression atelectasis. 2. Cholelithiasis without evidence of acute cholecystitis. 3. Multiple hypoattenuating lesions in both kidneys, most of which are too small to characterize. 4. Slightly increased amount of the pelvic ascites. 5. Resolution of abnormally distended urinary bladder and hydroureter. . CXR ([**2201-2-8**]) There has been interval removal of the feeding tube. The left AICD is unchanged. Sternal wires are unchanged. Again noted are diffuse interstitial infiltrates with more focal infiltrate in the left lower [**Month/Day/Year 3630**]. This left lower [**Month/Day/Year 3630**] infiltrate is slightly more confluent than on the film from the prior week. Brief Hospital Course: The patient is a 58 year old male with dilated cardiomyopathy who presents with cough, fevers and increased shortness of breath after a recent course of antibiotics for a pneumonia. Breif summary: [**11-27**] - [**11-30**]: admitted to the medicine service for pneumonia [**11-30**] - [**1-4**]: admitted to the MICU for respiratry failure, intubated until [**12-31**]. [**1-4**] - [**1-13**]: transferred to the floor, medicine [**1-13**] - [**1-21**]: readmitted to the MICU for repeat resp distress [**1-21**] - [**1-25**]: readmitted to the floor [**1-25**] - [**2-3**]: readmitted to the MICU with CHF excerbation [**2-3**]: transferred to the floor. 58 year old gentleman with atrial fibrillation, iCMP (EF of 20%), h/o VT on amiodarone, s/p pacemaker, CAD s/p CABG, COPD, who was initially admitted for pneumonia, but has had a complex hospital course included 3 MICU admissions, hypoxic respiratory failure secondary to pneumonia/CHF exacerbation, amiodarone-related thyrotoxicosis, ARF (resolved Cr peaked at 2.4, now resolved 0.4 today)leukocytosis, and thrombocytopenia, vocal cord paralysis. . the patient was originally admitted to medicine on [**11-27**] for pneumonia. On [**11-30**] the patient developed hypotension and hypoxic respiratory failure, was intubated, placed on triple pressors and transferred to MICU. He was on levaquin on admission, started on broad spectrum antibiotic course on MICU transfer which included azithromycin, ceftriaxone, and vancomycin. Pt also received flagyl course empirically for c. diff. MICU stay was prolonged and difficult. Pt was weaned off pressors by [**12-8**] but could not be extubated until [**12-31**] secondary to pneumonia and pulmonary edema related to decompensated cardiomyopathy that was difficult to manage in the setting of sepsis. The patient was also persistently febrile until [**12-31**]. No source could definitively be identified. Chest x-ray did reveal bilateral air space opacities. Numerous blood, urine and sputum cultures were not revealing of a source. BAL lavage was also unrevealing. DFA, viral cultures and legionella were negative. . The patients stay was further complicated by amiodarone related thyrotoxicosis, type II. Pt was started on steroids for this reason. Tapazole was briefly given but discontinued for secondary rise in LFT's and belief that this was type II. Thyrotoxicosis did not resolve. In addition, the pt had persistently elevated WBC--elevated LAP score pointed to leukemoid reaction. . The patient was transferred to the general medical floor on [**1-4**]. By that point his fevers had resolved and his respiratory status were satisfactory. Notably his mental status remained poor since his extubation. On the floor he was persistently delirious. His WBC remained elevated and he was intermittently tachycardic. His thyrotoxicosis did not resolve despite increased dosing of decadron. From [**1-12**] to [**1-13**] the pt developed diarrhea. On [**1-13**], the pt developed a fever to 103.9 and became tachycardic to the 140's. Vancomycin and zosyn was empirically started. It was also believed the mental status was somewhat worse. Laboratories revealed WBC of 24.5 from 21.6 and lactate of 2.6. Urinalysis and CXR was unrevealing. Pt was transferred to MICU given septic physiology. . While in the MICU patient improved. He had an NGT placed as he failed speech and swallow. In terms of thyrotoxicosis patient followed with endocrine, continued on steroids and Cholestyramine which was stopped on [**1-21**]. Patient was also noted to have thrombocytopenia so HIT Ab was sent which was negative. Antibiotics were stopped on [**1-17**]. Patient was called out to the floor on [**1-21**]. . Patient was maintained on 6L of shovel mask until [**1-25**], when he was noted to be more hypoxic. He pulled off his FM in the AM and O2 sats were 68% on RA transiently. His sats, which had been in the mid 90s over the past few days dropped to the low 90s on 10L mask. Pt had progressively [**Month/Day (4) 9140**] tachypnea and increasing O2 requirement on [**1-25**]. His ABG on a facemask was 7.55/30/49. He was placed on a 100% NRB. He was given 20 of IV lasix at 5 pm and put out 1 L in 2 hours. CXR done in the morning shows [**Month/Day (4) 9140**] bilateral airspace disease and possible component of pulmonary edema. He was again admitted to MICU for hypoxia and pulmonary edema on [**1-25**]. . While at the MICU for the 3rd time, he was treated for CHF exacerbation with IV lasix which he responded and his pulmonary status gradually improved; it was noted that he had melena on [**2201-1-31**] and drop in HCT with Hct nadired on [**2201-1-29**] at 23.6; GI was consulted, given pt HD stable and responded well to transfusion (1 unit during this MICU admission), EGD was held for now, and conservative management unless acute bleeding. Given his complicated hospital course, a family meeting was held on [**2201-2-2**] at which time pt was made DNR/DNI, no PEG placement, and he expressed wishs to be made comfortable; His defibrilator was turned off by EP per pt's request on [**2201-2-3**], and his pacer was left in place; Given his vocal cord paralysis, PEG has been recommended, however, pt currently refusing replacement of Dobhoff or feeding device, and prefered to eat by PO with understanding that po puts pt at very high risk for aspiration. he is being called to the floor on [**2201-2-3**] for further discussion of long term goal of his care. On the floor, he remained afebrile, and his SBP remained 80-100s, with transient drop of SBP to 68-72s and responded to fluid bolus IVNS 500cc; goals of care were readdress with the patient and his guardian (please see goals of care note by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 12879**], and pt expressed wishes to give IV TPN, PT and reahab a try, but goals of care needs to be readdress if siutation arises that he needs to be transferred to the MICU or coming back to the hospital after being discharged to rehab. He was started on IV TPN on [**2201-2-6**] and PT started working with the patient over the weekend of [**2201-2-7**] to get patient ready for rehab placement. Some of the other issues not addressed above are listed below: Acute Renal Failure: On the morning of [**2200-11-30**] the patient's creatinine was noted to have increased from 1.0 to 2.5 and ultimately peaked at 3.0 with associated decreased urine output. His renal failure occured in the setting of increased NSAID use, hypotension and new onset peripheral eosinophilia at 8%. Urine electrolytes revealed a FENA of 1.2 % in the setting of lasix use. Urinalysis showed many WBCs but no eosinophils. Urine did not contain muddy brown casts. The differential diagnosis for his acute renal failure included both prerenal azotemia, acute tubular necrosis and acute interstitial nephritis. He received IV fluids and pressure support to maintain his renal perfusion. NSAIDS were immediately discontinued. Ceftriaxone was also discontinued given concern for AIN. His renal function quickly improved with return to baseline creatinine by MICU day 8. On floor, renal function remained NL, w/Cr 0.3-0.4. . Thryotoxicosis: The patient was found to have elevated T4 and T3 levels and undetectable TSH on the [**11-21**], three weeks into his hospital course. He was treated with Methamizol and Dexamethasone. Methamizole was subsequently discontinued because of LFT elevation. Dexamethasone was tapered. TFT were trending down. Endocrinology was following. As the patient is dependent on Amiodaron for prevention of VT/Vfib it was continued. If the patient has recurrent problems due to thyroid hyperactivity, radioablation of the thyroid has to be considered. T4/T3 levels continued to trend down on the floor, but not to the point that steroids could be tapered. pt needs to continued for 2-3 months on IV methylpredinosolone 40mg, then continued a slow taper after than by for the next month. He needs to have his Thyroid function test checked weekely after discharge; . Thrombocytopenia: Pt. with falling platelet count starting [**1-9**]. Reached nadir oof 23 on [**2201-1-23**], then plateaued. Unclear etiology, but possibilities include amiodarone, methamazole. HIT seems less likely given negative HIT antibody x2. As plt count continued to decline on floor, hematology was consulted; he received a total of 1 unit of platelets during this admission and currently on steroids for amiodorone induced thyrotoxicosis. His Plateletes remained stable in the 50,0000s at the time of discharge. . Dilated cardiomyopathy: [**Date Range 461**] was performed on [**2200-12-1**] and [**12-31**] revealed severe LV global hypokinesis with an ejection fraction of 20%. Given his intial hypotension his outpatient cardiac regimen was held. Once his blood pressure had stabilized off pressors he was restarted on his outpatient eplerenone, ace-inhibitor and beta blocker; He was found to be in thyroid storm which is likely partly repsonsible for his worsened cardiac function. However, his meds were d/c'ed except metoprolol given his low BP at baseline prior to discharge. . Mitral Regurgitation: The patient has known 3+ MR status post mitral valve repair in [**2198**]. Repeat [**Year (4 digits) 113**] on this admission revealed 1+ mitral regurgitation. It was felt that this issue was stable throughout this admission. . Atrial Fibrillation: The patient is status post maze procedure in [**2198**]. The patient is also status post AICD placement for NSVT and throughout this hospitalization he was noted to be in either an atrial or ventricularly paced rhythm. Given initial concern that amiodarone might be contributing to his [**Year (4 digits) 9140**] pulmonary function his amiodarone was held for the majority of his hospitalization, but was then reintroduced when his pulmonary process became more clearly pulmonary edema. He went into a run of VT/Vfib with very frequent shocks and was reloaded with amiodarone drip x 1 day and was transitioned to amiodarone 200daily. EP changed his pacer settings to shock for VT with rate>183 and for VF. When he was discovered to have thyrotoxicosis he was started on an esmolol drip which improved his ectopy. He was then transitioned back to oral beta blockers. On the floor, pt had HR in 70's-90's, and was in sinus rhythm on telemetry. During his 3rd MICU admissions, pt decided to deactivate his AICD, and we continue to hold off his amiodorone given his pulm toxicity. . Cardiac: The patient is status post inferior MI in [**2189**] and stent placement in [**2197**]. His EKG was unchanged during this admission. Cardiac enzymes were unremarkable on admission to the MICU, which was rechecked while he was called to the floor as pt had multiple chest pain complaints (ECGs were paced, CE unremarkable); He had two [**Year (4 digits) 113**] done during this admission which remained poor EF 20%; However, ASA were stopped due to thrombocytopenia, melena with Hct drop; After he was kept on beta blocker (although didn't get much due to aspiration and hypotensive episodes by either mouth or IV), and all other Cardiac meds were d/c'ed prior to discharge due to low BP; He was to follow up with cardiology to address whether his cardiac meds need to be restarted; Depression/anxiety: Was continued on lexapro, then this was stopped when he was not taking POs. Pt became very depressed and psych was consulted. we restarted him on lexapro on [**2-3**] ( 5mg qday x 1 week, then increase to 10mg qday after that); see goals of care/code status below. Nutrition: The patient required a short course of TPN during his MICU course and otherwise received tube feeds while intubated for his nutritional needs. On the floor, he was reevaluated by speech and swallow and found to be completely unable to swallow any fluids without aspiration. Initially, he was amenable to a PEG tube, but this was been delayed in setting of thrombocytopenia. However, on transfer to the floor on [**2-3**], he was interested in the Dauboff out and no PEG placed. He understands that he may aspirated and die by making this decision; intially on the floor he expressed no interested of TPN or PEG, but on [**2201-2-6**] agreed to IV TPN for nutritional support, he was made NPO, but agreed to give small amounts of apple sauce, ice chips, small amounts of water, and small amounts of pureed foods for comfort, but remained for full aspiration precautions. Goals of care/Code: Initially he was full Code. However, after the prolonged hospital course, he voiced sentiments of being CMO. A family meeting with the MICU team and his guardian decided goals of care. The paitent was changed to DNR/DNI after this meeting on [**2-2**]. In congruence with this decision, the ICD were inactivated on [**2-3**] and his Dauboff was removed. If situation arises (any fever, chill, chest pain, SOB, or any concerning symptoms), please contact patient's gaudian ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 108846**] home [**Telephone/Fax (1) 108847**], cell [**Telephone/Fax (1) 108848**] work [**Telephone/Fax (1) 108849**]), goals of care needs to be readdressed at that point. Guardianship: [**Name (NI) 108850**] obtained this hospitalization after the long intubation period in [**Month (only) **]. patient's gaudian ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 108846**] home [**Telephone/Fax (1) 108847**], cell [**Telephone/Fax (1) 108848**] work [**Telephone/Fax (1) 108849**]), Medications on Admission: 1. Amiodarone 200 mg daily 2. Atrovent TID 3. ASA 81 mg daily 4. Beclomethasone (NASAL) 2 puffs each nostril [**Hospital1 **] 5. Clonazepam 1 mg TID 6. Coumadin 3 mg--one to two tablet(s) by mouth as directed by [**Company **] coumadin clinic 7. Eplerenon 25 mg daily 8. Lexapro 20 mg daily 9. Lisinoprol 5 mg daily 10. Lorazepam 1 mg daily PRN 11. Nasonex 50 mgc two sprays each nostril every day 12. Protonix 40mg daily 13. Senna 14. Toprol XL 25 mg 15. Triamcinolone 0.05 %--apply 2ml [**Hospital1 **] 16. Zocor 10 mg daily Discharge Medications: 1. TPN Day 3 Central standard TPN 3 in 1 with fat based on 80kg weight, total TPN Volume [**2194**], Amino Acid(g/d)340, Dextrose(g/d) 120, Fat(g/d) 40, Kcal/day [**2194**]; with trace elements and standard vitamin added; with 50 meqNaAc; 20 meq NaPO4; 10 meq KAc; 40 meq KPO4; 10 meq MgSO4, 12 meq CaGluc, 20 units insulin added to the TPN 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): please swab around inside mouth with this solution - cannot take swish/swallow as he aspirates but may have thrush . 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for mouth hygiene: please swab around inside mouth with this solution - cannot take swish/swallow as he aspirates but may have thrush . 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. sliding scale insulin please continue sliding scale insulin and check FS qid while pt is on TPN 8. Pantoprazole 40 mg IV Q24H if unable to tolerate PO protonix 9. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for Nausea. 10. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q6H (every 6 hours): hold for SBP<90 and HR<55. 11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): hold for oversedation. 12. Methylprednisolone Sodium Succ 40 mg Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 2 months: after 2 months, please continue a slower taper for the next mongh, decrease the dosage by 10mg per week; Please also make sure that you check weekly thyroid function tests including (T4, free T4, and T3) . 13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed. 14. PICC line PICC line care per rehab protocol 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 16. Lorazepam 2 mg/mL Syringe Sig: 0.5 ml Injection Q4H (every 4 hours) as needed for anxiety. 17. Morphine 10 mg/mL Solution Sig: 0.5 ml Intravenous every 4-6 hours as needed for pain: hold for oversedation or RR<12. 18. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO once a day: full aspiration precaustions, please crush meds and give with apple sauce. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: Pneumonia Congestive heart failure (exacerbation) responded to lasix Vocal cord dysfunction due to intubation thyroid toxicosis from amiodorone (improved) depression hyponatremia resolved Thrombocytopenia (platelets in the 50,000 and stable) Melena (responded to pRBC transfusion, and Hct remained stable) ------- Secondary diagnosis: Dilated cardiomyopathy (EF 20%) 3+ Mitral regurgitation (s/p repair [**8-29**] at [**Hospital1 112**]) Atrial fibrillation (s/p maze procedure [**8-29**], AV paced, on coumadin and amiodarone) both coumadin and amiodorone were stopped during this admission and AICD deactivated) COPD PFT [**5-30**](FVC=2.86, FEV1=2.28, MMF=2.09, FEV1/FVC=80) Hyperlipidemia Coronary artery disease s/p IMI in [**2189**] LAD stent in [**12-28**] (patent on cath [**8-29**]), s/p SVG to OM1 Discharge Condition: afebrile, VSS (SBP baseline upper 80-90s), with full aspiration precautions Discharge Instructions: Full aspiration precautions: Pt should remain NPO, and only offer PO for comfort (apple sauce, ice chips, small amounts of water, and small amounts of pureed foods); Patient is aware and understand the risks of aspiration when taking POs, and he is willing to accept these risks for comfort. . There were entensive discussion during this prolonged hospitalization; Given multiple medical problems, see goals of care discussion notes from Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 12879**] (attached); pt is DNR/ DNI, and expressing wishes to be comfort measure only at some point during his hospitalization, but now, he is willing to accept IV TPN and willing to work with PT; . If situation arises (any fever, chill, chest pain, SOB, or any concerning symptoms), please contact patient's gaudian ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 108846**] home [**Telephone/Fax (1) 108847**], cell [**Telephone/Fax (1) 108848**] work [**Telephone/Fax (1) 108849**]), goals of care needs to be readdressed at that point. . Other instructions: 1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. 2. Adhere to 2 gm sodium diet . Please take all your medications as prescribed. . Please follow up all of your appointments Followup Instructions: Please follow up with your PCP 1-2 weeks after discharge in addition to the following appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2201-2-27**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2201-2-27**] 3:40 Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2201-3-24**] 1:00 You will also need to follow up with otolaryngology (Ear, Nose, & Throat) for further evaluation of your vocal cords and throat. Call [**Telephone/Fax (1) 31733**] to make an appointment. Tell them you were seen by the ENT resident while you were in the hospital and were told to schedule a follow-up appointment. Completed by:[**2201-2-11**]

Admission Date: [**2169-11-18**] Discharge Date: [**2169-11-29**] Date of Birth: [**2098-11-18**] Sex: F Service: MEDICINE Allergies: Celebrex / Cipro / Augmentin / Vicodin Attending:[**First Name3 (LF) 9965**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 71F with RA/CREST on prednisone, possible COPD and recent workup for possible lung neoplasm who presents with 2 days of worsening dyspnea and cough productive of yellow sputum. The patient was in her USOH including being able to walk across the room without becoming SOB or stopping until approx. 2 days ago. She reports progressive dyspnea on exertion and now dyspnea at rest over the last 2 days. She is now unable to walk across the room without becoming SOB. She has also had a chronic cough for the last thirty years that is usually non-productive but has become productive of thick yellow sputum over the last 2 days. Denies hemoptysis. Denies fevers or chills at home. She denies CP, N/V, dysuria, urgency, frequency, HA, neck stiffness. No sick contacts. She received the influenza vaccine this year. She endorses a 10lb unintentional weight loss over the last month [**1-25**] poor appetite. She also endorses severe back pain that has been progressive over the last 3-4 weeks and was initially intermittent but is now constant. The pain is pleuritic in nature. She denies a h/o falls or trauma to the back. She has had back pain in the past but nothing similar to this. She denies other bony pain besides in the back. She endorses night sweats for the last ten days or so. She also has intermittent colitis flares, and has had one recently with no abdominal pain but [**3-28**] watery or loose BMs/day. She denies melena or hematochezia. She underwent colonoscopy in [**2169-4-23**] and reports that polyps removed had no evidence of cancer on pathology. . Regarding the patient's RLL mass, it was incidentally discovered on a CXR in [**2169-7-24**] after her chronic cough of 30 years intensified this summer. Her outside pulmonologist recommended CT scan and on CT there was a peripherally located, broad based RLL lesion. She was prescribed Augmentin but was only able to complete 3 days [**1-25**] GI upset. Repeat CT scan 1 month later was unchanged and decision was made to seek further investigation at [**Hospital1 18**]. On [**2169-10-25**] she underwent flexible bronchoscopy by IP service with normal airway surveillance. "Radial EBUS via the R basilar posterior segment showed a mass at 4cm from entrance from such subsegment". Brushings and washings were taken and BAL was done. She reports her cough has been worse since her bronchoscopy. Initial pathology on brushings/washings were positive for malignancy but after review this was equivocal and it was recommended to obtain more tissue. She was seen by Dr. [**Last Name (STitle) **] in thoracic surgery on [**11-7**] who recommended CT-guided core needly biopsy which was to be done on [**2169-11-20**]. . At the OSH, initial VS 98 108 120/54 16 94% 2L NC. Labs notable for WBC 25.9 with 30% bands, Cr 0.97.CXR showed RLL infiltrate. She was given a Duoneb and transferred to [**Hospital1 18**] for further management. . In the [**Hospital1 18**] ED, initial vs were: 99.8 96 102/42 19 94% 2L NC. CXR showed RLL infiltrate consistent with pnemonia. EKG showed sinus tachycardia with non specific ST changes anteriorly. Labs notable for WBC 22.9 with 88%N and 7% bands, Hct 33.5 (most recent 36), BUN 32, Cr 1.3, Mg 1.3, Phos 2.4, trop neg x1. Blood cultures and sputum culture was drawn and Foley was placed. Patient was given vancomycin, Zosyn. She was given codeine and benzonatate for cough, Tylenol 1 gram for fever, Mag sulfate for repletion, hydrocortisone 50mg given known chronic prednisone use. Initial lactate was 5.5, she was given 5L NS, repeat lactate 2.5 with subjective improvement in symptoms. She was seen by thoracic surgery who recommended MICU admission and they will follow along. VS at transfer: 99.4 94 109/50 16 97% 4L NC. . Upon arrival to the ICU, the patient reports feeling much better overall since presentation. She denies any SOB and says the codeine helped her back pain and cough tremendously. Past Medical History: ?COPD RLL lung mass found on CXR [**7-/2169**] Rheumatoid arthritis with CREST overlap syndrome with features of inflammatory polyarthritis, Raynaud's, reflux, sclerodactyly, on prednisone, followed by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3057**] HTN Diverticulosis Hemorrhoids R knee surgery for benign mass R ovarian surgery many years ago for benign mass h/o shingles infection 4 yrs ago Chronic rhinitis Osteoarthritis s/p right hip replacement Social History: Smoked 1-2ppd x 45 years, quit <10 years ago. Denies EtOH or illicits. Lives in [**Hospital1 1562**] with her husband who is a pharmacist. Worked as property manager for affordable housing. Daughter is pulmonologist at [**University/College **]. No recent travel. Family History: Father and PGM died of colon cancer in late 40s/early 50s. No known FH of lung disease/malignancy, autoimmune disease. Physical Exam: On Admission: Vitals: T: 98.7 BP: 153/55 P: 87 R: 23 O2: 92% 4L NC General: Alert, oriented, no acute distress, thin HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diminished BS on the right 2/3 up from the bases with inspiratory and expiratory crackles, pleural friction rub and egophony present, otherwise Clear without 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 GU: foley with pale yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, answering questions appropriately, moving all extremities. . On Discharge: Vitals - 98.9 (afebrile since 0735 on [**11-22**]) 142/64 92 24 92%2L General - Lying in bed in NAD. NC in place on 2L. CV - RRR, S1 and S2, no m/r/g Lung - CTA on left. Breath sounds remained decreased on right. Abdomen - Soft, NT/ND, BSx4 Ext- PICC line in place on left Neuro- Awake, alert and oriented. Moving all extremeties. Pertinent Results: Admission labs: [**2169-11-18**] 02:26PM WBC-22.9*# RBC-3.67* HGB-10.2* HCT-33.5* MCV-91 MCH-27.8 MCHC-30.5* RDW-17.8* [**2169-11-18**] 02:26PM NEUTS-88* BANDS-7* LYMPHS-0 MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2169-11-18**] 02:26PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-1+ [**2169-11-18**] 02:26PM PLT SMR-NORMAL PLT COUNT-404 [**2169-11-18**] 02:26PM PT-14.0* PTT-26.8 INR(PT)-1.2* [**2169-11-18**] 02:26PM GLUCOSE-137* UREA N-32* CREAT-1.3* SODIUM-145 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-22 ANION GAP-20 [**2169-11-18**] 02:26PM ALT(SGPT)-21 AST(SGOT)-30 ALK PHOS-124* TOT BILI-0.3 [**2169-11-18**] 02:26PM cTropnT-<0.01 AP CXR: Worsening consolidative opacification within the right lung base concerning for pneumonia. CTA chest: IMPRESSION: 1. Rapid interval progression of a consolidative process involving the right lower lobe and posterior aspect of the right upper lobe since the [**2169-11-13**] PET-CT, with obscuration of previously seen mass-like lesions at posterior aspect of the right lower lobe. Findings are most compatible with worsening pneumonia. An underlying co-existent neoplasm may also be present, but is obscured by this pneumonia. Right lower lobe bronchi appear impacted. 2. New small right pleural effusion. 3. 11-mm thyroid isthmus nodule. Comparison with prior ultrasound examinations or a non-emergent ultrasound evaluation is recommended when clinical stable. 4. Moderate to severe emphysema. EKG: ST 105, LAD, TWF I, aVL, V5-V6, II, III, aVF, low voltage limb leads, no ST depressions/elevations [**11-22**] ECHO: IMPRESSION: Mild mitral valve prolapse with moderate mitral regurgitation. Normal global and regional biventricular systolic function. Late saline contrast in left heart after injection of agitated saline suggesting intrapulmonary shunting. [**2169-11-24**] CT Chest: 1. Persistent right lower lobe consolidation and parapneumonic effusion with new cavitary changes, concerning for necrotizing pneumonia. Underlying mass cannot be excluded and followup CT is recommended after resolution of pneumonia for evaluation for pulmonary mass. Discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 25139**] by phone by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**] at 19:42 on [**2169-11-24**]. 2. Increased trace left pleural effusion. 3. Increased right hilar and subcarinal lymphadenopathy, which is likely reactive given the time course of development, but metastasis cannot be excluded and could be further evaluated after resolution of infection. 4. 11-mm thyroid isthmus nodule for which ultrasound could be performed for further evaluation if not done previously Brief Hospital Course: Ms. [**Known lastname **] is a 71 y/o F with RA on chronic prednisone, chronic cough and recent workup for possible lung neoplasm who presented with 2 days of worsening productive cough and dyspnea and was found to have a pneumonia. . # Pneumonia - The patient presented to an OSH where she was found to have an elevated WBC with a left shift. CXR showed a RLL PNA. Transferred to [**Hospital1 18**] where she was HD stable although was saturating 94% on 2L. Lactate noted to be 5.5 which improved following ~5L of IVF. CTA was performed that showed rapid interval progression of a consolidative process involving the right lower lobe and posterior aspect of the right upper lobe. Started on vanc zosyn and admitted to the MICU for further management. In the MICU the patient remained hemodynamically stable although continued to spike fevers up to 102.1. Transferred to the floor on HOD #1. On the floor the patient was intermittently febrile although continued to subjective improve. Continued on cefepime/vancomycin/azithro. Pulmonary and interventional pulmonary consulted. An ultrasound of the lung showed no fluid amenable to thoracentesis. A PICC line was placed for continued antibiotic therapy on [**2169-11-22**] and an xray showed good line placement. Also revealed significant interval improvement in the pleural effusion. There was some concern that her fevers were related to her antibiotics and her antibiotics were ultimately switched to meropenem from vancomycin/cefepime. The patient continued to have fevers on the day of discharge although frequency and severity were markedly improved. She clinically appeared well, was breathing comfortably on room air, subjectively better and lung sounds markedly improved. One urine legionella was sent at the time of discharge and will be followed by ID. Her last dose of meropenem will be on [**2169-12-2**]. . # ?Lung Malignancy: BAL brushings from [**10/2169**] were suspicious for adenocarcinoma although definitive biopsy deferred while patient was hospitalized. The patient will follow-up with thoracic surgery for further evaluation and likely biopsy. . # Anemia: The patient has a chronic anemia with hematocrit baseline ~36. Iron studies during this admission are c/w anemia of chronic disease. Throughout the patient's stay here her hct has been ~30. Acute on chronic anemia thought to be a combination of repeated blood draws and immunosupression for underlying malignancy and infection. Reitc count of 0.4 is supportive of this. No e/o hemolysis or active bleeding. There was some concern for medication induced marrow suppression and her cefepime was changed to meropenem. With this change in her meds, her anemia stabilized. She did require 1 unit of pRBC while on cefepime. . # RA/CREST: Chronic, on low dose prednisone. Managed by Dr. [**Last Name (STitle) 3057**]. Prednisone was initially held in-house although re-started on transfer to the floor. Hydroxychloroquine held during active infection although will re-start after discharge. Methotrexate on Saturday per home dosing. . # HTN: Held diltiazem initially although will restart on discharge. . # Chronic rhinitis: Stable. Continued home fluticasone. # Incidental findings: 11-mm thyroid isthmus nodule. Comparison with prior ultrasound examinations or a non-emergent ultrasound evaluation is recommended when clinical stable. # Transitional Issues: 1) Continue meropenem for 8 additional days to complete 10 day treatment course (last day [**2169-12-7**]) 2) Will need to re-address need for lung biopsy at upcomming thoracic surgery visit 3) F/u thoracic nodule as above 4) Repeat CBC at PCP appointment which should be within 1 week of discharge from rehab Medications on Admission: DILTIAZEM HCL - 240 mg Capsule,Ext Release Degradable - 1 Capsule(s) by mouth once a day FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts nasal once a day HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day except one on Wed. and Sat. IRON POLYSACCH COMPLEX-B12-FA [NIFEREX-150 FORTE] - 150 mg-25 mcg-1 mg Capsule - 1 Capsule(s) by mouth once a day KAPRIDEX - (Prescribed by Other Provider; PPI) - Dosage uncertain METHOTREXATE SODIUM - 2.5 mg Tablet - 8 Tablet(s) by mouth EVERY SATURDAY NABUMETONE - 500 mg Tablet - 1 Tablet(s) by mouth [**12-25**] qd pc as needed for prn pain OXAZEPAM [SERAX] - 15 mg Capsule - 1 Capsule(s) by mouth 1 po an hour prior to MRI or long air flights PREDNISONE - 1-5MG PO DAILY, usually takes 2-3mg daily, 3mg recently ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (OTC) - 500 mg Tablet - 2 (Two) Tablet(s) by mouth as needed ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg Tablet - 1 (One) Tablet(s) by mouth once a day CALCIUM CARBONATE-VIT D3-MIN - (OTC) - Dosage uncertain CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (OTC) - 100 mcg Tablet - 1 (One) Tablet(s) by mouth once a day LORATADINE [CLARITIN] - (Prescribed by Other Provider; OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (OTC) - 1,000 mg Capsule - 1 (One) Capsule(s) by mouth once a day Discharge Medications: 1. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 3. Niferex-150 Forte 150-25-1 mg-mcg-mg Capsule Sig: One (1) Capsule PO once a day. 4. nabumetone 500 mg Tablet Sig: 1-2 Tablets PO once a day as needed for pain. 5. prednisone 1 mg Tablet Sig: Three (3) Tablet PO once a day. 6. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for fever or pain. 7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 12. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO once a day. 13. codeine sulfate 30 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for cough. Disp:*30 Tablet(s)* Refills:*0* 14. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-2**] MLs PO Q6H (every 6 hours). Disp:*200 ML(s)* Refills:*0* 15. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous every six (6) hours for 4 days. 16. Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection every eight (8) hours. 17. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous every eight (8) hours. 18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] care and rehab Discharge Diagnosis: Primary: Pneumonia, Pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]! You were admitted due to shortness of breath and cough. While in the hospital you were found to have a pneumonia and fluid surrounding your lung. During your stay you were treated with antibiotics and your condition has significantly improved. You are now ready to be discharged to a rehabilitation facility for continuation of your care. See below for changes to your home medication regimen: 1) Please CONTINUE Meropenem 500mg IV every 6 hours for an additional 4 days to complete a 14 day course on [**2169-12-2**] 2) Please STOP Methotrexate until otherwise instructed 3) Please STOP hydroxychloroquine until you see Dr. [**Last Name (STitle) 3057**] next . See below for instructions regarding follow-up care: Followup Instructions: **Please follow-up with your Primary Care Physician, [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 33278**]), within 1 week of discharge from your rehabilitation facility** ****Please call Dr. [**Last Name (STitle) **] [**Location (un) 830**], [**Hospital Ward Name 23**] 9 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3020**] Fax: [**Telephone/Fax (1) 89999**] To schedule an appt for biopsy of your RLL lung mass . Department: RHEUMATOLOGY When: FRIDAY [**2170-3-9**] at 1 PM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: FRIDAY [**2169-12-15**] at 9:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2169-11-30**]

Admission Date: [**2147-11-8**] Discharge Date: [**2147-11-26**] Date of Birth: [**2147-11-8**] Sex: M Service: NBB HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 74435**] is the former 2.345 kg product of a 34 and [**3-15**] week gestation pregnancy born to a 34 year-old, G2, P1 now 2 woman. Prenatal screens: Blood type AB positive, antibody negative, Rubella immune, RPR nonreactive. Hepatitis B surface antigen negative. Group beta strep status unknown. Mother's obstetrical history was notable for a Cesarean section at 36 weeks due to breech presentation. This pregnancy was uncomplicated. She presented in preterm labor and was taken to elective repeat Cesarean section. This infant emerged with spontaneous respirations, required blow-by oxygen, in the delivery room had Apgars of 8 at 1 minute and 8 at 5 minutes. He was admitted to the NICU for treatment of prematurity. The intrapartum sepsis risk factors were a temperature of 99.6 degrees Fahrenheit. Rupture of membranes occurred at delivery. There was no intrapartum antibiotic treatment. The infant had a prenatal amniocentesis performed showing chromosomes of 46XY. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit, anthropometric measurements revealed a weight of 2.345 kg, length 44 cm, head circumference 32 cm, all 50th percentile for gestational age. Physical examination upon discharge: Weight 2.765 kg. Length 48 cm, head circumference 33 cm. General: Alert, active infant in room air. Skin warm and dry. Color pink. Diaper rash. Head, eyes, ears, nose and throat: Anterior fontanel open and flat. Sutures apposed. Positive red reflex bilaterally. Neck supple. Chest: Breath sounds clear and equal, easy respirations. Cardiovascular: Regular rate and rhythm, no murmur. Normal S1 and S2. Femoral pulses +2. Abdomen soft, nontender, nondistended. No masses. Cord on and drying. Genitourinary: Normal male phallus. Testes palpable bilaterally, high in the canal. Patent anus. Musculoskeletal: Spine straight, normal sacrum. Hips stable. Moves all extremities. Neuro: Alert, nonfocal, symmetric tone and reflexes. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: System 1: Respiratory. This infant required treatment with oxygen and continuous positive airway pressure. After admission to the NICU, a chest x-ray was remarkable for 9 rib expansion, some streaking perihilar densities, consistent with transient tachypnea of the newborn. He was able to wean off of C-pap to room air by day of life. He continued in room air for the rest of his Neonatal Intensive Care Unit admission. He did not have any episodes of spontaneous apnea and bradycardia. At the time of discharge, he is breathing comfortably in room air with a respiratory rate of 40 to 60 breaths per minute with oxygen saturations greater than 97%. System 2: Cardiovascular: This infant has maintained normal heart rates and blood pressures. A soft intermittent murmur was noted during admission but was not audible at the time of discharge. Baseline heart rate is 140 to 160 beats per minute with a recent blood pressure of 72/31 mmHg, mean arterial pressure of 46 mmHg. System 3: Fluids, electrolytes and nutrition. The infant was initially n.p.o. and maintained on IV fluids. Enteral feeds were started on day of life one. On day of life 2, he was noted to have thick, bilious green aspirate with abdominal distention and an abdominal x-ray showing dilated bowel loops. He was transferred to [**Hospital3 1810**] where he underwent upper gastrointestinal and enema studies. These were normal and he was returned to the [**Hospital1 **] Hospital and feedings were resumed. He has tolerated feedings well since that time. At the time of discharge, he is taking a minimum of 130 mm/kg per day of Enfamil 24 calorie per ounce formula all by mouth. Weight on the day of discharge is 2.765 kg. Serum electrolytes were sent 3 times in the first week of life and were all within normal limits. System 4: Infectious disease. Due to the unknown etiology of preterm labor and unknown group beta strep status of his mother, this infant was evaluated for sepsis upon admission to the Neonatal Intensive Care Unit. A white blood cell count and differential were within normal limits. A blood culture was obtained prior to starting IV ampicillin and gentamycin. The blood culture was no growth at 48 hours and the antibiotics were discontinued. System 5: Hematological. Hematocrit at birth was 49.4%. This infant did not receive any transfusions of blood products. System 6: Gastrointestinal. As previously mentioned, this infant had upper gastrointestinal and enema contrast studies done at [**Hospital3 1810**]. Both studies were within normal limits. The infant had not passed stool prior to the enema but has maintained normal stooling patterns since that time. Enteral feeds have been well tolerated. The peak serum bilirubin was noted on day of life #5, total of 11.2 mg/dl. A recheck level on [**2147-11-15**] was 9 mg/dl. He did not require any treatment. This infant will require follow-up with pediatric surgery 2 to 3 weeks after discharge. System 7: Endocrine. This infant was noted to have undescended testes bilaterally upon admission to the Neonatal Intensive Care Unit. He was evaluated by the urology team from [**Hospital3 1810**]. An abdominal ultrasound was performed on [**2147-11-10**] and the testes were not visualized. At the recommendation of the consult service, a serum testosterone level was sent and was 151 ng/dl and well above the normal range. During his admission, both testes have been noted high in the canals and are undescended but palpable at the time of discharge. This infant should follow- up with urology consult team with the attending Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 64463**] 4 to 6 weeks after discharge. System 8: Neurology. This infant has maintained a normal neurologic examination and there are no neurologic concerns at the time of discharge. System 10: Sensory Audiology: Hearing screening was performed with automated auditory brain stem responses. This infant passed in both ears. System 11: Psychosocial. [**Hospital1 188**] social work has been involved with this family. The contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**] and she can be reached at [**Telephone/Fax (1) 8717**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY CARE PHYSICIAN: [**First Name8 (NamePattern2) 40133**] [**Last Name (NamePattern1) 311**], [**Apartment Address(1) 76003**], [**Location (un) **], [**Numeric Identifier 68635**], telephone number [**Telephone/Fax (1) 76004**]. CARE AND RECOMMENDATIONS: 1. Feeding ad lib: Enfamil 24 calorie per ounce formula with a minimum of 130 ml/kg per day intake. 2. No medications. 3. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u. (may be provided as a multi-vitamin preparation) daily until 12 months corrected age. 4. Car seat position screening was performed. This infant was evaluated in his car seat for 90 minutes without any episodes of desaturation or bradycardia. 5. State newborn screens were sent on [**11-11**] and [**2147-11-26**] with no notification of abnormal results to date. 6. Immunizations: Hepatitis B vaccine was administered on [**2147-11-24**]. 7. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following four criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. This infant has not received ROTA virus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. FOLLOWUP: 1. Pediatric surgery with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], 2 to 3 weeks after discharge. Phone number [**Telephone/Fax (1) 76005**]. 2. Pediatric urology: Attending [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 64463**] 4 to 6 weeks after discharge. Phone number [**Telephone/Fax (1) 45268**]. DISCHARGE DIAGNOSES: 1. Prematurity at 34 and 3/7 weeks gestation. 2. Respiratory distress, consistent with transient tachypnea of the newborn. 3. Suspicion for sepsis ruled out. 4. Undescended testicles. 5. Suspicion for bowel obstruction ruled out. [**First Name8 (NamePattern2) 73452**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 73453**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2147-11-26**] 00:49:42 T: [**2147-11-26**] 15:28:59 Job#: [**Job Number 76006**]

Admission Date: [**2177-12-18**] Discharge Date: [**2177-12-23**] Date of Birth: [**2126-9-8**] Sex: M Service: Trauma Surgery CHIEF COMPLAINT: Stabbing to left upper quadrant. HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old male, who presented to the ED following a stabbing to the left upper abdomen with a reported significant blood loss at the scene. Hematocrit on arrival in the ED was 12 with a blood alcohol of 31, systolic blood pressure of 110, and a heart rate of 115. The patient was taken emergently to the operating room for an exploratory laparotomy. PAST MEDICAL HISTORY: Hypertension, otherwise unknown. PAST SURGICAL HISTORY: Unknown. MEDICATIONS: Aspirin, otherwise unknown. ALLERGIES: Unknown. PHYSICAL EXAMINATION: The patient's first set of vital signs at 7:20 a.m. were recorded as heart rate 100, blood pressure 160/palp, respiratory rate 20, saturations were 100%. The patient was not intubated at the time. Patient's physical exam was notable for a stab wound to the left upper quadrant below the costal margin and anterior to the anterior axillary line with tenderness to palpation greater on the left than on the right. The abdomen was distended and had guarding to palpation. was distended. Patient's rectal examination was guaiac negative with normal tone. LABORATORIES: The patient's hemoglobin was 4.5, hematocrit was 14, platelets 203. Coags revealed an INR of 1.1, PT of 13, PTT of 21.1, lactate was 2.9, fibrinogen 261. Blood gas was 7.46/28/269/21/-1. Blood alcohol was 31. Peripheral IV access was established in the ED and blood transfusion immediately initiated. A left subclavian central line was placed, and the patient was emergently taken to the operating room. Intraoperatively, the patient was noted to have a transverse colonic stab injury with minimal soilage. The injury was repaired primarily. Exploration of his abdomen revealed no further injury. The wound was only closed at the fascial level and otherwise, the skin was left open. The patient received 5,000 mL of crystalloid, and 4 units of packed red blood cells intraoperatively. Estimated blood loss was 150 cc, which included some clot. Hematocrit at the end of the case was 29 following 4 units of red blood cells infused in total. The patient was left intubated on transfer to the Intensive Care Unit. The patient was extubated without complication on postoperative day #1. Patient had an epigastric tube in place. The patient had an uncomplicated ICU course and was transferred out to the floor on postoperative day #3. The patient had been started on triple antibiotics of ampicillin, Levaquin, and Flagyl. This was continued on transfer to the floor. The patient's hematocrit remained stable. The patient was alert and oriented with pain well controlled following extubation. Patient was started on clear liquids as a diet on postoperative day #4, and started on medications by mouth. His midline incision was noted to have some slight erythema in the superior pole. This was unchanged by postoperative day #5. By postoperative day #5, the patient was ambulating comfortably and had a bowel movement. He was tolerating a regular diet. He was discharged home on Levaquin and Flagyl for one week, and instructions on wound care. He was to keep the wound covered with dry gauze. The patient's Left upper quadrant was clean, dry with no evidence of infection and was covered with a Vaseline gauze and a gauze dressing. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Aspirin 81 mg p.o. q.d. 3. Levaquin 500 mg p.o. q.d. x7 days. 4. Flagyl 500 mg p.o. t.i.d. x7 days. 5. Dilaudid 2-4 mg p.o. q.4h. FOLLOWUP: The patient was to followup in the Trauma Clinic in one week. MISCELLANEOUS: The patient was to receive visiting nurse care for dressing changes to his stab wound as well as his midline incision to be changed once a day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 14131**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2177-12-24**] 12:50 T: [**2177-12-29**] 05:19 JOB#: [**Job Number 100472**]

Admission Date: [**2161-3-2**] Discharge Date: [**2161-3-8**] Date of Birth: [**2089-11-15**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: s/p suboccipital craniotomy for tumor resection and biopsy History of Present Illness: 71F with NSCLC, HTN, hypercholesterolemia, admitted with refractory nausea/vomitting since starting Tarceva. She denies abdominal/chest pain, SOB, diarrhea/constipation or problems w/bladder incontinence. She does have unsteadiness of gait as well as trouble using her right hand. Past Medical History: 1. NSCLC: prior w/u at [**Hospital1 112**]/[**Company 2860**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3273**])- lung nodules found on preop CXR [**6-14**], CT showed RLL nodule c/w primary lung cancer and multifocal bronchoalveolar carcinoma, PET/CT showed FDG-avid R lung nodule and mediastinal/pericardial LAD, s/p bronch/mediastinoscopy with mediastinal LN dissection with path showing NSCLC-adenoca; sought 2nd opinion at [**Hospital1 18**] ([**Doctor Last Name 3274**]/[**Doctor Last Name 1058**]), s/p 2 cycles of Taxol and carboplatin from [**Date range (1) 3275**], s/p 4 cycles Navelbine on [**2165-9-14**], CT chest [**2-16**] showed interval worsening of lung metastases and LAD, started Tarceva ?[**2-20**] 2. Hypertension 3. Hypercholesterolemia 4. Degenerative joint disease Social History: She is a former smoker of half to one pack a day for 20 to 30 years, but she quit about 20 years ago. She does not have significant amount of passive smoking exposure, no asbestos exposure, and rare social drinking. Family History: Positive for cardiac or vascular disease, but no cancer. She has a possible history of amoxicillin allergy, although it is not clear whether this was poor tolerance, and she has taken penicillin in the past without difficulty. She has a daughter who is a physician and who comes with her to the visit along with her son-in-law. She worked as a bookkeeper in an electrical company in the past. Physical Exam: T:96.9 BP:140/78 HR:64 RR:20 O2Sats:95% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs-intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. 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 [**6-13**] throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, heel to shin (+) Romberg Pertinent Results: [**2161-3-2**] 09:10PM WBC-11.9* RBC-5.25 HGB-15.3 HCT-44.5 MCV-85 MCH-29.2 MCHC-34.4 RDW-16.7* [**2161-3-2**] 09:10PM NEUTS-70.0 LYMPHS-24.3 MONOS-4.0 EOS-1.3 BASOS-0.5 [**2161-3-2**] 09:10PM ANISOCYT-1+ MICROCYT-1+ [**2161-3-2**] 09:10PM PLT COUNT-406 [**2161-3-2**] 09:10PM GLUCOSE-97 UREA N-34* CREAT-0.8 SODIUM-133 POTASSIUM-7.7* CHLORIDE-98 TOTAL CO2-26 ANION GAP-17 [**2161-3-2**] 09:10PM estGFR-Using this [**2161-3-2**] 09:10PM ALT(SGPT)-33 AST(SGOT)-97* ALK PHOS-109 AMYLASE-111* TOT BILI-0.6 [**2161-3-2**] 09:10PM LIPASE-81* [**2161-3-2**] 09:10PM CALCIUM-9.6 PHOSPHATE-4.4 MAGNESIUM-2.4 MRI head: 1. Enhancing mass in the right cerebellar hemisphere, with mass effect as described above, most consistent with a metastatic lesion. No additional mass/abnormal enhancement. 2. Old lacune in the left caudate nucleus and a nonspecific T2 hyperintensity in the right frontal lobe, likely post-traumatic or chronic small vessel ischemic change. 3. Mucosal changes in the right sphenoid sinus. CT abdomen/pelvis: 1. No evidence of intra-abdominal metastatic disease. 2. A 9-mm hypoattenuating liver lesion is likely a cyst but should be monitored closely on followup exams. 3. New small bilateral pleural effusions with adjacent atelectasis. 4. Large paraesophageal hernia. 5. Stable pericardial lymph node. Brief Hospital Course: # Nausea and vomiting: Concerning presentation for brain metastasis. Tarceva d/c'd on thursday of last week w/continued N/V as well as unsteadiness of gait # NSCLC: further treatment plans per Dr. [**Last Name (STitle) 3274**] and [**Doctor Last Name 1058**] - hold Tarceva - CT head as above # Code status: DNR/DNI On [**3-4**], the patient came from the [**Hospital Ward Name **] to the SICU on the west. She underwent preop evaluation and surgery was scheduled for [**3-5**] with Dr. [**Last Name (STitle) 548**]. She had a very successful surgery with no reported complications. Please see the operative note for full details. She went back to the ICU for 24 hours and then came to the floor. Physical therapy saw her and had no major issues with her progression. She plans to say with her daughter for several days to recuperate. The patient will see neuro oncology and Dr. [**Last Name (STitle) 548**] next week and will be on a course of steroids for the unforeseeable future. Medications on Admission: [**Doctor First Name **] 60MG [**Hospital1 **] FLONASE 50 mcg 2 sprays ou qd LIPITOR 10 MG qd PRILOSEC 40 mg qd Discharge Medications: 1. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) for 2 days. Disp:*12 Tablet(s)* Refills:*0* 2. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO twice a day for 2 days: Start this dose after taking 3mg TID. Disp:*8 Tablet(s)* Refills:*0* 3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day: Once you have finished taking 3mg [**Hospital1 **], take 2mg [**Hospital1 **] until directed by MD otherwise. Disp:*60 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation: Please take this medication as long as you are taking percocet. . Disp:*60 Capsule(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: cerebellar mass Discharge Condition: neurologically stable Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending * Please continue all of your preadmission medications that you were on before coming into the hospital. ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Need to follow-up with oncologist for 9-mm hypoattenuating liver lesion which is likely a cyst but needs to be watched. PLEASE RETURN TO THE OFFICE IN 7 DAYS FOR REMOVAL OF YOUR STAPLES/SUTURES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) 548**] TO BE SEEN IN 1 WEEK. YOU WILL NOT NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST Completed by:[**2161-3-8**]

Admission Date: [**2198-3-13**] Discharge Date: [**2198-3-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2234**] Chief Complaint: Bloody bowel movements Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is an 86 y/o F with PMH of diverticulosis, hepatic cyst s/p resection, and HTN who presents to the ED with BRBPR X 3 at home. Patient was feeling well today until 1430 pm when she had a large loose bowel movement with bright blood. This occurred X 2 more and patient presented to the ED. Of note, she has a known history of diverticular bleed requiring ICU admission and transfusion of 4 U PRBCs in 9/[**2196**]. She denies abdominal pain throughout. She denies chest pain, shortness of breath, and dizziness/lightheadedness today. In the ED, the patient's initial vitals were HR 67, BP 127/64. BP remained in 110s-130s systolic. She received 2 L normal saline. Her hematocrit demonstrated decrease to 29.7 from 31-32 (2 weeks ago); repeat Hct at [**2190**] pm (four hours after presentation) demonstrated further drop to 24.4 (no interval transfusion but did receive IVF). Two large-bore peripheral IVs were placed, and the patient was transfused 1 U PRBCs (still running when she arrived on the floor). She remained asymptomatic throughout. GI was [**Year (4 digits) 653**] and recommended observation in the ICU and tagged RBC scan if bloody BMs continued. In the MICU she received one unit of pRBC. She stabilized, and was hemodynamically stable. She had two small episoded of BRBPR. GI evaluated and deferred scope at this time as she likely has diverticular bleed and no easy intervention. She feels well on transfer to the floor, without any complaints of pain. Past Medical History: 1. Hypothyroidism 2. H/O E. Coli Sepsis ([**4-/2194**]) 3. HTN 4. H/O Bronchitis 5. Hepatic Cystadenoma S/P Resection ([**2184**]) 6. Cholangitis S/P Stenting 7. PUD (Duodenum) 8. TAH/BSO 9. DJD 10. CAD (2VD s/p DES to D1) 11. Osteoarthritis of the knees 12. Diverticulosis 13. Neuropathy 14. Spinal stenosis Social History: Lives at an [**Hospital3 **] facility in [**Location (un) 583**], moved to U.S. from rural [**Country 651**] 40 years ago. Denies smoking, alcohol, and drug use. Lives alone in [**Hospital3 4634**] with family near by. Previously worked in laundering/ironing. Family History: No known liver, gall bladder, lung or heart disease. No known cancers. Physical Exam: VS: 98.6, BP 133/62, HR 81, O2Sat 98 RA, RR 20 GEN: pleasant, comfortable, elderly female in NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, supple RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: slighlty distended with prior midline & right-sided scars, +b/s, soft, nontender to palpation, no masses or hepatosplenomegaly EXT: trace anterior tibial edema, extremities warm SKIN: no rashes/no jaundice NEURO: AAOx3. face symmetric & speaking clearly in full sentences. moving all extremities without difficulty. Pertinent Results: [**2198-3-13**] 04:20PM WBC-6.8 RBC-3.76* HGB-10.1* HCT-29.7* MCV-79* MCH-26.9* MCHC-34.1 RDW-14.0 PLT COUNT-344 NEUTS-78.0* LYMPHS-14.2* MONOS-5.4 EOS-2.0 BASOS-0.3 [**2198-3-13**] 08:09PM BLOOD Hgb-8.1* Hct-24.4* [**2198-3-14**] 07:51AM BLOOD WBC-7.3 RBC-3.57* Hgb-9.6* Hct-27.8* MCV-78* MCH-26.7* MCHC-34.3 RDW-14.9 Plt Ct-284 [**2198-3-15**] 05:35AM BLOOD WBC-6.3 RBC-3.33* Hgb-9.0* Hct-26.7* MCV-80* MCH-26.9* MCHC-33.6 RDW-14.6 Plt Ct-245 [**2198-3-16**] 06:00AM BLOOD WBC-6.5 RBC-3.51* Hgb-9.5* Hct-27.7* MCV-79* MCH-27.0 MCHC-34.2 RDW-15.6* Plt Ct-257 [**2198-3-13**] 04:20PM GLUCOSE-115* UREA N-21* CREAT-1.3* SODIUM-136 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14 EKG Sinus rhythm and occasional atrial ectopy. Compared to the previous tracing of [**2198-2-28**] the atrial morphology has changed and the rate has slowed. Atrial ectopy has appeared. Otherwise, no diagnotic interim change. Intervals Axes Rate PR QRS QT/QTc P 68 200 88 390/404 0 Brief Hospital Course: 86 year old female with known history of diverticulosis presents with BRBPR and drop in hematocrit. # GI bleeding: Likely diverticular bleed given history of diverticula and clinical presentation. Hemodynamically stable with minimal bloody bowel movements since second day of admission. Coagulation studies were checked and found to be within normal limits. During her admission she received 1 unit of PRBC and HCT then remained stable. The GI service was consulted on admission and thought there was no role for colonoscopy for now as this likely represented a diverticular bleed. Her family, who are her primary caregivers, were [**Name (NI) 653**] to discuss the nature of diverticular bleeding and that very little intervention can be done via colonoscopy. Given that her HCT remained stable for three days post-initial transfusion, she was discharged home with follow-up. Specifically, she will have a HCT check by VNA 3 days post-discharge and will be seen by her PCP 6 days post-discharge. # Acute Renal Failure: Likely related to hypovolemia from diarrhea/blood loss. Resolved after hydration. # Hypothyroidism: Continued Levothyroxine. # History of choledocholithiasis: Continued ursodiol at home dose. # Hypertension: Anti-hypertensives were initially held given concern for potential hemodynamic instability. While in ICU, she was restarted on Amlodipine at her home dose. During the remainder of her inpatient stay, Metoprolol and Cozaar were both restarted. Thus, she was discharged on her prior outpatient regimen. Medications on Admission: amlodipine 5 mg daily actigall 300 mg [**Hospital1 **] cozaar 25 mg daily levothyroxine 75 mcg daily meloxicam 15 mg once daily - patient self-d/c metoprolol 50 mg [**Hospital1 **] prilosec 20 mg daily darvocet prn calcium/vitamin D Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Calcium 600 + D 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 8. Outpatient Physical Therapy To evaluate and treat in home as needed. 9. Outpatient Lab Work VNA to continue outpatient services. Additionally, a CBC should be drawn [**2198-3-19**] and results should be faxed to Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 16691**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Gastrointestinal bleeding, likely due to diverticuli Secondary: Hypertension, hypothyroidism Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted with blood in your stool and black stools. You were found to have bleeding from your intestines, likely from diverticuli as you've had this in the past. You were transfused one unit of blood and your blood levels have been stable since. Thus, you're being discharged with outpatient follow-up and physical therapy at home for continued recovery. Take all medications as prescribed. Your medications have not been changed while you were in the hospital. Please keep all outpatient appointments. Return to the hospital or seek medical advice if you notice fever, chills, difficulty breathing, chest pain, bloody stools, black stools, bloody vomit or for any other symptom which is concerning to you. Followup Instructions: Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2198-3-22**] 12:40 Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2198-4-4**] 11:30

Admission Date: [**2129-10-14**] Discharge Date: [**2129-10-17**] Date of Birth: [**2070-7-27**] Sex: M Service: Neurosurgery HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old gentleman who has a past medical history of hypertension and a subarachnoid hemorrhage for a ruptured basilar tip aneurysm which was treated using coil embolization in [**2129-5-5**]. He returns now for stent placement and coil embolization of the residual basilar tip aneurysm. HOSPITAL COURSE: The patient underwent the procedure on [**2129-10-14**] with placement of a stent and coiling of the remainder of the aneurysm without intraprocedural complication. The patient was monitored in the PACU, doing well without complaints. No pain, confusion, chest pain, shortness of breath, or nausea or vomiting. He had no apparent anesthesia complications. Postoperatively, he was awake, alert, without complications, moving everything well, lying flat, oriented times three, speech was clear. The pupils were equal, round, and reactive to light. EOMs were full. No diplopia. No nystagmus. Right groin sheath was removed with some oozing but no hematoma, good pedal pulses. The patient was out of bed ambulating, tolerating a regular diet, transferred to the regular floor. He was continued on Plavix and aspirin. He was discharged to home on postprocedure day number three in stable condition, neurologically intact with follow-up with Dr. [**Last Name (STitle) 1132**] in one month for repeat angiogram at that time. Continue on Plavix for one week and aspirin indefinitely. DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 25 mg p.o. q.d. 2. Percocet one to two tablets p.o. q. four hours for pain. CONDITION ON DISCHARGE: Stable. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2129-10-17**] 10:53 T: [**2129-10-17**] 14:48 JOB#: [**Job Number 47665**]

Admission Date: [**2152-9-29**] Discharge Date: [**2152-10-4**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: CC:[**CC Contact Info 41404**] Major Surgical or Invasive Procedure: none History of Present Illness: 86 female w/ breast ca briefly on tamoxifen, paroxysmal afib, presumed diastolic dysfunction, ?COPD now being eval for resp distress. Per daughter, [**Name (NI) 41405**] until increased sob/tachypnea x [**12-31**] days treated w/ levaquin for ?pna and diuretics for volume overload. On day of admission, initially improved following additional lasix but then w/ episode of shaking, diaphoresis followed by reported unresponsiveness and then lethargy. Transferred to ED where afebrile, hypertensive to systolic 170's but 86% ra w/ abg7.35/74/59. Started on bipap, diuresed w/ 60 iv lasix and 1200 cc urine output. Repeat gas on 100 fio2 7.25/99/257. In MICU Pt was placed on Bipap with target O2 sat 90-92%, diuresed, and abx tx continued with vanc + ceftaz. MICU achieved 95-97% O2 sat weaned off BIPAP to 3L NC. Transferred to medical floor. Past Medical History: COPD (1L O2 baseline, Sat not reported) Breast Ca (tamoxifen) Paroxysmal AFIB ??????no coumadin (fall risk) Diastolic Dysfunction (CHF) Hypothyroidism HTN UTI (previous proteus enterococcus, both susceptible to levo. Per [**Hospital1 18**] records). s/p R hip ORIF [**2152-7-7**] Social History: Resides at [**Location (un) 2716**] Point (extend care). Per record, quit smoking 30 years ago, 3 cigs qd. Retired teacher. Family History: Not reported in records. Son ([**Telephone/Fax (1) 41406**]) is MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] Diabetes Center. Physical Exam: T:98.1 97.9 BP: 120-130/30-40 HR 90 (70-110) RR:20 O2Sat:95(92-97) 3LNC Gen: Pt. is awake, and alert but disoriented. According to home health aide (present) pt. is at baseline today. Skin: Nl. Skin turgor. Small well healed surgical scar on neck base. HEENT: EOMI. Sclera anicteric. Heart: Irreg. Irreg. On auscultation. No murmurs noted. No rubs or gallop. S1 S2 JVP < 10cm. Lungs: Distant breath sounds. Bibasilar rales B/L (R>L), no wheezes, no rhonchi. Abd: Soft, obese, nontender to palpation, nondistended, no [**Doctor Last Name **]??????s sign. Normal bowel sounds. Extrem: Strength 4/5 flexion & extension UE b/l. Strength 4-/5 LLE raise, [**4-3**] LLE extension, Strength 2/5 RLE raise, [**2-3**] RLE extension. Plantarflexion and dorsiflexion 4-/5 b/l. 1+ edema b/l. Pertinent Results: [**2152-9-29**] 01:25PM BLOOD WBC-7.2 RBC-3.94* Hgb-11.6* Hct-36.6 MCV-93 MCH-29.4 MCHC-31.6 RDW-13.5 Plt Ct-250 [**2152-9-29**] 01:25PM BLOOD PT-12.1 PTT-24.6 INR(PT)-0.9 [**2152-9-29**] 01:25PM BLOOD Glucose-141* UreaN-17 Creat-0.8 Na-141 K-4.4 Cl-93* HCO3-39* AnGap-13 [**2152-9-29**] 01:25PM BLOOD Acetone-NEG [**2152-9-29**] 01:25PM BLOOD TSH-3.6 [**2152-9-29**] 01:38PM BLOOD Type-ART pO2-59* pCO2-74* pH-7.35 calHCO3-43* Base XS-10 [**2152-9-29**] 04:51PM BLOOD Lactate-0.6 [**2152-9-29**] 04:51PM BLOOD freeCa-1.11* [**2152-9-30**] PORTABLE CHEST: Comparison is made from film from one day earlier. The patient has made a slightly improved inspiratory effort on the current film. The cardiac and mediastinal contours are unchanged, with prominence of the left hilum again noted. Previously noted pulmonary edema persists without change. There is some improved aeration in the left base. [**2152-10-2**] SWALLOWING EVAL RECOMMENDATIONS: 1.Advance to regular consistency po diet. 2.Should pt develop s/s aspiration, worsening pna, or difficulty with upper airway secretions, please reconsult for a video swallow study. [**2152-9-29**] EKG: Sinus arrhythmia Normal ECG No change from previous Brief Hospital Course: 1. COPD: Patient was observed at her Nursing Home ([**Location (un) 2716**] Point) to have increased SOB for two days and was seen by PCP [**Last Name (NamePattern4) **] [**2152-9-29**]. She was noted to have oxygen saturation of 80% RA, thought potentially secondary to CHF exac vs. PNA. She was treated with levofloxacin and lasix with some improvement in her oxygen saturation to 85% RA, but BP incr. 160s. IV nitro was started at her nursing home, antibiotics were switched to azithro + ceftaz, and she was transferred to the [**Hospital1 18**] ED. On arrival to the ED, she was diaphoretic, shaky and unresponsive. Her temperature was 99.6 and pt was hypertensive to 160-170/60, with oxygen saturation of 86% RA. An ABG was 7.25/99/257 suggesting CO2 retention. Per MICU note, daughter reported [**Name2 (NI) **], no recent F/C/N/V, no CP mild SOB over the last couple of weeks, no PND , no orthopnea. Daughter reports increased LE edema and some weight gain (undocumented) over [**2-1**] weeks, but no urinary Sx. In MICU, pt was placed on BIPAP with target O2 sat 90-92%, diuresed, and abx tx continued with vanc + ceftaz. MICU achieved 95-97% O2 sat weaned off BIPAP to 3L NC. Transferred to medical floor and we continued to wean O2, continued steroids (prednisone taper) and continued ipratropium neb, added albuterol neb. 48 hours later, patient was weaned from 3L NC 02 with 90-95% sats to RA and >95% sats with mild crackles at base. She was d/ced in this condition. 2. CHANGE IN MS: Pt. was found unresponsive and brought to the ED diaphoretic, acidotic, with low O2 Sat. Was confused and disoriented, not at baseline per home attendant. In Unit, palced on BiPAP with improving sats but hypercarbic, retaining. Still poor mental status. As BiPAP was weaned and on day of transfer to floor, pt was much closer to baseline per home health aide. At d.c from medicine floor, home health aid reports that patient is at baseline mentation. Although still not oriented, her thoughts are organized and she is vocal. 3. ID: Pt's COPD and CXR with infiltrate are worrisome for PNA + COPD exac. Txed inpatient with Vanc+ceftaz, transferred to floor and continued on ceftaz, then converted to azithro+ceftriax. Will d/c with wbc 5.4 crit 33.1 plat 228, abx 10d of cefpodoxime 200 [**Hospital1 **] and azithro 250 QD. 4. Atrial fibrillation: Per PCP, [**Name10 (NameIs) **] patient is a fall risk, and PCP does not recommend coumadin or lovenox given risk. Her beta blocker dose was titrated up for improved rate control. 5. Hypothyroidism: The patient's TSH was checked on admission and was within normal limits. On discharge it was midly elev at 5.0. Her levothyroxine was continued at her present dose. PCP should consider TSH level in 2wks to determine if current levoxyl dose is adequate. 6. Documented desat during sleep ? sleep apnea. Pt. was observed for 15 min on 02 sat during sleep. awake o2 sat 90-92% RA, pt desats to low 80s high 70s after 30 sec apneic events during sleep, then sats rise to high 80s. We will d/c on nocturnal 02 2L, but may wish to consider sleep apnea w/u as o.p. 6. C/o R eyelid pain. On [**10-4**] pt c.o mild R eye discomfort - she and home health aid admit to chronic R eye dryness/discomfornt. No exudate, scleara clear, no obvious foreign body, no erythema, no edema. Txed with artificial tears. No clinical indication on exam of pathologic process. Medications on Admission: ON ADMIT: zyprexa 2.5 qhs, levoxyl 125 qd, neurontin 100 tid, donezepil 10 qhs, trazodone 50 qhs, atrovent neb qid FROM MICU: Famotidine 20 mg IV Ipratropium Bromide Neb 1 NEB Q6H Levothyroxine 125 mcg PO Aspirin 81 mg PO Heparin 5000 UNIT SC TID Ceftazidime 1 gm IV Vancomycin HCl 1000 mg IV Q24H Nitroglycerin 0.05 mcg/kg/min IV DRIP TITRATE TO sbp under Olanzapine 2.5 mg PO Methylprednis. Succ 60 mg IV Q8Hx3d Metoprolol 25 mg PO BID hold for sbp<100 or hr<60 Olanzapine 2.5 mg PO TID PRN Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation every eight (8) hours. 2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO TID PRN (). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO QD (once a day): Taper from day 1 ([**2152-10-3**]):40,40,40,20,20,20,10,10,10,10. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 10 days. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 11. Nocturnal 02 2L nasal can. Discharge Disposition: Extended Care Facility: [**Location (un) 2716**] [**Last Name (un) **] - [**Location (un) 55**] Discharge Diagnosis: COPD exacerbation + PNA 1. COPD exacerbation + PNA 2. Dementia 3. Hypothyroidism 4. Diastolic dysfunction 5. Depression Discharge Condition: fair. Discharge Instructions: Please return to the ED if you experience increasing shortness of breath, increased oxygen requirement, shortness of breath and [**Location (un) **], fever, chest pain. Followup Instructions: Please follow up with your primary care physician within the next 2 weeks.

Admission Date: [**2103-9-20**] Discharge Date: [**2103-9-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7708**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: [**2103-9-24**] Colonoscopy History of Present Illness: Ms. [**Known lastname 72724**] is a [**Age over 90 **] y/oF with history of remote colon ca s/p resection ~23 years ago, and mild hypertension who is admitted night of [**2103-10-21**] with BRBPR. She has noticed some change in her stools for the last few days, but brought to her daughter??????s attention last night with maroon stool in the toilet. She had another episode of red blood this morning, moderate quantity. She has not had this problem before. She has no abdominal pain, but has had occasional nausea but no vomiting. Her only other change in bowel habits was a few days earlier, when she ahd some constipation and had to use her finger to aid in evacuation of stool. She has no history of hemorrhoids. . She has DJD and had been taking more naproxen PRN, and more of one analgesic more recently, that the daughter thinks is Tylenol. . In the ED: her initial vitals were T 97.6, HR 72, BP 127/48 RR 18 Sat 98% 2L. She received 2L of normal saline. She had an episode of BRBPR in the ED of about 500cc. Vitals however remained stable without tachycardia or hypotension. Her rectal exam was frankly bloody, but no hemorrhoids appreciated. She was seen by GI with decision to not scope immediately and see if this clears, with back-up plan of IR scan/embolism likely preceded by endoscopy. . In the ICU: She presented with a Hct of 27.4, but dropped to 24.7 that same night. She subseqently received 2 units on [**9-20**], and 1 unit PRBC on [**9-21**]. Her Hct has remained stable in the 30s since then. Past Medical History: - Colon Ca s/p resection 23 years ago in [**Last Name (un) 51768**], FL - Hypertension - Depression - Degenerative Joint Disease Social History: lives at home with daughter and son-in-law, denies etoh, smoking Family History: NC Physical Exam: Vitals: 96.8, 121/48, 65, 18, 98%RA HEENT: NC/AT, clear oropharynx, MMM Neck: supple, no LAD CV: RRR s m/g/r Chest: CTAB Abd: +BS NT/ND, soft Ext: no c/c/e Skin: no rashes, lesions, or jaundice Neuro: A&Ox3 Pertinent Results: LABS: [**2103-9-20**] WBC-8.8 RBC-3.05* HGB-9.0*# HCT-27.4*# MCV-90 MCH-29.6 MCHC-33.0 RDW-13.4 [**2103-9-20**] 02:50PM CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.1 [**2103-9-20**] 02:50PM cTropnT-0.02* [**2103-9-20**] 02:50PM CK(CPK)-94 [**2103-9-20**] 02:50PM GLUCOSE-117* UREA N-47* CREAT-1.0 SODIUM-140 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-30 ANION GAP-12 [**2103-9-20**] 03:35PM URINE RBC-0-2 WBC-<1 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2103-9-20**] 03:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2103-9-20**] 07:47PM WBC-7.8 RBC-2.76* HGB-8.6* HCT-24.7* MCV-89 MCH-31.1 MCHC-34.8 RDW-13.5 [**9-21**] 5:18pm - Hct 30.2 [**9-22**] 1:35pm - Hct 30.7 [**2103-9-23**] 03:02PM BLOOD Hct-32.1* [**2103-9-24**] 05:25AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.3* Hct-30.7* MCV-89 MCH-30.1 MCHC-33.7 RDW-13.9 Plt Ct-249 [**2103-9-25**] 05:15AM BLOOD WBC-8.5 RBC-3.39* Hgb-10.4* Hct-30.3* MCV-90 MCH-30.7 MCHC-34.2 RDW-13.8 Plt Ct-263 [**2103-9-25**] 05:15AM BLOOD Glucose-105 UreaN-12 Creat-0.9 Na-139 K-3.8 Cl-104 HCO3-28 AnGap-11 . Imaging: CXR: no acute CP process ECG: Sinus 1:1 at 70 bpm, normal axis, intervals. No e/o ischemia Colonoscopy: Diverticulosis of the sigmoid colon and descending colon Two small polyps in the sigmoid and ascending colon 1.5 cm penduculated polyp in the sigmoid colon. (polypectomy) Erythema and petechiae on several colonic folds in the sigmoid colon Otherwise normal colonoscopy to cecum Brief Hospital Course: [**Age over 90 **] y/oM with remote h/o semi-colectomy for colon ca a/w likely lower GI bleed in the absence of abdominal pain. # GIB: Patient reported painless hematochezia and maroon stools x 2-3 days prior to admmission and then BRBPR on morning of admission. Differential included diverticulosis, AVM, colon CA, or colonic ischemia. Pt's Hct nadired to 24.7. She received 3 units PRBC in ICU. She remained hemodynamically stable during floor hospital course. For the remainder of her hospital course and she did not require any further transfusions after [**2103-9-21**]. The day after [**Hospital **] transfer to floor she reported two bloody bowel movements and [**Hospital1 **] hematocrit checks were continued but HCT remained stable around 30. She reported no further bloody or maroon bowel movements. She had a colonoscopy on [**2103-9-24**] which showed diverticulosis as well as polyps. She had a polypectomy and pathology is pending. Although initially started empirically on IV PPI [**Hospital1 **], this was changed to PO daily dosing prior to discharge. # HTN- Norvasc initially held but restarted prior to discharge at home dose 5 mg daily. # [**Name (NI) 1068**] Pt Remained stable on zoloft. # Code: Full Medications on Admission: Allergies: NKDA Home medications: Zoloft 50mg PO daily Norvasc 5mg PO daily Naproxen PRN Tylenol PRN Aspirin PRN Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. 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* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis 1. Gastrointestinal Bleed 2. Diverticulosis 3. Sigmoid/Colon Polyps. Biopsy reports pending Secondary Diagnosis 1. Depression 2. Osteoarthritis 3. Hypertension Discharge Condition: Hemodynamically stable, stable hematocrit x 3 days, afebrile Discharge Instructions: You were admitted to the hospital with maroon colored stools and bleeding from your gastrointestinal tract. Your blood counts were initially low so you were transfused 3 units of blood. After this, your blood counts remained stable and you did not have any further bleeding. You had a colonoscopy on [**2103-9-24**] which showed diverticulosis, which are small outpouchings in the colon, and polyps. One polyp was removed and a biopsy was sent for pathology. The results of the biopsy were pending at the time of discharge. We made the following changes to your medications 1. We added Pantoprazole 40mg by mouth daily Please take all medications as prescribed and follow up with your primary care doctor as below. Please return to the ED or call your primary care physician if you develop bloody, maroon or dark tarry stools or notice bleeding from you rectum. Also call if you develop nausea, vomiting, lightheadedness, dizziness, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Thursday [**10-4**] at 5:15pm. Call [**Telephone/Fax (1) 14825**] if you have any questions regarding your appointment. A repeat hematocrit should also be checked at this time. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**] MD [**MD Number(1) 7715**]

Admission Date: [**2118-5-7**] Discharge Date: [**2118-5-12**] Date of Birth: [**2070-8-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12174**] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD Radiofrequency ablation of liver lesions History of Present Illness: 47 yo man with h/o etoh/HCC cirrhosis, esophageal varices with melena with black emesis and dark tarry stools [**5-6**]. He states the melena started [**5-5**]. He also had some lightheadedness. He notes some abdominal pain during the ambulance ride that improved with zofran. His partner encouraged him to go to the [**Name (NI) **]. At [**Doctor First Name 8125**] hct 37.2. In the ED VS: 98.7 76 117/75 18 99% on 2L NC. He 2L NS. 2 Melenic, guaiac + stools. HR 80, SBP 120, hemodynamically stable. Was initially to go to floor, housestaff uncomfortable. ROS: no wt change, change in abdominal girth, fevers, chills, head ache, chest pain, sob, palpitations, sob, dysuria, hematuria, confusion, rash. Past Medical History: - Etoh/HCV cirrhosis with varices, ascites, and previous episodes of encephalopathy, Last viral load 7,340 IU/mL [**2117-2-26**]. The patient has not had a liver biopsy nor has the patient had any treatment to date for his hepatitis C followed by Dr. [**Last Name (STitle) 497**] (last seen [**4-11**]). EGD [**2115-12-23**] revealing varices at the lower third of the esophagus, with two bands placed, and portal gastropathy. Grade 3 esophageal varices with multiple admissions for GIB, banding in past; last EGD [**9-11**] varices too small to band. - Ethanol abuse with history of DTs: + hallucinations in the past but no intubations or seizures. - h/o Nephrolithiasis. - MVA [**2113-5-4**] with two fractured lumbar vertebrae, torn rotator cuff, and humeral head fracture. - h/o coagulopathy, anemia (baseline Hct ~30), thrombocytopenia - foot surgery - facial reconstruction as a child - leg cramps - asthma - Hep B SAg/sAb negative ; Hep A immune - HIV negative [**2115-7-5**] - AFP 1.81 [**2117-2-4**], U/S [**2117-2-25**] with 1.1cm echogenic focus in left lobe, f/u MRI limited Social History: He has a long history of alcohol abuse (since high school). currently drinking a pint of vodka per day with some mixed drinks, last drink [**5-6**] am. He has a history of DTs, no seizures or intubations for this but + hallucinations. He currently smokes less than a pack per day and has smoked 30+ years. He is unemployed but used to work as a carpenter. He has a history of IVDU (cocaine and heroin) but last use 15 years ago. He has a history of incarceration in the past. Family History: He does not know of any liver disease or colon cancer. Father with a history of alcoholism Physical Exam: VS: T 97.9 HR 89 BP 129/82 RR 24 Sat 93% on RA GEN: NAD HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: protuberant, soft, NT, ND, + BS, no obvious HSM on percusion, ? small fluid wave, no caput EXT: warm, dry, +2 distal pulses BL, no femoral bruits Skin: spider angiomas on chest, scattered [**Last Name (LF) 94195**], [**First Name3 (LF) **] damage NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis. PSYCH: appropriate affect, no anxiety, tremulousness, diaphoresis Pertinent Results: Admission labs: [**Age over 90 **]|105|10 -----------<128 3.7|25|0.6 Ca: 7.5 Mg: 1.3 P: 2.6 ALT: 38 AP: 124 Tbili: 4.9 Alb: 2.3 AST: 111 . 11.8 7.5>--<152 33.9 PT: 19.6 PTT: 35.6 INR: 1.8 Fibrinogen: 256 D EGD: no actively bleeding vessels (please see full report in OMR for further details) Radiofrequency ablation: 1. Successful radiofrequency ablation of the patient's liver tumor. [**2118-5-12**] 05:45AM BLOOD WBC-6.0 RBC-2.72* Hgb-10.1* Hct-28.6* MCV-105* MCH-37.1* MCHC-35.2* RDW-17.0* Plt Ct-91* [**2118-5-12**] 05:45AM BLOOD Plt Ct-91* [**2118-5-12**] 05:45AM BLOOD Glucose-169* UreaN-8 Creat-0.6 Na-130* K-3.4 Cl-96 HCO3-29 AnGap-8 [**2118-5-12**] 05:45AM BLOOD ALT-29 AST-92* LD(LDH)-276* AlkPhos-107 TotBili-3.6* [**2118-5-12**] 05:45AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.4* Brief Hospital Course: 46 yo man with alcoholic cirrhosis, known esophageal varices admitted with melena and emesis. The patient was hemodynamically stable throughout his admission. He had no further episodes of melena during this hospital course. The patient was initially maintained with two large bore IVs with a plan to transfuse for a hematocrit less than 28. He had an EGD which did not demonstrate any actively bleeding lesions. The patient was actively drinking prior to admission. Although he denied a history of withdrawal seizures he was tachycardic, hypertensive and nauseated on admission. He was maintained on a q2 hour CIWA scale, with decreasing benzo requirements throughout his admission. The patient was also maintained on thiamine, folate and a multivitamin. His clonidine was discontinued on admission and restarted once the patient was called out to the floor. The patient has a coagulopathy secondary to his chronic cirrhosis. His disease is secondary to ETOH with HCC, and he is followed by Dr. [**Last Name (STitle) 497**]. His disease is complicated by portal hypertension, hypertensive gastropathy, esophageal varices s/p banding and melena in the past, as well as ascites, thrombocytopenia, anemia, and coagulopathy. His medications were initially held but once it was clear the patient was not actively bleeding, his nadolol, furosemide, spironolactone and lactulose were restarted. The patient had a stable thrombocytopenia. He did receive FFP prior to a planned RFA for three liver lesions. The procedure went well and the patient was discharged the following day. The patient was continued on his outpatient pain regimen of Neurontin and a lidocaine patch. He also had a chronic stable anemia which was macrocytic, likely multifactorial given GIB, EtOH use and liver disease. Vitamin B12 1787 [**4-12**], folate 11.8 [**4-12**]. The patient was a full code throughout this admission. Communication was as follow: mother [**Name (NI) **] (HCP) [**Telephone/Fax (1) 94196**], Partner [**Name (NI) **] (h) [**Telephone/Fax (1) 94197**], (c) [**Telephone/Fax (1) 94198**]. Medications on Admission: Pt poor historian, unable to verify meds Clonidine 0.1 mg PO TID Fluticasone 50 mcg/Actuation Nasal [**Hospital1 **] Folic Acid 1 mg PO DAILY Furosemide 40 mg PO DAILY Gabapentin 300 mg PO Q8H Lactulose 10 gram/15 mL ThirtyML PO four times a day - only takes when constipated Nadolol 40 mg PO DAILY Pantoprazole 40 mg PO Q24H - states [**Hospital1 **] Ferrous Sulfate 325 mg PO DAILY Hexavitamin PO DAILY - not likely taking Thiamine HCl 100 mg PO DAILY Lidocaine 5 %(700 mg/patch) Topical DAILY Spironolactone 100 mg PO DAILY Nicotine 21 mg/24 hr Transdermal DAILY Discharge Medications: 1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 7. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for 12, off for 12 hours. 12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Alcoholic cirrhosis GI bleed Secondary: HCV Liver lesions Asthma Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with concern for gastrointestinal bleeding. While you were in the hospital, you had an EGD which did not demonstrate any actively bleeding vessels. You also had radiofrequency ablation of the lesions in your liver. Your blood counts have been stable since your admission to the hospital. Please take all of your medications as prescribed. Please call your physician or come to the emergency room with anyfevers, vomiting, blood in your stool or your vomit, confusion or other symptoms you find concerning. Followup Instructions: Please call [**Telephone/Fax (1) 250**] to schedule an [**Telephone/Fax (1) 648**] with your primary care doctor to follow up after discharge. Please call the Liver Center at ([**Telephone/Fax (1) 1582**] to set up an [**Telephone/Fax (1) 648**] with Dr. [**Last Name (STitle) 497**] within several weeks of discharge.

Admission Date: [**2155-8-10**] Discharge Date: [**2155-8-27**] Service: HISTORY OF THE PRESENT ILLNESS: This is a 80-year-old white female with a past medical history significant for non-Q-wave MI on 6/[**2155**]. The patient was transferred to [**Hospital1 346**] from [**Hospital6 33**] with a question of small-bowel obstruction. The patient was in her a bowel movement. Prior to admission she felt bloated, although she did not have any nausea or vomiting, but had stopped passing gas approximately two days prior to admission. The patient was brought to [**Hospital6 33**] on [**8-9**] secondary to increased abdominal pain, which was diffuse across the lower abdomen, mostly crampy. She was admitted and fluid resuscitated at [**Hospital6 33**]. NG [**Hospital **] Hospital showed dilated loops of small bowel with an air-fluid level. PAST MEDICAL HISTORY: 1, The patient was found to have small-bowel obstruction and she was transferred to the [**Hospital1 188**] for exploratory laparotomy and lysis of adhesions. Past medical history is significant for non-Q-wave MI in [**2155-6-21**], at which time approximately four cardiac stents were placed. 2. Chronic obstructive pulmonary disease. 3. Hypertension. PAST SURGICAL HISTORY: The patient had a colectomy approximately 30 years ago and vaginal hysterectomy. ALLERGIES: The patient has no known allergies to medications. HOME MEDICATIONS: 1. Serevent two puffs q.h.s. 2. Combivent 2 puffs q.i.d.p.r.n. 3. Albuterol and Atrovent 25/500 q.i.d. 4. Zantac 50. 5. Ativan 2 mg q.4h. to 6h. for anxiety. 6. Morphine for pain. 7. Hydralazine 2 mg IV q.8h. for blood pressure control. SOCIAL HISTORY: The patient is a long-term smoker. PHYSICAL EXAMINATION: Physical examination on admission revealed the following: VITAL SIGNS: Temperature 97.4, blood pressure 150/20, pulse 82, respiratory rate 16, saturation 93% on room air. HEAD AND NECK: Head and neck examination: Pupils equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes moist. RESPIRATORY: The patient is clear to auscultation bilaterally. She is moving air well. CARDIAC: Examination showed regular rate and rhythm, normal S1 and S2 without murmurs, rubs, or gallops. ABDOMEN: Abdomen was noted to be soft, distended, with mild tenderness diffusely. There is no guarding or rebound. EXTREMITIES: Without edema, stools were guaiac negative at that time. LABORATORY DATA: Prior to admission, labs drawn at [**Hospital6 3622**] revealed the white count of 11.0, hematocrit 37.1, platelet count 346,000, sodium 136, potassium 3.5, BUN 25, creatinine 1.3, glucose 132, calcium 10.5, magnesium 1.9, LFTs and ALT 1125, AST 21, amylase 20, lipase 22. On [**2155-8-11**], the patient received a CT scan of the abdomen, which demonstrated multiple loops of small bowel with a region of narrowing in the right lower quadrant and iliac fossa consistent with mechanical small-bowel obstruction, single low attenuation cyst in the liver, tiny gallstone without evidence of cholecystitis, scattered sigmoid diverticula without diverticulitis, extensive vascular calcification in the region of the mesenteric artery. HOSPITAL COURSE: Given the patient's CT findings, it was decided that the patient would be taken to the operating room for emergent exploratory laparotomy and lysis of adhesions. On [**2155-8-11**], the patient had the exploratory laparotomy and she tolerated the operation well. Approximate blood loss was 200 cc. She was transfused intraoperatively with six units of platelets, 800 cc crystalloid. Intraoperative central line was placed, and a chest film was obtained to confirm placement The patient was transferred from the operating room to the Post Anesthesia Care Unit. From there, she was transferred to the Surgical Intensive Care Unit for observation and monitoring after laparotomy given her history of non-Q-wave MI and chronic obstructive pulmonary disease. In the Post Anesthesia Care Unit, the patient was evaluated by the Cardiology Service, where she was noted to have transient right bundle branch block and the Post Anesthesia Care Unit decided to resume her Aspirin. Overnight, from postoperative day #0 to postoperative day #1, the patient did not have any major events. She was continued to be monitored in the Surgical Intensive Care Unit. In the Intensive Care Unit it was decided to diurese the patient. She was transfused with one unit of packed red blood cells. The hematocrit was noted to increase to 29.7. Overnight, from postoperative day #1 to postoperative day #2, the patient was noted to have low urine output. While in the ICU, the patient was kept NPO. She was noted to have an increasing hematocrit after infusion of one unit of packed red blood cells. On [**2155-8-12**] the patient received a transthoracic echocardiogram, which demonstrated preserved left ventricular ejection fraction. It was decided to start Lopressor on the patient for rate and pressure control. From postoperative day #2 to postoperative day #3, the patient continued to do well without major events. The NG tube was noted to be draining 350 cc from postoperative day #2 to postoperative day #3. Again, the patient was noted to have a low hematocrit of 27.7 on [**2155-8-13**]. The patient continued to do well, although she did have one episode of anxiety. It was decided on [**2155-8-13**] to change the patient from a pCO2, regular morphine prn. She was found to be stable on Lopressor and IV Vasotec. She was transfused again with one unit of packed red blood cells. During the evening of [**2155-8-13**], the patient was transferred from the Intensive Care Unit to the floor, where she was noted to be doing well with no overnight events from [**8-13**] to [**8-14**]. Overnight, from [**8-13**] to [**8-14**], the patient's NG tube put out approximately 150 cc. She was still not passing flatus. On postoperative day #4 to postoperative day #5, [**2155-8-14**] to [**2155-8-5**] the patient continued to do well. She had decreased abdominal pain, and she was able to ambulate. The patient remained without flatus. The patient was diuresed 3.5, which was repleted. At this point, total parenteral nutrition was started for the patient. The patient tolerated TPN well and she was advanced to goal total parenteral nutrition on [**2155-8-15**]. On [**2155-8-16**], the patient was evaluated by rehabilitation services and physical therapy. The patient was noted to be making progress with ambulatory ability. Overnight, from [**2155-8-16**] to [**2155-8-17**] the patient noticed increased amounts of flatus. She was able to pass flatus at this point. She remained on TPN on [**2155-8-17**]. The NG tube was noted to put approximately 250 cc out on [**2155-8-16**]. On [**2155-8-17**] to [**2155-8-18**] the patient continued to do well. On [**2155-8-17**], the patient had the NG tube pulled. She is to be taking small sips. TPN was continued, IV fluids were not. On [**2155-8-18**], the Dermatology Service was consulted for a facial rash. Their impression was that she was an 80-year-old female with onset of malar rash after treatment for small-bowel obstruction. They prescribed hydrocortisone 1% cream for the patient, which seemed to help with the contact dermatitis. Overnight, [**2155-8-18**] to [**2155-8-19**], the patient complained of some shortness of breath to approximately 4 in the morning, which was relieved with nebulizers. LABORATORY DATA: The patient was found to have a hematocrit of 26. TPN was continued through [**2155-8-19**]. On [**2155-8-19**], the Pulmonary Service was consulted because of the patient's complaint of dyspnea. Their impression was that she was an 80-year-old female with known chronic obstructive pulmonary disease status post myocardial infarction and recent abdominal surgery with the differential diagnosis for episodes of dyspnea were mostly multifactorial with chronic obstructive pulmonary disease exacerbation. They recommended increasing Atrovent to four puffs b.i.d.; restarting Flovent and checking for PFTs. Also, the differential diagnosis of bronchitis with increased amounts of sputum and increased shortness of breath. However, the patient was without any clear chest x-ray or infiltrate. The patient was treated with Azithromycin for possible tracheobronchitis for a total course of five days. The differential diagnosis was pulmonary edema and deconditioning given prolonged hospital course. It was decided to treat the patient with approximately five days of Azithromycin and to adjust her MDIs and nebulizers according to the recommendations. On [**2155-8-20**], the patient was transfused with one unit of packed red blood cells. The hematocrit improved from 26 to 33. The patient continued to do well. She was ambulating. However, overnight from [**2155-8-19**] to [**2155-8-20**], the patient started to vomit twice. The nasogastric tube was replaced, it drained approximately 100 cc from the stomach. The Dermatology Department followed the patient. The patient was given an increase in the Hydrocortisone ointment from 1% to 2.5% b.i.d. for the worsening facial rash. Overnight, from [**2155-8-20**] to [**2155-8-21**], the patient had no complaints. She felt that her respiratory status was better in the morning. She was without nausea or vomiting after the NG tube was replaced. Overnight, the NG was noted to put out approximately 350 cc. The hematocrit was stable at 33.8 from 33.9 the day before. Overnight, from [**2155-8-21**] to [**2155-8-22**], the patient did well. The nasogastric tube was noted to have put out only 650 cc of fluid the previous day. The hematocrit was stable at 33.2. The blood pressure medications at this time were IV Lopressor Enalapril, and Hydralazine. The patient tolerated these well with good pressures and rate. She was maintained on telemetry. The patient was diuresed with 2 mg of Lasix on [**2155-8-21**]. On [**2155-8-22**], it was decided that the patient was passing flatus and was able to have a bowel movement. At this point, the nasogastric tube was taken out. The patient was noted to tolerate about 630 PO ice chips on [**2155-8-22**]. Overnight, from [**2155-8-22**] to [**2155-8-23**], the patient continued to do well with the nasogastric tube discontinued and she had no complaints of nausea, vomiting, or abdominal pain. The TPN was continued. At this point, the patient decided that the best course of action would be to go to acute rehabilitation prior to leaving for home in [**State 760**]. Overnight, from [**2155-8-23**] to [**2155-8-24**], the patient continued to do well. She began tolerating a clear liquid diet. She continued to pass flatus. The labs were noted to be stable. She was diuresed again with 10 mg of Lasix on [**2155-8-24**]. Overnight, from [**2155-8-24**] to [**2155-8-25**], the patient continued to do well. She was able to tolerated her clear liquid diet throughout the day without nausea or vomiting. The hematocrit was noted to be stable at 32.8. Overnight, from [**2155-8-25**] to [**2155-8-26**] the patient continued to do well. She felt a slight amount of nausea with soft diet. She was diuresed with approximately 20 mg of Lasix from [**2155-8-25**] to [**2155-8-26**] given the positive fluid balance over the course of the past two days, weight was noted to be 75.8, which was fairly close to her known dry weight. The patient, however, did not have emesis with her soft diet. It was decided to continue the soft diet. At this point, it was decided to stop the patient's TPN; discontinued the central line; switch her from the IV cardiac medications to PO cardiac medications; and take her off telemetry. Overnight, from [**2155-8-26**] to [**2155-8-27**], the patient continued to do well. It was decided at this point that she be transferred to an acute rehabilitation facility here in [**State 350**], prior to her going her to [**State 760**]. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Small-bowel obstruction, status post exploratory laparotomy. 2. Non-Q-wave myocardial infarction. 3. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: 1. Protonix 40 mg PO q.d. 2. Enalapril 5 mg PO b.i.d. 3. Metoprolol 12.5 mg PO b.i.d. 4. Enteric aspirin 325 mg PO q.d. 5. Ativan 0.5 mg 6. Colace 10 mg PO b.i.d. 7. Ipratropium bromide 4 puffs q.i.d. 8. Flovent 110 mcg two puffs b.i.d. 9. Albuterol nebulizers one nebulizer q.6h.p.r.n. bronchospasm. 10. Albuterol one to two puffs q.4h. to 6h.p.r.n. bronchospasm. 11. Salmeterol two puffs b.i.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Name8 (MD) 16207**] MEDQUIST36 D: [**2155-8-27**] 04:56 T: [**2155-8-27**] 10:02 JOB#: [**Job Number 43770**]

Admission Date: [**2161-8-27**] Discharge Date: [**2161-9-3**] Date of Birth: [**2121-2-5**] Sex: M Service: MED Allergies: Bactrim Attending:[**First Name3 (LF) 15241**] Chief Complaint: sob Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 15225**] is a 40 year old man with AIDS (criteria of CD-4 counts and opportunistic infections) who is being admitted for dyspnea, fevers, and hypoxia. Mr. [**Known lastname 15225**] says that he was in his usual state of (chronically poor) health until about 3 days ago when he began to have more fatigue than usual. He then began to have fevers up to 99.0-100.0 and yesterday started to develop left sided chest pain that came on with deep breaths and coughing, and fevers up to 103 degrees with chills but no rigors. He is coughing up scant, thick yellow sputum, without any blood in the sputum. He came to the Infectious Disease Outpatient Clinic this morning and was found to have a temp of 102 degrees, and an oxygen saturation after walking down the hallway that was 71.%. He was brought to the Emergency Room and admitted from there. He was last hospitalized here from [**6-29**] -> [**2161-7-6**] for persistent pain from a right-sided kidney stone. During the hospital- ization, he had a stent placed into the right kidney to help remove the stone. The stent was removed prior to his discharge. A chest X ray during that admission revealed a faint opacity in the left lower lobe that obscured the left hemidiaphragm on the lateral view. He was, therefore, put on cefpodixime for 7 days." In ER VSS were temp of 101.7 HR of 99 BP 112/72 R24, 74% on RA, 99% on 2L. Cxray notable for LLL infiltrate. EKG notable for sinus tach at 92, negative axis, R wave transition in v3, flat T waves V5-V6, q3T3, q in [**12-30**]/avf (no change from baseline). INR was 0.9. Cr of 1.6. Blood cultures were sent. In ed received tylenol, ceftriaxone 2mg iv, MS contin and heparin IV. 40 M w/AIDS (CD4 count of 9 on [**2161-4-23**]) admitted [**8-27**] for dyspnea, fevers to 103, and hypoxia. (In [**Hospital **] clinic with temperature of 102 degrees and ambulatory o2 sat of 71%. Please see ID admit note in OMR for complete HPI/history.) In short, patient was in his usual state of health until three days prior to admission when he experienced more fatigue, fevers up to 99.0-100.0, pleuritic chest pain and cough. (Patient was last hospitalized at [**Hospital1 18**] from [**6-29**] to [**2161-7-6**] for persistent pain from a right-sided kidney stone, a stent was placed and removed.) In ER on admission: VSS were temp of 101.7 HR of 99 BP 112/72 R24, 74% on RA, 99% on 2L. Chest xray was notable for LLL infiltrate. EKG notable for sinus tach at 92, negative axis, R wave transition in v3, flat T waves V5-V6, q3T3, q in [**12-30**]/avf (no change from baseline). INR was 0.9. Cr of 1.6. In the ed the patient received tylenol, ceftriaxone 2mg IV, MS contin and heparin IV. ROS: Man with HIV/AIDS last CD4 count of 9. On transfer to the [**Hospital Ward Name **] patient continues to express sharp chest pain in left sternal area radiating to left shoulder [**5-7**] in intensity worse with inspiration, patient also reports not some SOB. Patient reports intermittent hematuria. He denies abdominal pain, diarrhea, melena, headache, sore throat, dysuria, lower extremity swelling or pain, orthopnea. Past Medical History: 1. AIDS dx [**2142**]: [**5-1**] VL 23K; [**3-31**] CD4 1 VL 47K- initially on monotherapy starting in [**2144**], now with variable degrees of resistance to HAART. 2. PCP x5: [**2146**](intubated) c/b perirectal HSV and pancreatitis from pentamidine and/or steroids, [**1-/2155**] c/b LUE axillary vein thrombosis, [**5-/2155**], [**7-/2155**], [**3-/2157**] 3. Disseminated MAC bacteremia [**2148**] 4. Didanosine associated pancreatitis [**6-/2150**] 5. Aseptic meningitis [**1-/2154**] secondary to TMP/SMX 6. Cerebral MAC (diff from [**2148**] organism) c/b seizures [**3-/2157**] 7. Necrotic HSV L chest wall lesion resistant to acyclovir and ganciclovir and treated with Foscarnet [**3-30**] 8. Acyclovir resitant HSV R chest wall lesion [**5-1**] treated with Foscarnet (to stop [**2161-7-2**]) 9. Neurosurgical drainage of a R sided subdural fluid collection [**11-27**] c/b post-op seizure and intubation for airway protection 10. HTN 11. Chronic peripheral neuropathy (legs>arms) 12. Systolic CHF (Echo [**9-30**] EF 50% w/ 1+AR, [**11-28**]+MR, 1+ TR) 13. Coagulopathy [**12-29**] lupus anticoagulant c/b DVT/PE [**4-28**] and [**9-30**], on anticoagulation with IVC filter in place 14. IMI [**4-28**] (presumed [**12-29**] hypercoagulable state) s/p RCA stenting 15. Aflutter s/p ablation [**12-31**] 16. Thrush-resistant to fluconazole (now tx w/ voriconazole) 17. Asthma 18. Chronic renal failure 19. Hyperkalemia Social History: -Divorced; contracted HIV from his ex-wife after their child died of AIDS. They were subsequently tested and found to both be HIV+ and wife admitted to IVDU. She has since died.-Lives alone with dog, [**Month/Year (2) 15233**]. Lives in studio apt rented from his mother.-Smoked 1 ppd x 2 years (on job). Quit 5 mths ago when he stopped working as a an operations manager in scrap metal. -EtOH- occas wine; Marijuana occas for nausea; Exercises 5x/wk-H/o asbestos exposure Family History: Mom-mild HTN and hypercholesterolemia; brother- asthma, HTN. 3 sisters-alive and healthy Physical Exam: OBJ: T 99.9 BP 142/104 HR 97 R 20 98% on 1.5 L GEN: emaciated gentleman, in mild respiratory distress HEENT: OP clear, no evidence of thrush, no cervical lymphadenopathy CV: RRR with systolic murmur LUNG: crackles auscultated on Left base ABD: +BS/NT/ND, no organomegally, no rebound, no guard EXT: no edema/cyanosis/pulses intact, skin dorsum of hands is red-purple in color right greater than left NEURO:[**1-8**] intact, upper extremity, lower extremity strength symmetric and intact Skin: normal skin tone, no erythema/rashes Pertinent Results: [**2161-8-27**] 01:15PM POTASSIUM-4.4 [**2161-8-27**] 12:55PM PT-12.0 PTT-18.2* INR(PT)-0.9 [**2161-8-27**] 11:56AM LACTATE-1.9 [**2161-8-27**] 11:54AM GLUCOSE-92 UREA N-23* CREAT-1.6* SODIUM-135 POTASSIUM-6.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-18 [**2161-8-27**] 11:54AM ALT(SGPT)-15 AST(SGOT)-43* ALK PHOS-73 AMYLASE-31 TOT BILI-1.3 [**2161-8-27**] 11:54AM ALBUMIN-3.8 [**2161-8-27**] 11:54AM WBC-3.1* RBC-3.36* HGB-11.3* HCT-35.6* MCV-106* MCH-33.7* MCHC-31.8 RDW-16.2* [**2161-8-27**] 11:54AM NEUTS-71.6* LYMPHS-11.6* MONOS-12.3* EOS-3.6 BASOS-0.7 [**2161-8-27**] 11:54AM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-3+ [**2161-8-27**] 11:54AM PLT COUNT-223 renal u/s ([**2161-8-5**]): IPRESSION: 1. Diffuse echogenicity of bilateral kidneys consistent with the patient's history of HIV. 2. Simple cyst in upper pole of right kidney which is slightly smaller than on prior examination. 3. No evidence of hydronephrosis, stones or masses bilaterally. Ct abdomen: [**2161-6-17**] IMPRESSION: 6-mm partially obstructing calculus within the proximal right ureter, with acute forniceal rupture. EKG: EKG notable for sinus tach at 92, negative axis, R wave transition in v3, flat T waves V5-V6, q3T3, q in [**12-30**]/avf (no change from baseline). cath [**5-28**]: FINAL DIAGNOSIS: 1. Patent RCA stents. 2. Normal biventricular filling pressures. 3. Mild LV systolic dysfunction with dopamine infusion. CXRAY ([**2161-8-27**]): IMPRESSION: Patchy bibasilar opacities consistent with pneumonia. Lower extremity u/s:IMPRESSION: Chronic deep venous thrombosis extending from the proximal left superficial femoral vein to the left popliteal vein, with multiple collaterals. Brief Hospital Course: 40 M w/ AIDS (CD4 of 9), multiple medical problems presents with dypnea and fever. SOB - On the floor antibiotic was changed to cefipime. One day following admission, patient developed additional chest pain and hypoxia initially read in o2 sat of 70s requiring 10L of O2 at which patient was 93% (abg was 7.35/34/90 on 10L face-mask), patient's systolic blood pressure was also in 100s compared to baseline of 130s. Unclear if relative hypotension was secondary to pain medications, dehydration, developing heart failure from possible PE, verus worsening PNA, therefore patient was transferred to unit. In [**Hospital Unit Name 153**] supportive measures were continued. The patient was provided with IV fluid. Empiric treatment for PCP [**Name Initial (PRE) **] (primaquine) but then discontinued. CT on [**8-29**] showed: LLL PNA, effusion, enlargement of nodule at left lung apex and new nodule in the medial LUL nodule, possibly representing differences in slice selection compared to [**9-30**]. Patient will need to follow up with Dr. [**Last Name (STitle) 2148**] regarding further work-up of these findings. (A contrast CT was not performed secondary to the patient's CRI.) Labs on [**8-31**] notable for HCT 25.5, Retic 0.7, LDH normal, INR of 1.6, Cr at 1.6 (down from elevated 1.9 on admission), of note Trop maximum at 0.83 and an echo was performed on [**8-29**] which demonstrated normal systolic function, therefore felt to represent possible RV strain. Patient's respiratory status improved on antibiotics and patients transferred out of unit. Of note cryptococcal antigen was negative. Nasopharyngeal culture for ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV was negative. CMV DNA was negative. Patient o2 sat was 94% while ambulating on discharged but with subjective feeling of intermittent dyspnea we discharge with oxygen. Patient will also be discharged on Lovenox SC, until INR is therapeutic. A picc line was placed on discharge for outpatient cefipime. 2. Fever - Patient with AIDS, history of fever and chest xray/chest CT notable for PNA. Blood cultures / urine cultures in-house were negative. Patient without diarrhea. Reticulocyte low, LDH normal, D bili was slightly elevated. 3. CRI/Hematuria - Patient with a history of renal stones, recent admission for kidney stone and urthethral stent presents with elevated CR compared to baseline. The etiology was likely prerenal as patient responded to fluids. On discharge CR was 1.3 (baseline 1.3-1.8). 4. Cardiac/CAD - Of note patient with a history of RCA stent, IMI in past, q waves on inferior leads on EKG. Patient is not maintained on cardiac medications secondary to concerns regarding drug interactions (discussed with attending). Patient experienced elevated troponins during episodes of chest pain. An echo demonstrated intact systolic function. Patient discharged on aspirin. 5. HIV - Patient on antiretroviral medications tonofovir, stavudine, ritonavir, Fuzeon, Emtricitabine, Atazanavir. Patient is on empiric AIDS coverage with cipro, azithro, acyclovir. 6. Neurology/History of seizure - Maintain on kepra. Seizure thought to be due to a focus from scar of a prior brain abscess. Patient reports using gabapentin for neuropathic pain. 7. Anemia - Patient presented with a hematocrit of 34, wide variation in baseline (34-44). Throughout hospitalization hematocrit went down to 25 but stabilized. This decrease likely reprented fluid shifts from hydration. The differential for anemia includes low production given anemia of chronic disease, low reticulocyte count. Iron studies demonstrated low iron, low b12. Therefore b12 was provided. Patient has history of procrit use which will be resumed on discharge. 10. Code - DNR/DNI. Medications on Admission: (per OMR on [**2161-8-4**]) ACYCLOVIR 400MG--One capsule by mouth twice a day ALBUTEROL 90MCG--2 puffs every 4 hours as needed for coughing not relieved by serevent. ATAZANAVIR 150 MG--Two capsules (300 mg) by mouth once (one time) daily. AZITHROMYCIN 250MG--One capsule by mouth twice a day CIPROFLOXACIN HCL ORAL 500 MG TABLET 500MG--One tablet by mouth twice a day COUMADIN 5MG--Take 7.5 mg/day until further notice. DILAUDID 2MG--One tablet every 3 hours as needed for pain not controlled with morphine contin. EFFEXOR XR 75MG--One capsule daily. EMTRICITABINE 200 MG--One capsule by mouth daily. ETHAMBUTOL HCL 400MG--One tablet by mouth three times a day FLONASE 50MCG--Two sprays each nostril twice a day FUSEON 90 MG--Inject one vial (90 mg) sq [**Hospital1 **]. ITRACONAZOLE 10MG/ML--20 cc (200 mg) swish and swallow daily. KEPPRA 500MG--One tablet by mouth twice a day for suppression of seizures LOVENOX 120MG/.8ML--One injection sq daily. NEUPOGEN 300MCG/0.5--Inject one cc every other week (every 2 weeks). NEURONTIN 100MG--Two capsules three times a day with two of the 400 mg capsules for 1000 mg by mouth three times a day for control of discomfort from peripheral neuropathy. OPIUM 10%--One cc by mouth four times a day as needed for diarrhea OXANDROLONE 10MG--One tablet (10 mg) by mouth twice a day for weight loss. PENTAMIDINE ISETHIONATE 300MG--Given by aerosol monthly PERCOCET 5-325MG--One to two tablets every 4 hours as needed for pain not controlled by morphine contin. PROCRIT [**Numeric Identifier **] U/ML--One cc every other week (every 2 weeks). RITONAVIR 100MG--One capsule once daily, with two capsules of atazanavir (reyetaz). SEREVENT DISKUS 50MCG--Two puffs [**Hospital1 **]. STAVUDINE 15MG--One capsule by mouth twice a day SYRINGE/SAFETY GLIDE 25GX0.625"--Use one cc 25 g x 0.625" syringes for procrit and g-csf injections. TENOVOFIR 300 MG--One tablet daily ULTRASE MT 18 59-18-59--Two capsules by mouth with each meal ZOFRAN 4MG--One tablet by mouth q 6 hours as needed for nausea / vomiting MEGACE 40MG--One tablet daily, for enhancement of appetite. -per patient he does not take albuterol/dilaudid/itraconazole -he does take gabapentin and amphotericin Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:*1 30* Refills:*0* 2. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO QD (once a day). Disp:*90 Capsule(s)* Refills:*2* 3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO QAM (once a day (in the morning)). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 6. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO qd (). Disp:*30 Capsule(s)* Refills:*2* 7. Ethambutol HCl 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [**Hospital1 **] (2 times a day): 90 mg SC injection. Disp:*60 Kit(s)* Refills:*2* 9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Morphine Sulfate 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO Q8H (every 8 hours). Disp:*4 Tablet Sustained Release(s)* Refills:*2* 11. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 12. Oxandrolone 2.5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). Disp:*240 Tablet(s)* Refills:*2* 13. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QD (once a day). Disp:*30 Capsule(s)* Refills:*2* 14. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours): (50 mcg) 2 INH IH Q12H . Disp:*60 Disk with Device(s)* Refills:*2* 15. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 16. Stavudine 30 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 17. Amphotericin B 50 mg Recon Soln Sig: One (1) Recon Soln Injection QID (4 times a day): DOSE: 20 mg. Disp:*120 Recon Soln(s)* Refills:*2* 18. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 20. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:*1 30* Refills:*2* 21. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 22. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* 23. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. Disp:*15 ML(s)* Refills:*0* 24. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO at bedtime. Disp:*45 Tablet(s)* Refills:*2* 25. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1) injection of 0.8 ML Subcutaneous Q12H (every 12 hours) for 4 days. Disp:*8 injection of 0.8 ML* Refills:*0* 26. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain for 7 days. Disp:*20 Tablet(s)* Refills:*0* 27. Outpatient Lab Work Please obtain INR value on [**2161-9-6**] 28. Cefepime HCl 2 g Piggyback Sig: One (1) Piggyback Intravenous Q12H (every 12 hours) for 10 days. Disp:*20 Piggyback(s)* Refills:*0* 29. Other Please continue procrit administration as prior to hospitalization. Normally given every other Tuesday. 30. instruction Please take pentamadine as prior to hospitalization. (dose provided in the hospital on [**8-28**]) 31. Outpatient Lab Work Please obtain INR as an outpatient. Please send results to Dr. [**Last Name (STitle) 2148**] 32. Oxygen Oxygen 2L via nasal cannual PRN dyspnea 33. oxygen 2 liters continuous Discharge Disposition: Home With Service Facility: Staff Builders-TLC-[**Location (un) 1456**] Discharge Diagnosis: PNA Discharge Condition: stable Discharge Instructions: Please return if you experience increasing shortness of breath, chest pain or pressure Please continue procrit and pentamadine as prior to hospitalization. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 2148**] within 2 weeks. ([**Telephone/Fax (1) 457**]) Appointment made Tuesday at 3:00 pm. Provider UROLOGY UNIT Where: [**Hospital6 29**] SURGICAL SPECIALTIES Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2161-9-23**] 9:00 Provider [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2161-9-28**] 1:15 [**Name6 (MD) **] [**Last Name (NamePattern4) 15242**] MD, [**MD Number(3) 15243**]

Admission Date: [**2108-3-8**] Discharge Date: [**2108-3-16**] Date of Birth: [**2047-10-22**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: CP and fatigue Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->OM, PDA) [**2108-3-12**] History of Present Illness: This 60 y/o WF has had exertional angina and it has increased to having it at rest. She underwent cardiac cath at [**Hospital3 6101**] on [**2108-3-8**] which revealed 50-60% LM stenosis, 100% RCA and she was transferred on [**3-8**] for cardiac surgery. Past Medical History: CAD s/p MI PVD OA s/p cardiac thrombus obesity s/p carotid->carotid bypass s/p TAH ^chol. Social History: Lives with husband. [**Name (NI) 1403**] as a computer operator. Cigs: 20-30 pk. yr., quit in [**2094**] ETOH: denies Family History: F died of MI at age 53, brother +CAD Physical Exam: WDWNWF in NAD AVSS HEENT: NC/AT, PERLA, oropharynx benign Neck: FROM, supple, carotids without bruit Lungs: Clear to A+P CV: RRR without R/G/M Abd: +BS, soft, nontender, without masses or hepatosplenomegaly, obese Ext: without C/C/E, pulses Fem: 2+ bil., DP: 1+ bil., PT: 1+ bil., Rad: 2+ bil. Neuro: nonfocal Pertinent Results: [**2108-3-16**] 03:27AM BLOOD WBC-8.3 RBC-3.38* Hgb-10.3* Hct-30.4* MCV-90 MCH-30.4 MCHC-33.9 RDW-13.7 Plt Ct-144* [**2108-3-15**] 08:44PM BLOOD PT-12.9 PTT-29.8 INR(PT)-1.1 [**2108-3-16**] 03:27AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-138 K-4.3 Cl-101 HCO3-29 AnGap-12 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2108-3-13**] 4:17 PM CHEST (PORTABLE AP) Reason: eval ptx s/p ct d/c [**Hospital 93**] MEDICAL CONDITION: 60 year old woman s/p CABG REASON FOR THIS EXAMINATION: eval ptx s/p ct d/c CHEST, AP PORTABLE SINGLE VIEW INDICATION: Status post bypass surgery. Discontinued lines and extubated. Evaluate for pneumothorax. FINDINGS: AP single view of the chest obtained with patient in sitting semi-upright position is analyzed in direct comparison with the next preceding chest examination of [**2108-3-12**]. During the interval, the patient has been extubated, and the NG tube has been removed. The same holds for the Swan-Ganz catheter and the sheath which has been replaced with a central venous line seen to terminate overlying the SVC at the level 2 cm below the carina. No pneumothorax has developed, and no new infiltrates are seen. _____ on previous examinations, the noted parenchymal densities in the upper lobe areas have resolved. They were interpreted as representing edema. IMPRESSION: Satisfactory chest findings after instrument removal, no evidence of pneumothorax. DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 6102**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 6103**] (Complete) Done [**2108-3-12**] at 1:31:43 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2047-10-22**] Age (years): 60 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Chest pain. Coronary artery disease. Shortness of breath. ICD-9 Codes: 786.05, 786.51, 440.0 Test Information Date/Time: [**2108-3-12**] at 13:31 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% to 55% >= 55% Aorta - Ascending: 3.1 cm <= 3.4 cm Findings LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity. Cannot exclude LAA thrombus. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Mild regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: 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. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions PRE-CPB:1. The left atrium is mildly dilated. A left atrial appendage thrombus cannot be excluded. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with anterior mid and apical hypokinesis. 3. . Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. POST-CPB: On infusion of phenylephrine. Episode of transient RV dysfunction secondary to air visible in RCA. Epi 8-10 mcg given with prompt resolution. Preserved biventricular systolic function. Trace MR. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2108-3-12**] 16:17 Brief Hospital Course: The patient was transferred from [**Hospital6 5016**] on [**3-8**]. She had a preop vascular evaluation regarding her previous carotid surgery and she was cleared. Carotid doppler showed a patent graft. On [**2108-3-12**] she underwent CABGx3(LIMA->LAD, SVG->OM, PDA). The cross-clamp time was 50 mins., total bypas time was 66 mins. She tolerated the procedure well and was transferred to the CVICU in stable condition on Neo and Propofol. She was extubated on the post op night and continued to progress. She was on neo and eventually weaned off. Her chest tubes were d/c'd on POD#1 and wires were d/c'd on POD#3. She continued to progress and was discharged to home in stable condition on POD#4. Medications on Admission: Metformin 1000 mg PO BID Avandia 4 mg PO daily Fosamax 70 mg PO q week Verapamil SR 240 mg PO BID Lipitor 80 mg PO daily Isordil 140 mg PO TID Toprol XL 25 mg PO daily Lisinopril 10 mg PO daily Folic acid 1 mg PO daily ASA 81 ng PO daily Nitro spray PRN Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Rosiglitazone 8 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. Disp:*4 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD PVD OA s/p MI s/p cardiac thrombus obesity ^chol. Discharge Condition: Good Discharge Instructions: Follow medications in discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office with sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 6104**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 4783**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Wound check on [**Hospital Ward Name 121**] 6 on [**3-26**] at 11AM. Call [**Telephone/Fax (1) **] with any changes. Completed by:[**2108-3-16**]

Admission Date: [**2143-7-6**] Discharge Date: [**2143-7-20**] Date of Birth: [**2073-7-21**] Sex: F Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 2736**] Chief Complaint: Shortness of breath, nausea Major Surgical or Invasive Procedure: cardiac cath [**2143-7-15**] cardiac cath [**2143-7-18**] cardiac biopsy [**2143-7-18**] History of Present Illness: 69 y/o w/ HTN, CAD (Lcx 99%, 40% mLAD, 40% r PDA), systolic CHF EF 30-35% w/ significant LVH, recent NSTEMI, presented with generalized weakness, mild confusion, nausea and vomitting. She was just discharged from [**Hospital 26580**] hospital where she was admitted from [**Date range (3) 54882**]. Per obtained discharge summary, she presented with progressive SOB and LE edema and ruled in for NSTEMI with trop 0.38, 0.48, 0.98. She subsequently had cardiac cath completed on [**2143-7-1**] which showed mid LAD 40% stenosis, mid Lcx 99% unfavorable total occlusion, rPDA 40% stenosis, pulmonary hypertension, mod-severe MR, depressed LVEF ~45% and LVH. She then had TEE to better evaluate MR on [**2143-7-2**] which showed 3+ MR [**First Name (Titles) 15015**] [**Last Name (Titles) **] hitting back wall with probably mild mitral stenosis and LVEF 30-35% with dilated atria b/l, elevated wedge pressure and significant LVH. She was diuresed with lasix (-10L per patient), and started on metoprolol and losartan. She was discharged on lasix 100mg [**Hospital1 **] and she reports improvement in SOB and edema with diuresis throughout hospital stay. . Upon discharge home, she was initially feeling well, but then became weak, more SOB and LE persisted and may have slightly worsened. No reported weight gain. No PND, +orthopnea (sleeps w/ 2 pillows nightly). The morning of admission she became nauseous and vomitted ~5 times (bilious w/ food non-bloody), was unable to take POs and thus re-presented to [**Hospital1 46**]. Per her cardiologist Dr. [**Last Name (STitle) 3321**], she was transferred to [**Hospital1 18**] for cardiac MRI and evaluation for MV repair/replacement. . At OSH, she was A&O x3, vitals prior to transfer were afebrile, HR 74 BP 86/61, 20 99% 4L. Upon arrival to the floor she has mild SOB and c/o LE edema. Nausea/vomitting much improved. Was feeling "spacy" earlier, but now feels lucid. Feels generalized weakness. Denies F/C, HA, vision changes, cough, CP, palpitations, abd pain, diarrhea, constipation, melena, hematochezia, dysuria or hematuria. Past Medical History: Recent NSTEMI admitted [**Hospital 26580**] hosp [**Date range (1) 54883**] CATH: [**2143-7-1**]: LMCA normal, mid LAD 40% stenosis, mid Lcx 99% unfavorable total occlusion, rPDA 40% stenosis, pulmonary hypertension, mod-severe MR, depressed EF ~45% CABG: none HTN DM2 systolic and diastolic CHF Peripheral vascular disease COPD - not on home O2 B12 deficiency Hypothyroidism H/o DVT [**2142-10-8**] - on coumadin Insominia Osteoporosis cholecystectomy hysterectomy appendectomy h/o thyroidectomy and parathyroidectomy exploratory laporotomy [**2142-10-8**] (for possible gut ischemia but none seen) h/o diverticulitis s/p partial colectomy w/ temp colostomy and reanastamosis Social History: lives w/ husband, independent in all ADL and iADLs, recently walking on treadmill at cardiac rehab, h/o 45 pack years quit tob 10 years ago, no ETOH or IVDA. Family History: mother w/ CVA, no known MI, HTN, malignancy or DM. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: 98.4 100/66 85 16 98% RA 55.3kg GENERAL: NAD, A&Ox3 HEENT: PERRLA, EOMI, sclerae anicteric, oral MM dry, no OP lesions. NECK: Supple, no thyroid gland, JVP 13cm HEART: RRR, nl S1, nl S2, cannot appreciate murmurs LUNGS: mild crackles bilateral bases R>L, no rh/wh, resp unlabored. ABDOMEN: Soft/NT/ND, no rebound/guarding, +BS. EXTREMITIES: 2+ pitting edema to knee b/l w/ venous stasis skin changes, decreased sensation in feet b/l, callus (? non-healing ulcer) left foot plantar surface, pulses diminished DP/PT b/l, 2+ peripheral pulses in UE b/l Pertinent Results: ADMISSION LABS: [**2143-7-7**] 06:24AM BLOOD WBC-7.2 RBC-5.83*# Hgb-15.8# Hct-50.0*# MCV-86# MCH-27.1# MCHC-31.6# RDW-19.1* Plt Ct-231 [**2143-7-7**] 06:24AM BLOOD Neuts-70.2* Lymphs-19.8 Monos-7.4 Eos-1.8 Baso-0.8 [**2143-7-7**] 08:40AM BLOOD PT-14.4* PTT-31.0 INR(PT)-1.2* [**2143-7-7**] 06:24AM BLOOD Glucose-98 UreaN-43* Creat-1.6* Na-137 K-4.0 Cl-97 HCO3-23 AnGap-21* [**2143-7-7**] 06:24AM BLOOD ALT-39 AST-50* LD(LDH)-364* CK(CPK)-41 AlkPhos-108* TotBili-1.1 [**2143-7-7**] 06:24AM BLOOD TotProt-6.6 Albumin-3.9 Globuln-2.7 Calcium-9.2 Phos-5.3*# Mg-2.4 Iron-PND [**2143-7-7**] 06:24AM BLOOD CK-MB-4 cTropnT-0.30* [**2143-7-19**] 01:55AM BLOOD WBC-12.1*# RBC-5.63* Hgb-15.3 Hct-47.1 MCV-84 MCH-27.1 MCHC-32.4 RDW-19.4* Plt Ct-190 [**2143-7-19**] 10:45AM BLOOD PT-16.8* PTT-115.7* INR(PT)-1.5* [**2143-7-19**] 01:55AM BLOOD Glucose-119* UreaN-51* Creat-1.8* Na-130* K-4.1 Cl-91* HCO3-23 AnGap-20 [**2143-7-19**] 01:55AM BLOOD Calcium-9.2 Phos-5.8*# Mg-2.3 [**2143-7-20**] 03:15AM BLOOD WBC-22.5*# RBC-5.99* Hgb-16.2* Hct-51.5* MCV-86 MCH-27.0 MCHC-31.4 RDW-19.7* Plt Ct-292# [**2143-7-20**] 03:15AM BLOOD Neuts-90* Bands-0 Lymphs-3* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2143-7-20**] 03:15AM BLOOD PT-19.3* PTT-90.8* INR(PT)-1.7* [**2143-7-20**] 03:15AM BLOOD Glucose-77 UreaN-66* Creat-3.0*# Na-131* K-4.8 Cl-87* HCO3-21* AnGap-28* [**2143-7-20**] 03:15AM BLOOD Calcium-9.5 Phos-7.0* Mg-2.3 Pertinent studies: Cardiac MRI ([**2143-7-8**])- 1. Normal left ventricular cavity size with segmental wall motion abnormalities (see above) and mildly reduced systolic function with the LVEF of 41%. The effective forward LVEF was severely depressed at 19%. There are multiple areas of hyperenhancement as described above consistent with myocardial infarction/scar. 2. Moderately to severely increased LV wall thickness. 3. Severely increased LV mass index. 4. Normal right ventricular cavity size with abnormal global systolic function. The RVEF was moderately depressed at 23%. 5. Severe mitral regurgitation. There is leaflet tethering consistent with "ischemic" (post-infarction) mitral regurgitation. 6. The indexed diameters of the ascending and descending thoracic aorta were normal. The indexed diameter of the main pulmonary artery was mildly enlarged. 7. Mild right and left atrial enlargement. 8. Normal coronary artery origins with no evidence of anomalous coronary arteries. 9. A note is made of moderate to severe right pleural effusion and small left pleural effusion. CXR ([**2143-7-10**])- Interval increase in a now moderate right effusion with associated atelectasis. New small left effusion. Spirometry ([**2143-7-11**])- Mild restrictive ventilatory defect with a severe gas exchange defect. The DLCO is reduced out of proportion to the reduction in TLC which is consistent with an interstitial or pulmonary vascular process. The reduced FEV1/SVC ratio (62.4, 87% of predicted) indicates a coexisting obstructive ventilatory defect. There are no prior studies available for comparison. TEE ([**2143-7-11**])- No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is borderline normal free wall function of the right ventricle. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened with no aortic valve stenosis or regurgitation. The mitral valve leaflets are structurally normal with mild (1+) mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is a small pericardial effusion with no echocardiographic signs of tamponade. Dobutamine stress echo ([**2143-7-12**])- Resting images were acquired at a heart rate of 85 bpm and a blood pressure of 84/60 mmHg. These demonstrated near-akinesis of the inferior wall with mild hypokinesis elsewhere (EF 35%). There is a small pericardial effusion. Doppler demonstrated mild mitral regurgitation with no aortic stenosis, aortic regurgitation or significant resting LVOT gradient. At low dose dobutamine [5mcg/kg/min; heart rate 84 bpm, blood pressure 84/58 mmHg), there was failure to augment systolic function of the inferior wall, with mild augmentation of all other segments. At mid-dose dobutamine [10 mcg/kg/min; heart rate 88 bpm, blood pressure 76/50 mmHg), there was failure to augment systolic function of the inferior wall, with mild augmentation of all other segments. . Cardiac cath ([**2143-7-15**])- 1. Two vessel coronary artery disease. 2. Moderate diastolic ventricular dysfunction. 3. Moderate pulmonary hypertension. 4. Successful PTCA and stenting of the distal Cx with a BMS. . Right Heart cardiac cath ([**2143-7-18**]) 1. Moderately elevated biventricular pressures. 2. Severe pulmonary hypertension. 3. Depressed cardiac index. 4. Successful RV biopsy. . Cardiac biopsy [**2143-7-18**]: Myocardial tissue with extensive amyloid deposition (confirmed with [**Country **] red stains) primarily subendocardial and associated with blood vessels. Urine culture [**2143-7-20**]: KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS Blood culture [**2143-7-20**]: Blood Culture, Routine (Final [**2143-7-26**]): NO GROWTH. Brief Hospital Course: [**Known firstname **] [**Known lastname **] is a 69 yo w/ HTN, CAD (Lcx 99%, 40% mLAD, 40% r PDA), systolic CHF EF 30-35% w/ significant LVH, ruled in for NSTEMI, 3+ MR, LVEF 30-35% with dilated atria b/l, elevated wedge pressure and significant [**Hospital 54884**] transferred to [**Hospital1 18**] for cardiac MRI and evaluation for MV repair/replacement, but only mild MR on repeat TEE, now s/p BMS of LCx, and cardiac biopsy positive for cardiac amyloidosis. --For a summary of her hospital course, please refer to accept note dated [**2143-7-19**]. After Pt was transferred to [**Hospital1 1516**], she had SBP in 80s/50s, remained asymptomatic, but at ~9pm, had one measurement to 60s/40s, although remeasurement was high 70s/50s. Pt was completely asymptomatic, even when sitting up, and remained talkative and was joking with MDs. The 60s/40s was felt to be due to measurement error due to Pt's very thin body habitus, even when using small adult cuff. Cardiology fellow and resident were both consulted, who felt that Pt was very stable. Pt remained afebrile and HR was in 70s-80s throughout. Pt did not have any discomfort or pain and was not dyspnic. She had O2 sat ~97% on 2L nc. The following morning ([**7-20**]) at 0700, Pt was found to tachypnic to 25 but still sat 95% on 2L nc. She was working harder to breathe but stated that she did not feel short of breath when questioned. When morning lab results returned at ~0830, Pt was noted to have leukocytosis to ~22k and Cr jumped to 3.0 from 1.8 the day prior. Stat blood cultures, urine analysis, and urine cultures, and chest XR were send. Her foley cath was discontinued. She was started on IV vancomycin and cefepime. Pt was never febrile, though she had one oral temp to 35.5C at ~ midnight that was ~36.1C four hours later. Pt was never tachycardic and her BP remained in 80s/50s, consistent with her prior BPs on the floor. Pt began to feel very short of breath at this time (0830), was tachypnic to 30s-40s, and put on non-rebreather mask. She looked very and her family was notified to come to the hospital given her rapidly deteriorating state. After the arrival of family and in discussion with the Pt, who was still lucid, Pt decided to be made comfort measures only with the exception of antibiotics, declined intubation and declined transfer to the CCU. Pt was given lorazepam and morphine to help with dyspnea, which was initially difficult to control. Palliative care was consulted who recommended IV morphine, which was provided, and Pt appeared to respond. Pt became less and less responsive by 1300, received Eucharist at 1400 and expired at 1440. Pt's family consented to autopsy. ------------ #Acute on chronic congestive heart failure: Mrs. [**Known lastname **] was admitted for CHF most likley due to MR but possibly secondary to ischemic cardiomyopathy versus infiltrative cardiomyopathy. She has evidence of diffuse coronary disease, but only significant single vessel disease (Lcx 99% stenosed) that likely does not explain her global hypokinesis. Additional contributing factors include MR (see below) and diastolic dysfunction (significant LVH seen) raising suspicion for potential infiltrative cardiomyopathy as well. Infiltrative etiologies to consider include amyloid, multiple myeloma, sarcoid, hemachromotosis, HIV or myocarditis, but have so far been negative. In the workup so far, serum protein electrophoresis, ACE, TSH, and iron levels, were all normal. Infiltrative disease was further supported by echo findings and a cardiac MRI. Given the negative work-up thus far this was highly concerning for specific cardiac amyloid without systemic involvement. Therefore the patient underwent a endocardial biopsy on [**2143-7-18**]. Results of the biopsy were consistent with cardiac amyloidosis ([**Country **] red stainin positive). Final stains and studies are still pending. Symptomatically, she initially had lower extremity edema, a stable right lower lobe pleural effusion, inspiratory crackles on exam and dyspnea. She initially responded well to diuresis with furosemide up to 80mg IV BID which was then decreased to 80 daily. However she continued to dyspnea and chest xray findings consistent with volume overload in the setting of low blood pressure which made further diuresis difficult. On HD8, patient had a right sided catheterization which showed elevated PA and PCWP pressures consistent with class II pulmonary artery hypertension resulting form left ventricular overload. Following cardiac catheterization with placement of BMS to the LCx, the patient was transferred to the CCU for diuresis with lasix gtt with pressure support initially with dopamine gtt. She did not have a good response to diuresis and was changed from dopamine to milrinone with improvement in urine output. Additionally, metolazone was added to augment diuresis. In the CCU she was diuresed 3 L in 4 days with improvement in her respiratory status. Milrinone was stopped with inital maintenance of blood pressure. Repeat right heart catherization on [**2143-7-18**], done for endocardial biopsy, showed continued elevation of right heart pressures as well as a persistent low cardiac index of 1.28. Though she was still volume overloaded lasix gtt was stopped due to hypotension and rising creatinine with improvement in blood pressure. The plan was to establish her on a home oral regimen as her congestive heart failure is end stage and the patient has expressed desire to go home. She was transferred to [**Hospital1 1516**]. . On further review of EKG and echocardiogram, it was noted that patient had a left bundle branch block causing a dyssynchronous rhythm. It was felt that cardiac output may improve with BiV pacing. However in further evaluation of the echocardiogram it was felt that BiV pacing would likely not be helpful as the patients right heart dysfunction was more significant than her left heart dysfunction. #Acute Respiratory Distress: see above . #Mitral regurgitation: On her outside hospital TEE, Pt was thought to have moderate to severe mitral regurgitation. Pt was transferred here for a cardiac MRI, which showed a normal left ventricular cavity size with segmental wall motion abnormalities and mildly reduced systolic function with the LVEF of 41% with a severely depressed calculated effective forward LVEF of 19%. Multiple areas of hyperenhancement were observed and interpreted as being consistent with myocardial infarction/scar. She also had moderately to severely increased LV wall thickness, severely increased LV mass index, a normal right ventricular cavity size with abnormal global systolic function and moderately depressed RVEF at 23%. Also observed on the cardiac MRI was severe mitral regurgitation with leaflet tethering consistent with "ischemic" (post-infarction) mitral regurgitation. Given these findings, cardiac surgery was consulted regarding the possiblility of mitral repair versus replacement and suggested a repeat TEE at [**Hospital1 18**], which surprisingly showed mild symmetric left ventricular hypertrophy, an overall low normal left ventricular systolic function is (LVEF 50-55%) and structurally normal mitral valve leaflets with only mild (1+) mitral regurgitation. Complex (>4mm) atheroma in the descending thoracic aorta were also observed. The Pt therefore did not require surgery, and attention re-centered on the known left circumflex stenosis (see below). . #Coronary artery disease: Pt had a diagnostic cardiac cath performed by Dr. [**Last Name (STitle) 3321**] just prior to admission showing stenosis of the Lcx 99%, 40% mLAD, 40% r PDA of unknown age, with no intervention at the time. To determine whether any of the affected areas were salvagable, the patient had a dobutamine viability echo, which showed minimal viability in the inferior wall but apparently-viable myocardium elsewhere. She was taken to cardiac cath on [**2143-7-15**] and a bare metal stent was placed in the left circumflex artery. Catherization also showed elevated filling pressures, pulmonary HTN and a cardiac index of 1.23. Following the procedure, patient was started on aspirin, plavix and heparin. Her catheterization site was c/d/i and no bruits or hematomas were appreciated. Right heart catherization for on [**7-18**] demonstrated continued poor cardiac index. . #Acute kidney injury: On admission her creatinine was noted to be 1.6 (1.0 on discharge two days before). This was thought to be pre-renal from poor kidney persusion from CHF, poor PO intake and nausea, and she had recently started losartan on her prior admission. Losartan was held during this admission. Because she was still volume overloaded she was gently diuresed. As above the patient did require additional diuresis with inotropic support. She was started on a lasix gtt with resultant increase in her creatinine. Furosemide was held due to decreased kidney function. . # Atrial Fibrillation: On HD # 8 the patient was noted to be in atrial fibrillation with RVR associated with nausea and vomiting. She was initally rate controlled with metoprolol. However, during her endocardial biopsy she was noted to have HR to the 130s and a drop in her systolic blood pressure to the 70s. She was given IV metoprolol and fluids with spontaneous conversion to sinus rhythm. She was then given a PO amiodarone load and started on a heparin drip. Given her CHADS2 score of 3 she was started on warfarin. This was discontinued on [**Hospital1 1516**]. . # RLL infiltrate: Patient noted to have possible RLL infiltrate vs atelectasis on chest xray and white count to 12. She remained afebrile and noted only a scant sputum. X ray also showed a R sided pleural effusion. Therefore it was felt changes likely represented atelectasis and antibiotics were not started. . #Nausea: Pt was reported significant nausea and vomiting on admission, was given PO zofran PRN which effectively controlled her nausea and she had only one episode of vomiting throughout the remainder of her hospital course. Nausea was always associated with volume overload or atrial fibrillation. . # Code Status: The poor prognosis of both her poor cardiac function and cardiac amyloid was discussed in depth with the patient and her family. She expressed understanding that her congestive heart disease was likely end stage. She additionally decided that she would not want intubation or CPR and was made DNR/DNI. Pt was made comfort measures only on [**7-20**] and expired at 1440 (see above). # COPD: no evidence of acute exacerbation. Pt was continued on her home albuterol and tiotropium. . # Diabetes: well controlled, on sliding scale # Hypothyroidism: stable on home levothyroxine, TSH normal # peripheral neuropathy: stable, vicodin PRN pain Medications on Admission: albuterol 1puff q4H PRN aspirin 81mg daily conjugated estrogens 1 vag application PRN furosemide 100mg [**Hospital1 **] hydrocodone/acetaminophen 5/500 1-2 tabs q4H PRN levothyroxine 75mcg daily oxazepam 15-30mg qHS PRN tiotropium 18mcg daily vitamin B12 IM coumadin 1mg daily zoledronic acid administered in clinic zolpidem 10mg qHS losartan 25mg daily metoprolol succinate 25mg daily KCL 20meQ daily Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Cardiac amyloidosis Congestive heart failure Coronary artery disease Secondary Diagnoses: Mild mitral regurgitation Hypothyroidism Diabetes mellitus, type 2 Chronic obstructive pulmonary disease (COPD) Discharge Condition: Pt expired on [**2143-7-20**]. Completed by:[**2143-7-28**]

Admission Date: [**2172-12-5**] Discharge Date: [**2172-12-18**] Date of Birth: [**2090-8-9**] Sex: F Service: SURGERY Allergies: Cephalexin Hcl Attending:[**First Name3 (LF) 3200**] Chief Complaint: abdominal pain, SBO Major Surgical or Invasive Procedure: [**2172-12-6**] 1. Exploratory laparotomy. 2. Small-bowel resection. 3. Ileocolic anastomosis. 4. Abdominal washout. 5. Closure abdominal wall defect. 6. post op ileus History of Present Illness: 82-year-old female who underwent laparoscopic robot assisted TAHBSO, LOA for endometrial cancer and reduction of hernia on [**2172-11-17**]. She was seen by the Acute Care service afterwards for a small bowel obstruction which resolved with conservative management. She has had a RLQ ventral hernia for the past nine years since her right hip replacement. This was reduced during her surgery but became reincarcerated post-operatively and was thought to be the likely source of her obstruction. She was ultimately discharged to home on [**2172-11-27**]. She returned to the [**Hospital1 18**] ED after presenting to an OSH with an acute abdomen. Past Medical History: Past Medical History: asthma, HTN, chronic sinusitis, LE edema/cellulitis, laparoscopic robot assisted TAHBSO, LOA for endometrial cancer ([**2172-11-17**]) Past Surgical History: right hip replacement ([**2163**]), bladder neck suspension, open appy, ovarian cystectomy, cytoscele/rectocele repair, thyroid surgery Social History: Denies smoking, alcohol, or drug abuse. She is a 20-pack-year smoker who quit over 20 years ago. Family History: Two sisters had breast cancer. Uterine cancer in her youngest daughter. [**Name (NI) **] history of ovarian or colon cancer. Physical Exam: In the ED: 98.7 99 122/50 18 97RA GEN: A&O, NAD, NGT in place HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: large R sided ventral hernia, minimally tender to palpation, feels firm and indurated, rest of abdomen is soft, minimally distended, no rebound or guarding Ext: No LE edema, LE warm and well perfused Pertinent Results: CT Abd/Pelvis [**2172-12-5**] : 1. New/increased fluid in the right lower quadrant hernia sac with ill-defined small bowel loops and mesenteric edema within the sac, as well as increased intermesenteric fluid in the peritoneal cavity, raises concern for bowel ischemia. Extraluminal gas in the hernia sac, while seen previously, it is now more remote from patient's surgery, and perforation can not be excluded. 2. Relative caliber change of small bowel at the hernia neck, but only mildy dilated proximal bowel loops, may be due to early/partial obstruction. 3. Increased/new pelvic fluid which appears to be organizing and with peritoneal enhancement; while findings may be reactive with peritonitis, underlying infection is not excluded. 4. Unchanged postsurgical soft tissue densities between the urethra and the rectum and between the right ischial tuberosity and the anus. 5. Small right renal hypodensity, too small to further characterize on this study, but which could be further evaluated on non-urgent ultrasound. [**2172-12-5**] 07:40PM WBC-20.6*# RBC-3.79* HGB-11.5* HCT-34.5* MCV-91 MCH-30.4 MCHC-33.3 RDW-12.9 [**2172-12-5**] 07:40PM NEUTS-56 BANDS-38* LYMPHS-0 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2172-12-5**] 07:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ [**2172-12-5**] 07:40PM PLT SMR-NORMAL PLT COUNT-290 [**2172-12-5**] 07:40PM PT-15.7* PTT-25.9 INR(PT)-1.4* [**2172-12-5**] 07:40PM GLUCOSE-129* UREA N-30* CREAT-2.2*# SODIUM-140 POTASSIUM-5.5* CHLORIDE-108 TOTAL CO2-20* ANION GAP-18 [**2172-12-5**] 07:45PM LACTATE-2.1* [**2172-12-6**] 12:28 am PERITONEAL FLUID GRAM STAIN (Final [**2172-12-6**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83986**] @ 5:41A [**2172-12-6**]. 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [**2172-12-10**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. ANAEROBIC CULTURE (Final [**2172-12-10**]): BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH. BETA LACTAMASE POSITIVE. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2172-12-7**]): Test cancelled by laboratory. PATIENT CREDITED. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Brief Hospital Course: Mrs. [**Known lastname 101374**] was evaluated by the Acute Care service in the Emergency Room as well as the GYN service given her recent surgery. She had a WBC of 20K and her CT scan demonstrated an incarcerated hernia with evidence of ischemia on exam. She was admitted to the ICU for vigorous fluid resuscitation and broad spectrum antibiotics. On [**2172-12-6**] she was taken to the Operating Room and underwent an exploratory laparotomy with repair of a strangulated, perforated ventral hernia. She tolerated the procedure well and returned to the ICU in stable condition. She maintained stable hemodynamics and her pain was well controlled with IV Dilaudid. She remained intubated overnight and was successfully weaned and extubated on post op day #1. Due to her extensive surgery her nasogastric tube remained in for decompression until her bowel function returned. Following transfer to the Surgical floor on [**2172-12-9**] she remained stable but her nasogastric tube was removed. She was taking only a small amount of liquids over the next few days and she became more distended and tympanic on exam. She stopped passing flatus and her KUB showed a dilated large bowel. She was treated with Methylnaltrexone which was immediately effective. She was passing flatus and had a normal bowel movement. Her narcotics were discontinued and her pain was effectively managed with Tylenol. Her diet was advanced to regular but her appetite was only fair. Eventually she improved with Carnation Instant Breakfast supplements along with the addition of Megace. The Physical Therapy service evaluated her on numerous occasions and due to her prolonged hospitalization and decreased mobility a short term rehab was recommended prior to her return home. She was dischargaed on [**2172-12-18**]. Medications on Admission: diovan 160', prevacid 30', lasix 20', ibuprofen, percocet Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 **] home Discharge Diagnosis: Strangulated, perforated ventral hernia. . Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-18**] 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. * Your staples will be removed at rehab. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**2-12**] weeks. Completed by:[**2172-12-18**]

Admission Date: [**2126-9-15**] Discharge Date: [**2126-9-17**] Date of Birth: [**2094-11-20**] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Headache Major Surgical or Invasive Procedure: Conventional Cerebral Angiogram History of Present Illness: The pt is a 31 year-old right-handed woman G3P3 post-partum day 7, who presents with sudden onset of severe headache starting at 3am. She reports that her most recent pregnancy was complicated by being GBS positive, and developing a temperature of 100.8. According to her husband, there was some concern about the baby's HR, so she was induced at that time. No excessive bleeding, and otherwise uncomplicated delivery on [**9-6**]. On [**9-10**] she reports developing a sore throat with mild exudate on her tonsils. She saw her PCP [**Last Name (NamePattern4) **] [**9-11**], and reportedly tested negative for strep. Her symptoms of sore throat improved, and she was feeling better until 3am on [**9-14**]. She reports that she awoke with a headache, initially [**6-23**], that escalated to [**11-23**] within 30 minutes. This was accompanied by photo and phonophobia, as well as nausea and vomiting. She notes that movement tended to make her symptoms worse. She took Motrin and 2 Excedrin with no relief, and around 9:30am called her PCP. [**Name10 (NameIs) **] was told to try caffeine, to see if that improved her symptoms, and if not, to come to the ED for further evaluation. In the ED she was given Dilaudid and Compazine, which improved her symptoms, and hydralazine for elevated blood pressure. As an adult, she has had headaches every few months described as throbbing. Usually the headaches are behind her left eye. Does not have nausea, vomiting, photophobia, or phonophobia, or autonomic symptoms with her headaches. HA start gradually. They respond well to Motrin or Excedrin. She has a first cousin with migraines but no other family member has migraines. [**Known firstname 26317**] had one headache during her second trimester that was throbbing and associated with photophobia. She notes increased frequency of headaches during her pregnancies but they were not as severe as the one described above during her second trimester. She denies any neck stiffness, rash, or confusion. No diplopia or blurred vision. She reports that she has been able to produce a small amount of milk, but has primarily been giving her child formula. This is similar to how things were during her prior pregnancies. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - Hypothyroidism - Anemia Social History: The patient lives in [**Location 2251**] with her husband and children. She currently is a stay-at-home Mom, but used to work as director of Multicultural affairs at a local [**Location (un) **]. No EtOH, smoking or illicits. Family History: Heart disease on maternal side, DM on paternal side. Physical Exam: Vitals: P:52 R: 16 BP:164/62 SaO2: 95% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**4-16**] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: Admission Labs: PT-11.8 PTT-29.9 INR(PT)-1.0 PLT COUNT-354 NEUTS-56.8 LYMPHS-38.5 MONOS-3.3 EOS-0.6 BASOS-0.7 WBC-5.9 RBC-4.88 HGB-12.2 HCT-39.4 MCV-81* MCH-25.0* MCHC-31.0 RDW-14.4 URIC ACID-6.3* ALT(SGPT)-167* AST(SGOT)-89* ALK PHOS-102 TOT BILI-0.3 GLUCOSE-83 UREA N-10 CREAT-1.0 SODIUM-144 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-25 ANION GAP-17 ALT(SGPT)-128* AST(SGOT)-49* ALK PHOS-92 [**2126-9-14**] 03:00PM URINE RBC-[**4-18**]* WBC-[**4-18**] BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2 BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2126-9-15**] 12:57AM CEREBROSPINAL FLUID (CSF) WBC-17 RBC-[**Numeric Identifier 47655**]* POLYS-83 LYMPHS-14 MONOS-3 CEREBROSPINAL FLUID (CSF) WBC-4 RBC-[**Numeric Identifier **]* POLYS-60 LYMPHS-34 MONOS-4 ATYPS-2 CEREBROSPINAL FLUID (CSF) PROTEIN-253* GLUCOSE-74 ALBUMIN-3.9 LIPASE-76* CT HEAD W/O CONTRAST Study Date of [**2126-9-14**] 2:52 PM Diffuse sulcal effacement involving the right posterior frontal and parietal regions. Differential considerations include subacute subarachnoid hemorrhage or focal meningitis. MRI is recommended for further assessment. MR HEAD W & W/O CONTRAST Study Date of [**2126-9-14**] 8:46 PM 1. Areas of negative susceptibility with enhancement in the cerebral sulci in the right frontal and the parietal lobes, raises the possibility of hemorrhage, with or without superimposed inflammation/infection related to cerebritis or meningitis. No acute infarction. 2. Associated cerebral edema involving the right cerebral hemisphere as described above. 3. No mass effect. 4. Patent major intracranial arteries without obvious evidence of aneurysm. 5. Consultation with interventional neuroradiology/neurosurgery, for further evaluation if necessary, by conventional angiogram can be considered, after performing a non-contrast CT head study, to document the presence of hemorrhage. 6. Patent major dural venous sinuses. Evaluation for cortical veins is limited on the present study. Correlation with clinical neurological examination and LP can also be considered given the imaging findings above. CTA HEAD W&W/O C & RECONS Study Date of [**2126-9-15**] 2:50 AM 1. Evidence of high attenuation in the right-sided cerebral sulci, which can relate to hemorrhage or enhancement from prior gadolinium administration, which may relate to leptomeningeal enhancement related to cerebritis or meningitis. Effacement of the cerebral sulci with associated edema on the right side, as seen on the prior study. 2. Patent major intra- and extra-cranial arteries without focal flow-limiting stenosis, occlusion, or aneurysm. 3 Prominent nasopharyngeal soft tissues, and tonsils, which can be correlated with direct visualization, with narrowing of the oropharynx. Mild right maxillary sinus disease. 4. Heterogeneous thyroid- non-emergent ultraosund can be considered. Conventional Angiogram on [**9-16**]: (prelim impression by Dr. [**Last Name (STitle) **] Mild beading of multiple distal vessels in the right MCA territory. No aneurysm or dissection or other vascular malformation seen. Brief Hospital Course: Ms. [**Known lastname **] is a 31 year-old G3P3 woman with a history of hypothyroidism who delievered her baby on [**9-6**] and then on [**9-14**] had onset of a severe bifrontal headache, associated with photo- and phonophobia, nausea and vomiting, over a period of 30 minutes. On arrival, the patient's exam was notable for hypertension. She was felt to have normal cognition, mild photophobia, and no meningismus. Laboratory results were remarkable for elevated LFTs (normal on [**9-3**]), with normal platelets. CT brain was suggestive of a small right frontal, parietal, temporal subarachnoid hemorrhage. LP was consistent with subarachnoid hemorrhage ([**Numeric Identifier **] RBCs in Tube 4). She was initially admitted to the ICU/Neurosurgery service for monitoring. She underwent conventional angiogram which did not show an aneurysm or AVM. She was hemodynamically and neurologically stable and therefore transferred to the neurology floor. Given the improvement in symptoms and lack of findings on neurologic exam, she was discharged with plans for follow-up in the stroke clinic. It was felt that the patient's presentation was most consistent with post partum cerebral angiopathy (otherwise known as Call [**Doctor Last Name 8271**] syndrome). Much less likely would be thrombosis of a small cortical vein then leading to right-sided subarachnoid hemorrhage. She was started on verapamil SR 180mg daily to prevent vasospasm from the SAH. She was given Keppra 500mg [**Hospital1 **] for seven days, then Keppra 500mg daily for three days, and then instructed to stop [**Doctor Last Name (ambig) 13401**]. [**Known firstname 26317**] was told not to drive, bath in a tub by herself, bath her children in a tub by herself, or climb for the next month. She was instructed to refrain from strenuous physical activity for three months (should not lift objects more than 20lbs.) At the time of discharge, RF, CRP, ESR as well as ANCA, [**Doctor First Name **], Homocystine, Protein C, S and ACA was pending. Medications on Admission: - Levothyroxine - Iron Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*5 Tablet(s)* Refills:*0* 3. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:*30 Tablet Sustained Release(s)* Refills:*3* 4. Over the counter fiber supplement for constipation. Use as directed. 5. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: take two tablets each day for seven days, then take one tablet daily for three days, then off. Disp:*17 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Post-partum cerebral angiopathy (Call-[**Doctor Last Name 8271**] Syndrome) Subarachnoid hemorrhage Migraine headaches. Discharge Condition: Normal neurological examination Discharge Instructions: You were admitted for a severe headache and found to have a small amount of bleeding on top of your brain in the subarachnoid space. This was likely due to abnormal narrowing of your blood vessels related to pregnancy and your history of migraines. You have a normal neurological examination. Your condition is expected to improve while taking verapamil as indicated. You should refrain from strenuous physical activity for three months. Please avoid any driving, tub bathing, swimming alone or any other activity where you may injure yourself or others should you suddenly lose consciousness for two weeks. Please return to the emergency room if you experience any new or different nature of your headaches. Difficulty speaking, visual loss, numbness, tingling or weakness or any other concerning symptoms. Followup Instructions: Please see Dr. [**Last Name (STitle) **] on Wednesday, [**2126-10-2**] at 4pm in the stroke neurology division at [**Hospital1 **]. Office is located on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building, [**Location (un) 858**]. Completed by:[**2126-9-17**]

Admission Date: [**2130-3-26**] Discharge Date: [**2130-4-4**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2130-3-29**] 1. Coronary artery bypass grafting x5 with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the posterior descending artery and sequential reverse saphenous vein graft to the first and second obtuse marginal artery and a reverse saphenous vein graft to the diagonal artery which is Y-grafted to the sequential vein graft. 2. Aortic valve replacement with a 23-mm St. [**Male First Name (un) 923**] Epic tissue valve. 3. Left atrial appendage resection. [**2130-3-30**] re-exploration mediastinum History of Present Illness: 88 year old male admitted to [**Hospital 5279**] Hospital with ACS from [**Date range (1) 85977**]. Cardiac catheterization at that time revealed coronary artery and mitral regurgitation. He was transferred to [**Hospital1 69**] for surgical evaluation. Past Medical History: Atrial fibrillation NSTEMI [**2-15**] Vertebral fx([**2063**]) Macular degeneration/legally blind [**Doctor Last Name 9376**] syndrome Benign Prostatic Hypertrophy Hypertension Bilateral knee arthritis Social History: Lives alone Occupation: retired dairy farmer and historic house restorer Tobacco: remote-quit many years ago, previously smoked 1ppd ETOH:[**1-11**] glasses of wine/week Family History: Brother-afib and heart failure; father and sister CVA Physical Exam: Pulse: 65 Resp: 14 O2 sat: B/P Right: 130/60 Height: 5'6" Weight:163lbs. General: Skin: Dry [x] intact [x] Old well-healed incision across left abdomen HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur II/VI SEM across pre-cordium Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities:[x] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:- Left:- Pertinent Results: [**2130-4-4**] 05:50AM BLOOD WBC-10.5 RBC-3.43* Hgb-10.4* Hct-30.6* MCV-89 MCH-30.3 MCHC-34.0 RDW-15.4 Plt Ct-162 [**2130-3-26**] 02:43PM BLOOD WBC-6.6 RBC-3.78* Hgb-11.7* Hct-33.9* MCV-90 MCH-30.8 MCHC-34.4 RDW-13.9 Plt Ct-218 [**2130-4-4**] 05:50AM BLOOD Plt Ct-162 [**2130-4-4**] 05:50AM BLOOD PT-17.8* INR(PT)-1.6* [**2130-3-26**] 02:43PM BLOOD Plt Ct-218 [**2130-3-26**] 02:43PM BLOOD PT-18.3* PTT-40.7* INR(PT)-1.7* [**2130-4-4**] 05:50AM BLOOD Glucose-104* UreaN-35* Creat-1.0 Na-140 K-4.0 Cl-103 HCO3-28 AnGap-13 [**2130-3-26**] 02:43PM BLOOD Glucose-91 UreaN-25* Creat-1.2 Na-136 K-4.3 Cl-96 HCO3-29 AnGap-15 [**2130-3-26**] 02:43PM BLOOD ALT-21 AST-20 LD(LDH)-225 CK(CPK)-189 AlkPhos-101 Amylase-62 TotBili-1.3 [**2130-3-26**] 02:43PM BLOOD Lipase-29 [**2130-3-26**] 02:43PM BLOOD cTropnT-0.04* [**2130-4-4**] 05:50AM BLOOD Mg-2.1 [**2130-4-1**] 02:52AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1 [**2130-3-27**] 02:52AM BLOOD %HbA1c-5.9 eAG-123 Final Report CHEST RADIOGRAPH INDICATION: Status post CABG, evaluation for interval change. COMPARISON: [**2130-4-1**]. FINDINGS: As compared to the previous radiograph, the lung volumes have increased. Small bilateral pleural effusions. Moderate cardiomegaly. No pulmonary edema. The right venous introduction sheath has been removed. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: SUN [**2130-4-2**] 4:40 PM Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.5 cm <= 5.2 cm Right Atrium - Four Chamber Length: *8.1 cm <= 5.0 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: 4.6 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.1 cm Left Ventricle - Fractional Shortening: 0.33 >= 0.29 Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Left Ventricle - Stroke Volume: 72 ml/beat Left Ventricle - Cardiac Output: 4.99 L/min Left Ventricle - Cardiac Index: 2.72 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.16 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 10 < 15 Aorta - Sinus Level: 2.5 cm <= 3.6 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Arch: *3.1 cm <= 3.0 cm Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 21 mm Hg Aortic Valve - LVOT VTI: 23 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 1.4 m/sec Mitral Valve - E Wave deceleration time: 170 ms 140-250 ms TR Gradient (+ RA = PASP): *39 to 41 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Marked LA enlargement. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Mildly dilated aortic arch. AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve leaflets. Moderate AS (area 1.0-1.2cm2) MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Conclusions The left atrium is markedly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic arch is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate aortic stenosis. Preserved regional and global biventricular systolic function. Moderate to severe tricuspid regurgitation. Moderate pulmonary hypertension. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2130-3-28**] 16:54 Brief Hospital Course: Transferred in from [**Doctor First Name 5279**] in NH on [**3-26**] for surgery. He required IV heparin and NTG pre-operatively. Pre-operative workup completed and he underwent surgery on [**3-29**] with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition on titrated epinephrine, phenylephrine, and propofol drips. Had developed tamponade and returned to the OR for re-exploration on the following morning [**3-30**]. Extubated later that afternoon without complications. Coumadin restarted for Atrial fibrillation. Transferred to the floor on POD #3 to begin increasing his activity level. Chest tubes and pacing wires removed per protocol. Gently diuresed toward his preop weight. He had urinary retention which required foley reinsertion and being discharged with foley to rehab on ampicillin until foley removed. He was ready for discharge to rehab [**4-4**]. He was discharged to rehab at Pleasantview in [**Location (un) **] [**Location (un) 3844**]. Medications on Admission: Aspirin 81 daily Lasix 40 daily Lisinopril 10 daily Metoprolol XL 50 daily Ocuvite Macrobid 100 daily Simvastatin 20 daily Flomax 0.4 QHS Nitroglycerin-prn Coumadin Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: due for INR check [**4-6**] - goal INR 2.0-2.5 dose to be adjusted based on lab results . 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 5 days: or until foley removed . 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): continue twice a day for 10 days then decrease to once a day . 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): twice a day with lasix for 10 days then decrease to once a day . 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Outpatient Lab Work please check cr/bun, potassium, magnesium twice a week while on twice a day lasix Discharge Disposition: Extended Care Facility: Pleasant View Discharge Diagnosis: aortic stenosis coronary artery disease PMH: Afib(coumadin), Vertebral fx([**2063**]), Macular degeneration/legally blind, [**Doctor Last Name 9376**] syndrome, Benign Prostatic Hypertrophy, Coronary Artery Disease, Hypertension, Bilat knee arthritis Discharge Condition: Alert and oriented x3 nonfocal gait *** Sternal pain managed with oral analgesics Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] *** Target INR 2.0-2.5 for A Fib; first blood draw at rehab after transfer please. Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Wed [**4-19**] @ 1:15 PM- please reschedule from rehab if still receiving high-level care Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 85978**] in 6 weeks Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 55499**] in 4 weeks Please call cardiac surgery if need arises for evaluation or readmission to hospital [**Telephone/Fax (1) 170**] Completed by:[**2130-4-4**]

Admission Date: [**2126-5-31**] Discharge Date: [**2126-6-7**] Date of Birth: [**2046-7-15**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: right pelvic/femur fracture Major Surgical or Invasive Procedure: [**2126-5-31**] ORIF of right subtrochanteric hip fracture with intramedullary nail History of Present Illness: Ms. [**Known lastname 48639**] is a 79 year-old lady with developmental delay who is transferred from group home were she was attending day care (lives primarily with brother, [**Doctor First Name **] due to hip pain and was found to have right pelvic/femur fracture. Initially it had been reported that she was "found down" but after further history was gathered it seems that she was found seated at a table, poorly interactive, screaming/crying, and tremulous (versus shaking). The patient's brother corroborates this by saying he was told she may have had a seizure - he was unaware of a fall report. She was brought to an outside hospital first where CT head was negative and a pelvic x-ray showed a pubic ramus fracture. She was unable to give a good history. She denied pain. At that point, the OSH transferred her to [**Hospital1 18**] for orthopedic evaluation. In the ED, initial vs were 5 98.1 80 98/52 18 98% 2L Nasal Cannula. Trauma exam included rectal exam without blood. CT torso showed no other signs of trauma but had "evidence of aspiration" so she was given Levofloxacin/Metronidazole. She was admitted to Medicine for further management. On transfer to the floor, VS were 99.1, 97, 24, 121/62, 100%. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: developmental delay HTN arthritis Social History: Lives with brother [**Name (NI) **] in [**Location (un) 5503**], MA Attends day care at group home No smoking, alcohol or illicits Family History: non-contributory Physical Exam: ADMISSION EXAM VS: 98.5, 114/62, 99, 20, 99% 2L NC GEN: Alert, oriented, no acute distress HEENT: NCAT MMM EOMI sclera anicteric, OP clear NECK: supple, no JVD, no LAD PULM: Good aeration, CTAB no wheezes, rales, ronchi CV: RRR normal S1/S2, no mrg ABD: soft NT ND normoactive bowel sounds, no r/g EXT: WWP 2+ pulses palpable bilaterally, no c/c/e NEURO: CNs2-12 intact, motor function grossly normal SKIN: no ulcers or lesions . DISCHARGE EXAM VS: 98.9-99.4, 118-123/63-66, 65-71, 18, 98-99%RA BM: none I/Os: poor PO intake, UOP not recorded as incontinent GEN: Alert, oriented, no acute distress HEENT: NCAT MMM EOMI sclera anicteric, OP clear NECK: supple, no JVD, no LAD PULM: Good aeration, CTAB no wheezes, rales, ronchi CV: RRR normal S1/S2, no mrg ABD: soft NT ND normoactive bowel sounds, no r/g EXT: WWP 2+ pulses palpable b/l, dressing over right lateral thigh/pelvis - c/d/i, non-tender to palpation, patient on left hip with legs slightly bent, but asking for legs to be straightened. Pertinent Results: ADMISSION LABS: [**2126-5-31**] 02:50AM BLOOD WBC-12.9* RBC-4.34 Hgb-12.5 Hct-37.1 MCV-86 MCH-28.8 MCHC-33.7 RDW-14.0 Plt Ct-125* [**2126-5-31**] 02:50AM BLOOD Neuts-91.5* Lymphs-6.0* Monos-1.9* Eos-0.3 Baso-0.2 [**2126-5-31**] 02:50AM BLOOD PT-13.7* PTT-26.7 INR(PT)-1.3* [**2126-5-31**] 02:50AM BLOOD Glucose-215* UreaN-19 Creat-0.8 Na-142 K-4.1 Cl-104 HCO3-20* AnGap-22* [**2126-5-31**] 02:50AM BLOOD ALT-26 AST-42* AlkPhos-110* TotBili-0.5 [**2126-5-31**] 02:50AM BLOOD Albumin-3.8 [**2126-6-1**] 05:01AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.7 DISCHARGE LABS: [**2126-6-5**] 06:22AM BLOOD WBC-6.8 RBC-3.68* Hgb-11.0* Hct-32.8* MCV-89 MCH-30.0 MCHC-33.7 RDW-15.6* Plt Ct-160# [**2126-6-4**] 07:30AM BLOOD Glucose-88 UreaN-12 Creat-0.5 Na-139 K-4.0 Cl-107 HCO3-27 AnGap-9 PERTINENT LABS: [**2126-5-31**] 06:24AM BLOOD Lactate-6.2* [**2126-5-31**] 06:47AM BLOOD Lactate-7.7* [**2126-5-31**] 07:18AM BLOOD Lactate-4.8* [**2126-5-31**] 11:57PM BLOOD Lactate-3.6* [**2126-5-31**] 02:50AM BLOOD cTropnT-<0.01 [**2126-5-31**] 11:35PM BLOOD cTropnT-<0.01 [**2126-6-1**] 05:01AM BLOOD cTropnT-<0.01 MICRO DATA: [**2126-5-31**] 05:55AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050* [**2126-5-31**] 05:55AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2126-5-31**] 05:55AM URINE RBC-5* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [**2126-6-2**] BLOOD CULTURE x2 NEGATIVE [**2126-6-2**] URINE CULTURE - NEGATIVE [**2126-5-31**] BLOOD CULTURE x2 [FINAL RESULT PENDING] [**2126-5-31**] URINE CULTURE - NEGATIVE EKG [**2126-5-31**]: Sinus rhythm. Possible right ventricular hypertrophy. Modest ST-T wave changes are non-specific. No previous tracing available for comparison. CT C-SPINE W/O CONTRAST [**2126-5-31**]: No fractures. Multilevel degenerative changes. CT ABD/PELVIS W/CONTRAST [**2126-5-31**]: 1. Comminuted right intertrochanteric, left acetabular, left ischial, and left sacral fractures. 2. Mixed density right upper lobe nodule. Recommend 6-month followup chest CT. 3. Probable pulmonary hypertension. 4. Probable cystitis, correlate with urinalysis. 5. 2.6-cm right adnexal cyst. Recommend non-emergent pelvic ultrasound for further evaluation. 6. Nonspecific liver and renal hypodensities. Recommend non-emergent abdominal ultrasound. CXR [**2126-5-31**]: No acute intrathoracic process or radiographic evidence of injury. Please refer to subsequent CT torso for further details, including small right apical lung nodules. BILATERAL HIP X-RAYS [**2126-5-31**]: 1. Comminuted right intertrochanteric fracture. 2. Fractures of the left acetabulum and ischium. 3. Severe bilateral hip and right knee osteoarthritis. LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R. [**2126-5-31**]: Images show placement of a metallic fixation device about the fracture of the proximal femur. Further information can be gathered from the operative report. HIP UNILAT MIN 2 VIEWS RIGHT IN O.R. [**2126-5-31**]: Images show placement of a metallic fixation device about the fracture of the proximal femur. Further information can be gathered from the operative report. EKG [**2126-6-1**]: Sinus rhythm. Short P-R interval. Left axis deviation, consider left anterior fascicular block. Intraventricular conduction delay of right bundle-branch block type. Since the previous tracing of [**2126-5-31**], the rate is faster, ST-T wave abnormalities are more prominent. RUQ ULTRASOUND [**2126-6-4**]: Focal liver lesions seen on recent CT correspond to simple hepatic cysts. The liver is otherwise normal in appearance showing no signs of cirrhosis or splenomegaly. The extrahepatic common bile duct dilatation is also noted, which could be age-related ectasia, but clinical correlation is recommended. CT HEAD W/O CONTRAST [**2126-6-4**]: 1. No acute intracranial process. 2. Ventriculomegaly with dilation of the occipital horns is likely due to atrophy. 3. Chronic small vessel ischemic disease. MR HEAD [**2126-6-5**]: No acute infarct seen. Ventriculomegaly out of proportion for sulci could be due to normal pressure hydrocephalus in proper clinical setting. Small vessel disease. Limited study due to motion. MR [**Name13 (STitle) **] [**2126-6-5**]: 1. Somewhat motion limited axial images. 2. No evidence of ligamentous disruption of marrow edema within the vertebral bodies to suggest acute trauma. 3. Multilevel degenerative changes with disc bulging at multiple levels and minimal extrinsic indentation on the spinal cord by disc bulging at C3-4 level. 4. No evidence of intrinsic spinal cord signal abnormalities. EEG [**2126-6-4**]: This is an abnormal awake and sleep EEG because of intermittent generalized frontally dominant bursts of slowing with admixed sharp features. These findings are indicative of mild to moderate diffuse encephalopathy most likely related to patient's history of static encephalopathy. No electrographic seizures are present. If clinical concern for seizures is high, a 24 hour bedside EEG telemetry study is recommended. Brief Hospital Course: Ms. [**Known lastname 48639**] is a 79 y/o lady w/ developmental delay who presented from her group home for a right pelvic and femur fracture. Her stay was complicated by a brief MICU stay for post-operative tachycardia and hypotension (possibly due to blood loss) that resolved. She also underwent workup for possibe seizure given the history obtained by providers at her group home. She was discharged to rehab. # Right pelvic and femur fracture: s/p surgery [**2126-5-31**]. She had a comminuted right intertrochanteric fracture, and a fracture of the left acetabulum and ischium. Now s/p ORIF of right subtrochanteric hip fracture with intramedullary nail on [**5-31**]. Pain well controlled with Tylenol and low-dose narcotics (which were not needed by the time of discharge). She was started on enoxaparin prophylaxis on [**5-31**] which should continue for 4 weeks (end day [**6-28**]). She is touch-down weight-bearing only on the right leg. She will f/u with Ortho in clinic on [**2126-6-18**]. # Mechanism of fracture: unclear, possibly a seizure. Though it was first believed that she had a fall, it was later clarified by group home staff that she was actually found seated at a table shaking (still unclear if tremulous/crying or if shaking/seizing). Patient was unable to describe the event. Since there was no fall, the fracture was initially suspicious for very severe osteoporosis in the setting of seizure versus possible elder abuse. Social Work has ongoing investigations regarding any elder abuse at the group home though it is felt to be unlikely. With regards to the cause, seizure was investigated due to her presentation. EEG and MR imaging of the head was performed and was not very suggestive of a seizure, but Neurology consult felt that a seizure is highly likely and probable given the history obtained. Seizure could explain her high lactate on presentation (~7). It was fellt that risks of antiepileptics outweighed the benefits so she was not started on one this admission. Tramadol was stopped due to risk of decreasing seizure threshold. She will follow up with Neurology on [**2126-7-15**]. # Osteoporosis: clinically diagnosed. Has not had a BMD scan (she has a clinical diagnosis of osteoporosis given this fracture). She was started on calcium and vitamin D; she might benefit from bisphosphonate therapy as an outpatient. No inpatient imaging indicated. # Post-operative tachycardia/hypotension: requiring MICU stay, resolved. After the operation on [**5-31**] she was noted to go into a fast heart rhythm (HR 140's); no EKG was done. Labs revealed a Hct drop from 37.1 to 26.4. She was given Metoprolol 5mg IV. Also over the next few hours, she received a few liters of IV fluids and 2 units of blood. Her tachycardia persisted and in the evening she developed hypotension to the 80's so she was observed in the MICU overnight. With time her tachycardia and hypotension resolved and she was able to return to the medical floor the next day. Estimated blood loss was 200cc but it is possible that this was underestimated and that this was from hypovolemia. Alternately, this could be related to the fact that she did not receive her home Metoprolol prior to the procedure causing tachycardia. Finally, other etiologies that were considered peri-operative MI but this was ruled out by EKG and serial troponins. She was normotensive (on antihypertensive meds) and did not have any more tachycardia for the duration of her stay. She was able to be continued on her antihypertensive medication (Lisinopril) and also Metoprolol. # Acute anemia: likely from blood loss, now Hct stable. She was s/p surgery with only 200cc blood loss, however did have pelvic/femur fractures which can bleed extensively. On [**5-31**], Hct fell from 37.1 to 26.4, then received 2u pRBC with repeat Hct 31.8. The next day ([**6-1**]) she was noted to have Hct 25 so she received 2u pRBC with Hct increasing to 33.9. Hct was stable by the time of discharge, and she did not require any more transfusions. Hct was 32.8 on [**6-5**]. No need for further Hct checks unless any clinical concern for bleeding. # Thrombocytopenia: unclear etiology. Four T score of 2 makes HIT unlikely. No obvious signs of cirrhosis or hypersplenism. No h/o ITP. No signs or symptoms to suggest TTP. Though her plt dropped from 125 to 75, platelet level stabilized with plt 160 at the time of discharge. # Leukocytosis: resolved, low suspicion for infection. WBC 12.9 on presentation (neutrophil predominance, no bands) but no signs and symptoms of infection (negative urinalysis and urine cultures, blood cultures with no growth to date, and clear CXR). No antibiotics were continued once she was admitted, and her leukocytosis resolved (WBC 6.8 at discharge). Initial leukocytosis might have represented a stress response from her fracture. # Hypertension: controlled. Besides her episode of hypotension (see above) she did require her antihypertensive medications and her blood pressure was reasonably controlled. She was continued on her Lisinopril and Metoprolol. # Developmental delay: stable, guardianship extension in progress. Mental status at baseline is alert and interactive, answering questions. Her family felt that she has derived great benefit from her adult day program. Has good family support (especially from brother [**Doctor First Name **]. She continues on Donepezil. Guardianship required an extension from the courts during this admission as [**Doctor First Name **] legal guardianship of [**Name (NI) **] did not include a [**Name (NI) 1501**] admission clause due to the date it was originally attained on. Legal paperwork is being processed and information will be shared with her rehab hospital. # Mixed density right upper lobe nodule: incidental finding on CT. 6-month followup chest CT was recommended. She should have this as an outpatient. # 2.6cm right adnexal cyst: incidental finding on CT. Non-emergent pelvic ultrasound was recommended for further evaluation. She should have this done as an outpatient. # Nonspecific liver and renal hypodensities: incidental finding on CT. Non-emergent abdominal ultrasound was recommended, and was done while she was an inpatient. This revealed several simple hepatic cysts and mild dilation of the extrahepatic bile duct. # Transitional issues -Code status: Full Code -Emergency Contact: [**Name (NI) **] [**Name (NI) 48639**] (brother): [**Telephone/Fax (1) 112245**] -Guardianship extension: paperwork submitted, and awaiting court date currently -Dispo: to rehab hospital per PT evaluation -Ongoing investigation into question of elder abuse at group home -Pending at the time of discharge: final result of blood cultures from [**6-2**] -Incidental findings requiring follow-up (see above): RUL lung nodule, right adnexal cyst -Lovenox duration: [**Date range (1) 94218**] -Patient might benefit from bisphosphonate therapy -Follow-up: with Ortho on [**2126-6-18**] and Neurology on [**2126-7-15**] Medications on Admission: (confirmed with [**Doctor First Name **], patient's brother) Donepezil 10mg daily Lisinopril 40mg daily Tramadol 50mg daily Metoprolol tartrate 100mg twice a day Colace [**Hospital1 **] Miralax 3350 1 packet PRN Discharge Medications: 1. Donepezil 10 mg PO HS 2. Lisinopril 40 mg PO DAILY hold for sbp < 100 or map < 60 3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain hod for sedation or rr < 10. 4. Metoprolol Tartrate 100 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Senna 2 TAB PO DAILY:PRN constipation 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Acetaminophen 650 mg PO Q6H:PRN pain/fever 9. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit Oral twice a day 10. Morphine Sulfate IR 5-10 mg PO Q8H:PRN pain Hold for sedation or RR < 12. 11. Enoxaparin Sodium 30 mg SC Q12H planned duration: weeks post-op ([**Date range (3) 112246**]) 12. Miconazole Powder 2% 1 Appl TP TID:PRN rash apply to affected area Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: PRIMARY: comminuted right intertrochanteric fracture fracture of the left acetabulum and ischium thrombocytopenia anemia SECONDARY: developmental delay osteoporosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted due to a right pelvis and femur fracture. You underwent surgery for this and are now being discharged to rehab with plans to follow-up with Orthopedic Surgery (appointment listed below). Note that during your stay, you were worked up for possible seizure and you will follow up with Neurology (appointment listed below). We made the following changes to your medications: -START Lovenox (Enoxaparin) injections to prevent blood clots (from [**Date range (1) 94218**]) -START Tylenol as needed for pain -START Morphine as needed for pain -START Calcium/Vitamin D for osteoporosis -STOP Tramadol (this could predispose you to having seizures) Followup Instructions: ORTHOPEDICS When: TUESDAY [**2126-6-18**] at 10:20 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ORTHOPEDICS When: TUESDAY [**2126-6-18**] at 10:40 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NEUROLOGY When: MONDAY [**2126-7-15**] at 4:00 PM With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD [**Telephone/Fax (1) 541**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Admission Date: [**2175-11-6**] Discharge Date: [**2175-11-13**] Service: . HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old man with a history of coronary artery disease status post coronary artery bypass graft surgery, severe aortic stenosis and a recent non-ST elevation myocardial infarction the week prior to admission, which was complicated by congestive heart failure with the ejection fraction in the 30s. At that time, his aortic valve area was noted to be 0.5 cm squared. The patient initially refused cardiac catheterization, pacemaker and anti-coagulation at the outside hospital and was discharged to home to return the next day with shortness of breath at rest. He was noted to have a systolic blood pressure in the 80s; temperature 100.6 F., with a right lower lobe infiltrate found on chest x-ray. He again ruled in for myocardial infarction and was started treatment with antibiotics, heparin drip and Natrecor. He was transferred to [**Hospital1 69**], initially admitted to the [**Hospital Unit Name 196**] Service and taken for cardiac catheterization. Catheterization revealed severe three vessel disease and severe biventricular diastolic dysfunction with patent graft. The patient also had critical aortic stenosis, severe pulmonary hypertension and a successful balloon valvuloplasty bringing the aortic valve area from 0.5 cm squared to 0.7 cm squared. The patient was started on Dobutamine in the catheterization laboratory and was transferred to the Cardiac Care Unit. Cardiac output on dobutamine was 2.88 and did not significantly change after the dobutamine was stopped. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2167**] with left internal mammary artery to the left anterior descending, saphenous vein graft to the left circumflex and obtuse marginal ramus, and saphenous vein graft to the right coronary artery. 2. Severe aortic stenosis with a valve area of 0.5 cm squared. 3. Tachycardia / Bradycardia syndrome. 4. Atrial fibrillation. 5. Recent non-ST elevation myocardial infarction. 6. Asthma. 7. Congestive heart failure with an ejection fraction of 30%. 8. Hypertension. 9. Chronic renal insufficiency. 10. Hyperlipidemia. 11. Diabetes mellitus type 2. 12. History of urinary tract infection. 13. Status post transurethral resection of the prostate. 14. Benign prostatic hypertrophy. MEDICATIONS AT HOME: 1. Captopril 6.25 mg twice a day. 2. Augmentin twice a day. 3. Lasix 60 mg p.o. twice a day. 4. Digoxin 0.125 mg p.o. q. day. 5. Coreg 3.125 mg p.o. twice a day. 6. Aspirin 325 mg p.o. q. day. 7. Pravachol 60 mg p.o. q. day. 8. Atrovent and Albuterol inhalers. 9. Flovent inhaler. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives at home; denies alcohol or tobacco use. PHYSICAL EXAMINATION: On admission, temperature 100.4 F.; pulse 69; blood pressure 105/38; respiratory rate 22; saturation of 99% on a non-rebreather. Generally, the patient is confused, moving around in bed. He had a jugular venous pressure of 7 cm with a II/VI systolic ejection murmur heard at the right upper sternal border. On lung examination he had diffuse wheezes and crackles at bases. The rest of his examination was unremarkable. LABORATORY: On admission showed a BUN and creatinine of 48 and 1.9. Troponin T was 2.38 and CK 40. EKG pre-cath showed atrial fibrillation at a rate of 60 beats per minute, left axis deviation, right bundle branch block with ST depressions in V1 through V6. SUMMARY OF HOSPITAL COURSE: The patient was transferred post catheterization to the Cardiac Intensive Care Unit. [**Unit Number **]. CORONARY ARTERY DISEASE: Catheterization revealed severe three vessel disease with patent graft. The patient was status post two recent non-ST elevation myocardial infarctions. To continue on aspirin and Pravachol. Initially, his beta blocker was held secondary to hypotension and presumed cardiogenic shock, however, his beta blocker, ACE inhibitor and digoxin were started prior to discharge without complications. 2. CONGESTIVE HEART FAILURE: The patient was shown to have an ejection fraction of 30% with severe biventricular diastolic dysfunction and a very low cardiac output. He was resumed on his home Lasix dose as well as his home ACE inhibitor and beta blocker and was felt to be euvolemic by the time of discharge. 3. SICK SINUS SYNDROME: The patient continues to refuse a pacemaker and while in-house he became bradycardic at times, but was otherwise in regular rate in his atrial fibrillation. 4. ATRIAL FIBRILLATION: The patient continues to refuse anti-coagulation and remained in atrial fibrillation. He is continued on Carvedilol for multiple indications, one of which is for rate control. 5. ASTHMA / QUESTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The patient was continued on oxygen via nasal cannula. He continued to saturate well throughout his admission as long as he was on two or three liters which he states is his home dose of oxygen. He was also continued on Atrovent and Albuterol nebulizers and transitioned over to inhalers by the end of his hospital stay as well as his Flovent inhaler. 6. PNEUMONIA: The patient had been treated with Levaquin for two days followed by Caveats and Clindamycin for two days at the outside hospital. He was continued on Ceftriaxone while here for a total of a ten day course. He appeared to improve in his oxygen saturation and his sputum production decreased by the time of discharge with no complications. 7. DIABETES MELLITUS: The patient was initially started on a Regular insulin sliding scale, however, his blood sugar remained less than 150 at all times, so the Regular insulin sliding scale was stopped prior to discharge. 8. CODE STATUS: The patient remained "DO NOT RESUSCITATE" and "DO NOT INTUBATE" throughout his hospital stay. 9. MENTAL STATUS: On admission, the patient appeared confused and continued to do so throughout his hospital stay. Likely that this patient has a baseline dementia, however, due to this, he is having difficulty swallowing. He was evaluated by the Speech and Swallow Team on the day of discharge who recommended that the patient not take anything by mouth until his mental status clears. If this does not happen, then he should be started on tube feeds and a PEG tube should be considered as he is a very high aspiration risk. DISCHARGE MEDICATIONS: 1. Digoxin 0.125 mg p.o. q. day. 2. Carbuterol 3.125 mg p.o. twice a day. 3. Lasix 60 mg p.o. twice a day. 4. Captopril 6.25 mg p.o. three times a day. 5. Lipitor 10 mg p.o. q. h.s. 6. Aspirin 325 mg p.o. q. day. 7. Flovent two puffs twice a day. 8. Risperidone 0.5 mg p.o. twice a day p.r.n. 9. Atrovent nebulizers q. six hours. 10. Albuterol nebulizers q. six hours. 11. Colace 100 mg p.o. twice a day. 12. Senokot one to two tablets p.o. q. day p.r.n. 13. Heparin subcutaneously 5000 units q. eight hours until ambulating. 14. Protonix 40 mg p.o. q. day. 15. Guaifenesin p.r.n. DISPOSITION: The patient will be discharged to a rehabilitation facility. DISCHARGE STATUS: Stable; the patient denied chest pain throughout this entire admission. DISCHARGE INSTRUCTIONS: Follow-up appointments to be determined. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Last Name (NamePattern1) 2543**] MEDQUIST36 D: [**2175-11-13**] 13:46 T: [**2175-11-13**] 14:33 JOB#: [**Job Number 53887**]

Admission Date: [**2149-7-29**] Discharge Date: [**2149-8-4**] Date of Birth: [**2117-7-23**] Sex: M Service: CARDIAC SURGERY HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 31 year-old gentleman with a known history of bicuspid aortic valve with severe aortic regurgitation who has been experiencing increasing dyspnea on exertion over the last three months. The patient was seen by Dr. [**Last Name (Prefixes) **] and admitted [**7-29**] for elective aortic valve replacement. Cardiac catheterization in [**2149-10-6**] showed a left ventricular ejection fraction at 52%, severe aortic regurgitation with mild aortic stenosis, mild left ventricular diastolic dysfunction, normal coronary arteries. Echocardiogram from [**2149-1-5**] showed moderate to severe aortic regurgitation, left ventricular ejection fraction of 55%, normal left ventricular function, dilated aortic root and bicuspid aortic valve. PAST MEDICAL HISTORY: Bicuspid aortic valve. MEDICATIONS: Zestril 10 mg po q.d. ALLERGIES: Fava beans. SOCIAL HISTORY: The patient lives with his parents. He denies tobacco use. Occasional ETOH use. HO[**Last Name (STitle) **] COURSE: The patient was admitted [**2149-7-29**] and was taken to the Operating Room with Dr. [**Last Name (Prefixes) **] where he underwent an aortic valve replacement with a 25 mm Carbomedic valve. The patient originally was scheduled for a Bentall procedure, but upon examination by transesophageal echocardiogram in the Operating Room it was found that there was no dilation of the proximal ascending aorta or sinotubular junction, so it was elected to proceed with a aortic valve replacement. Ejection fraction in the Operating Room was 50%. Please see operative note for further details. The patient was transferred to the Intensive Care Unit in stable condition. The patient was weaned and extubated from mechanical ventilation on his first postoperative night. The patient was consistently tachycardic with heart rates in the 1 teens to 120s sinus tachycardia, responded to intravenous Lopressor. The patient remained hemodynamically stable with minimal chest tube drainage. On postoperative day number one the patient began ambulating in the hallway. The patient remained in the Intensive Care Unit due to lack of bed availability on the floor. On postoperative day number two the patient was transferred out of the Intensive Care Unit to the regular floor in stable condition. The patient continued to have sinus tachycardia rates into the 1 teens on increasing doses of Lopressor. There was a question of whether or not the tachycardia was due to poor pain control. The patient's pain medications were switched to Dilaudid and the patient was started on around the clock Motrin, which seemed to improve the patient's pain control, but did not change the sinus tachycardia. Labetalol was added to the patient's regimen of Lopressor, which did improve the tachycardia and heart rate decreased into the 90s to low 100s. On postoperative day number two the patient was started on Coumadin for the patient's mechanical aortic valve. The patient began working with physical therapy and the patient's pacing wires were removed on postoperative day number three. The Labetalol was increased on postoperative day number three for continued tachycardia. On postoperative day number four the patient completed a level five with physical therapy walking 500 feet and climbing one flight of stairs. The patient remained in the hospital for continued titration of his Coumadin therapy. On postoperative day number five the patient's INR rose to 2.0 and on postoperative day number six the patient was cleared for discharge to home. CONDITION ON DISCHARGE: Temperature max 99.1, pulse 99 sinus rhythm, blood pressure 118/70, respiratory rate 16, room air oxygen saturation 95%. The patient's weight on [**8-4**] was 104 kilograms. The patient weighed 109 kilograms preoperatively. Neurologically the patient is awake, alert and oriented times three, nonfocal. Cardiovascular regular rate and rhythm. No murmur or rub, sharp valve click. Lungs breath sounds are clear bilaterally. No rales, wheezes or rhonchi. Gastrointestinal positive bowel wounds, obese, nontender, nondistended. Extremities 2+ pitting edema. Sternal incision is clean and dry. Sternum is intact. There is no erythema or drainage. LABORATORY DATA: White blood cell count 11.3, hematocrit 34.1, platelets count 342, sodium 138, potassium 4.5, chloride 101, bicarb 24, BUN 21, creatinine 0.9 and glucose 145. PT 20.8, INR 2.9. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg po b.i.d. 2. Lasix 20 mg po b.i.d. times seven days. 3. K-Ciel 20 milliequivalents po b.i.d. times seven days. 4. Colace 100 mg po b.i.d. 5. Zantac 150 mg po b.i.d. 6. Labetalol 40 mg po b.i.d. 7. Percocet 5/325 one to two tablets po q 4 hours prn. 8. Ibuprofen 600 mg po q 6 hours prn. 9. Coumadin 3 mg po on [**8-4**]. Blood is to be drawn on [**8-5**] and the results are to be faxed to his primary care physician [**Last Name (NamePattern4) **].[**Name (NI) 14088**] office who will determine further Coumadin dosing. DISCHARGE DIAGNOSES: 1. Aortic regurgitation. 2. Status post aortic valve replacement. Th[**Last Name (STitle) 1050**] is to follow up with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in one to two weeks and by phone on [**8-5**] for a Coumadin dose. The patient is to follow up with Dr. [**Last Name (STitle) 120**] his cardiologist in one to two weeks. The patient is to follow up with Dr. [**Last Name (Prefixes) **] in four weeks. The patient is to be discharged to home in stable condition. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2149-8-4**] 11:23 T: [**2149-8-4**] 11:36 JOB#: [**Job Number 14089**]

Admission Date: [**2185-5-15**] Discharge Date: [**2185-5-23**] Date of Birth: [**2129-2-10**] Sex: M Service: MEDICINE Allergies: Aspirin / Prednisone Attending:[**First Name3 (LF) 898**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: -Right internal jugular central access line placed [**5-15**] and removed [**5-19**] -Peripheral arterial line placement History of Present Illness: Mr. [**Known lastname 24078**] is a 56-year old male with a history of pulmonary sarcoidosis, obstructive sleep apnea and asthma who presents from home with one day of chills, myalgias, cough productive of yellow sputum tinged with blood and right sided chest pain. Of note he was previously diagnosed with community acquired pneumonia in [**Month (only) 956**] and treated with azithromycin with complete resolution of symptoms. He was feeling well until one day prior to presentation when these symptoms developed suddenly. The pain is primarily in the right side of his chest and worsens with deep inspiration. He is unable to take a deep breath secondary to pain. His breathing is worse when lying flat or on his left side. He has had myalgias and chills but has not taken his temperature at home. He has had mild nausea but no vomiting, abdominal pain, diarrhea or constipation. He has had blood tinged sputum for one day. He has been taking normal PO intake and had normal urine output without dysuria. He denies lower extremity edema. He denies any recent travel or sick contacts. [**Name (NI) **] has not been on recent steroids or other immunosuppresants. He is not a smoker. All other review of systems negative. . In the ED, initial vs were: T: 98.7 P: 116 BP: 73/45 R: 16 O2 sat: 88% on RA. He had a chest CT with contrast which showed no pulmonary embolism but showed a severe right middle and right lower lobe pneumonia. He received 5 liters of normal saline. His blood pressure ranged from the 70s to 90s systolic and he subsequently had a right sided sepsis catheter placed and was started on levophed which was soon stopped. He received levofloxacin, vancomycin, aspirin 325 mg and morphine 4 mg IV x 1, tylenol 1000 mg PO x 1. He had an EKG which showed sinus tachycardia, normal axis, normal intervals, isolated 1 mm STE in lead III which resolved on subsequent EKGs. He was admitted to the MICU for further management. . Past Medical History: Sarcoidosis complicated by uveitis Hyperglycemia Hypercholesterolemia Obstructive Sleep Apnea Anxiety Depression Benign Prostatic Hypertrophy Exercise Induced Asthma Social History: He denies a history of smoking, alcohol or illicit drug use. He lives with his wife and his dog. No recent travel or sick contacts. . Family History: No family history of sarcoidosis or other lung disorders. Physical Exam: INITIAL ADMISSION PHYSICAL EXAM ON [**2185-5-15**]: Vitals: T: 97.4 BP: 95/56 P: 96 R: 27 O2: 93% on 100% NRB General: Alert, oriented, tachypneic, not using accessory muscles HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Left side with coarse breath sounds, right with inspiratory and expiratory ronchi, dullness to percussion on the right, egophony on the right CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neurologic: Alert and oriented x 3, strength 5/5 throughout, sensation intact to light touch across all dermatomes . . PHYSICAL EXAM ON TRANSFER TO THE MEDICAL FLOOR FROM ICU ON [**2185-5-19**]: Vital Signs: Tmax [**Age over 90 **]F, BP 142/81, HR 77, RR 18, Oxygen Sat 97% on room air General: Alert & oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Right sided basilat decreased breath sounds and rhonchi with expiration/inspiration, left side with decreased aeroation at bases. 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. Trace edema bilaterally noted (R=L) Neuro: CNs [**3-10**] grossly in tact, PERRLA, EOMI, no focal deficits. Gait assessment deferred. Pertinent Results: ADMISSION LABS: [**2185-5-15**] 11:00AM GLUCOSE-158* UREA N-25* CREAT-1.6* SODIUM-139 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16 [**2185-5-15**] 11:00AM ALT(SGPT)-31 AST(SGOT)-21 CK(CPK)-46 ALK PHOS-64 TOT BILI-1.5, LIPASE-17 [**2185-5-15**] 11:01AM LACTATE-2.4* [**2185-5-15**] 11:00AM TOT PROT-6.4 ALBUMIN-4.0 GLOBULIN-2.4 CALCIUM-9.1 PHOSPHATE-1.9* MAGNESIUM-1.5* [**2185-5-15**] 11:00AM CORTISOL-45.6* [**2185-5-15**] 11:00AM CRP-89.2* [**2185-5-15**] 11:00AM WBC-10.6# RBC-5.22 HGB-14.1 HCT-41.1 MCV-79* MCH-27.0 MCHC-34.4 RDW-13.9 [**2185-5-15**] 11:00AM NEUTS-71* BANDS-18* LYMPHS-6* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2185-5-15**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2185-5-15**] 11:00AM PLT SMR-NORMAL PLT COUNT-183 [**2185-5-15**] 11:00AM PT-14.1* PTT-25.0 INR(PT)-1.2* . . CARDIAC ENZYMES: [**2185-5-15**] 06:16PM CK(CPK)-72 [**2185-5-15**] 06:16PM CK-MB-NotDone cTropnT-<0.01 [**2185-5-15**] 11:00AM cTropnT-<0.01 [**2185-5-15**] 11:00AM CK-MB-NotDone . ABGs: [**2185-5-15**] 06:28PM TYPE-ART TEMP-36.3 PO2-88 PCO2-28* PH-7.42 TOTAL CO2-19* BASE XS--4, LACTATE-1.4 . URINE STUDIES: [**2185-5-15**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2185-5-15**] 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG . IMAGING STUDIES: [**2185-5-15**] PORTABLE CXR -Findings consistent with right lower lobe atelectasis.Superimposed infection cannot be excluded. Document resolution upon treatment to exclude an underlying obstructive process. . [**2185-5-15**] CTA: 1. Severe right middle lobe pneumonia with involvement of portions of the right lower lobe, right upper lobe and lingula. No evidence of aortic dissection or pulmonary embolism. 2. Unchanged sequelae of known underlying sarcoidosis. 3. Unchanged non-obstructive left renal calculi. . [**2185-5-19**] CHEST XRAY, PA AND LATERAL: Since [**5-18**], consolidation in the right middle and lower lobes is improved. Moderate-to-severe left mid and upper pulmonary edema is unchanged. Left-sided pleural effusion is slightly increased from [**2185-5-17**]. Atelectatsis in the right lower lobe is stable. The right central line has been removed. The remainder of the exam is unchanged. IMPRESSION: 1. Improving pneumonia in the right middle and lower lobes. 2. Persistent moderate edema, despite decreased central venous pressure. 3. Slight increase in left side pleural effusion. . MICROBIOLOGY: [**2185-5-15**] Blood Culture, Routine (Final [**2185-5-21**]): NO GROWTH. [**2185-5-16**] Sputum Culture results--> **FINAL REPORT [**2185-5-18**]** GRAM STAIN (Final [**2185-5-16**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2185-5-18**]): SPARSE GROWTH OROPHARYNGEAL FLORA. . [**2185-5-15**] 5:35 pm URINE Source: CVS. **FINAL REPORT [**2185-5-16**]** Legionella Urinary Antigen (Final [**2185-5-16**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . EKGs [**2185-5-15**] -[**2185-5-16**]: Sinus tachycardia, normal axis, normal intervals, isolated 1 mm STE in lead III which resolved on subsequent EKGs . DISCHARGE LABS: Brief Hospital Course: In summary, this is a 56-year-old male with sarcoidosis, OSA, anxiety/depression, and hyperlipidemia who presented with shortness of breath, right sided chest pain and fevers and he was found to have multifocal right sided PNA per chest CT imaging. Admitted to ICU for sepsis concerns in setting of hypotension to systolic range in 70s with mild tachycardia. Resuscitated with generous IVFs and given IV antibiotics, supportive oxygen and briefly on Levophed for blood pressure stabilization. Patient hemodynamically stabilized well over [**1-28**] days in ICU and never required any intubation. He was transferred to general medical floor on [**2185-5-19**]. For more detailed hospital course please see below: . #Multifocal PNA: Patient's initial presentation was concerning for septic shock as he became tachycardic to 120s range and hypotensive to systolic 70s in the emergency room on [**2185-5-15**]. Blood pressures improved with generous IVFs and he only required brief pressor support with Levophed. CTA chest done at admission on [**2185-5-15**] showed right sided multi-focal PNA. Of note, Mr. [**Known lastname 24078**] has pre-existing poor pulmonary reserve at baseline from his sarcoidosis and asthma. He also endured 2 previous bouts of pneumonia over the past year. He was initially started on triple coverage in the ED with Levaquin, and IV Vancomycin & Zosyn. This was continued in the ICU up until [**5-18**] when he was switched to IV Ceftriaxone with continuance of Levaquin. He arrived on the general medical floor on [**5-19**] but appeared to have more labored breathing later in the afternoon so a repeat CXR done and team decided to place him back on his prior Vancomycin and Zosyn regimen and CTX and Levaquin were discontinued. The CXR done [**2185-5-19**] showed mild effusions but overall improving pneumonia in the right middle and lower lobes. He continued to have improved shortness of breath and decreasing oxygen requirements and his cough was persistent but phlegm production lessened. Fevers gradually defervesced. Initial blood cultures were negative. Sputum gram stain showed >25 PMNs and 3+ gram positive cocci in pairs and chains and 2+ gram negative rods also identified. Sputum culture only showed sparse growth of oropharyngeal flora. Patient developed drug rash, leukocytosis and eosinophilia, Zosyn was discontined. Placed only on PO levoquin high-dose. To complete total of 14 day course. asked to follow-up as an outpatient with his pulmonologist, Dr. [**Last Name (STitle) **], over the next few weeks. . #Sarcoidosis: Mr. [**Known lastname 24078**] has both pulmonary sarcoidosis and extrapulmonary manifestations of sarcoid in the form of prior uveitis flare-ups. He does not typically take any home oral steroids on an ongoing basis for his sarcoid and on chest CT on this admission his sarcoid disease appeared to be stable as compared with prior films. Given his acute infection there was no role for any additional steroids on this admission. Moreover, his dyspnea and respiratory congestion seemed to gradually improve on antibiotics and supportive oxygen alone. He was, however, continued on his usual inhaled steroids with ongoing Advair and Albuterol nebulizers. . #Obstructive Sleep Apnea: He was continued on his usual home nightly CPAP regimen while inpatient. . #Hypercholesterolemia: Daily cholestyramine was continued. Mr. [**Known lastname 24078**] had also been enrolled to participate in a research study which included daily administration of possible statin (vs. placebo) and this protocol was completed on [**5-21**]. . #Depression: During his hospital course he had occasional apparent depressed moods at times but denied any suicidal ideation and he maintained an appropriate affect after he was transferred to the general medical floor. He was continued on his usual Effexor and daily clonazepam was continued for his concomitant anxiety. . #Benign Prostatic Hypertrophy: He was given his usual home finasteride therapy and at time of discharge he will return to his usual Flomax as well. He reported no difficulty with urination during his hospital course. . #Exercise Induced Asthma: He was continued on his usual daily Advair and monteleukast. In place of his PRN albuterol inhaler he was given nebulizer treatments on an as-need basis q4-6 hours. . #GERD: He was continued on a PPI regimen for his severe GERD history. . #Hyperglycemia / Pre-diabetes: He had not been on any home standing medications for his mild to moderate hyperglycemic tendency. He had QID fingersticks and a sliding scale insulin regimen with meals and QHS. Fasting and post-prandial glucose levels were predominantly normal to borderline normal for hospital course. No additional standing insulin or oral medications were added to his medications. . # Fluids, Electrolytes and Nutrition: He had several liters of IVFs over the initial 48 hours of his hospital stay and then once he had good PO intake IVFs were tapered. Electrolytes were monitored and repleted as needed and he was continued on a regular diet. . # Prophylaxis: Subcutaneous heparin was given TID for DVT prevention, PPI for GERD as above, and a bowel regimen with Colace and Senna was continued. . # Code Status: Patient was maintained as a full code status for entire hospital course ; confirmed directly with patient. Medications on Admission: Albuterol 90 mcg 1-2 puffs q4-6H:PRN Cholestyramine-Aspartame 2 grams daily Clonazepam 0.5 mg PO daily:PRN Fexofenadine 60 mg Tablet [**Hospital1 **] Finasteride 5 mg PO daily [Proscar] Flomax 0.4 mg daily Fluticasone nasal 50 mcg 2 sprays daily Fluticasone-Salmeterol 500 mcg-50 mcg 1 puff [**Hospital1 **] Montelukast 10 mg PO QHS Omeprazole 40 mg [**Hospital1 **] Ranitidine HCl 300 mg daily Venlafaxine 100 mg TID Aspirin 81 mg q 3 days Bismuth Subsalicylate [Pepto-Bismol] 1 tablet QID:PRN Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-28**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. Cholestyramine-Sucrose 4 gram Packet Sig: 0.5 Packet PO DAILY (Daily). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. Ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO once a day. 12. Venlafaxine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QMOWEFR (Monday -Wednesday-Friday). 14. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1) Tablet PO QID (4 times a day) as needed. 15. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*18 Tablet(s)* Refills:*0* 16. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for Itch for 7 days: Do not drive as this is a sedating medication. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: -Pneumonia -Respiratory distress . Secondary: -Sarcoidosis -Hyperglycemia -Hypercholesterolemia -Obstructive Sleep Apnea -Anxiety -Depression -Benign Prostatic Hypertrophy -Exercise Induced Asthma Discharge Condition: Clinically stable. No apparent distress and normal vital signs at time of discharge. Discharge Instructions: It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted with fevers, a cough and shortness of breath. Additional imaging studies revealed that you had a right sided pneumonia. You were initially taken care of in the intensive care unit where you were given IV antibiotics, IV fluids and supportive oxygen therapy to help with your breathing. . Once you had clinically stabilized and your symptoms improved you were transferred to the general medical wards. You were continued on supportive oxygen which was slowly weaned and antibiotics were continued. Chest physical therapy was also provided to help you recuperate faster. . It is very important that you follow-up with your appointments as listed below. Also, please continue to take all of your listed medications as prescribed and outlined below. . If you experience any new fevers, chills, bloody sputum, worse cough, worse shortness of breath, dizziness, lightheadedness, chest pains, heart palpitations or any other concerning symptoms then please return to the emergency room or call your primary care physician. Followup Instructions: 1) Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **] on [**6-8**] at 8:45am. Phone:[**Telephone/Fax (1) 9347**] . 2) Please call #[**Telephone/Fax (1) 612**] to set up a follow-up appointment with your pulmonologist, Dr. [**Last Name (STitle) **] over the next 1-2 weeks time. . Completed by:[**2185-5-23**]

Admission Date: [**2111-7-1**] Discharge Date: [**2111-7-2**] Service: MED Allergies: Macrobid Attending:[**First Name3 (LF) 99**] Chief Complaint: bradycardia, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 82F w/ PMH sig for HTN, Fe deficiency anemia, cardiomegaly now p/w [**12-26**] mth h/o increasing gait unsteadiness, falls, dysphagia, nonproductive cough, DOE, bilat ankle edema, generalized weakness. Around 9:30pm 1 day PTA, pt's daughter noted her to be pale, cool to the touch, with slurred speech and increased gait unsteadiness. At the time, her PO temp was noted to by 94 degrees w/ SBP in the 90s (baseline 130s), but the patient's daughter did not seek medical attention. Over the course of the day today, the pt was noted to become progressively more lethargic, 'slumping down multiple times' and was thus brought to the ED by her daughter for further eval. ROS also notable for 2 days of subjective chills, constipation, and abdominal pain en route to the ED. Past Medical History: HTN CVA '[**81**] "large heart" no hx MI AI osteoporosis hyperchol L hip pinning TAH/BSO Fe def anemia Social History: lives w/ dtr at home no tob, no EtOH, no OTC/illicit drug use uses wheelchair but independent in all her ADLS Family History: noncontributory Physical Exam: T92.8 BP92/60 P66 RR20 100% sat on AC 550 x 20, peep 5, 100% FiO2 Gen - pale, intubated & sedated [**Year (2 digits) **] - PERRL, OP clear, MM dry Neck - RIJ site ok, no JVP/LAD Lungs - [**Month (only) **] at L base o/w clear CV - RRR, no R/M/G Abd - soft, NT/ND, NABS, no masses, no rebound/guarding Ext - 1+ LE edema bilat, warm, no rashes, 1+ pedal pulses Neuro - moves all 4 ext spont, symmetric DTRs, normal muscle tone Pertinent Results: [**2111-7-1**] 08:15PM WBC-25.5*# RBC-3.02* HGB-8.5* HCT-26.9* MCV-89 MCH-28.0 MCHC-31.4 RDW-14.0 PLT COUNT-135* [**2111-7-1**] 08:23PM GLUCOSE-125* LACTATE-10.1* NA+-135 K+-6.2* CL--101 TCO2-15* UREA N-44* CREAT-3.4*# CALCIUM-8.4 PHOSPHATE-5.6*# MAGNESIUM-1.7 [**2111-7-1**] 08:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-MOD [**2111-7-1**] 08:26PM PO2-274* PCO2-14* PH-7.46* TOTAL CO2-10* BASE XS--9 INTUBATED-INTUBATED O2 SAT-90 [**2111-7-1**] [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: Upon arrival to the ED, the patient was noted by triage nurses to be unresponsive, 'cold & clammy,' with heart rate in the 30s, no palpable pulse, and breathing agonally. No improvement with 1 mg each of atropine, epinephrine, or glucagon, so she was externally paced, intubated, and started on levophed. She was given broad spectrum antibiotic coverage for presumed sepsis (levo/flagyl/vanc), along w/ agressive fluid recussitation and subsequently transferred to the MICU for further management. Unfortunately, despite agressive pressor and fluid therapy, the patient's clinical condition continued to rapidly deteriorate over the next 12 hours. She continued to display signs and symptoms of vasodilatory shock, including hypothermia, a rising lactate, leukocytosis, and hypotension refractory to fluid and maximum dosages of 3 simultaneous pressors. It was decided based on her grave clinical condition and poor prognosis that CPR would not be medically indicated, and the patient passed away at 7am [**2111-7-2**]. Her family was notified, but an autopsy was not granted. Medications on Admission: vitamin d3 400 daily calcium carbonate 500 q6hrs lipitor 10 daily lisinopril 40 daily hctz 25 daily procardia XL 90 daily atenolol 100 daily [**Month/Day/Year **] 325 daily actonel 30 once a week iron 325 twice a day percocent/ambien/[**Last Name (un) **] #3/ativan/trazadone PRN Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Likely Septic/Vasodilatory Shock Discharge Condition: expired Completed by:[**0-0-0**]

Admission Date: [**2198-5-27**] Discharge Date: [**2198-6-5**] Date of Birth: [**2144-10-19**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11344**] Chief Complaint: AMS, hypothermia Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 53yo male with PMH of Cerebral palsy, mental retardation, and seizures who presents via EMS for hypothermia and altered mental status. This AM, his caretaker noticed he was not responding like he normally does and was gurgling. He was found to be hypothermic to 32C. Last night was his normal self with no cough, [**First Name3 (LF) **], abd pain. His caretaker states he presents this way when he has infections. He recently had a uti 3 weeks ago, and completed an abx course. He also went to [**Hospital1 **] 3 days ago for a seizure. He is on keppra, dilantin, and lamictal. In the ED, initial VS were: BP80/55 HR52 RR13 O2sat:100% RA Temp31.5. He received 2LNS with improvment in SBP to 100, which then dropped to 80's systolic again at which point he was started on norepinephrine gtt. A CVL was placed and he received another 500cc. An EKG showed sinus brady 43 qtc 505. Head CT showed no acute process and CXR showed bowel above the liver and no pneumonia. Labs showed WBC count of 2.8 and clean UA. FS 78, and he was started on D5 IVF with the levophen gtt. A dilantin level was 18.2. He was given hydrocortisone 100iv and vancomycin 1gm and zosyn 4.5g for question sepsis. Vital signs prior to transfer were Current VS 64 98% RA 33.7F 109/61 off levophed. For access he has an 18 and a 20g IV. . On arrival to the MICU, his vital signs were T34.6C, HR77, BP136/101, RR18, O2sat:98%. He is noted to have a right sided fat deposit in his right neck near the central line noted in ED. There is no ecchymosis associated with it or stridor appreciated. He is calm and obeys commands intermittantly. . Review of systems: Unable to obtain secondary to altered mental status Past Medical History: Cerebral palsy mental retardation seizures lower extremity edema thought to be secondary to venous insufficiency seasonal allergies contact dermatitis status-post treatment bowel and bladder incontinence, aspiration pneumonia in [**2196**] UTI and aspiration pneumonia in [**2197**] Social History: He lives with his caretaker [**Name (NI) 123**], phone number is [**Telephone/Fax (1) 93387**]. No immediate family is still alive. He goes to daily daycare. His current guardian is [**Name (NI) **] [**Name (NI) 93392**] and the phone number is [**Telephone/Fax (1) 93393**]. At baseline, pt appears to be quite interactive, is able to respond meaningfully. Family History: His aunt passed away 3 years ago from lung cancer. Both parents have passed away. His mother died of heart condition. It is unclear what his father passed away of. Physical Exam: Physical Exam on Admission: Vitals: T34.6C, HR77, BP136/101, RR18, O2sat:98%General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: full ROM, right IJ in place CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: no wheezes or rales, positive for upper airway rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moves all 4 limbs to command, unable to otherwise participate in neuro exam ****************** At discharge: Neuro: awake, alert. Mumbles, typically not able to be understood by anyone who doesn't know him well. Does not follow commands. Looks around room. Moves RUE > others spontaneously, but moves all extremities at least antigravity in response to light touch. Pertinent Results: Lab Results on Admission: [**2198-5-27**] 10:45AM BLOOD WBC-2.3* RBC-4.72 Hgb-14.9 Hct-46.6 MCV-99* MCH-31.7 MCHC-32.1 RDW-14.4 Plt Ct-167 [**2198-5-27**] 10:45AM BLOOD Neuts-56.7 Lymphs-31.3 Monos-4.7 Eos-3.8 Baso-3.6* [**2198-5-27**] 10:45AM BLOOD Glucose-190* UreaN-12 Creat-0.6 Na-145 K-4.7 Cl-110* HCO3-29 AnGap-11 [**2198-5-27**] 10:45AM BLOOD ALT-25 AST-36 AlkPhos-128 TotBili-0.2 [**2198-5-27**] 10:45AM BLOOD cTropnT-<0.01 [**2198-5-27**] 10:45AM BLOOD Albumin-4.0 [**2198-5-28**] 03:52AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.6 [**2198-5-30**] 06:10AM BLOOD Cortsol-8.6 [**2198-5-29**] 03:10AM BLOOD TSH-2.0 [**2198-5-27**] 10:45AM BLOOD Phenyto-18.2 [**2198-5-28**] 03:52AM BLOOD Phenyto-20.2* [**2198-5-27**] 10:53AM BLOOD Lactate-1.4 [**2198-5-27**] 10:53AM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP [**2198-5-27**] 11:14AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2198-5-27**] 11:14AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Discharge labs: [**2198-6-5**] 04:30AM BLOOD WBC-10.8 RBC-4.42* Hgb-14.8 Hct-42.6 MCV-96 MCH-33.4* MCHC-34.7 RDW-13.8 Plt Ct-227 [**2198-6-5**] 04:30AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-139 K-4.4 Cl-100 HCO3-28 AnGap-15 [**2198-6-5**] 04:30AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1 [**2198-6-4**] 05:25AM BLOOD Phenyto-20.0 [**2198-5-30**] 12:29 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2198-5-31**]** C. difficile DNA amplification assay (Final [**2198-5-31**]): This test was cancelled because a FORMED stool specimen was received, and is NOT acceptable for the C. difficle DNA amplification testing.. PATIENT CREDITED. Studies: Cardiovascular Report ECG Study Date of [**2198-5-27**] 10:46:20 AM Marked sinus bradycardia at 43 beats per minute. Q-T interval is prolonged. Cannot rule out inferoposterior myocardial infarction of indeterminate age. Compared to the previous tracing of [**2198-4-30**] there is no significant change Radiology Report CT HEAD W/O CONTRAST Study Date of [**2198-5-27**] 10:41 AM IMPRESSION: 1. No acute hemorrhage or intracranial process. 2. Chronic developmental abnormalities . Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-5-27**] 10:51 AM IMPRESSION: No acute intrathoracic process within the limitations of this study. Radiology Report -77 BY DIFFERENT PHYSICIAN [**Name9 (PRE) 2221**] Date of [**2198-5-27**] 1:33 PM FINDINGS: Tip of right internal jugular central venous catheter terminates in the expected location of the body of the right atrium and could be withdrawn several centimeters for standard positioning. There is no visible pneumothorax. Lung volumes remain low, accentuating the cardiac silhouette and bronchovascular structures. Even allowing for this factor, there is likely mild pulmonary vascular congestion present. Patchy areas of atelectasis have developed at both bases. Questionable small left pleural effusion. Radiology Report -76 BY SAME PHYSICIAN [**Name9 (PRE) 2221**] Date of [**2198-5-27**] 2:34 PM FINDINGS: Tip of right internal jugular central venous catheter may have been withdrawn slightly, but continues to terminate in the expected location of the body of the right atrium below the cavoatrial junction. Otherwise, no significant change in the appearance of the chest since the recent radiograph performed about one hour earlier. Neurophysiology Report EEG Study Date of [**2198-5-28**] IMPRESSION: This is an abnormal continuous ICU monitoring study because of the presence of a moderately diffuse encephalopathy with extremely active epileptiform features that are both multifocal and generalized in their appearance. Additionally, there were two sustained electrographic seizures recorded and are reported above. Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-5-28**] 11:35 AM IMPRESSION: Nasogastric tube in the stomach The preliminary impression that the tube could have folded back on itself in the gastro-esophageal junction was communicated with Dr. [**Last Name (STitle) **] at 2 p.m by phone at [**2198-5-28**]. After subsequent confirmatory radiograph, final positioning was communicated via page at 3 pm. Radiology Report PORTABLE ABDOMEN Study Date of [**2198-5-28**] 11:35 AM IMPRESSION: No radiographic evidence for obstruction. Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-5-28**] 2:21 PM IMPRESSION: Nasoenteric tube projects over the expected position of the stomach. Neurophysiology Report EEG: [**2198-5-29**] IMPRESSION: This is an abnormal continuous ICU monitoring study because of the presence of a mild to moderate diffuse encephalopathy with extremely active paroxysmal multifocal independent interictal discharges and frequent runs of generalized rhythmic epileptiform activity. These bursts and discharges did not appear to have an obvious clinical accompaniment. In comparison to the previous day's tracing, there were no symptomatic electrographic/clinical seizures. [**5-30**]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of mild diffuse encephalopathy with perhaps some subtle left hemisphere predominance. There is extremely active multifocal and generalized epileptiform activity. Some of the latter activity appeared to be sustained but not associated with any clear clinical accompaniment. [**5-31**]: IMPRESSION: This is an abnormal video EEG monitoring session because of a prolonged electrographic seizure accompanied by clinical features as described under pushbutton activations. Also, in the second half of the recording, there were 10-15 seconds runs of epileptic discharges and one of these that lasted 20 seconds had minor left arm tonic extension and likely represented a brief seizure. In addition, there were frequent generalized polyspikes and abundant multifocal epileptic discharges. These findings are indicative of diffuse cortical irritability with epileptogenicity. In addition, background activity was diffusely slow and disorganized with intermittent runs of further slowing indicative of moderate diffuse encephalopathy consistent with patient's history of static encephalopathy. Compared to the prior day's recording, this study was worse due to significant increased in epileptiform activity and two electrographic seizures. [**6-1**]: IMPRESSION: This is an abnormal video-EEG monitoring session due to frequent generalized polyspikes and abundant multifocal epileptic discharges. These findings are indicative of diffuse cortical irritability with potential epileptogenicity. Additionally, background activity was disorganized and diffusely slow indicative of moderate diffuse encephalopathy consistent with patients history of static encephalopathy. Compared to the prior day's recording, this study was significantly improved due to absence of electrographic seizures. [**6-2**]: IMPRESSION: This is an abnormal video-EEG monitoring session because of frequent generalized polyspikes and abundant multifocal epileptic discharges. These findings are suggestive of wide spread cortical irritability with potential epileptogenicity. In addtion, background activity was diffusely slow and disorganized signifying moderate diffuse encephalopathy consistent with patients history of static encephalopathy. Compared to the prior day's recording, this study was unchanged. [**6-3**]: IMPRESSION: This is an abnormal video-EEG monitoring session because of two electrographic and clinical seizures lasting less than one minute. These seizures are described earlier under pushbutton activations and seizure detection programs. In addition there were abundant multifocal epileptic discharges and frequent generalized polyspike discharges. These findings are indicative of wide spread cortical irritability with potential epileptogenicity. Furthermore, background activity was disorganized and diffusely slow indicative of a moderate diffuse encephalopathy consistent with patients history of static encephalopathy. Compared to the prior day's recording, this study was worse due to two brief electrographic seizures. [**6-4**]: [**6-5**]: pending Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient is a 53yo male with PMH of Cerebral palsy, mental retardation, and seizures who presented via EMS for hypothermia and altered mental status. He was treated recently for UTI 3 weeks prior to admission and had completed a course of antibiotics. On presentation to the ED he became hypotensive, and recovered his blood pressure with IVF and hydrocortisone. He was admitted to the ICU where he was rewarmed with the bair hugger and maintained blood pressure without aggressive fluid resuscitationa or pressors after initial resuscitation. He experienced several short-lasting seizures in the unit and was transferred to the floor with hypothermia and shock picture resolved and no infectious source indentified. He was transferred to the neurology epilepsy monitoring unit. . # Hypothermia: Patient had temperature reportedly at 32C at home and recorded at 31.5C in the ED. It recovered with bair hiffer but dropped again to 34C on [**5-29**] with recovery on bair hugger again. He was not hypotensive following the initial resuscitation. Potential etiologies of hypothermia include hypothalamic dysfunction vs. hypopituitarism vs. medications, infection, post-ictal state. TSH found to be normal along with AM cortisol. After cultures, exam, and monitoring, no infectious source was identified. Vancomycin and Zosyn were started on admission but discontinued after [**Month/Year (2) **] curve and WBC returned to [**Location 213**] with no source on culture data. . 2. Seizure Disorder: Patient has baseline seizure disorder on 3 different anti-epileptics. He has had recent dose adjustments at home and a presentation for seizure 3 days PTA at OSH. Overnight on [**4-11**], patient had another cluster of 3 brief tonic-clonic seizures and was given 1mg lorazepam. EEG from [**5-28**] showed epileptiform discharges and brief organized seizures. The EEG from [**5-29**] showed no organized seizure activity. He was continued on levetiracetam, phenytoin, and lamotrigine via NGT. Antibiotics were discontinued when no infectious source was identified and it was felt that the antibiotics were lowering the seizure threshold. During his monitoring, he had several more seizure including 1 prolonged (45min) clonic seizure that involved 1-2 min of right arm extention followed by agitated behavior. His antiepileptics were increased as follows: MEDICATION INCREASES: Lamictal 300mg by mouth twice daily Levetiracetam (Keppra) 2000mg by mouth twice daily CONTINUED: phenytoin (Dilantin) 100mg by mouth twice daily He was at his typically seizure baseline prior to discharge. . 3. Shock: Patient had hypotension, hypothermia, and WBC count <4000 on admission, meeting criteria for shock. Underlying infection was suspected but no infectious source was identified. He rceived Fluid resuscitation and pressors resolved patient's hypotension in the first night and he required no further resuscitation following. . # Altered mental status: Patient remained more somnolent than baseline on admission. He presented with acute change in behavior from his baseline interactiveness to minimal responsiveness. He reportedly has presented like this with infections in the past. Differential includes infection, seizure, or toxic/metabolic encephalopathy. TSH checked and normal, as was cortisol. He was seen to have organized seizure activity on EEG monitoring and his AEDs were adjusted as mentioned above. He returned to his normal mental baseline (per caregiver) prior to discharge. . # Gurgling in throat: Patient's caregiver reports that he has a new gurgling sound in his throat. This is likely secretions from URI but may represtent aspiration, especially considering he is being treated for potential infection. Speech and swallow saw patient and found him to be safe to swallow with no aspiration. . #Hct drop: Patient??????s Hct dropped from 46.6 to 37.2 overnight [**5-27**], then slowly downtrending from there to 36.9. Possibly from fluid boluses and hospitalization. Patient was hemodynamically stable and has no obvious sign of bleed, and Hct stabilized and then returned to baseline without intervention. Medications on Admission: hydrocortisone 2.5% cream apply to areas of redness twice daily as needed lamotrigine 250mg PO BID levetiracetam 500mg tabs. Take 3 tabs by mouth at 6am and 4 tabs by mouth at 9pm dilantin 200mg PO once daily???? timolol maleate 0.5% solution. 1 gtt to the right eye QAM MVI one capsule daily loratadine 10mg PO daily senna 8.6 mg PO BID prn constipation potassium chloride 10meq PO daily bisacodyl 10mg PR daily prn constipation thiamine 100mg PO daily carbamide peroxide 6.5%drops, one dropper full each day as needed for ear wax Discharge Medications: 1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 2. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*2* 3. loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day): hold for loose stool. 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 9. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: viral infection epilepsy generalized clonic seizures Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro: awake, alert. Mumbles, typically not able to be understood by anyone who doesn't know him well. Does not follow commands. Looks around room. Moves RUE > others spontaneously, but moves all extremities at least antigravity in response to light touch. Discharge Instructions: Dear Mr. [**Known lastname 26010**] and your caregiver, [**Name (NI) **] were admitted to the hospital for evaluation of seizures and hypothermia. We did an infection evaluation that did not show any specific source for infection, likely indicating a viral illness as a cause of your temperature changes and seizure frequency. While you were here we saw a long seizure that started with the right arm going out straight, followed by agitated behavior. We increased two of your seizure medications, Lamictal and and levetiracetam (Keppra). We increased these medications as listed below, and your caregiver felt that you were at your baseline prior to discharge. Please continue on the same phenytoin (Dilantin) dose as you were previously was taking. MEDICATION INCREASES: Lamictal 300mg by mouth twice daily Levetiracetam (Keppra) 2000mg by mouth twice daily CONTINUE: phenytoin (Dilantin) 100mg by mouth twice daily Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2442**] in the [**Hospital 875**] clinic as follows: Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2198-8-21**] 9:00 Please follow up at your previously scheduled appointments: Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 1112**], MD Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2198-6-6**] 1:45 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2199-5-7**] 9:45

Admission Date: [**2146-9-19**] Discharge Date: [**2146-9-27**] Date of Birth: [**2074-12-2**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Aortic stenosis Major Surgical or Invasive Procedure: [**2146-9-22**]: Aortic valve replacement with a size 21-mm [**Doctor Last Name **] Magna tissue valve. History of Present Illness: 71 year old male who has been experiencing mild chest pressure dizziness, fatigue and SOB over the past several months. He presented to [**Hospital 11560**] [**Hospital3 **] [**9-15**] with worsenig SOB and chest pain that extended into his left hand. He also notes dyspnea on exertion when climbing stairs. He was admitted and ruled out for myocardial infarction. His echocardiogram revealed significant aortic stenosis. Cardiac cath revealed no sigificant CAD and carotids were clear. Of note during this admission he was noted to have thrombocytopenia with platelet counts around 70,000 and was seen by Hematology who felt that he had idiopathic thrombocytopenic purpura. They ok's him to receive ASA and to proceed with the cath. He was transferred to [**Hospital1 18**] for surgical evaluation for an aortic valve replacement. Past Medical History: Aortic Stenosis Benign Prostatic Hyperplasia Thrombocytopneia I ITP Past Surgical History: Tonsillectomy herniorrhaphy Social History: Race:Caucasian Last Dental Exam: Lives with: wife, has 3 daughters Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 112498**] Occupation: Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [x] [**2-8**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Father died at 65 in sleep Mother died at 90 with Diabetes Sister had breast cancer Brother had stomach cancer at 62 Physical Exam: Physical Exam Pulse:63 Resp:18 O2 sat:97/RA B/P Right:134/81 Left:128/84 Height: 5'8" Weight:205 lbs General: Skin: Warm [x] Dry [x] intact [xX] HEENT: NCAT [X] PERRLA [X] EOMI [x] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade [**4-8**] HSM______ Abdomen: Round Soft [X] non-distended [X] non-tender [X] bowel sounds + [] Extremities: Warm [X], well-perfused [X] Edema [] _____ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: +2 Left:+2 DP Right: +2 Left:+2 PT [**Name (NI) 167**]:+2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit: Right: referred Left:Referred Pertinent Results: Echocardgiogram [**2146-9-22**] PREBYPASS: Normal LV wall motion and systolic function with LVEF > 55%. Mild to moderated LVH. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined because of the level of calcification, but it is functionally bicuspid.. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). The mitral valve appears structurally normal with trivial mitral regurgitation. Normal TV and PV. No clot in LAA. Intact interatrial septum with no PFO seen. The descending thoracic aorta has mild diffuse atherosclerotic plaque. The coronary sinus appears normal. Normal transmitral diastolic inflow velocity spectral profile (E > A)and pulmonary venous spectral Doppler profile (S >D) With e' = 6-8 cm/sec indicating perhaps either normal diastolic function or a mild decrease in active relaxation. There is no pericardial effusion. POSTBYPASS: Normallly functioning bioprosthetic AV with no significant AS or AI. LVEF > 60%, Otherwise unchanged Spleen Ultrasound [**2146-9-21**]: Transverse and sagittal images were obtained of the spleen. There is borderline splenomegaly and the spleen measures 13.3 cm in length. IMPRESSION: Borderline splenomegaly. Chest CT [**2146-9-20**]: FINDINGS: Cardiac size is normal. The aorta is normal in caliber. The ascending aorta measures up to 3.4 cm. There is a tiny area of calcification in the proximal medial ascending aorta. There is also two small calcifications in the arch. The descending aorta is normal in caliber. Mediastinal lymph nodes do not meet CT criteria for pathologic enlargement. There is calcification of the aortic valve. There is no pleural or pericardial effusion Peripheral Blood Smear: Normal RBC and WBC morphology, big platelets and rare megakaryocyte fragments. . [**2146-9-27**] 06:10AM BLOOD WBC-6.5 RBC-3.37* Hgb-10.4* Hct-30.4* MCV-90 MCH-30.9 MCHC-34.2 RDW-14.3 Plt Ct-132* [**2146-9-26**] 05:22AM BLOOD WBC-5.4 RBC-3.30* Hgb-10.3* Hct-29.2* MCV-89 MCH-31.2 MCHC-35.2* RDW-14.2 Plt Ct-113* [**2146-9-25**] 04:54AM BLOOD WBC-6.4 RBC-3.19* Hgb-9.8* Hct-28.2* MCV-88 MCH-30.8 MCHC-34.9 RDW-14.5 Plt Ct-85* [**2146-9-24**] 01:31AM BLOOD WBC-7.9 RBC-3.54* Hgb-10.9* Hct-30.9* MCV-87 MCH-30.8 MCHC-35.3* RDW-14.5 Plt Ct-120* [**2146-9-27**] 06:10AM BLOOD PT-13.0* PTT-25.3 INR(PT)-1.2* [**2146-9-24**] 01:31AM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.3* [**2146-9-27**] 06:10AM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-137 K-4.4 Cl-102 HCO3-30 AnGap-9 [**2146-9-26**] 05:22AM BLOOD Glucose-102* UreaN-20 Creat-0.7 Na-136 K-3.8 Cl-99 HCO3-32 AnGap-9 [**2146-9-25**] 04:54AM BLOOD Glucose-105* UreaN-16 Creat-0.8 Na-138 K-3.9 Cl-101 HCO3-30 AnGap-11 Brief Hospital Course: Mr. [**Known lastname **] was transfer from [**Hospital6 3105**] for surgical evaluation for an aortic valve replacement. Hematology was consulted for his underlying cause of thrombocytopenia, which is unclear. Splenic Ultrasound showed Borderline splenomegaly. Given the range of his current platelet count it would be safe for him to undergo heart surgery with the appropriate anticoagulation. The patient was brought to the Operating Room on [**2146-9-22**] where the patient underwent Aortic valve replacement with a size 21-mm [**Doctor Last Name **] Magna tissue valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with services in good condition with appropriate follow up instructions. Medications on Admission: None Discharge Medications: 1. Aspirin EC 81 mg PO DAILY if extubated RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Atorvastatin 10 mg PO DAILY RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 4. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily Disp #*7 Packet Refills:*0 5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg [**1-3**] tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 6. Metoprolol Tartrate 25 mg PO TID hold for hr less than 60 and sbp less than 100 RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: Care Tenders Discharge Diagnosis: Aortic Stenosis Benign Prostatic Hyperplasia Thrombocytopneia I ITP ? MRSA UTI, Tonsillectomy herniorrhaphy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2146-10-4**] 10:45 Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2146-10-25**] 1:30 Cardiologist Dr. [**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**] [**2146-10-20**] at 1:00pm ( Address: [**Doctor Last Name **] [**Hospital1 3597**], NH Phone: [**Telephone/Fax (1) 37284**]) Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],RAOUF [**Telephone/Fax (1) 112499**] in [**4-7**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2146-9-27**]

Admission Date: [**2169-6-9**] Discharge Date: [**2169-6-13**] Date of Birth: [**2103-1-1**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Doctor First Name 1402**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: none History of Present Illness: 66M with no known PMH, but suspected HTN and DM, who presents with shortness of breath and increased LE edema. The patient has not followed up with doctors, and is a somewhat difficult historian, but essentially reports 2-3 weeks of increased difficulty breathing, with LE edema and difficulty ambulating at home with a fall this AM. He reports having to sleep sitting in a chair for the past year and a half. Denies any chest pain at rest or with exertion; no LH, palpitations, URI sx, F/C. Reports an occasional cough, non-productive. Was seen in ED about a year ago for a fall on the job, where he was noted to have elevated sugars and hypertension, and was seen in follow up not at [**Hospital1 18**] (uncertain where), and was told to start metformin although he did not take it. Reports today that he woke from sleep and "couldn't get a deep breath." Tried to walk around, but felt unsteady and apparently fell, although he did not hit his head. No LOC or presyncope Past Medical History: ?Hyperglycemia, HTN. s/p injury from fall about 1 year ago--seen in [**Hospital1 18**] ED. Social History: Retired appliance technician and mechanic, retired since injury last year. Lives in [**Location 86**] with wife, son here as well. Smoked 1-2ppd over 30+ years, quit about 20 years ago. ETOH: about 3 pints of whisky a week, with heavier use in younger years (about 1.5 gallons a week). Denies cocaine or IVDU. Family History: No significant CAD, HTN, DM Physical Exam: per Dr. [**Last Name (STitle) **]: VS: T 97.5 BP 146/88 HR 107 RR 28 O2 95% 2LNC Gen: Obese male, NAD. Slightly dyspneic. HEENT: NCAT. Sclera anicteric. Dry MM. Neck: Supple with JVD to ear. Thick neck. CV: Irregularly irregular, normal S1, S2. P2 tap on palpation. No m/r/g appreciated. No S3 or S4. Chest: BS BL, diminished at bases. No appreciable crackles, wheezes. Abd: Distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: Skin changes c/w venous stasis. 3+ pitting edema. Skin: Acanthosis nigricans on neck. Venous stasis changes as above. Pertinent Results: Admit EKG: Atypical flutter vs Afib at 122. Low voltage. NL axis/intervals. QS in V1V2 concerning for prior anterior MI. Nonspecific TW flattening in inferior-lateral leads. No prior available for comparison. . Admit CXR: Cardiac size cannot be evaluated. Large bilateral pleural effusions are present. Some upper zone redistribution is seen. Appearances are most suggestive of cardiac failure. Infiltrates in both lower lobes cannot be excluded. IMPRESSION: Evidence of failure with bilateral effusions. . Admit labs: Trop-T: 0.01 to 0.02 CK: 214 to 146 MB: 5 to 4 136 97 8 --------------< 331 4.2 34 1.0 ALT: 38 AP: 79 Tbili: 0.4 Alb: 3.6 AST: 29 LDH: Dbili: TProt: TSH:2.8 Cholesterol:149 Triglyc: 79 HDL: 65 LDLcalc: 68 proBNP: 1730 . 14.2 6.5 >----< 230 43.6 N:63.7 L:26.7 M:7.8 E:1.7 Bas:0.1 . Discharge labs: WBC-5.1 RBC-4.78 Hgb-13.3* Hct-41.4 Plt Ct-222 PT-13.8* PTT-53.1* INR(PT)-1.2* Glucose-150* UreaN-11 Creat-0.9 Na-141 K-4.2 Cl-100 HCO3-36* AnGap-9 . Radiology [**6-11**]: Echo: The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 16-20 mmHg. There is moderate symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%). The right ventricular cavity is moderately dilated with free wall hypokinesis. 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. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The main pulmonary artery is dilated. There is no pericardial effusion. IMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis, pulmonary artery dilation and moderate pulmonary artery systolic hypertension. This constellation of findings is suggestive of a primary pulmonary process. Prominent left ventricular hypertrophy with low normal systolic function. In the absence of a history of systemic hypertension, an infiltrative process (e.g., amyloid) should be considered. . [**6-12**]: DVT scan: negative Brief Hospital Course: 66M with likely PMH DM, HTN, and COPD, who p/w progressive LE edema and shortness of breath in the setting of taking no medications. He was also found to be in atrial fibrillation. Hospital course by problem: . #) CHF: diastolic dysfunction and predominantly right sided heart failure. The patient likely had untreated CHF and a progressive decline. The etiology was likely [**2-10**] 1) untreated HTN leading to diastolic dysfunction, 2) OSA leading to right heart failure, and 3) atrial fib leading to mild systolic dysfunction. We aggressively diuresed initially to IV lasix (pt responds to 40 IV) with goal 2-3 L negative per day. We diuresed 11L with improvement in his O2 requirement to RA and improvement in his leg edema. He also initially was treated with a nitro gtt but this was weaned off in the setting of starting the ACEi, aldactone, lasix PO, and BB. The patient had an echo as above which supported these conclusions. Upon discharge, he was on RA and ambulating. We also counseled him on the importance of low Na diet and monitoring weight closely. ** discharge weight is 136 kilograms ** . # Cards Ischemic: There was no evidence of ischemia which prompted the above exacerbation. EKG and echo as above. We started ASA, checked lipids, treated with BB. He will need close followup with PCP and NP as outpt for management. . # Cards Rhythm: patient presented in AFib with unknown chronicity. We treated with increasing doses of metoprolol for rate control. We also treated with heparin gtt and bridged with coumadin for three days. His INR remained subtherapeutic at d/c. He received coumadin 5mg qhs x3 doses. Per [**Company 191**] anticoag nurses, we discharged him on 7.5mg qhs x1 then back to 5mg qhs thereafter. He has an INR check scheduled for [**6-15**] at [**Company 191**]. -We recommend he followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] for echo and potential DCCV in [**1-10**] months if he is documented properly anticoagulated for >1 month time. We are concerned he will not be a good candidate for longterm anticoagulation given poor med compliance in the past. TSH normal. . # DM: A1c was checked and pending. We treated with ISS and temporarily with glargine. We held metformin on dispo given his heart failure. We started glyburide 5 daily with followup in [**Last Name (un) **]. If he becomes hypoglycemic, please d/c glyburide. . # OSA: patient with witnessed desats and apneic episodes at night. Has thick neck. We were unable to get BiPap trial in house [**2-10**] patient refusal. He will benefit from outpt sleep study. This was strongly conveyed to patient and wife. . # HTN: ACEI, aldactone, and BB as above, titrated up to current doses . # Dysuria: U/A neg, resolved. received one dose of cipro but this was stopped. . # FEN: DM/Low Na/Cardiac diet. Lytes need to be checked later this week then again several weeks later to ensure that K and Creatinine are stable. . # Code: Full . # Contact/social: family very involved. patient had not received medical care in the past. He will need frequent followup and encouragement. Without his wife present, he can get somewhat agitated but redirected easily. . # Dispo: we strongly recommended rehab but the patient refused. Medications on Admission: none Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. GlyBURIDE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Succinate 100 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* 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Outpatient Lab Work please have your INR and electrolytes checked on [**6-15**]. Your goal INR is [**2-11**] and your coumadin may need to be adjusted. Your potassium needs to be monitored and your cardiac meds adjusted as needed. 8. Warfarin 2.5 mg Tablet Sig: variable Tablet PO at bedtime: ** take 3 tabs (7.5mg) the night of [**6-13**], then 2 tabs (5mg) the following night. then have your INR checked on [**6-15**] and the [**Company 191**] nurses will make further adjustments. Disp:*100 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: - CHF exacerbation: right sided failure, mild systolic dysfunction, diastolic dysfunction. - DMII - HTN - Atrial fibrillation (unknown duration) - likely obstructive sleep apnea Secondary: - hyperlipidemia Discharge Condition: fair Discharge Instructions: You were admitted with shortness of breath. You had atrial fibrillation and congestive heart failure. You also have diabetes, high blood pressure, high cholesterol, and obstructive sleep apnea. We treated you for all of these conditions. . You came in with no medications. We started multiple medications and it is very important for you to take them all as instructed. . You need to keep your followup appointments as scheduled. It is important for you to have your coumadin level checked regularly. You should also have your electrolytes and INR checked within three days . Please weigh yourself daily. Please adhere to a low sodium diet. Your weight on discharge was 136 kilograms. If you gain more than 2 pounds in a day, please contact your PCP. . Please contact your PCP or return to the emergency department if you experience shortness of breath, chest pain, worsening leg swelling, abdominal pain, dizziness, severe headache. . We recommended that you go to rehab for a short stay to improve your physical and medical health. You refused despite our request. Followup Instructions: *** Please contact [**Name (NI) 191**] at [**Telephone/Fax (1) **] TONIGHT or TOMORROW to confirm your registration info. ***** Please followup with Dr. [**Last Name (STitle) **] at [**Company 191**] on [**6-15**] at 4:10 pm. His number is [**Telephone/Fax (1) **]. His office is located on [**Hospital Ward Name 23**] [**Location (un) **] in the central suite. Please have lab work performed at this time. . Please followup with Dr. [**First Name8 (NamePattern2) 48991**] [**Name (STitle) 19868**] on [**7-19**] at 2pm. His office is located in the [**Hospital 191**] clinic on [**Hospital Ward Name 23**] 6, at [**Hospital1 18**] [**Hospital Ward Name **]. Phone number [**Telephone/Fax (1) **]. . Please followup in the [**Hospital **] Clinic. They are located at 1 [**Last Name (un) **] Way. Phone number: ([**Telephone/Fax (1) 4847**]. Thursday [**6-22**] at 2pm. . Please followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in one month. His number is ([**Telephone/Fax (1) 1987**]. Please contact his office for an appointment. . Please have a sleep study performed. The phone number is ([**Telephone/Fax (1) 48992**]. Please contact them for an appointment . The coumadin clinic at the [**Company 191**] center will monitor your coumadin level for you.

Admission Date: [**2104-9-14**] Discharge Date: [**2104-9-28**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 21990**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: [**Age over 90 **]M h/o CAD/CABG, Dementia, who presented to [**Hospital1 18**] ED with fever (101.5) and mild decr of OS (93%) with CXR demonstrating LLL infiltrate. He also had RLE erythema consistent with cellulitis. Pt was given IV levaquin, flagyl, and ancef and was DCed back to NH on PO levaquin/flagyl/keflex. Once at the NH, he had rigors/shaking, hypoxia (OS74%) and he promptly returned to the ED. He received Benzos en transit to the ED for empiric seizure Rx. In the ED, he was lethargic, T104.6, HR110, BP160/100, RR14 and OS100%. He was intubated emergently for airway protection and was placed on the sepsis protocol. He received ceftriaxone 1 gm IV , vancomycin 1 gm IV, and IVF (total of 5L NS). A CK was 1012, MB 72 (MBI 7.1) and troponin was 1.31. EKG showed only an old RBBB. Health care proxy met with cardiologist, decided that pt should be DNR and is not cath candidate, but they decided to keep pt intubated. Later in ED, had recurrence of possible seizure activity. He was seen by Neuro: head CT was negative, LP with thousands RBCs (but reported traumatic tap). Pt was started on empiric acyclovir for possible HSV Meningitis. Pt was then sent to [**Hospital Unit Name 153**]. Past Medical History: Dementia, CAD S/P CABG ([**2086**]) S/P NSTEMI ([**9-13**]), CHF (EF43% - '[**02**]), 2+ MR, Chronic Venous Stasis, HTN, Glaucoma Social History: Pt is demented, but is reportedly functional at baseline in his nursing home. He converses with all the other residents, is quite social, and can feed himself. He is continent of stool and urine. No tobacco/EtOH. Family History: Unknown. Physical Exam: T99.7 BP120/57 HR84 RR28 OS97%RA GEN: Awake and Alert. Conversing (wants to go home). SKIN: Warm and dry. RLE erythema now absent. CV: RRR. II/VI SEM LSB/Apex Rad to Axilla. Lungs: Mild end-expiratory wheezes at R base. Dim BS at L base. ABD: Mildly distended. S/NT. Pos BS. Ext: No C/C/E. 1+ DPs. Pertinent Results: [**2104-9-25**] 03:30AM BLOOD WBC-16.1* RBC-3.50* Hgb-10.3* Hct-32.0* MCV-91 MCH-29.4 MCHC-32.2 RDW-13.8 Plt Ct-322 [**2104-9-24**] 04:18AM BLOOD WBC-14.7* RBC-3.25* Hgb-9.8* Hct-29.3* MCV-90 MCH-30.1 MCHC-33.4 RDW-14.5 Plt Ct-293 [**2104-9-23**] 04:15AM BLOOD WBC-18.0* RBC-3.29* Hgb-9.6* Hct-29.8* MCV-91 MCH-29.1 MCHC-32.1 RDW-14.0 Plt Ct-260 [**2104-9-22**] 05:36PM BLOOD WBC-21.2*# RBC-3.52* Hgb-10.6* Hct-32.1* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.4 Plt Ct-306 [**2104-9-22**] 06:34AM BLOOD WBC-13.9* RBC-3.59* Hgb-10.7* Hct-32.2* MCV-90 MCH-29.8 MCHC-33.3 RDW-14.4 Plt Ct-305 [**2104-9-21**] 05:00AM BLOOD WBC-12.4* RBC-3.92* Hgb-11.6* Hct-34.6* MCV-88 MCH-29.7 MCHC-33.7 RDW-13.8 Plt Ct-322 [**2104-9-20**] 05:49AM BLOOD WBC-9.7 RBC-3.62* Hgb-10.8* Hct-32.2* MCV-89 MCH-29.7 MCHC-33.4 RDW-13.9 Plt Ct-256 [**2104-9-19**] 04:28AM BLOOD WBC-7.6 RBC-3.45* Hgb-10.5* Hct-30.0* MCV-87 MCH-30.6 MCHC-35.1* RDW-14.4 Plt Ct-227 [**2104-9-18**] 03:57AM BLOOD WBC-8.1 RBC-3.39* Hgb-10.2* Hct-29.7* MCV-87 MCH-30.0 MCHC-34.3 RDW-14.0 Plt Ct-183 [**2104-9-17**] 05:00AM BLOOD WBC-8.1 RBC-3.48* Hgb-10.6* Hct-30.7* MCV-88 MCH-30.4 MCHC-34.4 RDW-14.7 Plt Ct-171 [**2104-9-16**] 05:15AM BLOOD WBC-7.5 RBC-3.36* Hgb-10.1* Hct-29.5* MCV-88 MCH-30.0 MCHC-34.1 RDW-14.0 Plt Ct-159 [**2104-9-15**] 11:56AM BLOOD WBC-7.3 RBC-3.76* Hgb-11.2* Hct-33.0* MCV-88 MCH-29.8 MCHC-33.9 RDW-14.5 Plt Ct-160 [**2104-9-15**] 05:12AM BLOOD WBC-7.1 RBC-3.54* Hgb-10.8* Hct-30.9* MCV-88 MCH-30.4 MCHC-34.7 RDW-14.3 Plt Ct-147* [**2104-9-14**] 05:00PM BLOOD WBC-9.9 RBC-4.04* Hgb-12.2* Hct-36.8* MCV-91 MCH-30.1 MCHC-33.0 RDW-13.7 Plt Ct-186 [**2104-9-14**] 04:30AM BLOOD WBC-6.8 RBC-4.22* Hgb-12.5* Hct-36.5* MCV-86 MCH-29.5 MCHC-34.2 RDW-13.6 Plt Ct-191 [**2104-9-25**] 03:30AM BLOOD Plt Ct-322 [**2104-9-24**] 04:18AM BLOOD Plt Ct-293 [**2104-9-24**] 04:18AM BLOOD PT-13.0 PTT-41.4* INR(PT)-1.1 [**2104-9-23**] 04:15AM BLOOD PT-13.2 PTT-56.8* INR(PT)-1.1 [**2104-9-22**] 06:34AM BLOOD PT-13.0 PTT-41.0* INR(PT)-1.1 [**2104-9-18**] 03:57AM BLOOD PT-13.5 PTT-53.1* INR(PT)-1.2 [**2104-9-15**] 06:54AM BLOOD PT-13.7* PTT-65.2* INR(PT)-1.2 [**2104-9-14**] 05:00PM BLOOD PT-13.7* PTT-42.2* INR(PT)-1.2 [**2104-9-14**] 04:30AM BLOOD PT-13.3 PTT-43.3* INR(PT)-1.1 [**2104-9-25**] 03:30AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-141 K-4.1 Cl-104 HCO3-24 AnGap-17 [**2104-9-24**] 04:18AM BLOOD Glucose-95 UreaN-36* Creat-0.9 Na-139 K-4.3 Cl-104 HCO3-27 AnGap-12 [**2104-9-22**] 05:36PM BLOOD Glucose-159* UreaN-44* Creat-1.2 Na-139 K-3.7 Cl-101 HCO3-25 AnGap-17 [**2104-9-21**] 05:00AM BLOOD Glucose-118* UreaN-31* Creat-0.9 Na-143 K-4.1 Cl-102 HCO3-31* AnGap-14 [**2104-9-20**] 08:25PM BLOOD K-4.1 [**2104-9-20**] 05:49AM BLOOD Glucose-97 UreaN-25* Creat-1.0 Na-142 K-4.2 Cl-107 HCO3-30* AnGap-9 [**2104-9-19**] 04:28AM BLOOD Glucose-116* UreaN-26* Creat-0.9 Na-144 K-4.3 Cl-112* HCO3-25 AnGap-11 [**2104-9-18**] 03:57AM BLOOD Glucose-100 UreaN-26* Creat-1.1 Na-141 K-3.3 Cl-110* HCO3-24 AnGap-10 [**2104-9-17**] 05:00AM BLOOD Glucose-99 UreaN-28* Creat-1.0 Na-140 K-3.8 Cl-111* HCO3-20* AnGap-13 [**2104-9-16**] 05:15AM BLOOD Glucose-93 UreaN-28* Creat-1.2 Na-139 K-4.2 Cl-113* HCO3-20* AnGap-10 [**2104-9-15**] 05:16PM BLOOD Glucose-92 UreaN-29* Creat-1.1 Na-141 K-3.8 Cl-112* HCO3-20* AnGap-13 [**2104-9-15**] 11:56AM BLOOD Glucose-85 UreaN-29* Creat-1.1 Na-140 K-4.5 Cl-110* HCO3-20* AnGap-15 [**2104-9-15**] 05:12AM BLOOD Glucose-94 UreaN-29* Creat-1.1 Na-141 K-3.3 Cl-111* HCO3-21* AnGap-12 [**2104-9-14**] 11:37PM BLOOD Glucose-116* UreaN-30* Creat-1.1 Na-141 K-3.6 Cl-111* HCO3-21* AnGap-13 [**2104-9-14**] 05:00PM BLOOD Glucose-184* UreaN-37* Creat-1.6* Na-139 K-4.6 Cl-101 HCO3-15* AnGap-28* [**2104-9-14**] 04:30AM BLOOD Glucose-120* UreaN-37* Creat-1.3* Na-139 K-4.2 Cl-103 HCO3-25 AnGap-15 [**2104-9-21**] 05:00AM BLOOD CK(CPK)-127 [**2104-9-20**] 05:49AM BLOOD CK(CPK)-140 [**2104-9-19**] 04:28AM BLOOD CK(CPK)-104 [**2104-9-18**] 03:57AM BLOOD CK(CPK)-194* [**2104-9-17**] 12:35PM BLOOD CK(CPK)-249* [**2104-9-17**] 05:00AM BLOOD CK(CPK)-308* [**2104-9-15**] 11:56AM BLOOD CK(CPK)-794* [**2104-9-15**] 05:12AM BLOOD CK(CPK)-858* [**2104-9-14**] 05:00PM BLOOD ALT-28 AST-116* LD(LDH)-426* CK(CPK)-1012* AlkPhos-104 TotBili-0.6 [**2104-9-21**] 05:00AM BLOOD CK-MB-3 cTropnT-2.01* [**2104-9-20**] 05:49AM BLOOD CK-MB-4 cTropnT-2.75* [**2104-9-19**] 04:28AM BLOOD CK-MB-5 cTropnT-3.33* [**2104-9-18**] 03:57AM BLOOD CK-MB-8 cTropnT-3.64* [**2104-9-17**] 12:35PM BLOOD CK-MB-11* MB Indx-4.4 cTropnT-2.54* [**2104-9-17**] 05:00AM BLOOD cTropnT-2.60* [**2104-9-15**] 11:56AM BLOOD CK-MB-50* MB Indx-6.3* cTropnT-1.73* [**2104-9-15**] 05:12AM BLOOD CK-MB-56* MB Indx-6.5* cTropnT-1.60* [**2104-9-14**] 05:00PM BLOOD CK-MB-72* MB Indx-7.1* [**2104-9-14**] 05:00PM BLOOD cTropnT-1.31* [**2104-9-25**] 03:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.2 [**2104-9-17**] 12:35PM BLOOD Triglyc-145 HDL-31 CHOL/HD-4.5 LDLcalc-81 [**2104-9-14**] 05:00PM BLOOD Cortsol-54.2* [**2104-9-22**] 10:55PM BLOOD Type-ART pO2-105 pCO2-35 pH-7.49* calHCO3-27 Base XS-3 Intubat-INTUBATED [**2104-9-21**] 05:42PM BLOOD Type-ART pO2-413* pCO2-43 pH-7.43 calHCO3-29 Base XS-4 [**2104-9-21**] 06:33AM BLOOD Type-ART pO2-108* pCO2-44 pH-7.46* calHCO3-32* Base XS-6 [**2104-9-20**] 02:42PM BLOOD Type-ART Temp-36.6 pO2-120* pCO2-28* pH-7.48* calHCO3-21 Base XS-0 [**2104-9-18**] 11:13AM BLOOD Type-ART pO2-144* pCO2-38 pH-7.39 calHCO3-24 Base XS--1 Intubat-INTUBATED [**2104-9-16**] 05:25PM BLOOD Type-ART pO2-167* pCO2-30* pH-7.37 calHCO3-18* Base XS--6 [**2104-9-15**] 10:56AM BLOOD Type-ART PEEP-5 O2-50 pO2-125* pCO2-30* pH-7.40 calHCO3-19* Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [**2104-9-15**] 12:05AM BLOOD Type-ART pO2-380* pCO2-30* pH-7.41 calHCO3-20* Base XS--3 [**2104-9-21**] 05:42PM BLOOD Lactate-2.1* [**2104-9-14**] 06:46PM BLOOD Lactate-3.0* [**2104-9-14**] 05:26PM BLOOD Lactate-15.2* [**2104-9-14**] 04:35AM BLOOD Lactate-1.7 Brief Hospital Course: 1. Pulmonary: The pt was intubated in the ED for airway protection. He did have a LLL infiltrate on CXR that was not overwhelmingly impressive. While in the ICU, he did well on the vent and was on pressure support at minimal settings for most of the time. His RSBIs were often elevated >100 [**2-11**] agitation, and during a spontaneous breathing trial on [**9-22**], he became tachypneic, tachycardic, and was pulling on his tube (he did at that time manage to pull out his OGT.) He also began having more secretions suctioned from his tube around that time. Later that day, while being turned, he turned [**Doctor Last Name 352**] and became hypoxic to the 80s, with some generalized tonic-clonic activity. A large mucous plug was suctioned from his tube and his sats began to rise. On [**9-24**], it was decided to extubate him, as it appeared that his mental status was not going to tolerate being on the vent without sedation, meaning that he would never have a great RSBI or spontaneous breathing trial. After a long discussion with his health care proxy, [**Name (NI) **] [**Name (NI) **], it was decided that we would extubate Mr. [**Known lastname 6930**] and would not reintubate him if he failed extubation. He tolerated extubation well and for the remainder of his stay in the ICU had O2 sats greater than 96% on RA. His infiltrates slowly improved on CXR. 2. Cardiovascular: On admission, Mr. [**Known lastname 6930**] had an elevated troponin and CKs. It was decided by his cardiologist/PCP that he was not a candidate for cath and that he would be managed medically. During the first few days of his hospitalization, his CK and MB declined as expected, but his troponins continued to rise, peaking at 3.64 on HD#5. Cardiology was consulted, as he had no EKG changes to suggest ongoing ischemia and his CKs were at that time flat. They did not have an explanation for the rising troponins, and it eventually trended downward. For his rhythm, he was in and out of atrial fibrillation and also had a wandering atrial pacemaker at time. His blood pressure was labile while he was here, and at times he had systolics in the 90s. Eventually, his pressure came back to a normal range and he was started on a beta-blocker and an ACE, as well as continued on an ASA. He also had a lipid panel checked and it was normal. A statin was not started [**2-11**] elevated ALT at baseline. 3. GI: He developed diarrhea during his admission, and a C diff toxin was positive. He was begun on Flagyl 500 mg po tid for a total of a 14 day course. 4. Infectious Disease: He never grew any bacteria from his sputum, blood, or urine cx. He was treated with ceftaz for a total of 14 days. He was initially treated with vancomycin given that he appeared septic and had a cellulitis. That was d/c'ed after approximately 5 days as the cellulitis did not appear to be that impressive, but he began spiking fevers to 102 after it was stopped and so it was restarted. It was discontinued again after the CDiff returned positive, as we felt that had caused the fevers. However, he spiked another fever and had a leukocytosis after the vanc was stopped, and so finally it was restarted so that he would have a total of 14 days of vancomycin. 5. Neuro: On presentation there was concern that he had had a seizure, although with a temp of 104 it seemed much more c/w rigors. He was evaluated by Neuro in the ED and had a normal head CT. An LP was done as well, which didn't reveal a leukocytosis but he did have quite a few red cells, and so HSV PCR was sent and he was begun on acyclovir. It was later felt that the tap was bloody (the ED resident said that he had hit an artery) and so the acyclovir was discontinued. Later in his admission, during his aforementioned episode with the hypoxia and mucous plug, it was felt he again had seizure activity with tonic clonic jerking. He was again evaluated by Neuro, who felt that it was likely due to hypoxia and not an actual seizure disorder. He had an EEG that revealed generalized mild encephalopathy but no frank epileptiform discharges. Once he was extubated, his mental status quickly returned to his baseline (per his PCP), which is a mild dementia. 6. Heme: On [**9-26**], the pt had a hematocrit drop from 32 to 27. This stabilized to a Hct of 29 on day of discharge without intervention. Iron studies are consistent with anemia of chronic disease. 7. Code Status: DNR/DNI Medications on Admission: ASA 81 mg po qd Metoprolol 25 mg po bid Risperdal 0.25 mg po bid MVT Brimonidine eye drops NTG sl prn Discharge Medications: 1. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). Disp:*1 bottle* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 3. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days. Disp:*33 Tablet(s)* Refills:*0* 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 inh* Refills:*5* 8. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 5 days. Disp:*10 grams* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary Dx: Pneumonia Secondary Dx: Clostridium Dificile Colitis, Hypoxia-Induced Seizures, Non ST-Elevation Myocardial Infarction, Anemia of Chronic Disease. Discharge Condition: Fair. Discharge Instructions: 1) If you have any fevers, chills, pain, shortness of breath, diarrhea, or any other concerning symptoms, please contact your doctor or return to the ER. 2) Take your medications as instructed. 3) Please have your doctor evaulate your liver enzymes. If they become normal, you may benefit from statin therapy to decrease your LDL and raise your HDL cholesterol levels. Followup Instructions: 1) Please see your primary doctor in the next 1-2 weeks ([**Last Name (LF) **],[**First Name3 (LF) **] N. [**Telephone/Fax (1) 719**]).

Admission Date: [**2178-11-3**] Discharge Date: [**2178-11-4**] Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is an 82-year-old female with a past medical history significant for non-insulin-dependent diabetes mellitus, gastric cancer, status post an upper gastrointestinal bleed treated with radiation therapy, hypertension. She is an 82-year-old female that is status post an inferior wall myocardial infarction with post infarction ventricular septal defect changes who was transferred her with an intra-aortic balloon pump in place on Neo-Synephrine and dopamine with a systolic blood pressure of around 80. She had large ST elevations in the inferior leads. She was anuric with a lactic acid of 8.5. Cardiac catheterization revealed ventricular septal defect changes. She arrived in gravely ill condition. ALLERGIES: She has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Her vital signs on admission were temperature of 95.2, heart rate 183, in atrial fibrillation, blood pressure 123/81, respirations 14, satting at 97%; arterial blood gas 7.28/23/180/111. The physical examination was deferred by the family. LABORATORY DATA ON PRESENTATION: Her laboratories were white blood cell count of 18.1, hematocrit 37.9, and platelets of 240. Magnesium of 2.5. Her ALT was 33, AST 53, alkaline phosphatase 145. Creatine kinase was 216. Troponin I of 37.7. Total bilirubin 0.6. HOSPITAL COURSE: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] discussed the possibility of surgery with the patient's family, and given the very low (if not zero) chance of survival the family whished to not proceed with the surgery and to stop support. On [**2178-11-4**], on hospital day two, the drips were discontinued earlier during the day. Systolic blood pressure dropped to 50s and then 40s. The patient was maintained on a morphine drip at 10 mg per hour. She became asystolic without vital signs at 1:35 a.m., and she was pronounced dead at this time. Dr. [**Last Name (STitle) 70**] was notified. The medical examiner's office was notified but declined autopsy. The patient wished to proceed with autopsy. DIAGNOSIS AT TIME OF DEATH: Post infarction ventricular septal defect. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 15735**] MEDQUIST36 D: [**2178-11-13**] 13:22 T: [**2178-11-17**] 08:37 JOB#: [**Job Number 29579**]

Admission Date: [**2125-8-9**] Discharge Date: [**2125-8-19**] Date of Birth: [**2069-9-23**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 2485**] Chief Complaint: Back pain, RUQ pain, dyspnea Major Surgical or Invasive Procedure: Right arterial line History of Present Illness: 55 yo F w/history of metastatic renal cell carcinoma in the setting of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau syndrome presented to clinic [**8-8**] she appeared ill and complained of three weeks worsening right lower quadrant and back pain, nausea/vomiting, weakness, fatigue, and inability to rise from a chair. She reported a subjective 20lb weight loss. She also had two episodes of bladder incontinence during over the past two days. ED COURSE: Initial vitals 89/62, HR 60 SR an 97% on RA. BP inc to 110/72 after 1 liter NS bolus. she was found to have a K of 6.2 and a Ca of 13.3. For her hyperkalemia she was given 10 units insulin with 1 amp D50, 1 amp calcium gluconate, 30mg kayecelate. For her neurological symptoms, she was given 10 mg decadron and head CT, and thoracolumbar MRI were performed to rule out CNS involvement and cord compression respectively. A UA was also sent. Ms. [**Known lastname **] was then trasferred to the OMED service for further care. FLOOR COURSE: Ms. [**Known lastname **] arrived to the floor with a K of 6.2 and a Ca of 11.5. The patient was having difficulty with word finding and was very sleepy after receiving narcotics. History was therefore obtained from chart. Per these reports, she noted shortness of breath, dyspnea with exertion preventing her from carrying out activities of daily living, diffuse body aches, diarrhea and fecal incontinence. . Given the incontinence and thoracic pain, she had a neurologic work up for ?cord compression, and subsequently an c, t, l spine MRI which was notable for metastatic disease diffusely and evidence of epidural disease at the L5 vertebral body level, but no compression. The patient received lasix, insulin, glucose and bicarb as well as kayexalate for electrolyte management, and also received a total of 3L of NS for acute pancreatitis. Her total uop on the floor in response to the lasix was 720cc. She had a progressive O2 requirement with tachypnea and on the morning of transfer to the [**Hospital Unit Name 153**] was satting 93% on 5L by nasal cannula. She doesn't admit to increased shortness of breath overnight but notes that in general, her dyspnea has been worsening over the last few days. She complains of severe abdominal pain, and admits to LH. She denies chest pain, headache, weakness, but notes that she has severe chronic pain related to spinal metastasis. She was transferred to the [**Hospital Unit Name 153**] for hypoxia and volume management. Past Medical History: Past Oncological History: Initially presented at age 9 with vision changes secondary to hypertensive emergency. She was diagnosed with a pheochromocytoma and underwent left adrenalectomy. She underwent right adrenalectomy in [**2088**] after being diagnosed with a second pheochromocytoma. In [**2111**], she underwent a hysterectomy which was complicated by postoperative bleeding. An ultrasound noted renal cysts leading to a biopsy of the right kidney, which was reported as normal. She then did well until [**2120**] when she was diagnosed with an L2 vertebral hemangioma after presenting with back pain with radicular symptoms. One year prior, her daughter had been diagnosed with a brain tumor, which was likely a hemangioma, and through testing was found to have [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**]-Lindau disease. -Nexivar was discontinued in [**2125-5-29**] following progression of disease to her liver. She was seen at [**Hospital1 18**] [**2125-6-27**], and at that time options for treatment with Sutent vs enrollment in a trial on perifosine were discussed. She has remained off therapy and returned to [**Hospital1 18**] with anticipation of enrollment on perifosine. -In [**2121-5-29**], Ms. [**Known lastname **] developed left flank pain and hematuria. Left radical nephrectomy on [**2121-6-2**] revealed a polycystic kidney with five clear cell type renal cell carcinomas ranging in size from 0.6 cm to 9 cm. There was no tumor invasion of the renal capsule, perinephritic adipose tissue, or large renal veins, and margins were negative. No lymph nodes were recovered in the specimen. Her TNM stage was T2 Nx Mx. -Ms. [**Known lastname **] was subsequently followed with MRIs every six months. MRI in [**3-/2124**] was notable for polycystic kidney disease in the right kidney and gradually increasing size of a lesion in the caudate lobe of the liver. Biopsy of this liver lesion on [**2124-6-29**] revealed metastatic clear cell renal cell carcinoma. In [**2124-7-29**], she was started on sorafenib (Nexavar). Because of some confusion, she was taking 200 mg p.o. b.i.d. MRI on [**2125-4-11**] showed growth of the liver lesion to 6 cm. In addition, in the polycystic right kidney, there was a 5 cm mass with enhancement in the peripheral margins and septations, raising concern for a slowly growing cystic neoplasm. The patient went off Nexavar because of progression in the liver and the development of a probable new tumor in the remaining right kidney. . PRIOR TREATMENT: 1. Left adrenalectomy at age 9 and right adrenalectomy at age 18 for pheochromocytomas. 2. Left nephrectomy for renal cell carcinoma (5 independent tumors noted) in [**2121-5-29**]. 3. Biopsy-documented metastatic disease in the caudate lobe of the liver in [**2124-3-29**], after which the patient was started on sorafenib. 4. Development of progressive disease in the liver and a probable new renal primary (or metastases) in the right kidney in the setting of polycystic disease. . Past Medical History: Ms. [**Known lastname **] has never been officially diagnosed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**]-Lindau disease, but her daughter was diagnosed with it and her personal and family history makes us fairly certain that she has it. She also has hypertension. . Past Surgical History: - L nephrectomy [**5-31**] - Bilat adrenalectomy [**3-2**] pheochromocytoma - TAH/BSO for benign ovarian abnormalities, - appendectomy in [**2088**] - right knee surgery for a ligament tear - resection of a hemangioma in [**2121**]. Social History: -Lives with husband in [**State 2748**] - Remote tobacco use - No EtoH or drug use Family History: - Pt's daughter has been diagnosed with [**Name (NI) **] [**Last Name (NamePattern1) 21354**], she has a hx of benign brain tumors, pheochromocytomas, & bilateral renal cell carcinoma - A brother died from a brain tumor in [**2103**] - Her mother died of renal failure at age 47 - A sister was diagnosed in her late 40s with breast CA - Another sister has diabetes mellitus, diabetic nephropathy & is s/p renal transplant - A brother died of myocardial infarction at age 58 - Maternal grandmother had hx of kidney problems Physical Exam: Vitals: T 97 HR 84 BP 98/60 R 22 Sat 93% on 5L by nasal cannula Gen: 55 yo F, very pale, ill-appearing, round face, no obvious respiratory distress, no accessory muscle use. HEENT: conjunctival pallor, anicteric, PERRL/EOMI, MM dry, op clear. Neck: JVD flat, supple CV - RRR, no MRG Resp: CTAB with faint bibasilar rales ABD - hypoactive BS, with mild distention and marked tenderness to palpation diffusely, but especially in the epigastrium, no rebound/guarding. Skin - pale, dry but warm and well perfused. EXT - no c/c/e, tender to touch Neuro - sleepy but arousable to voice. oriented x 3. Nonfocal exam, but limited secondary to pain. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2125-8-17**] 04:05AM 37.3* 3.71* 8.9* 29.0* 78* 23.9* 30.5* 22.0* 178 [**2125-8-16**] 04:38AM 27.1* 3.54* 8.7* 27.3* 77* 24.7* 32.0 21.8* 211 [**2125-8-15**] 04:38AM 20.2*1 3.99* 9.5* 30.7* 77* 23.8* 30.9* 21.5* 270 . [**2125-8-11**] 05:00AM 15.1* 3.00* 6.4* 22.6* 75* 21.3* 28.3* 21.8* 363 [**2125-8-9**] 01:00PM 12.7* 3.14* 6.8* 24.2* 77* 21.6* 28.1* 21.5* 484* [**2125-8-8**] 01:35PM 9.1 3.27* 6.9* 24.5* 75* 21.0* 28.0* 21.7* 596* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2125-8-17**] 04:05AM 121* 79* 2.1* 143 3.3 105 17* 24* [**2125-8-16**] 04:01PM 124* 72* 2.1* 138 3.1* 103 16* 22* [**2125-8-15**] 02:52PM 119* 73* 2.3* 139 3.2* 100 19* 23* [**2125-8-13**] 08:28PM 80 79* 3.0* 136 4.6 101 12* 28* . [**2125-8-10**] 05:15AM 119* 49* 2.1* 140 5.0 108 19* 18 [**2125-8-9**] 01:00PM 107* 48* 2.1* 135 6.7 107 17* 18 . Alb Calcium Phos Mg [**2125-8-17**] 04:05AM 1.9* 8.8 4.4 2.2 [**2125-8-14**] 07:58PM 10.0 6.2* 2.5 [**2125-8-11**] 05:00AM 2.3* 4.0* 3.5 1.6 [**2125-8-8**] 01:35PM 3.3* 13.3* 3.8 2.5 . ENZYMES & BILIRUBIN - ALT & AST remained WNL during admission - LDH increased from 120's to peak of 870, then was trending down prior to death - Alk Phos at 601 & Amylase was 1789 on admission & continued to trend down during admission to 169 & 78 respectively. . Lactate [**2125-8-17**] 09:05AM 1.6 . MICRO: URINE CULTURE (Final [**2125-8-13**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. VANCOMYCIN SENSITIVITY CONFIRMED BY ETEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S . BLOOD CULTURES X8-NGTD STOOL: C-DIFF X2-Negative VRE-Swab: negative . IMAGING: . Chest xray: - [**2125-8-16**]: Essentially unchanged chest radiograph with left atelectasis and pleural effusion. . - [**2125-8-15**]: AP chest compared to [**8-13**] through 17: Mild pulmonary edema is new. Left lower lobe atelectasis has worsened, and right infrahilar atelectasis is new. Moderate cardiac enlargement persists. Small left pleural effusion may be present, not changed appreciably. No pneumothorax. Nasogastric tube ends in the distal stomach. No pneumothorax. . - [**2125-8-8**]: 1. Enlarged cardiac silhouette. 2. No evidence of acute congestive heart failure or consolidation . CT HEAD: - [**2125-8-16**]: There is no significant interval change compared to prior examination from [**2125-8-8**]. However, due to motion artifact, the study is limited and a subtle lesion cannot be entirely excluded. . [**2125-8-8**]: 1. No acute abnormality including no intracranial hemorrhage is detected. 2. Although no obvious intracranial metastasis was identified, small isodense metastasis cannot be excluded on this non contrast study. MRI of the brain is recommended for further characterization. Small hypodense area in the right frontal [**Doctor Last Name 534**] might represent a metastasis although it is not a proper location for brain metastasis. . CT ABDOMEN & PELVIS: - [**2125-8-16**]: 1. Somewhat limited examination due to the lack of IV contrast however no evidence for abscess. Extensive phlegmon involving the peripancreatic soft tissues and the mesentery. 2. Liver metastases and bone metastases unchanged, pericardial effusion, left pleural effusion stable.3. Multiple cysts in the right kidney with complex lesion in the right lower pole unchanged. . - [**2125-8-9**]: 1. Compared to prior study, there is increased stranding surrounding the pancreas, tracking to the left paracolic space, with mild wall thickening seen in the descending colon. Findings are concerning for acute pancreatitis. . [**2125-8-13**] ECHOCARDIOGRAM: PERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood, inflammation or other cellular elements. No RV diastolic collapse. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Significant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. Small pericardial effusion without overt tamponade. . [**2125-8-13**] RUQ Ultrasound: 1. No evidence of cholelithiasis. A mildly distended gallbladder lumen with moderate amount of sludge is not uncommon in an ICU patient. If high clinical suspicion for acute cholecystitis, can consider correlation with HIDA scan. 2. Reidentification of known hepatic metastatic lesions and complex right renal cysts. Brief Hospital Course: A/P: 55 yo F with metastatic RCC in the setting of VHL who presented with acute pancreatitis from hypercalcemia, ARF, mental status changes, respiratory distress and significant back pain. . #. Respiratory Distress: Mild hypoxemia on 3L NC she was initially placed in a NRB and her O2 sats improved. In the setting of severe pancreatitis we were concerned about ARDS, however, she never required intubation for airway protection. Her CXRs on multiple occassions were clear without evidence of a consolidation. However, she remained hypoxic most likely caused by continued severe LLL atelectasis + small pleural/pericardial effusions, as well as a depressed mental status. She was not diuresed due to pancreatitis, her narcotic regimen was initially held to help improve her mental status, which did not clear. She remained on supplemental O2 throughout her hospital course and was not intubated. . #. Acute Renal Failure: Baseline creatinine unknown admitted with Cr 2.1, likely compromised by L nephrectomy thus single kidney with polycystic kidney disease in the setting of VHL, >5cm RCC mass in R kidney. Also in the setting of poor PO intake possibly pre-renal. - Continued anion gap metabolic acidosis likely due to chronic renal failure as pt had low lactate levels. - Multiple electrolyte abnormalities during admission including hyperphosphatemia & hypocalcemia requiring therapy; Initially admitted with hyperkalemia & hypercalcemia which resolved. She initially received one dose of Calcitonin on the floor which is possible cause of hypocalcemia. Another possibility of severe hypocalcemia was her pancreatitis. Repleted calcium IV with calcium drip. - Had required bicarbonate repletion, however this was discontinued as pt's bicarb levels improved. - The renal service was consulted, provided recommendations for therapy during admission. . #. Infection/inflammation w/increasing WBC and left shift - Had low grade fevers, however on steroids, at first stress dose then slowly titrated to down, however due to elevated WBC she was remained on stress dose levels. When pt was made CMO her steroids were d/c'd alltogether. - Known enterococcus UTI, not VRE colonized; unlikely source of infection. Other sources of infection included pancreatitis phlegmon & pneumonia/atelectasis. Abd CT showed large peripancreatic phelgmon with increased fat stranding likely resulting in considerable intra-abdominal inflammation. She was started on broad spectrum abx with vanco and zosyn, then switched to ampicillin for entoroccus UTI. Her Vanco was then switched to Meropenem for an abdominal source as noted below. All abx were d/c'd when pt made CMO as noted below. . #. Coagulopathy. likely from decreased nutritional status and antibiotics - INR improved from max 2.9 ->to 1.5 [**8-16**] after vitamin K x1. - Did not actively have any bleeding during admission, but there was concern especially given known hemangiomas. . #. Acute Pancreatitis: Potentially [**3-2**] cyst from VHL complex or metastasis. - Although admitted with elevated amylase, lipase, LDH & alk phos,ALT & AST remained nml. Initially pt was not given aggressive IVF due to her tenous respiratory status. Her T bili trended up to 4.4 on [**8-17**]. She had Increased fat stranding and phlegmon suggests inflammation and likely infection. Her pancreatitis was resolving but she had persistent abdominal pain with a very large 10cm liver mass. An U/S was done c/w biliary sludge, however no cholelithiasis. She was started on Meropenem for an intra-abdominal source of infection on [**8-17**]. Her pain was managed with dilaudid prn as her renal failure prevented use of morphine. However, Morphine drip was started when pt. was made CMO. . #. Cardiovascular dysfunction: -->Pump: Non-contributory pericardial effusion, but appears bloody/cellular/inflammatory on ECHO. EF >75%, mild diastolic dysfunction. -->Rhythm: Continued sinus tach (100-120) with frequent APBs, likely due to pain and infection. Also with a h/o pheochromocytoma on norvasc, labetolol and valsartan, which were all initially held due to hypotension. During her course she became tachycardic HR 150s most likely MAT. She was started on lopressor 5mg TID and titrated to control her HR. HR also controlled with pain control. -->Ischemia: No wall motion abnormalities or signs of ischemic dysfunction . #. Adrenal insufficiency in the setting of bilateral adrenalectomy, home steroid dependence, prednisone 5mg daily. Pt. was placed on stress dose steriods due to hypotension and infection. steroids were d/c'ed once pt was made CMO. . #. Metastatic RCC: CT scans negative for cord compression, however, 10cm liver metastasis, abundant evidence of probable VHL hemangiomas in the cervical, lumbar and thoracic spine. Heme Onc followed pt. & discussed the possibility of treatment with Sutent when pt was stable for d/c to a medicine floor. She was too tenuous throughout her [**Hospital Unit Name 153**] course to receive sutent. Pt's pain was controlled with aggressive pain medication. Palliative care was consulted for pain control and help with goals of care when her clinical status deteriorated. she was managed with a morphine drip once made CMO. . #. MS changes: Pt was drowsy and sedated, but appeared to be in pain with movement. MS changes likely combination of pain, uremia, ICU delerium, inflammation/ infection. She underwent 2 head CTs which did not show an acute process, however due to movement, and a limited study, a subtle lesion could not be entirely excluded. Despite no narcotics for several days she was not interactive or responsive. . #. Code status: Initially full code then made DNR/DNI, and CMO prior to death with help from Palliative care and [**Hospital Unit Name 153**] team as clinical status persistently deteriorated. . #. Goals of care. Ms. [**Known lastname **] had known advanced metastatic RCC with diffuse liver metastases in the setting of severe acute pancreatitis with a rising white count and continued MS changes despite electrolyte normalization and being off sedation. - A family meeting with spouse addressing concerns of worsening status including resp distress, an elevated WBC despite abx, & metastatic RCC, resulted in change of code status to DNR/DNI and shifting care to comfort only. - A morphine drip was initiated to ease pain & make her comfortable; prior to CMO she had adequate pain control via standing pain medications. - Palliative care was following the pt since [**8-10**]. . Pt expired on morning of [**8-19**] at 11am. Per pt's request her organs were donated to NDRI in coordination with our pathology department. Her husband agreed to an autopsy. Medications on Admission: Prednisone 5 mg p.o.daily Norvasc 10 mg p.o. b.i.d. Trandate 200 mg p.o. b.i.d., Diovan 160 mg p.o. daily. Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: n/a